The Ultimate AIPG

New Pattern Based Revision

FLASH CARDS
 th
1) Wilson’s disease-Recommended Anticopper drugs (Ref:Harrison 18 ed page 3189)

DISEASE STATUS FIRST CHOICE SECOND CHOICE

Hepatitis or Cirrhosis without Zinc Trientene
decompensation
Hepatic decompensation
Mild Trientene and Zinc Penicillamine and zinc
Moderate Trientene and zinc Hepatic transplantation
Severe Hepatic transplantation Trientene and Zinc
Initial neurologic/psychiatric Tetrathiomolybdate and Zinc Zinc
Maintenance Zinc Trientene
Presymptomatic Zinc Trientene
Pediatric Zinc Trientene
Pregnant Zinc Trientene

¾ Penicillamine was previously the primary anticoppertreatment,but now plays a minor role
because of two reasons:
a)Toxicity
b)Worsens existing neurological disease if used as initial therapy

If Penicillamine is given,it should always be accompanied by 25mg/day of Pyridoxine.

¾ Mechanism of action of Zinc in Wilson’s disease

a)Produces negative copper balance by blocking intestinal absorption of copper
b)Induces hepatic metallothioneinsynthesis,which sequesters additional copper.

¾ Disease severity in Wilson’s disease is assessed by Nazer’s prognostic index.Patients with score
less than 7 are usually managed with medical therapy.Patients with scores more than 9 should be
considered immediately for liver transplantation.Scores from 7 to 9 require clinical judgement as
to whether to recommend transplantation or medical therapy.
nd
2)Mosquito-borne diseases (Ref:Park 22 ed page 716)
Type of Mosquito Disease
Anopheles Malaria
Filaria (not in India)
Culex Bancroftianfilariasis
Japanese Encephalitis
West Nile fever
Viral arthritis(epidemic/polyarthritis)
Aedes Yellow fever (not in India)
Dengue
Dengue Haemorrhagic fever
Chikungunya fever
Rify valley fever
Filaria (not in India)
Mansonoides Malayan (Brugian) filariasis
Chikungunya fever

th
3)Differences between Caput succedaneum and Cephalhematoma(Ref:O.P.Ghai 8 ed page 141)

Characteristic Caput succedaneum Cephalhematoma

Incidence Common Less common
Location Subcutaneous plane Over parietal bones,between skull and
periosteum
Time of presentation Maximum size and firmness at birth Increasing size for 12-24 hour and
then stable
Time course Softens progressively from birth and Takes 3-6 weeks to resolve
resolves within 2-3 days
Characteristic findings Diffuse;crosses suture line Does not cross suture line;has distinct
margins
Association None Linear skull fracture(5-25%) ;
hyperbilirubinemia

4)Embryology of Ear
Pinna develops from six ectodermal tubercles
Tragus develops from first arch.Rest of the pinna develops from second arch.So, majority of the pinna
develops from second arch.
st
External auditory canal develops from 1 branchial cleft
Tympanic membrane develops from all the three germ layers(ecto,meso,endoderm)
Middle ear cleft (Middle ear + Eustachian tube + Mastoid antrum) develops from
st nd
Tubotympanicrecess.Tubotympanic recess develops from dorsal part of 1 and 2 pharyngeal pouch.
st nd
Ossicles of ear develops from cartillages of 1 and 2 branchialarch.First arch cartilage is also known
as Meckel’scartilage.Second arch cartilage is also known as Reichert’s cartilage.
Inner ear develops from otocyst(develops from cranial ectoderm).Bony labyrinth develops from
mesenchyme (ossifies from 14 centres).The development is complete by 16-20 weeks.Vestibular part
develops earlier than cochlear.
Pinna achieves adult size by 5-6 years.
ANATOMY
 Named Fasciae
Camper’s fascia - superficial fatty layer of superficial fascia of abdomen
Scarpa’s fascia - Deep membraneous layer of superficial layer of abdomen
Colles fascia - membraneous layer of superficial fascia of perineum
Fascia lata - Deep fascia of thigh
Buck’s fascia - Deep fascia of penis
Denonvillier’s fascia - Rectovesical fascia
Fascia of Waldeyer - condensed pelvic fascia behind rectum
Colles fascia - Deep cervical fascia
Gerota’s fascia - covering around kidney / adrenal gland
Sibson’s fascia - suprapleural membrane (apex of lung)
Fascia bulbi - covering around the eye
Glisson’s capsule - Liver
 Heart – Chambers
The interior of Right atrium is divided into two spaces indicated by Sulcus terminalis cordis externally and
crista terminalis internally
Prominent margin of Fossa ovalis is limbus fossa ovalis
Musculi pectinati is the rough area on the superior inner wall of Right atrium
Torus aorticus is the bulge in the anterosuperior portion of membraneous septum that marks the location
of non-coronary sinus of aorta
SA node is located at the superior end of crista terminalis at the junction of SVC and right atrium
Koch’s triangle is the anatomical landmark for AV node bounded by base of tricuspid valve, tendon of
todaro and coronary sinus
Trabeculae carnea are the numerous muscular structures in the walls of the inflow portion of right
ventricle
Three papillary muscles are present in the right ventricle with anterior one being largest and most
consistent
Left atrium forms the base / posterior surface of heart
Two papillary muscles are present in the left ventricle
Anterior interventricular sulcus contains the anterior interventricular artery and great cardiac vein
Posterior interventricular sulcus contains the posterior interventricular artery and the middle cardiac vein
 Blood supply of Heart
Right coronary artery arises from anterior aortic sinus of ascending aorta
Left coronary artery arises from the left posterior aortic sinus of ascending aorta
Right bundle branch is supplied by Left coronary artery
In 65% cases, SA node is supplied by right coronary artery and in the rest, it is supplied by left coronary
artery
Left anterior descending artery is also known as Widow’s artery because it is mostly affected by
atherosclerosis
Posterior interventricular artery is also known as ‘posterior descending artery’
Kugel’s artery, diagonal artery and obtuse marginal artery are branches of Left coronary artery
Person is said to have a ‘Right dominant’ heart, if the posterior interventricular artery is given off by Right
coronary artery
Coronary sinus orifice is guarded by thebesian valve while IVC orifice guarded by Eustachian valve
Anterior cardiac veins open directly into the anterior wall of right ventricle
Thebesian veins / Venae cordis minimi are numerous small veins present in all four chambers
 Eponyms in Anatomy
Arantius nodules - small nodules in the free border of aortic valves
Adamkiewicz’s artey - largest anterior medullary feeder artery to the anterior spinal artery
Baillarger bands - - visible striations in sections of cerebral cortex
Bergmann cells - glial cells of cerebellum
Bowman’s glands - glands in the olfactory mucosa
Brodel’s plane - line of division between areas of kidney supplied by anterior and posterior
branches of renal artery
Bruch’s lamina - basal membrane of choroid
Charcoat’s artery - lenticulostriate branch of middle cerebral artery; prone for rupture
Clocquet’s node - lymph node in the femoral canal
Fordyce’s spots - ectopic sebaceous glands in lips, tongue
Arcade of Frohse - arcade between two layers of supinator muscle, transmits posterior
interosseus nerve
Henle’s layer - outer layer of cells in the root sheath of hair
Holden’s line - transverse skin crease at the groin
Kerckring’s valve - valvulae conniventes; circular folds of small intestine
Ladd’s bands - congenital bands across the duodenum in volvulus neonatorum
Lister’s tubercle - prominence on posterior surface of distal radius, groove for EPL
Rexed’s lamina - subdivisions of cells of spinal cord grey matter
Scarpa’s ganglion - vestibular ganglio
Von Brunn nests - epithelial masses in male urethra and urinary bladder
Whitnall’s tubercle - tubercle on the orbital surface of the zygomatic bone
 Named nerves
Vidian nerve - Nerve of pterygoid canal
Nerve of latarjet - Branch of left vagus present in the lesser curvature of
stomach
Jacobson’s nerve - tympanic branch of glossopharyngeal nerve
nd
Nerve of Kuntz - Grey rami running upward from 2 thoracic nerve
Nervi erigentes - parasympathetic efferents from S2,3,4 that is motor to detrusor and
inhibitory to bladder sphincters
Nervus spinosus - Meningeal branch of mandibular nerve
Nervus hesitans - Deep peroneal nerve
Arnold’s nerve - Auricular branch of vagus
Nervus intermedius - sensory component of facial nerve
Criminal nerve of Grassi - Branch of vagus to parietal cells of stomach
 Tongue
th
All muscles of tongue develop from occipital myotomes except palatolossus which develops from 6 arch
st
Epithelium of anterior two-thirds develop from lingual swellings of 1 arch and tuberculum impar;
rd rd
posterior 1/3 develop from hypobranchial eminence of 3 arch
rd
Sensory innervations of posterior 1/3 of tongue including vallate papilla is by Glossopharyngeal nerve;
posterior most is supplied by internal laryngeal branch of vagus
All intrinsic and extrinsic muscles of tongue are supplied by Hypoglossal nerve except Palatoglossus
supplied by cranial accessory nerve through Pharyngeal plexus
Protrusion of tongue is carried out by Genioglossus while retraction is by styloglossus
Safety muscle of tongue is genioglossus
The main muscle forming the floor of the mouth is mylohyoid
Pharyngeal plexus is formed by vagus, glossopharyngeal and branches of superior cervical sympathetic
ganglion
All muscles of soft palate are supplied by Pharyngeal plexus except Tensor Veli Palatini which is supplied
by N. to medial pterygoid (from Mandibular nerve)
Lymph drainage from the tip of tongue is towards submental nodes
 Sources of Bleeding

In Duodenal ulcer Gastroduodenal A.

In Extradural haemorrhage Middle meningeal A.

In Subdural hemorrhage Bridging veins

In hemoptysis and bronchiectasis Bronchial A.

In blunt eye injury(tennis ball injury) Circulus iridis major

In retropubic prastectomy Dorsal venous plexus

In menstruation Spiral arteries

In hysterectomy Internal iliac A.

Anterior epistaxis Keisselbach’s plexus

Posterior epistaxis Woodruff’s plexus

 Glands

Parotid Submandibular Subligual Lacrimal

Nerve supply Auriculotemporal branch Chorda tympani Chorda tympani Greater pertrosal
of mandibular division of branch of facial nerve branch of Facial branch of facial
th
5 nerve + lesser petrosal nerve nerve via
th
branch of 9 via otic Pterygopalatine
ganglia ganglion

Duct Stenson’s duct Wharton’s duct Bartholin’s Lacrimal ducts

Opens in vestibule of Opens in mouth on duct(Rivinus duct) Open just below the
mouth opposite second summit of sublingual Open into upper eyelid
molar teeth papilla(on either side Wharton’s duct or
of frenulum) directly into floor of
mouth

Histology Purely serous acini Mixed Mixed but mainly

(serous>mucinous) mucinous

\
 Muscles

Composite Digastric muscles Subcutaneous muscles Cruciate muscles

muscles
Muscles which Muscles with 2 bellies(or 2 - Platysma Muscles in which fasiculi
have innervations heads) with 2 different - Dartos are crossed
from 2 different origins - Palmaris brevis - Sternocleido
nerves or 2 - Occipitofrontalis - Subareolar mastoid
different - Omohyoid muscles of - Masseter
embryological - Digastric nipple - Adductor
counterparts but - Rectus femoris - Muscles of magnus
have the same - Gastrocnemius scalp
function - Sterno- - Corrugator
- Pectineus cleidomastoid cutis ani
- Adductor magnus
- Biceps femoris
- Quadriceps
femoris
 Vertebral levels

STRUCURE LEVEL
Hyoid bone C3 vertebra
Thyroid cartilage C4 & C5 vertebra

Cricoid cartilage C6 vertebra

Isthmus of thyroid gland Second to fourth tracheal rings
nd st
Superior angle of scapula Overlies part of 2 rib – 1 intercostal space superior
to angle

Spine at root of scapula Opposite third thoracic spine

th th
Inferior angle of scapula Overlies part of 7 rib – 7 intercostal space inferior
to angle

Manubrium sterni T3 & T4

Xiphisternal joint T9 vertebra

Vena caval foramen T8 vertebra

Esophageal hiatus T10 vertebra
Aortic hiatus T12 vertebra
th
Spleen Oblique along axis of 10 rib

Celiac trunk L1 vertebra (superior border)

Pylorus of stomach L1 vertebra

Inferior mesenteric artery L3 vertebra (subcostal plane)

Right kidney Superior pole: T12 vertebra

Inferior pole: L3 vertebra
Hilum: L1 vertebra

Pancreas head L2 and L3 vertebra

Spinal cord termination L1 (adults), L3 (new born)

Bifurcation of abdominal aorta L4 vertebra

Origin of inferior vena cava L5 vertebra

Umbilicus Between L3 and L4 vertebra

Anterior superior iliac spine S1 vertebra

Posterior superior iliac spine S2 vertebra

Transtubercular plane L5 vertebra

 SPECIALIZED CELLS
Special cells Region

Hassal’s corpuscles Thymus

Myofibroblast Wound margin

Hoffbauer cells Placenta / Umbilical cord

Kulchitsky cells (APUD cells) Lungs

Cords of Bilroth Spleen

Space of disse/Space of Mall Liver

Rockitansky Aschoff sinus Gall bladder

Myoid cells Testes

Reinke crystals Leydig cells of testes & hilus cells of ovary

Halo cells Ductus epididymis

Pores of Kohn Alveoli

Dust cells Alveoli

 OSTEOLOGY
Basic unit of bone : osteon
Osteon: composed of lamellae arranged around Haversian canals
Rich in glycoproteins & proteoglycans – highly basophilic
Central Haversian canal: neurovascular canal containing 1 or 2 capillaries
Haversian canals communicate with each other via Volkman’s canal(nutrient/vascular perforating
channels)
Epiphysis: ends & tips of bone, ossifies from secondary centres
Epiphyseal growth plate(physis): part b/w epiphysis & metaphysic, zones of maximum growth
Diaphysis: ossifies from primary centres, strongest part of the bone
Diaphyseal nutrient arteries are directed away from the dominant growing epiphysis.
Metaphysis:
o Zone of active growth
o Highly vascularised zone
o Hair pin arrangement of blood vessels
o More prone for injury
o Most common site for osteomyelitis in children
Bone receives 5% to 10% of the cardiac output
Long bones receive blood flow from three sources: 1. The nutrient blood vessel that enter the diaphysis
through nutrient foramen, 2. The metaphyseal complex, and 3. The periosteal capillaries
The epiphyseal and metaphyseal arterial supply is richer than the diaphyseal supply
 Types of Joints
Synovial Joints

Uniaxial joints

Plane/flat joint Acromioclavicular joint, inter metatarsal joint

Hinge joint (only flexion & extension) Elbow, ankle, injterphalageal joint

Pivot( trochoid) joint Sup. & Inf. Radioulnar, Atlanto-axial

Biaxial joints

Ellipsoid joint Wrist, all MCPs, Atlanto-occipital

Condylar joint Knee, Temporo-mandibular joint of jaw

Saddle joint Thumb(first CMC), sternoclavicular,

calcaneocuboidal, ankle, Incudo-malleolar joint

Multi axial joints

Ball&Socket Shoulder, hip, talocalcaneonavicular, incudo-

stapedial joint

Fibrous
Sutures of skull
Syndesmosis: Distal tibiofibular joint, interosseus membrane of forearm
Gomphosis: teeth in its socket
Schindylesis: Vomer-sphenoidal rostrum junction
Cartilagnous
0
Synchondrosis (1 cartilagnous): epiphysio-diaphyseal joint, first chondrosternal, costochondral
0
Symphysis (2 cartilagnous): manubriosternal, intervertebral, sacrococcygeal
 Cartilages

Hyaline (most abundant) Fibro cartilage Elastic

Covers articular surfaces of Intra articular disc Never calcify, resistant to

typical synovial joints Intervertebral disc degeneration
Forms epiphyseal growth Menisci
plates Acromio clavicular joint
Joints/Symphysis
Aretynoid Auricle
Glenoid labrum (Shoulder
Articular cartilage(most Auditory tube
joint)
synovial joints) Corniculate laryngeal cartilage
Acetabular labrum (hip joint)
Cricoid, Costal cartilage Cuneiform laryngeal cartilage
Thyroid, tracheobronchial External auditory meatus
Nose (Septum & nasal wall) (lateral part)
Epiphyseal plate, trachea, Epiglottis, apex of aretynoid
xiphoid
 Brachial plexus
The cords are named according to their relative position to the second part of axillary artery as it lies behind the
pectoralis minor muscle.
A. Branches of the Roots:
Nerve to serratus anterior(Long thoracic nerve of Bell)(C5,C6,C7)[paralysis causes winging of
scapula]
Nerve to rhomboideus(Dorsal scapularN)(C5)

B. Branches of the Trunks (arise only from the upper trunk)

Suprascapular N(C5,C6)[Largest branch of upper trunk, supplies supraspinatus & infraspinatus]
Nerve to subclavius(C5,C6)

c. Branches of the cords

Branches of lateral cord(LML) Branches of the medial cord Branches of posterior cord

Lateral pectoral(C5-C7) Medial pectoral .N(C8,T1) Upper subscapular(C5,C6)

Musculocutaneous(C5-C7) Medial cutaneous N of arm(C8,T1) Lower subscapular(C5,C6)
Lateral root of Median Medial cutaneous.N of fore-arm(C8,T1) Nerve to Lattismus dorsi
N(C5-C7) Medial root of median N(C7,C8,T1) (thoraco-dorsal N)(C6,C7,C8)
Axillary N(C5,C6)
Radial N(C5-C8,T1)
 Collateral nerves

Long thoracic nerve Serratus anterior

Medial pectoral nerve Pectoralis major & minor

Lateral pectoral nerve Pectoralis major & minor

Upper subscapular nerve Subscapularis

Lower subscapular nerve Subscapularis & Teres major

Thoracodorsal nerve Lattissmus dorsi

Suprascapular nerve Supraspinatus & Infraspinatus

Dorsal scapular nerve Rhomboids

 CARPAL BONES
The carpus contains eight bones in proximal and distal rows of four
In radial(lateral)and ulnar(medial) order, the scaphoid, lunate, triquitrel,and pisiform make up the
proximal row, and the trapezium, trapezoid, capitates and hamate make up the distal row.
The scaphoid is the most frequently fractured bone, typically as a result of fall on to an outstretched
hand.
The fracture usually crosses the long axis of the bone.
The Capitate is the largest of the carpal bones
Scaphoid is the largest of the proximal row
The carpal bones are usually cartilaginous at birth.
T he first carpal bone to ossify is the Capitate and the last to ossify is pisiform.
Fracture dislocation of lunate can result in injury to median nerve producing carpal tunnel syndrome
 LIGAMENTS OF KNEE JOINT
Fibrous capsule: Ligaments: coronary ligament short lateral ligament
Ligamentum patellae: Common tendon of insertion of quadriceps femoris
Medial(tibial collateral) lig.: Corresponds to the degenerated tendon of adductor magnus
Lateral(fibular collateral)lig.: Represents the femoral attachment of the peronneus longus
Oblique Popliteal lig.: Expansion from the tendon of semimembranosus
Arcuate Popliteal lig.: Posterior expansion from the short lateral lig.
Cruciate lig.: (Anterior & Posterior)Very thick and strong fibrous bands
1. Act as a direct bonds of union between tibia and femur
2. Maintain anteroposterior stability of knee joint
3. Posterior is thicker & stronger
4. Supplied by middle genicular vessels and nerves
Menisci(semilunar cartilages): deepen the articular surfaces of the condyles of the tibia
Transverse ligament: Connects the anterior ends of medial & lateral menisci.
Unhappy triad of O’ Donoghue refers to the combined injury od medial collateral ligament,
medial meniscus and anterior cruciate ligament
 Lower limb - miscellaneous
Most important arch: medial longitudinal arch, primarily affected in pes planus & pes cavus
Main joint of medial longitudinal arch: Talocalcaneonavicular joint
Main joint of lateral longitudinal arch: Calcaneocuboid
st
Metatarsus primus varus: adduction deformity of the 1 metatarsal commonly associated with hallux
valgus
Flat-foot Deformity: The longitudinal arch is lost
Subtalar Arthritis would prevent a person from being able to walk on unlevel ground easily – no inversion
and eversion of hindfoot
nd
Claw toe Deformity: scarring of quadratus plantar muscle(2 layer), common symptom of compartment
syndrome in this compartment in the foot
Master’s Knot of Henry: The crossing of the Flexor Digitorum Longus and Flexor Hallucis Longus tendons,
on the medial side of the foot
Intra articular tendon: popliteus
Holden’s line: line of attachment of deep layer of superficial fascia to deep fascia of thigh
Fresher’s syndrome: over exertion of the muscles of the anterior compartment of leg-edema of leg-severe
pain
Peripheral heart: soleus
Largest sesamoid bone: Patella
Highest point of medial longitudinal arch of foot:talus
Nervus hesitans: deep peroneal nerve
rd rd th
Morton’s neuroma – enlarged common plantar nerve, usually in the 3 interspace between 3 & 4 toes
Tarsal Tunnel: Posterior tibial artery & posterior tibial nerve
th th th th
Overriding toes most commonly involves the 4 & 5 toes. The 4 toe is depressed overridden by 5 toe
Arteria comitans nervi ischiadici (Artery of sciatic nerve):
1. A very small vessel, a branch of the internal iliac artery
2. Represents the primitive axial artery of the lower limb
 Rib
Shortest broadest and most curved 1st
Typical ribs 3-9
True ribs/vertebro sterna ribs 1-7
False ribs/vertebra chondral 8-12
Floating ribs 11,12
Typical intercostal nerves 4-6
Costal margin formed by 7-10

Components of a Rib

Head: Connected to the vertebra

Neck
Tubercle: Contains the articular facet, which articulates with the transverse process of the vertebra
Angle
Shaft, containing the Costal Groove
Costochondral Joint: The joint where bone ends and cartilage begins. The bone extends
anteroinferiorly, whereas the cartilage extends back posterosuperiorly
Costal groove: Groove for intercostal arteries, veins, and nerves, on inferior aspect
 OESOPHAGUS
rd
Upper 1/3 : Striated muscle
rd
Middle 1/3 : Striated and smooth muscle
rd
Lower 1/3 : Smooth muscle
Lined by stratified squamous non keratinized epithelium
Constrictions: Compressed by surrounding structures at four locations

15 cm Junction of the esophagus with the pharynx in the neck

22.5cm Superior mediastenum where the esophagus is crossed by the arch of aorta

27.5cm Posterior mediastenum where the esophagus is compressed by the left main bronchus

40cm Posterior mediastenum at the esophageal hiatus at the diaphragm

Passes through the right crus of the diaphragm, usually at the level of vertebrae T10.
Blood supply:
1. Cervical part upto arch of aorta: Inferior thyroid artery
2. Thoracic part: Oesophageal branches of descending thoracic aorta
3. Abdominal part: Oesophageal branches of Left gastric artery
4. Bronchial artery
5. Left inferior phrenic artery
Venous drainage:
1. From upper part: Brachiocephalic veins
2. Middle part : azygos
3. Lower part: left gastric vein
 EXTRA OCULAR MUSCLES
All extra-ocular muscles arise from the apex of orbit except inferior oblique
The four recti arise from a common annular tendon or tendinous ring
Lateral rectus has only one muscular artery
Superior rectus is slightly larger than the other recti muscles
Superior oblique is a fusiform muscle
th
Superior oblique is usually not paralysed in retro bulbar block since the 4 cranial nerve is outside the
muscle cone
Superior muscles (both oblique & rectus) are intortors
Inferior muscles (both oblique & rectus) are extortors
Medial, Inferior & Superior recti are adductors whereas Lateral rectus, Superior & inferior oblique are
abductors
Superior rectus and Inferior oblique are elevators
Superior Oblique and Inferior rectus are depressors
CHIEF TORTORS: In ABDucted eye,Obliques; In ADDucted eye, Recti
Earlest muscle involved in thyroid oculopathy – Inferior Rectus
 VENTRICLES OF THE BRAIN
st nd
Lateral ventricles(1 & 2 ventricles): largest cavities of the ventricular system
rd
3 ventricle
They each include two central portions(body and atrium) and three extensions(horns)
Trigone of lateral ventricle: junction b/w anterior & posterior horns
There is no choroid plexus in the anterior & posterior horns
Tapetum of the corpus callosum separate the ventricles from the optic radiation, and form the roof and
lateral wall of the posterior horn
Third ventricle: a slitlike cavity between the right and left halves of the diencephalon is continuous
th
posteroinferiorly with the cerbral aqueduct(aqueduct of midbrain/sylvius), to the 4 ventricles
th
The 4 ventricle in the posterior part of the pons and medulla extends inferoposteriorly
It is continuous through the central canal in the spinal cord
th
CSF drains from the 4 ventricle through a single median aperture(foramen of megendie) and paired
lateral apertures (foramen of Luschka)in to the subarachnoid space.
 Ammonia transport and Urea cycle
Glutamine is the sole form of transport of ammonia in brain
In metabolic alkalosis, there is decreased ammonia excretion in urine
Urea is produced in the liver and transported to kidneys for excretion
Urea cycle is the first metabolic cycle to be elucidated – by Hans Krebs and Kurt Hensleit
(Krebs-Hensleit cycle)
First two reactions in mitochondria and remaining in cytosol
Kidney and intestine possess all the urea cycle enzymes except arginase
Carbamoyl phosphate synthetase I is the rate limiting enzyme
Synthesis of 1 mol of urea requires 3 mol of ATP
Ornithine transcarbamylase deficiency is the most common of the urea cycle disorders
All urea cycle disorders are autosomal recessive except Hyperammonemia Type 2 (Ornithine
transcarbamylase deficiency)
HHH syndrome: Hyperornithinemia, Hyperammonemia, Homocitrullinuria; due to mutation in ORNT1
gene
Mutation in Ornithine aminotransferase cause gyrate atrophy of retina
Arginosuccinic acidemia produces Trichorrhexis nodosa
 Heme synthesis and porphyrias
Heme is synthesised from succinyl coA and glycine
ALA synthase is the rate limiting enzyme of heme synthesis
Synthesis of ALA occurs in mitochondria
High levels of Lead can inhibit the enzymes ALA synthase, Ferrochelatase and ALA dehydratase
Porphobilinogen is the first precursor of heme with a ring structure
Site of heme synthesis: Liver and Bone marrow
Porphyria cutanea tarda is the most common type of porphyria
All porphyrias are Autosomal dominant except Congenital erythropoetic porphyria which is
Autosomal recessive
Acute Intermittent porphyria caused by deficiency of Uroporphyrinogen I synthase presents with
abdominal pain and neuropsychiatric symptoms
Soret band: sharp absorption band near 400 nm for a solution of porphyrin in 5% HCl
 Specialised products from amino acids
Glycine - Creatinine, Glutathione, Heme, Purines, Conjugated bile acids
Tyrosine - Thyroxine, Epinephrine, Nor rpinephrine, Dopamine, Melanine
Tryptophan - NAD, NADP, Serotonin, Melatonin
Methionine - Creatine, Epinephrine
Histidine - Histamine
Arginine - Creatine, Niric oxide
Lysine - Carnitine
Glutamate - GABA, Glutathione, Gamma carboxy glutamate
Aspartate - Purines, Pyrimidines
Serine - Sphingomyelin, Choline, Phosphatidyl choline
Beta alanine - Coenzyme A
 Amino acid combinations
Glycine + Arginine + Methionine Æ Creatine

Glycine + Succinyl coA Æ Heme synthesis

Glycine + Cysteine + Glutamate Æ Glutathione

Glycine + Aspartate + Glutamine + Serine Æ Purine

Aspartate + Glutamine Æ Pyrimidine

Histidine + Arginine + Lysine Æ Keratin

Arginine + Lysine Æ Histone

Beta Alanine + Histidine Æ Carnosine

Glycine + Serine + Methionine Æ Choline

Amines produced by decarboxylation of amino acids:

- Histidine Æ Histamine

- Lysine Æ Cadaverine

- Ornithine Æ Putrescine

- Tyrosine Æ Tyramine

- Tryptophan Æ Tryptamine
 Lipoproteins and Triglycerides
Activator of LCAT: Apo A-1

Activator of extrahepatic lipoprotein lipase: Apo C2

Arginine rich lipoprotein: Apo E

Apo E4 binds avidly to beta amyloid in neuritic plaques of Alzheimer’s disease

Apoprotein for chylomicrons only: Apo B48

Common apoprotein of VLDL, LDL, IDL: Apo B 100

Apo (a) shows structural homologies to plasminogen

Cholesterol ratio = Total cholesterol / HDL (Ideal Æ 3.5:1)

VLDL transports endogenously synthesised TG to adipose tissue, skeletal and cardiac muscle

Fredrickson Classification of Hyperlipoproteinemias

- Triglycerides are normal only in Type II

- Cholesterol is increased only in Type II and III

- Both Cholestrol and triglycerides are increased in Type III

In Abetalipoproteinemia, early death can be avoided by fat soluble vitamins especially Vitamin E

In Tangier disease and Fish eye disease there is low or near absence of HDL (Orange tonsils are seen

in Tangier disease)
 Lipids......

Largest amount of prostaglandins seen in : Seminal fluid

Jamaican Vomiting Sickness – from eating of unripe fruits of AKEE tree (rich in hypoglycin)
Cerebro Hepato Renal (Zellweger’s) syndrome: inherited defect in peroxisomes (most severe
form of Peroxisome biogenesis disorders)
Brain, RBCs, Adrenal medulla cannot use fatty acids for energy
Friedewald formula: LDL cholestol = Total cholesterol –(HDL cholesterol + TG/5)
Phospholipase A2: Pancreatic fluid and snake venom
Phospholipase C: Bacterial toxin
Phospholipase D: Mammalian signal transduction
Saponification number: Index of molecular weight (chain length) of fatty acid, inversely
proportional to molecular weight of fatty acids
Iodine number: Index of degree of unsaturation (number of double bonds) of fatty acids,
directly proportional to the number of double bonds
Acid number: indicates the degree of rancidity of given fat
Hormones produced by adipose tissue are Adiponectin (modulation of glucose and lipid
metabolism), Leptin (energy homeostasis) and Perilipin (inhibition of lipolysis)
Decreased cardiolipin levels are associated with aging, heart failure, hypothyroidism and Barth
syndrome (cardioskeletal myopathy)
 Vitamin and Micronutrient malnutrition
Scurvy is the first disease identified due to dietary deficiency
Vitamin C supplementation is useful in Chediak Higashi syndrome and Osteogenesis Imperfecta
Vitamin whose deficiency and excess produces myopathy : Vitamin E
Other features of Vitamin E deficiency: Peripheral neuropathy, spinocerebellar ataxia, retinopathy
Choline and betaine restricted diets are of therapeutic value in trimethylaminuria (fish odour
syndrome)
Tongue changes in Vitamin deficiency
- Riboflavin Æ Magenta tongue
- Niacin Æ Beefy red tongue (fiery red tongue)
- B12 Æ Baldness of tongue
- Folic acid Æ Painful tongue
Increased levels of homocysteine and methyl malonic acid is associated with B12 deficiency
Vitamin deficiency in pancreatic insufficiency : Vitamin A
Riboflavin deficiency is almost always associated with pyridoxine deficiency
Coenzyme A requires Vit. B6 & Coenzyme A is the active form of Pantothenic acid
Heat labile vitamins are Vitamin C & Folic acid
Severe hypermagnesemia can cause acute rhabdomyolysis
Milk alkali syndrome is due to excess Calcium
Refractory hypochromic anemia, neutropenia, osteopenia, defective keratinisation and
pigmentation of hair is a feature of Copper deficiency
Chromium deficiency can produce impaired glucose tolerance
Micronutrient deficiency producing Restless leg syndrome – Iron
Molybdenum deficiency increases the risk for mouth and esophageal cancer
Zinc deficiency is associated with Diarrhea, poor wound healing, immune dysfunction and
hypogonadism
Selenium deficiency produces Keshan disaease (endemic cardiomyopathy) and Kashin Beck disease
(endemic osteoarthritis)
Ouch ouch (Itai-itai) disease is due to toxicity of Cadmium
 Rate limiting enzymes of Metabolic processes
Glycogenesis - Glycogen synthase
Glycogenolysis - Glycogen phosphorylase
Glycolysis - Phosphofructokinase 1
Gluconeogenesis - Phosphoenolpyruvate carboxy kinase (most important)
Fatty acid synthesis - Acetyl CoA carboxylase
Cholesterol synthesis - HMG CoA reductase
Bile acid synthesis - 7 alpha hydroxylase
Urea synthesis - Carbamoyl phosphate synthetase 1
Uric acid synthesis - Xanthine oxidase
Purine biosynthesis - Phosphoribosyl phosphate synthetase
HMP shunt - G6PD
TCA cycle - Isocitrate dehydrogenase
Fatty acid oxidation - Carnitine acyl transferase 1
 Enzyme deficiencies and disorders of lipid metabolism

Disease Enzyme deficient

Wolman disease Acid lipase

Farber’s disease Acid ceramidase

Niemann Pick disease Sphingomyelinase

Gaucher disease Glucocerebrosidase

Krabbe leukodystrophy Galactocerebrosidase

Metachromatic leukodystrophy Arylsulfatase A

Fabry’s disease Alpha galactosidase

Tay Sach’s disease Hexosaminidase A

Sandhoff’s disease Hexosaminidase B

Schindler disease Alpha N acetyl galactosaminidase

GM1 gangliosidosis Beta galactosidase

 Enzymes and cofactors
Zinc - Superoxide dismutase, Carbonic anhydrase, Alkaline phophatase,
ALA dehydrogenase

Magnesium - Transketolase, Phosphatase, Adenyl cyclise, Ribonuclease

Selenium - Glutathione peroxidise
Pyridoxine - Transaminases
Biotin - Carboxylase
Calcium - Lecithinase, lipase
Vitamin C - Hydroxylation
Copper - Tychrrosinase, Cytochrome oxidase, Dopamine hydroxylase
Molybdenum - Xanthine oxidase, Sulfite oxidase
Manganese - Hydroalse, Transferase
Iron - Hemoglobin, Cytochrome oxidase, Catalase, Peroxidase
 Carbohydrate metabolism
All the enzymes for glycolysis are present in cytosol
Glycolysis is the only pathway that is taking place in all cells of the body
Rate limiting step in glycolysis is the one catalysed by Phospho fructokinase 1
Warburg hypothesis: Cancer cells depend on anaerobic process / glycolysis for ATP
Pasteur effect: inhibition of glycolysis by excess oxygen
Crabtree effect: inhibition of oxygen consumption by addition of glucose
Two irreversible steps of TCA cycle are those catalysed by Citrate synthase and alpha ketoglutarate
dehydrogenase
Fluroacetate inhibits aconitase, arsenite inhibits alpha keto glutarate dehydrogenase and malonate
inhibits succinate dehydrogenase
Initial steps of glycogenesis is mediated by a protein called glycogenin
Essential pentosuria occurs due to deficiency of Xylitol dehydrogenase or Xylulose reductase
One mole of NADH yields 2.5 ATP whereas one mole of FADH yields 1.5 ATPs
 Mitochondrial DNA
Constitutes 1% of total cellular DNA
Circular, double stranded, with heavy and light chains
Contains 16,569 base pairs
Encodes 13 protein subunits of respiratory chain
- Seven subunits of NADH dehydrogenase
- Cytochrome b of complex III
- Three subunits of cytochrome oxidase
- Two subunits of ATP synthase
Encodes large (16S) and small (12S) mitochondrial ribosomal RNAs
Encodes 22 mitochondrial tRNA molecules
High mutation rate
Disorders due to mutation in mitochondrial DNA:
- Leber’s Hereditary optic neuropathy
- MELAS
- Neuropathy, Ataxia, Retinitis pigmentosa (NARP)
- Pearson syndrome
AGA and AGG are the terminator codons in mitochondrial DNA
 Important tests

Substance to be detected Tests

Proteins Heller’s nitric acid test

Heat coagulation test
Biurate test

Bile pigments Gmelin’s test

Fouchet’s test
Rosenbach’s test

Bile salts Hay’s test

Urobilinogen Ehrlich’s test

Blood Benzidine test

Differentiate between mono and Barfoed’s test

disaccharides Fehling’s test

Tyrosine Millon’s test

Differentiate between aldose and ketoses Seliwanoff’s test

Foulger’s test
Rapid furfural test

All carbohydrates Molisch test

Arginine Sakaguchi test

Pentoses Bial test

Galactose Mucic acid test

Glucose Oxidase peroxidise method

Nelson somogyi method
Folin Wu method

DNA Fuelgen staining

Urinary calcium Sulkowitz test

Barbiturates Modified Koopany test

 Enzymology

Enzymes don’t alter the energy of reaction but lower the energy of activation
Vmax = maximum velocity with specified amount of enzyme
Km = concentration of substrate required to produce half Vmax
Enzyme activity is measured as micromoles / min
Competitive inhibition
- Reversible
- Vmax is same, Km is increased
- Substrate affinity to enzyme is lowered
Non competitive inhibition
- Can be reversible or irreversible
- Vmax is decreased, Km is unaltered
Allosteric inhibition
- Inhibitor binds to enzyme at a site different than active site
- Does not follow Michelis Menton kinetics
- Follows sigmoid kinetics

Low Km reflects high affinity of enzyme

 Markers of organelles
Organelle Marker

Nucleus DNA

Mitochondria Glutamate dehydrogenase

Lysosome Acid phosphatase

Plasma membrane 5’ nucleotidase

Na+K+ ATPase
Adenyl cyclase

Golgi apparatus
- Cis golgi - Galactosyl transferase I
- Medial golgi - Golgi mannosidase II
- Trans- golgi - Galactosyl transferase
- Trans golgi network - Sialyl transferase

Peroxisomes Catalase

Cytosol Lactate dehydrogenase

Intermitochondrial membrane ATP synthase

 Cell cycle
Stage Details Importance

G0 phase Quiescent cells, resting phase Gene transcription occurs

Non proliferative cells remain in this stage

G1 phase Pre synthetic phase Longest phase

Most variable phase
Growth factors are most effective

S phase DNA replication phase Proportion of cells in S phase is increased in

cancer

G2 phase Preparation for cell division Arrest by p53 gene occurs here
DNA repair

M phase Mitotoc phase

- G2-M phase cells are most susceptible to radiation injury

- Cells are most resistant towards the end of S phase
- If cells are irradiated in G1 phase, chromosomal abnormalities may occur
- If cells are irradiated in G2 phase, chromosomal aberrations may occur
 India – General Information (2011 Census)
Population of India - 121 crores
Annual Growth rate - 1.64
Population density - 382 / sq km
Sex ratio in India - 940 females / 1000 males
Literacy Rate - 74.04 (Males- 82; F- 65)
Life Expectancy at birth - Males = 63; Females= 66
Total fertility rate - 2.6
Birth rate - 22.1
Death rate - 7.2

- UP has largest rural population

- Maharashtra has largest urban population
- Kerala has highest literacy rate and Bihar has lowest
- India’s population pyramid has a broad base and tapering top
 Important days of public health importance
th
30 January : Anti leprosy day
th
15 March : World disabled day
th
24 March : Anti Tuberculosis day
th
7 April : World Health day
th
8 May : World Red Cross day
st
1 week of May : Malaria week in India
nd
2 week of May : Thalassemia week
st
31 May : No smoking day
th
5 June : World Environment day
th
26 June : International day against drug abuse and illicit trafficking
June : Anti malaria month
st
1 July : Doctor’s day, Census
th
11 July : World population day
st
1 week of August: World Breast feeding week
th
8 September : World Literacy day
st
1 October : National voluntary blood donation day
nd
2 Wednesday of October: World disaster reduction day
th
10 October : World mental health day
th
7 November : National Cancer awareness day
th
10 November : Universal Immunisation day
st
1 December : World AIDS day
rd
3 December : International day for disabled persons
th
10 December : Human Rights day
 Suggested norms of health personnel

Category Norms suggested

Doctors 1 per 3500 population

Nurses 1 per 5000 population

Health worker (male and female) 1 per 5000 population in plain areas
1 per 3000 population in hilly and tribal area

Trained dai 1 for each village

Health assistant (male and female) 1 per 30000 population in plain areas
1 per 20000 population in hilly and tribal areas

Pharmacists 1 per 10000 population

Lab technician 1 per 10000 population

ASHA 1 per 1000 population

 Medical Entemology

Arthropod Disease transmitted

Anopheles Malaria

Mosquito Culex Japanese encephalitis

West nile fever
Bancroftian filariasis
Viral arthritis
Aedes Yellow fever
Dengue
Chikungunya
Rift valley fever
Mansonoides Brugian filariasis
Sand fly Kala azar
Oriental sore
Sandfly fever
Oraya fever

Tsetse fly Sleeping sickness

Hard tick Tick typhus

Viral encephalitis
Kyasanur Forest Disease

Soft tick Q fever

Relapsing fever

Louse Epidemic typhus

Relapsing fever
Trench fever
Pediculosis

Black fly (Simulium) Onchocerciasis

Rat flea Bubonic plea

Endemic typhus
Chiggerosis
Hymenolepis diminuta

Reduvid bug Chagas disease

Itch mite Scabies

Trombiculid mite Scrub typhus

Rickettsial pox

Cyclops Guinea worm disease, Fish tape worm

 Some important National programmes
1951 - National Family Planning Programme
1953 - National Malaria Control Programme
1955 - National Filaria Control Programme
1955 - National Leprosy Control Programme
1958 - National Malaria Eradication Programme
1962 - Naional Tuberculosis Programmes
1975 - Integrated Child Development Services
1975 - 20 points programme
1975-76 - National Cancer control programme
1976 - National Programme for Control of Blindness
1982 - National Mental Health Programme
1983 - National Leprosy Eradication Programme
1987 - National AIDS Control Programme (NACP)
1992 - RNTCP
1992 - CSSM programme
1995 - Pulse polio immunization programme
1997 - RCH programme
1999- 2004 - NACP II
2005 – 2012 - NRHM
2006- 2011 - NACP III
 Some acts of Public Health Importance

ESI Act, Factories Act - 1948

Central Government Health Scheme - 1954
MCI Act - 1956
Dowry Prohibition Act, Maternity Benefit Act - 1961
Registration of Births and Deaths Act - 1969
MTP Act - 1971
Consumer Protection Act - 1986
Mental Health Act - 1987
Transplantation of Human Organs Act - 1994
Vandemataram scheme - 2004
Right to Information Act - 2005
 Vaccines and Strains
BCG - Danish 1331
Measles - Edmonston Zagreb, Schwartz
Chicken Pox - Oka strain
Mumps - Jeryl Lynn strain
Japanese Encephalitis - SA 14-14-2, Nakayama strain
Hepatitis A - HM 175, GBM strain
Rubella - RA 27 / 3
Diphtheria - Park Williams 8 strain
Rabies - Pitts Moore strain
Yellow fever - 17D , Dakar
Malaria - SPf66, Pf25
Polio - Lansing, Leon strains
 History of Medicine
Father of Medicine - Hippocrates
First true epidemiologist – Hippocrates
Father of Indian surgery- Susrutha
Theory of spontaneous generation: Aristotle
Father of modern epidemiology – John snow
Father of Public health – Cholera
Barometer of social welfare - Tuberculosis
Prevention of scurvy by citrus fruits – James Lind
Quarantine was first applied for: Plague
Theory of Multifactorial causation: Pettenkoffer
Life cycle of Plasmodium elucidated by Ronald Ross
Web of causation: McMahon and Pugh
Edward Jenner developed the first vaccine and coined the term ‘vaccination’
First country to socialise medicine: Russia
First country to introduce compulsory sickness insurance: Germany
First country to start Family planning programme: India
th
WHO declared global eradication of small pox on 8 May 1980
 Indicators of MCH care
Bleeding is the most common cause of Maternal mortality worldwide
MMR of India is 212 per 100000 live births
In India, Assam has the highest MMR of 390 and Kerala has lowest of 81 per 100000 live births
MMR strongly reflect the overall effectiveness of the health system.
Karnataka has the highest still birth rate while Bihar has the lowest still birth rates among Indian
states
Most common cause for neonatal mortality is Preterm birth complications
Infant mortality rate is the most important indicator of the health status of the community and the
effectiveness of MCH services
IMR for India in 2011 is 47 per 1000 live births
Kerala has the lowest IMR (13) and Madhya Pradesh has the highest IMR (62)
Under 5 mortality rate is considered as the single best indicator of social development and well being
of a community
Child survival index = (1000 – Under 5 mortality rate) / 10
Child survival rate of India (2011) is 94.1
 Commonest Site of Skin Lesions
Erysipelas - Face and scrotum
Keloid - Sternum, face and Neck
Lymphangioma and hemangioma - Tongue, lip
Carbuncle - Back, nape of neck and shoulders
Nodular Leprosy - Face, arm
Implantation dermoid - Hand and finger
Dermoid cyst - External angle of eye
Lupus vulgaris - Face and arm
Dercum’s disease - Trunk
Dermatofibroma - Limbs
Kaposi’s Sarcoma - Limbs
Granuloma Pyogenicum - Face, fingers, toes
Malignant Melanoma - Males – trunk; Females- leg
Hutchinson’s Melanotic freckle - Sun exposed areas
Sub–ungual exostosis - Great toe
Hyperpigmentation in Addison’s disease - Exposed areas and creases of palms
Pregnancy tumour - Gums and tongue
Erythema Multiforme - Extensor surfaces
Psoriasis - Knee, elbow, scalp
Inverse psoriasis - Body folds (severe itching present)
Chronic discoid lupus - Face (Tacklike scales)
Tinea versicolor - Trunk
Keratoderma blenorrhagicum - Sole of the foot
 Nails and disease
Koilonychia - Iron deficiency anemia
Splinter hemorrhage - Infective endocarditis, Trauma
Pterygium of nail - Lichen planus
Half and half nail - Chronic renal failure
(Lindsay nail)
Pitting of nail - Psoriasis, Alopecia aerata
Terry’s nails - Cirrhosis
Mee’s lines - Chronic arsenic poisoning
Hippocratic nails - Clubbing
Beau’s lines - acute systemic illness
Blue nails - Wilson disease, Chloroquine
Yellow nails - Yellow nail syndrome (pleural effusion, sinusitis, pedal edema)
Onycholysis - hyperthyroidism, psoriasis, trauma
 Psoriasis
Basic pathology is increased epidermal proliferation rate
Associated with HLA CW6
nd rd
Onset on 2 and 3 decades
Commonly seen on extensor aspects of elbows, knees, scalp, hands
Stable plaque psoriasis is the most common variety
Guttate psoriasis occurs in children often preceeded by streptococcal throat infection
Auspitz sign is the appearance of pin point bleeding spots on removal of scales over the lesion
Woronoff’s ring is whitish halo around the lesion
Histological examination reveals acanthosis, parakeratosis, spongiform pustules and Munro’s
microabscesses
Parapsoriasis is term used for well defined maculopapualr erythematous lesion which can be a
precursor for mycosis fungoides
Thimble pitting, onycholysis and subungal hyperkeratosis are the features of nail involvement
Opera glass hand / Pencil in cup appearance is characteristic Xray appearance of hand involvement
of Psoriatic arthritis
Drug of choice for psoriatic arthritis is Methotrexate
 Dermatitis (Eczema)
Irritant contact dermatitis is also known as House wive’s eczema and most commonly involves hands
Allergic contact dermatitis is an example for Delayed (Type IV) hypersensitivity
It is most commonly due to plant derived antigens like parthenium
Definitive diagnosis is made by patch test (Finn test and true test)
Atopic dermatitis
- Pruritus is the most consistent symptom
- Lichenification is the presence of thick leathery skin due to chronic scratching
- Dennie morgan fold is an extra fold of skin that develops under the eye
- Hertoghe / Queen Ann sign is the thinning of lateral half of eyebrows
- Can be associated with shield cataract and keratoconus
Seborrheic dermatitis is associated with infection by Pityrosporum orbiculare
In Infants, it may present as cradle cap (scalp) or napkin dermatitis (diaper area)
Stasis / Gravitational eczema affects lower legs and is associated with signs of venous insufficiency
Nummular (discoid) eczema presents as coin like vesicular lesions on the pretibial area or on the
dorsum of hands
 Important signs in dermatology
Asboe Hansen sign - bullae spread sign in Pemphigus
Button hole sign - Neurofibromatosis
Buschke Ollendorf sign - deep dermal tenderness on pressing the lesion
(secondary syphilis)
Crowe sign - axillary freckling in neurofibromatosis
Darier sign - Urticaria pigmentosa
Dubois sign - short little finger in congenital syphilis
Forscheimer sign - enanthem on soft palate in Rubella
Groove sign - Lymphogranuloma venereum
Lesar trelat sign - multiple seborrheic keratosis as a part of internal malignancy
Nikolsky sign - pemphigus, SJS, SSSS (peeling of epidermis on stroking)
Oil drop sign - nail bed discolouration in psoriasis
Prayer sign - Diabetic cheiroarthropathy in Type I diabetes
Russel’s sign - Bulimia nervosa (knuckle scarring and pigmentation due to
repeated episodes of self induced vomiting)
Shawl sign - erythema of upper back and shoulders in Dermatomyositis
 Cutaneous markers of Internal malignancy

Acanthosis nigricans - gastric adenocarcinoma, ca lung

Tripe palms - carcinoma lung
Necrolytic migratory erythema - Glucagonoma
Dermatomyositis - carcinoma breast, lung, ovary
Erythema gyratum repens - carcinoma bronchus
Migratory thrombophlebitis - carcinoma pancreas, stomach
Bazex syndrome - paraneoplastic acrokeratosis
Paraneoplastic pemphigus - Non Hodgkin lymphoma
Lesar trelat sign - colorectal malignany
Sweet syndrome (panniculitis) - Leukemia
Bowen disease - Intraepidermal carcinoma
 Infectious diseases of skin
Non bullous impetigo is caused commonly by Group A beta haemolytic streptococci while bullous
impetigo is commonly caused by Staph aureus
Scarlet fever is characterised by sandpaper texture of skin, Pastia lines and strawberry tongue
Erysipelas are commonly caused by Streptococcus pyogenes
Recurrent erysipelas caused by staphylococcus secondary to lymphedema is also known as ‘St.
Anthony’s Fire’
Ecthyma gangrenosum is a skin manifestation of Psudomonas aeruginosa bacteremia
Erythrasma is caused by Corynebacterium minutissimum
Post herpetic neuralgia most commonly involve the trigeminal area
Presence Herpes zoster ophtalmicus is a marker of stroke in the coming years
Herpes labialis is the most frequent manifestation of reactivation HSV infection
HSV-1 causes lesions of face and oropharynx and HSV-2 causes genital lesions
Butcher’s wart is caused by HPV-7
Hand Foot and Mouth disease is caused by Coxsackie virus A16
Ecthyma contagiosum is associated with parapox virus and Milker’s nodules is caused by paravaccinia
virus
 Wood’s lamp
Wood’s lamp is made of nickel oxide and silica
Generates 360 nm UV light

Condition Colour

Erythrasma Coral red

Tinea capitis Brilliant green

Pseudomonas infection Pale blue / Green

Vitiligo White

Tinea versicolor Dull yellow

Tuberous sclerosis Blue white

Porphyria cutanea tarda Pinkish red

 ‘Erythemas’ in dermatology
Erythema nodosum - Streptococcus infection
- TB
- Sarcoidosis
- Ulcerative colitis
- Sulfonamides
Erythema multiformae - Bull’s eye / target lesions
- Herpes simplex
- Drugs, internal malignancy
Erythema marginatum - Rheumatic fever
- mainly on trunk
Erythema chronicum migrans - Lyme disease
- caused by Borrelia burgdoferi
- starts at the site of tick bite
Erythema infectiosusm - parvo virus B19 infection
- slapped cheek appearance
Erythema gyratum repens - concentric arcs and wavefronts
- assoc. with internal malignancy
Erythema toxicum - normal finding in a term neonate
Erythema ab igne - chronic exposure to infrared rays
Erythema induratum - Bazin’s disease
- panniculitis of lower legs
Erythema pernio - exposure to cold
 Sexually transmitted diseases
Chancroid is caused by gram negative bacillus Hemophilius ducreyi
The characteristic lesion is an ulcer which is painful, non indurated and sharply circumscribed
Ito test was the previously used skin hypersensitivity test for chancroid
Donovanosis is caused by Calymmatobacterium granulomatis
Organism gives a ‘safety pin’ appearance on Giemsa staining and intracellular ‘Donovan
bodies’ are seen in infected cells
Pseudo-buboes are a feature
Lymphogranuloma venereum is caused by C. trachomatis strains L1, L2, L3
Miyagawa’s corpuscles are seen and Frei’s intradermal test is used
Classical lesion of this disease is a satellite abscess identified on lymph node biopsies
Groove sign of Greenblatt is positive
Doxycycline is the drug of choice
Syphilis is known as the ‘great imitator’
Primary syphilis is characterised by’ chancre’ and secondary syphilis shows features like
moth eaten alopecia, condyloma lata, snail track ulcers, systemic involvement etc
Quarternary syphilis involves cardiovascular syphilis with tree bark appearance of ascending
aorta, cor bovinum, aortic regurgitation etc
Yaws is caused by T. pertenue and Pinta is caused by T. carateum
 STAGES IN DEVELOPMENT
WEEK 1
Day 1 : Fertilization, zygote is formed, in fallopian tube
Day 2 : blastomeres are formed
Day 3 : Morula forms ICM and trophoblast
Day 4 : Blastocoel is formed, zona pellucida breaks down
Day5/6 : Implantation into uterine wall
WEEK 2
Trophoblast connects with maternal circulation
Bilaminar germ disc forms (epiblast and hypoblast)
Amniotic cavity forms
WEEK 3
Gastrulation: primitive streak and node, formation of mesoderm and endoderm
Notocord forms from notochordal plate
Cloacal membrane and allantois form
Development in a cranial to caudal direction
WEEK 4
Neurulation: neural plates, neural folds, neural plates; proceeds middle to ends
Neural crest cells forms. Paraxial, intermediate and lateral plate mesoderm can be distinguished
Paraxial mesoderm form somites, cranial to caudal directions; somites differentiates into dermo, myo
and sclerotome parts.
Intermediate mesoderm begins to form mesonephros.
Lateral plate mesoderm give rise to somatic and splanchnic mesoderm, intraembryonic coelom forms
 Development of nervous system
rd
3 week Neural tube formation
th
4 week Fusion of neural folds
th th
25 day Closure of anterior pore(posterior pore 27 day)
th
28 day Most cranial pair of cervical spinal ganglia develops
th
5 week Formation of brain vesicle, sympathetic ganglia, cerebral hemispheres
th
8 week Formation of cerebellum
th
10 week Formation of corpus callosum
th
12 week Formation of cerebellar cortex and purkinje cells
th
15 week Formation of dentate nucleus
th
4 month Myelination begins
Structures derived from neural crest Disturbances in neural crest can lead to

Connective tissue and bones of face and Hirchsprung’s disease

skull Cardiac-septal defects (Aortico-Pulmonary0
Spinal(dorsal root) ganglia Cleft-lip & cleft palate
Cranial nerve ganglia(5,7,8,9,10) Fronto- nasal dysplasia
C cells of thyroid gland or parafollicular Neuro-fibromatosis
cells Tumors of adrenal medulla
Conotruncal septum in the heart Albinism
Odontoblasts
Dermis in face and neck
Sympathetic chain and preaortic ganglia
Parasympathetic ganglia of GIT
Adrenal medulla
Schwann cell and glial cells
Arachnoid and pia mater(leptomeninges)
Melanocutes, APUD, paraganglia, para
aortic body
 DERIVATION OF VARIOUS PARTS OF THE EYE BALL

Lens Surface ectoderm

Retina Neuro ectoderm (optic cup)

Vitreous, ciliary body, iris Mesoderm

Choroid Mesoderm (infiltrated by neural crest cells)

Ciliary muscles Mesenchymal cells covering the developing ciliary body(Neural crest)

Muscles of iris Neuroectoderm(from optic cup)

Sclera Mesoderm(infiltrated by neural crest cells)

Cornea Surface epithelium by ectoderm, substantia propria & inner epithelium by

neural crest

Conjunctiva Surface ectoderm

Blood vessels Mesoderm

Optic nerve Neuroectoderm(coverings – pia, arachnoid and dura from mesoderm)

 Mesodermal origin Muscles Innervation

Somitomeres 1,2 Superior, medial, ventral recti Occulomotor(III)

Somitomeres 3 Superior oblique Trochlear(IV)

Somitomeres 4 Jaw closing Trigeminal(V)

Somitomeres 5 Lateral rectus Abducent(VI)

nd
Somitomeres 6 Jaw opening other 2 arch Facial(VII)

Somitomeres 7 Stylopharyngeus Glossopharyngeal(IX)

Somites 1,2 Intrinsic laryngeals Vagus(X)

Somites 2-5 Tongue Hypoglossal(XII)

 EMBRYOLOGIC HEART DERIVATIVES
Embryonic structure Adult structure

Truncus Arteriosus Aorta, Pulmonary trunk

th
Aortic sac, Left 4 aortic arch, left dorsal aorta Arch of Aorta

Left dorsal Aorta and fused dorsal aorta Descending Aorta

Primitive ventricle Trabeculated part of Rt. & Lt. Ventricle

Primitive atrium Trabeculated part of Rt. & Lt. atrium

Sinus venosus Smooth part of Rt. Atrium(sinus venarum), coronary

sinus, oblique vein of Lt. atrium

Remnant of first aortic arch Maxillary .A, may form Exy. Carotid. A.
nd
Remnant of 2 aortic arch Hyoid & Stapedial arteries

Right horn of aortic sac Brachiocephalic .A

th th
Right 4 arch artery & 7 cervical Intersegmental A., Right subclavian.A
right dorsal aorta

th
Left 7 Cervical Intersegmental A, Left subclavian
rd
Proximal part of 3 arch artery Common Carotid.A
rd
Distal part of 3 arch artery and cervical part of Internal Carotid A
dorsal aorta

rd
Bud from 3 arch artery External Carotid A
th
Part of 6 arch arery Pulmonary artery
th
Part of left 6 arch artery between lung bud and Ductus arteriosus
aorta

Third arch Fourth arch Sixth arch

Right side Left side

Carotid arteries (Common Brachiocephalic & Aortic Arch & Left Right and Left Pulmonary
and Internal) Right subclavian A. subclavian A. arteries and ductus arteriosus
 Remnant of Structure

Ductus arteriosus Ligamentum arteriosum

Ductus venosus Ligamentum venosum

Left umbilical vein Ligamentum teres hepatis(Round ligament)

Right umbilical vein Disappears

Vitello intestinal duct Meckel’s diverticulum

Urachus Median umbilical ligament

Vitelline arteries Celiac, superior mesenteric and inferior

mesenteric arteries

Proximal part of umbilical A Internal iliac & Superior vesical Artery

Distal part of umbilical A Medial umbilical ligament

Left common cardinal vein/Cuvier’s left Oblique vein of left atrium

duct
Derivatives of foregut Derivatives of midgut Derivatives of hindgut

Artery: Coeliac trunk Artery: Sup. Mesentric. A Artery: Inf. Mesentric. A

rd
Tongue, pharynx, Duodenum: part distal to major papilla Left 1/3 of transverse colon,
Thyroid Jejunum & Ileum Descending and sigmoid colon
Oesophagus & Stomach, Caecum and Appendix Ascending Rectum
Duodenum (upto the major colon Upper part of anal canal
rd
duodenal papillae) Right 2/3 of transverse colon Parts of the uro-genital system
Liver, Bile duct, Gall bladder
Pancreas
Respiratory system
 MESONEPHRIC/WOLFFIAN DUCT

IN MALES IN FEMALES

Structures formed Remnants Structures formed Remnants

Posterior wall of Superior aberrant Posterior wall of Paroophoron(equivalent

Prostatic Urethra tubule female urethra to paradidymis in males)
Ureteric buds Inferior aberrant Ureteric bud Epoophoron/Gartner’s
forming ureter, tubule forming ureter, duct(equivalent to ductus
Pelvis, Calyces and Paradidymis pelvis, calyces and deferens in males)
collecting duct collecting tubules
Trigone of bladder Trigone of the
Appendix of bladder
epididymis
Ductus deferens
Epididymis
Ejaculatory ducts
Prostate (partly
from endoderm)
Seminal Vesicles
 Fate of Pharyngeal Arches (Mesoderm)

ARCH NERVE SKELETAL COMPONENT MUSCLES OF THE ARCH

First Arch(Mandibular Mandibular Nerve Malleus,Incus, Mylohyoid, Muscles of

arch/Meckel’s cartilage) Sphenomandibular lig. Mastication, Anterior
Anterior lig. of malleus belly of digastrics, Tensor
Palati, Tensor tympani

Second Arch(Hyoid Facial Nerve Stapes, Styloid Process, Stapedius, Stylohyoid,

arch/Richter’s cartilage) Stylohyoid ligament, Posterior belly of
Smaller Cornu of hyoid, digastric, Muscles of
Superior part of body of Facial expression,
hyoid Articularis, Buccinator,
Frontalis, Platysma,
Orbicularis oris & Oculi

Third Arch Glossopharyngeal Nerve Greater Cornu of hyoid, Stylopharyngeus

Lower Part of body of
hyoid

Fourth Arch Superior Laryngeal Cartilage of larynx Constrictiors of Pharynx,

N(Vagus) Cricothyroid, Levator
Palatine

Sixth Arch Recurrent Laryngeal Intrinsic muscles of

N(Vagus) larynx

Fifth Arch DISAPPEARS

 Anatomy of Nose
Superior and middle turbinates are parts of ethmoid bone while inferior turbinate is a separate bone
Nasal cavity communicates with nasopharynx through choanae
Sinus lateralis of Grunwald: the space above and below the bulla ethmoidalis together form this
lateral sinus
Atrium is a shallow depression infront of middle turbinate
Agar nasi is the elevation just anterior to the attachment of middle turbinate
Antral puncture is done through middle meatus
Nasolacrimal duct opens into the inferior meatus with its terminal end guarded by Hasner’s valve
Middle ethmoidal air cells, Frontal sinus, Maxillary sinus and anterior ethmoidal sinus opens into
middle meatus
Superior meatus receives opening of Posterior ethmoidal sinus
Picadli’s circle is the osteo-meatal complex
The vestibule of nose is supplied by infraorbital nerve
Excessive rhinorrhea in vasomotor and allergic rhinitis can be controlled by section of Vidian nerve
(nerve of pterygoid canal)
 Anatomy of Larynx
Paired cartilages Unpaired cartilages

- Arytenoid - Thyroid (largest)

- CornicuClate (cartilage of Santorinii) - Cricoid
- Cuneiform (cartilage of Wrisberg) - Epiglottis

Intrinsic muscles of larynx

Action Intrinsic muscle

Abductor of vocal cord Posterior crico arytenoid

(safety muscle of larynx)

Adductor of vocal cord Thyro arytenoids (external part)

Lateral crico-arytenoid
Transverse arytenoids

Tensor of Vocal cord Cricothyroid

Thyro-arytenoid

Opener of laryngeal inlet Thyro-epiglottic (part of thyroarytenoid)

Closers of laryngeal inlet Inter arytenoids (oblique and ary-epiglottic parts)

All intrinsic muscles are supplied by recurrent laryngeal nerve except Cricothyroid which is
supplied by External laryngeal nerve
Sensory innervations up to the level of vocal cords is by Internal laryngeal nerve, below the
level of vocal cords is by Recurrent laryngeal nerve
 Disorders of nose
Rhinophyma / Potato tumor is due to the hypertrophy of sebaceous glands on the tip of the nose
Asch’s forceps is used for reducing fractures of nasal septum and Walsham forceps is used for
disimpacting and reducing fractures of nasal bone
Rhinitis caseosa also known as ‘Nasal cholesteatoma’ is a condition where nose is filled with purulent
discharge and cheesy material probably as a sequelae of chronic sinusitis
Merciful anosmia is seen in Atrophic rhinitis (Ozaena)
In atrophic rhinitis, ciliated columnar epithelium of the nasal cavity is replaced by stratified squamous
epithelium
Young’s operation is performed for atrophic rhinitis
Perforation of bony part of nasal septum is seen in Syphilis
Potato nose, Hebra nose, Elephentiasis of nose etc is associated with Rhinoscleroma
In Rhinoscleroma, there is woody feel of nose and histological examination reveals presence of
plasma cell infiltration (Miculicz cells) and Russel bodies
Treatment is with streptomycin and tetracycline
Black necrotic mass filling the nasal cavity and eroding the septum, common in diabetes patients and
immunocompromised is a feature of Mucormycosis
Choanal atresia is due to persistence of bucconasal membrane
Beta 2 transferrin is specific for CSF thus helping to distinguish it from nasal discharge
 Conductive Hearing Loss
Hearing loss in lesions of conductive apparatus
Complete obstruction of ear canal 30 dB
Perforation of tympanic membrane 10-40 dB
Ossicular interruption with intact drum 54 dB
Ossicular interruption with perforation 38 dB
Malleus fixation 10 -25 dB
Closure of oval window 60 dB

Management of conductive hearing loss

Myringotomy – incision over TM (in Serous otitis media &bulging drum of ASOM)
Myringoplasty – repair of tympanic membrane (with temporal fascia)
Ossiculoplasty – Reconstruction of ossicular chain
Tympanoplasty - repair of TM and ossicles

Wullstein’s classification of Tympanoplasty

Type I - myringoplasty
Type II - for TM perforation + erosion of malleus
Type III - Myringostapedopexy / Columella tympanoplasty
Type IV - only footplate of stapes present; graft placed between oval and round
window ; Baffle effect
Type V - Fenestration operation
Type VI - Sonoinversion
 Otosclerosis
Normal enchondral layer of bony otic capsule replaced by spongy bone
Made worse by pregnancy, menopause or an accident or trauma
Fistula ante fenestrum infront of the oval window is the most common site
The immature focus seen histologically as Blue mantles of Manasse
Schwartz sign: reddish hue seen on promontory through TM indicating an active focus
Van der hoeve syndrome: Osteogenesis imperfect, Blue sclera, Otosclerosis
Paracusis willisi- Patients with otospongiosis tend to hear better in noisy surroundings
Carhart’s notch: dip in the bone conduction curve at 2000 Hz and disappears after a successful
stapedectomy
Bezold’s triad: absolute negative Rinne’s, raised lower tone limit, prolonged bone conduction
Sodium Flouride is used in the medical therapy of otosclerosis
Stapedectomy / Stapedotomy with placement of prosthesis is the treatment of choice
 CSOM and complications
Long process of incus is the most common ossicular structure undergoing necrosis
Round window shielding effect: patient hears better in the presence of discharge than when the ear
is dry
Cholesteatoma is the presence of keratinizing squamous epithelium in the middle ear or mastoid
Most common site of cholesteatoma: Posterior epitympanum
Theories regarding origin of cholestetoma:
- Wittmaack’s theory : invagination of TM as retraction pockets
- Ruedi’s theory: basal cell hyperplasia
- Sade’s theory: metaplasia
- Habermann’s theory: epithelial invasion through TM perforation

Multiple perforations in TM with painless ear discharge is characteristic of Tuberculous otitis media
Bezold abscess is the tracking of pus which presents as a swelling in the upper neck
Luc abscess is the meatal abscess and Citelli’s abscess is pus behind the mastoid towards the occipital
bone
Toby Ayer test and Crowe beck test are positive in Lateral sinus thrombophlebitis
Delta sign in CT /MRI is diagnostic of the condition
In diffuse serous labrynthitis, there is spontaneous nystagmus with quick component towards
affected side while in diffuse suppurative labrynthitis, quick component is towards the normal side
 Diseases of External ear
Otomycosis presents with ‘wet blotting paper’ like greyish white debris
Malignant otitis externa is caused by Pseudomonas auruginosa
Presence of granulations at bony-cartilagenous junction and multiple cranial palsies are characteristic
(MC – facial nerve)
Keratosis obturans: presence of pearly white mass of desquamated epithelial cells in deep meatus
Preauricular sinus is fomed due to the faulty union between first and second branchial arches
Myringitis bullosa is caused most commonly by Mycoplasma pneumonia
Mouse nibbled ulceration of pinna – Leprosy
Cauliflower ear is due to the hematoma of auricle
In Wildermuth’s ear, antihelix is more prominent than helix
Darwin’s tubercle is a pointed tubercle on the upper part of helix
Most common cancer of pinna – Basal cell carcinoma
 Diseases of larynx
Acute epiglottitis is most commonly caused by H. Influenza type B; ‘thumb sign’ on Xray lateral view
Croup is most commonly caused by Parainfluenza I; ‘barking seal’ like cough present and ‘steeple sign’
on AP view
The presence of heaped up reddish granulation tissue in the region of interarytenoids and posterior
part of vocal cords and presence of contact ulcer in vocal cords is characteristic of Pachyderma
laryngis
Mouse nibbled ulceration of vocal cord, impaired adduction of cords, turban epiglottis and
mamillated appearance of interarytenoid region are features of Tuberculosis of larynx
Lupus larynx involves anterior larynx (TB involves posterior structures)
Laryngomalacia is the most common congenital anomaly of larynx
Omega shaped epiglottis and the presence of stridor that increases on crying but decreasing when put
on prone position are features of laryngomalacia
Semon’s law: in all organic lesions, abductor fibres are more susceptible and paralyzed earlier than
the adductors
Wagner and Grossman hypothesis: Cricothyroid receives innervations from SLN, keeps the vocal cord
in paramedian position
 Tumors of nose and paranasal sinuses
Ringertz tumor / Schneiderian papilloma
- arises from the lateral wall of nose in the middle meatus
- HPV is thought to be a risk factor
- Medial maxillectomy is the treatment of choice

Squamous cell carcimoma of nasal septum is known as Nose picker’s cancer

Esthesioneuroblastoma is also known as olfactory neuroblastoma or olfactory placode tumor
Most common site for malignant melanoma of nasal cavity is the anterior part of nasal septum
Osteomas are most common in frontal sinus
Fibrous dysplasias are most common in maxillary sinus
Among the paranasal sinuses, maxillary sinus is the most common site for malignant neoplasms
Malignancy of PNS has strong association with working in furniture and nickel refining industries
Ohngren’s classification and Lederman’s classification are used in anatomical classification of
maxillary sinus carcinoma
Ohngren’s line is an imaginary plane drawn from the medial canthus of eye to the angle of mandible
 Miscellaneous in Ear

Korner’s septum: persisting petrosquamosal suture that overlies the mastoid antrum
Citelli’s angle is situated between sigmoid sinus and middle fossa dura plate
Oort’s anastomosis: Vestibulocochlear nerve anastomosis
Bill’s bar: separates facial nerve from the superior vestibular nerve in the internal acoustic meatus
Roll over phenomenon is seen in retrocochlear hearing loss
Type B tympanogram is seen in serous otitis media, ehile Type C is seen in retracted tympanic
membrane
Recruitment is a phenomenon seen in cochlear lesions (Meniere’s disease, Presbycusis)
Stenger’s test is used to detect malingering / non organic hearing loss
Best graft for myringoplasty is temporal fascia
BPPV is diagnosed by Hallpike manoeuvre and treated by Epley’s manoeuvre
Gradenigo syndrome is apical petrositsis characterised by triad of ear discharge, diplopia and retro
orbital pain
Tullio phenomenon, Diplacusis, Tumarkin’s otolith crisis etc are associated with Meniere’s disease
 Miscellaneous in Oral cavity and pharynx
Aphthous ulcer spares hard palate and gingival
Vincent’s angina is caused by Borrelia vincenti and Fusobacterium fusiformis
Buccal mucosa and oral commisusures are the most common sites of Leukoplakia
Malignant potential of erythroplakia is 17 times more than that of leukoplakia
Hairy leukoplakia is associated with EBV infection
Gateway of tears: Increased chance of perforation occurring through Killian’s dehiscence during
esophagoscopy
Fossa of Rosenmuller: recess present above and behind the torus tubaris; most common site of
nasopharyngeal carcinoma
Gerlach tonsil: Tubal tonsil
Passavant’s ridge is the mucosal ridge raised by the fibres of palatopharyngeus
Beta haemolytic streptococci are the most common cause of acute tonsillitis
Antral sign / Holman muller sign on CT, broadening of nasal bridge, frog face deformity etc are
associated with Juvenile Nasopharyngeal Angiofibroma
Bocca sign: absence of laryngeal crepitation as in post cricoids malignancy and perichondritis
Trotter’s triad: conductive deafness, ipsilateral temporo parietal neuralgia, palatal paralysis; seen in
nasopharyngeal carcinoma
 Courts of Law

Court Imprisonment Fine

Supreme court Any sentence Ant amount of fine

High court Any sentence authorised by law Any amount of fine

Sessions court Any sentence authorised by law Any amount of fine

(but death sentence must be
confirmed by High court)

Assistant sessions court 10 years imprisonment Any amount of fine

Chief Judicial magistrate 7 years imprisonment Any amount of fine

First class judicial magistrate 3 years imprisonment 5000 rupees

Second class judicial magistrate 1 year imprisonment 1000 rupees

Supreme court and high court will hear only referrals not trials
Courts below the rank of Sessions court cannot hear murder trials as they cannot award death
sentence
Juvenile Magistrates are generally women
 Important sections in Indian Penal Code
Related to Injury, Death, Murder, Suicide

Section (IPC) Offence

44 Injury

46 Death

299 Culpable homicide amounting to murder

300 Murder definition

302 Murder punishment

304 Culpable homicide not amounting to murder

304-A Causing death by rash and negligent act

304-B Dowry death

306 Abetment of suicide

309 Attempt to commit suicide

319 Hurt

320 Grievous hurt

351 Assault

326 A & B Causing grievous hurt by throwing acid

 Important sections in Indian Penal Code
Related to Sexual offences, Abortion, Pregnancy, Infanticide
Section (IPC) Offence

277 Necrophilia, Necrophagia

290 Frotteurism

294 Exhibitionism

312 - 314 Causing miscarriage

317 Abandoning a girl child

318 Concealment of birth of a girl child

354 Indecent assault

354- A Sexual harassment

354 - C Voyeurism

354 - D Stalking

370 Trafficking

375 Definition of Rape

376 Punishment for rape

377 Unnatural offences

497 Adultery
 Sections related to poisoning

39 CrPC Private practitioner should inform the police or magistrate, if he suspects homicidal
176 IPC poisoning

309 IPC Private practitioner need not inform the police if he is sure that the poisoning is
suicidal
201 IPC Not preserving samples with the intention of protecting the accused

Sections related to criminal responsibility and consent

82 IPC A child under 7 years of age is incapable of committing an offence

84 IPC Criminal responsibility of mentally ill

85 IPC An act done by a person, due to intoxication is not an offence, if he is

intoxicated without his knowledge or against his will

86 IPC An intoxicated (voluntary drunkenness) person is criminally responsible, if

he had intention or knowledge of committing a crime

87 IPC A person above 18 years of age can give valid consent to suffer any harm,
which may result from an actnot intended or not known to cause death or
grievous hurt

89 IPC A child under 12 years and an insane person cannot give valid consent

90 IPC Consent given by a person under fear of injury, intoxication,

misunderstanding of a fact is not valid

92 IPC Any harm caused in good faith, even without the person’s consent is not an
offence
 Sections related to medical practice

IPC Section Definition

52 Nothing is said to be done in good faith which is done without due care and
attention
74 Nonattendance in obedience to summons from court

175 Omission to produce document to public servant

176 Omission to give notice or information to public servant

177 Furnishing false information

179 Refusing to answer public servant authorised to question

191 Giving false evidence (Perjury)

197 Issuing or signing false certificate

201 Causing disappearance of evidence of offence or giving false information to

screen offenders
204 Destruction of document to prevent its production as evidence

269 Negligent act likely to spread infection of disease dangerous to life

160 Police officer has the power to summon any witness (doctor) to police station
for recording a statement
87 - 93 Legal protection to medical doctors
 Medicolegal Autopsy
Clinical / Pathological autopsy - consent of relatives needed
Medicolegal autopsy - consent of relatives not needed
Virtual autopsy / Virtopsy - a combination of CT and MRI

Method of removal of organs:

Virchow’s technique: individual organs are removed one by one
Rokitansky technique: in-situ dissection combined with en-bloc removal
Letulle’s technique: en masse removal of cervical, thoracic, abdominal and pelvic organs and
dissected as organ block
Ghon’s technique: cervical, thoracic, abdominal and pelvic organs are removed as organ blocks

In case of air embolism, head should be opened first and the surface vessels of brain examined for gas
bubbles

Obscure autopsy is one where a definite cause of death is not found and the findings may be minimal,
indefinite or obscure

Negative autopsy is one where the cause of death could not be found, even after gross and
microscopic examination, toxicological analysis, histopathological examination and microbiological
investigations
 Feature Male skull Female skull

Muscle ridges, Glabella, More prominent Less prominent

zygomatic arch

Forehead Steeper, less rounded Vertical, round

Mastoid process Large, round, blunt Small, smooth, pointed

Fronto nasal junction Distinct angulation Smoothly curved

Palate Large, U shape Small, parabolic

Feature Male Pelvis Female Pelvis

Pelvic brim Heart shaped Circular or elliptical
Greater sciatic notch Smaller, narrower, deeper Large, wide, shallow
o o
Sub pubic angle V sahped, 70-75 U shaped, 90- 100
Obturator foramen Large, oval with base upwards Small, triangular with apex
forwards
Sacrum Long, narrow, even curvature Short, wide, upper half straight,
lower half curve forward
 Medicolegal importance of age
Age Medicolegal importance

7 months (intra Viability attained by the fetus; Killing after this age- infanticide
uterine)

> 5years Criminal responsibility as per Railways act

< 7 years No criminal responsibility as per Section 82 IPC

7 – 12 years Criminal responsibility if sufficient maturity of understanding the nature and

consequences of act as per Section 83 IPC

< 12 years Consent to be obtained from parent / guardian for examination, surgery etc

< 14 years Cannot be employed in factory jobs

14 – 15 years Non hazardous factory jobs can be given in day time

> 15 years Can be employed in any factory jobs

< 15 years Sexual intercourse with a girl, even with his wife, with or without consent amounts
to rape

< 16 years Convicted boys are sent for reformatory school for punishment

< 16 years Taking away a boy without consent of the parent / guardian – Kidnapping

<18 years Taking away a girl without consent of the parent / guardian – Kidnapping
Sexual intercourse with a girl, with or without consent amounts to rape

> 18 years Valid consent for any harm not known to cause death or grievous hurt
Valid consent given by a girl for sexual intercourse
Attainment of majority
Can make valid will

> 21 years Attainment of majority for those under guardianship of court

 Age group X-ray region
6- 12 years Elbow, wrist
13-16 years Elbow, Pelvis
16-17 years Ankle joint
17-18 years Hip joint
18-19 years Knee, shoulder, wrist
20-21 years Pelvis

Ossification centres present before birth

2 months - Upper segments of sacrum, Mandible
5 months - Middle segments of sacrum
6 months - Calcaneum
7 months - Talus
8 months - Lower segments of sacrum
9 months - Lower end of femur
10 months - Upper end of tibia

Sternum
Four pieces of the body of sternum fuse with one another between 14-25 years
Xiphoid fuses with the body - 40 years
Manubrium fuses with the body - 60 years
 Post mortem changes
Immediate changes Early changes Late changes
(Somatic death) (Cellular death) (Decomposition)

- Cessation of brain function - Changes in the skin - Putrefaction

- Cessation of respiration - Changes in the eye - Mummification

- Algor mortis - Adipocere

- Cessation of circulation
- Livor mortis
- Primary flaccidity of
muscles - Rigor mortis

Changes in the Eye after death

Pupillary dilatation
Tache noir: two yellow triangles on either side of cornea in 3 to 4 hours of death due to dessication of
conjunctiva and deposition of cell debris and mucus, if the eyelids are open after death
Kevorkian sign: Fragmentation of blood column in the retinal vessels when viewed through an
ophthalmoscope
Cornea appears dull, hazy, opaque and wrinkled
 Poison and post-mortem staining

Poison / Condition Post mortem staining

Phosphorous, Copper Yellow or dark brown
Carbon monoxide Cherry red
Nitrites, Aniline, Chlorates Chocolate or Copper brown
Hydrogen cyanide Pink / Bright red
Opium Black
Hydrogen sulphide Bluish green
Clostridium perfringens septicemia Bronze or greenish brown

Post mortem hypostasis

Also known as Livor mortis, Post mortem staining, Post mortem lividity, Darkening of death
In supine position, lividity seen on back with contact pallor
In hanging, glove and stocking hypostasis seen
In drowning, staining seen on face, upper limbs and abdomen
Hypostasis of viscera may be mistaken for MI, lungs for pneumonia and intestine for hemorrhahic
infarction
 Peculiar effects of firearms

Ricochet bullet - before striking the target, bullet strikes an intervening object and
rebounds to the target
Yawning bullet - travel in irregular fashion, produce a key hole entry wound
Dum Dum bullet - a jacketed bullet with nose cut off
Tumbling bullet - rotates in end to end
Souvenir bullet - left in the body for sometime and covered with dense fibrous
tissue
Tandem / Piggy back bullet- two bullets ejected one after other, first one failed to leave and
ejected by the next one
Frangible bullet - fragments at the site of impact
Mushroom bullet - expand upon impact and thus produces more serious wounds
Crime bullet / Exhibit bullet – bullet found in the body
Tracer bullet - Projectiles that are built with a small pyrotechnic charge in their
base
Test bullet - test fired bullet

Wounding power of bullet: directly related to the kinetic energy at the moment of impact
(depends mainly on the velocity of the bullet)
 Forensic Psychiatry
Mens rea - criminal mind
Actus rea - actual physical act causing death
A person is criminally responsible only when both actus rea and mens rea are present
Holograph will is one written by a testator in his own hand writing
Testamentary capacity is the mental ability of a person to make a valid will
Observation time for a person for diagnosis of insanity – usually 10 days, but with permission of
Magistrate can be extended to 30 days
Reception order: issued by the Magistrate for admission and detention of a psychiatric patient, valid
for 30 days
Section 84 IPC: (based on McNaughten rule) Nothing is an offence which is done by a person, who at
the time of doing it, by reason of unsoundness of mind, is incapable of knowing the nature of act or
that he is doing what is either wrong or contrary to the law
During lucid interval a person
- Can make a valid will
- Can give valid evidence in court of law
- Is legally responsible for his deeds
 Pregnancy
Positive signs of pregnancy
- Fetal parts and movements felt by abdominal palpation
- Fetal heart sounds
- Funic or umbilical souffle
- Placental soufflé
- Ultrasound

Pseudocyesis / Spurious / Phantom pregnancy

- Women believes she is pregnant though she is not
- Occurs in young women and those nearing menopause or just achieved menopause
Super fecundation - fertilization of two ova formed from the same menstrual cycle by two separate
acts of coitus at short interval
Super fetation - fertilization of second ovum in a woman who is already pregnant (ova from
different menstrual cycle)
Atavism – child does not resemble parents, but grandparents
Suppositious child – a child presented by a woman to have been delivered by her, though she has not
delivered the child
Posthumous child – child who is born after the death of its father
Surrogate mother (Womb leasing)
- Accepts pregnancy and bears child either by artificial insemination or IVF for another woman
who is incapable to carry child
 Unnatural Sexual Offences
- Dealt in Section 377 IPC

Sodomy / Buggery - anal intercourse

Gerontophilia - when the passive agent is an adult in sodomy
Paedarasty - when the passive agent is a child (catamite) in sodomy
Pedophile - adult who repeatedly engages in sexual activities with children
Eunuchs - male prostitutes, act as passive agents in sodomy
Buccal coitus or Sin of Gomorrah or Coitus per os – penis introduced into the mouth
Tribadism / Lesbianism / Sapphism – female homosexuality
Bestiality - sexual intercourse of a human being with a lower animal
 Sexual perversions
Uranism - sexual gratification by fingering, fondling, licking and sucking the genitalia
of opposite sex
Paraphilias - unorthodox sex play by using objects or parts of the body
Sadism - sexual gratification obtained from acts of cruelty or infliction of pain on the
partner
Masochism - opposite to sadism, asking the partner to inflict pain on himself for sexual
pleasure
Bondage / Algolagnia - Sadism + Masochism
Fetichism - sexual excitement by seeing undergarments of a woman
Transvestism / Eonism – desire to be identified as opposite sex
Scatalogia - obscene telephone calls
Fellatio (Irrumination) - oral stimulation of male genitalia
Cunnilingus - oral stimulation of female genitalia
Exhibitionism - exposure of genitalia in a public place to obtain sexual pleasure
Frotteurism - sexual satisfaction by rubbing his genitalia against a female in crowd
Bobbit syndrome - female amputates penis of her male partner
Oedipus complex - sexual desire of son towards his mother
Electra complex - sexual desire of daughter towards his father
Pharoan complex - sexual desire of brother towards his sister
 Infanticide
Infanticide - unlawful destruction of a child less than one year
Foeticide - killing of fetus at any time before birth
Filicide - killing of child by parents
th
Still birth - born after 28 week of pregnancy, which did not show any signs of life
after birth; child was alive inutero but dies during the process of birth
Spalding’s sign - in fetal death, overriding of skull bones
Dead birth - died in utero and shows one of the signs following delivery
ƒ Rigor mortis at birth
ƒ Maceration (aseptic autolysis; first sign is reddening of skin with peeling
and slippage)
ƒ Mummification

Tests for live birth

Static or Fodere’s test: average weight of lungs before respiration is 30 -40gms; after
respiration is 60-66 gms
Plocquet’s test: the ratio of weight of lungs to weight of the body before
respiration- 1/70; after respiration – 1/35
Hydrostatic test / Raygat’s test – the specific gravity of lungs before respiration; 1040-
1050; after respiration :940
Breslau’s second life test – air swallowed in to the stomach which floats
Wredin’s test – middle ear changes after birth
Viscera preserved routinely in cases of suspected poisoning
Stomach and contents
Small intestine (upper 30 cm) and contents
Liver (200 -300g)
One half of each kidney
Blood (30ml)
Urine (30 ml)

Additional viscera to be preserved

Viscera Poison

Heart Strychnine, Digitalis, Oleander

Brain Opiates, CO, Cyanide, Strychnine, Anesthetics

Spinal cord Strychnine

CSF Alcohol

Vitreous Alcohol, Chloroform

Skin Hypodermic injection marks

Bone, nails Arsenic, Antimony, Thallium

Fat Insecticides, pesticides

Poison Odour

White phosphorous, Arsenic, Garlic

Aluminium phoosphide, Parathion

Ethanol, chloroform, nitrites Sweet or fruity

Paraldehyde, Chloral hydrate Acrid

Hydrogen sulphide, Mercaptans Rotten egg

Zinc phosphide Rotten fish

Hydrogen cyanide Bitter almonds

Organophosphates Kerosene

Cannabis Burnt rope

Carbon monoxide Coal gas

Nitrobenzene Shoe polish

 Tests Poisons

Trinder’s test Salicylates

Ferric chloride test Phenol, Phenothiazines, Salicylates

Lee Jones test Cyanide (blue colour)

Qualitative Desferrioxamine colour test Iron

Meixner test, Melzer test Amatoxin (Mushroom)

Isonitrile test Carbon tetrachloride, Chloroform

Litmus test Corrosives

Marqui’s test Opium

Marsh test Arsenic

Tensilon test Botulism

Poison Colour of Urine

Rifampicin, Phenothiazines Orange

Aniline, Brufen Pink

Riboflavin Yellow

Vitamin A, Warfarin Yellowish orange

Phenol Brownish green

Nitric acid Brown

Barbiturates Liquid gold

Picric acid Ruby red

Porphyrins Purple

Poison Stomach mucosa appearance

Mercury Slate coloured

Arsenic Red velvety

Sulphuric acid Black, spongy, charred and eschar formation

Nitric acid Yellow

Oxalic acid White, bleached, scalded appearance

Carbolic acid Grey or brown, leathery

Copper Blue or green

 Poisons and antidotes

Drug overdose Antidote

Paracetamol N- acetyl cysteine

Beta adrenergics Propranolol

Alpha adrenergics Phentolamine

Beta blockers Glucagon

Cholinergic agents Atropine

Opium Naloxone

Nitrates Methylene blue

Amanitins Crystalline penicillin

Cyanide Amyl nitrire, sodium nitrite

Ethylene glycol, Ethanol Fomepizole

Ergotism Sodium nitroprusside

Botulism Guanidine

Benzodiazepines Flumazenil

Organophosphates Atropine

Carbon monoxide Tocopherol

 Poisonous snakes
Identification
Head scales
Small - Viper
Large + pit between eye and nostril – Pit viper
Large + third labial touches eye and nasal shields - Cobra or coral snake
Large, no pit, third labial does not touch nose and eye – Krait

Snake venom
- Ophitoxaemia is poisoning by snake venom

Cobra, Krait Viper Sea snakes

- Neurotoxic - Hemotoxic - Myotoxic

- Ptosis is the earliest neurologic - Marked local symptoms - Little or no local signs
symptom - Hematuria, - Polymyositis
- Diplopia, ophtalmoplegia haemorrhages in GIT, - Trismus
- Complete paralysis after 2 hours conjunctiva - Myoglobinuria
- Death due to respiratory failure - Death due to shock and
hemorrhage

-
 Alcohol
Blood level of alcohol (mg%) Behavior
< 10 Sober
20 -70 Drinking
80 - 100 Under the influence
150- 300 Intoxicated, drunk
> 400 Coma

Conc. Of alcohol in blood (mg %) Symptoms

0 - 50 Mild euphoria
50 - 100 Increased confidence, impaired judgement,
nystagmus
100 - 150 Confusion, impaired memory, slow reaction time
150 -300 Staggering gait, increasing confusion, loss of
muscle coordination
300 - 400 Decreased response to stimuli, stupor
> 400 Deep coma, death

Methods to find blood and Urine alcohol levels

Alcohol dehydrogenase method
Kozelka & Hine test
Gas chromatography ( most specific)
 Plants and active principles
Plant Active principle
Ricinus communis Ricin (Toxalbumen)
Abrus precatorius Abrin, abrine, abralin
Capsicum annum Capsicin, Capsaicin
Calotropis Calotoxin, Uscharin
Atropa belladonna, Datura Hyoscine, Hyoscamine, atropine
Cannabis sativa Cannabidiol, Cannabinols
Cocaine Ecgonine, hygrine, cinnamyl cocaine
Digitalis purpurea Digitoxin, digoxin, digitonin
Nerium odorum Oleandrin, nerin, folinerin
Cerebera thevetia Thevetin, ouabain, nerifolin
Cerebra odallam Cerebrin, cerebroside, odollin, odolotoxin
Aconite Aconitine
 Drug Slang name

Chloral hydrate Knock out drops

Alcohol + Chloral hydrate Mickey Finn

Methylene dioxy methamphetamine Ecstasy, club drug

Methylene dioxy amphetamine Love drug

Street heroine (brown sugar) Smack, Junk, Dope

Opium Black stuff, brick

Cocaine Star dust, happy dust

Cannabis Viper’s weed, Grass, pot

barbiturates Candy, Goof ball

Narcotics Cotton brothers, Dr. White

Morphine God’s machine, Miss Emma

Phencyclidine Angel dust

Ketamine Purple
 Fathers in Medicine

Thomas Starzl - father of modern transplantation ( first human liver

transplants)
Theodor Billroth - father of modern abdominal surgery
Harvey Cushing - father of modern day brain surgery.
John Hunter - Father of modern surgery
William Osler - father of modern medicine
Father of Modern Laparoscopy - Dr. Camran Nezhat
Joseph Lister - Father of antiseptic surgery
Sushruta - "Father of Surgery"
Rudolf Virchow - "the father of modern pathology"
Claude Bernard - Father of Modern Physiology and Experimental Medicine
Hippocrates - Greek father of medicine
Robert Koch - "Father of Bacteriology"
john snow - Father of epidemiology -
H.J. Muller - " Father of Radiation Biology, Cytogenetics"
Marcello Malpighi. - " Father of Microscopic Anatomy"
Thomas Addison - "Father of Endocrinology"
Ivan Pavlov - " Father of Conditional Reflexes"
Ignatz Nascher - "father of geriatrics"
Xavier Bichat - "Father of Histology"
Bateson - "Father of Modern Genetics"
Karl Ernst Von Baer - "Father of Modern Embryology"
"Platter" - "Father of Parasitology
Zakariya Razi - father of pediatrics
J.Marion Sims - father of gynaecology
Oswald Schmiedberg - Father of pharmacology
Bernard Spillsbury - father of forensic medicine-
Johann Weyer - father of modern psychiatry-
Emil kocher - father of thyroid surgery
John J. Wild - "father of medical ultrasound"
Ian Donald: father of obstetric ultrasound
Raymond Carhart - Father of Audiology
Martinus Beijerinck - Father of Virology
Antonie van Leeuwenhoek - Father of Protozoology
Aaron T. Beck - Father of Cognitive therapy
 Pioneers in Medicine

Christian Barnard - first successful human-to-human heart transplant.

Thomas Starzl - first human liver transplants

Joseph Edward Murray - performed the first successful human kidney transplant

Dr. James Hardy - performed the world's first human lung transplant

Dr.Eduard Zim - The first cornea transplant

Charles richet - anaphylaxis

Jules bordet - develpoed complement fixation test

Eric Muhe - first lap cholecystectomy

Kurt Semm - first lap appendectomy

Pnemococcus - Frankel

Max Theiler - yellow fever vaccine

William Hamstaedt - used cocaine for the first time as anaesthetic

David Morley - designed the Growth chart

Sigmund freud - psychoanalysis

Kari Jasper - concept of DELUSION -

Raymond damadin - discovered MRI

 Ataxic disorders
Commonest etiology of gait disorder: Sensory deficits
Gait apraxia is characteristic of: Frontal gat disorder
Neurological disorder where the patient has characteristic tendency to fall backwards: Progressive
supranuclear palsy
Most common inherited autosomal dominant ataxia : Machado Joseph disease (Spino cerebellar
ataxia Type 3)
Most common form of inherited ataxia is Friedrich’s ataxia
Spino cerebellar ataxia Type 7 is distinguished from others by the presence of retinal pigmentary
degeneration
SCA 17 has presentation similar to Huntington’s disease
Neurotransmitter that function by signalling from post synaptic to pre synaptic cell – Nitric oxide
Friedrich’s ataxia is a autosomal recessive ataxia caused by mutation of gene in chromosome 9 that
codes for the gene Frataxin
Idebenone is a drug if used in early stages reduces the cerebellar manifestation in Friedrich’s ataxia
Ataxia Telangiectasia / Louis Bar syndrome is an autosomal recessive disorder due to mutation of
ATM gene in chromosome 11
Telangiectasia are characteristically seen in the bulbar conjunctiva
Alpha Fetoprotein levels are raised in patients with ataxia telangiectasia
 Ischemic heart disease
Squeezing, central, substernal discomfort in Angina is termed Levine’s sign
Glagov phenomenon: arteries remodel to maintain constant flow despite increase in atherosclerotic
mass
Radiation of pain towards trapezius muscles is characteristic of pericarditis
Agatston score is used for quantifying coronary calcium
Prinzmetal angina is due to focal spasm of an epicardial coronary artery more common in right
coronary artery
Patients with anterior wall MI has an icreased risk for systemic or pulmonary thromboembolism that
at other areas
Triflusal is a platelet aggregation inhibitor used in angina pectoris
Ischemia modified albumin, Glycogen phosphorylase isoenzyme B and PAPA-A are newer cardiac
biomarkers
Ischemic preconditioning is an intrinsic process whereby repeated short episodes of ischemia protect
the myocardium against a subsequent ischaemic insult
Bradycardia is most common in inferior wall MI whereas tachyarrythmias are most common in
anterior wall MI
Ivabradine is a selective If sodium channel blocker used as a bradycardic / cardiotonic drug used in
angina
 ADRENAL DISORDERS
Most common cause of endogenous Cushing’s syndrome is adrenal hyperplasia from an ACTH
secreting pituitary microadenoma (Cushing’s disease)
The myopathy of Cushing’s syndrome typically involves the proximal muscles of lower limbs or
shoulder girdle
Cushing’s syndrome is associated with amenorrhea or oligomenorrhea and not with menorrhagia
Hypokalemic alkalosis is a prominent manifestation of ectopic ACTH production
The commonest cause of Adrenal insufficiency (Addison’s disease) in underdeveloped countries is
Tuberculosis followed by autoimmune disorders
The diagnosis of Adrenal insufficiency should be made only with ACTH stimulation test/ Cosyntropin
stimulation test
In ACTH stimulation test,serum cortisol levels >495 mmol/L exclude the diagnosis of Addison’s disease
while <495 suggests a possible diagnosis of Adrenal insufficiency (primary / secondary)
Arterial hypotension with postural accentuation is a feature of Addison’s disease alongwith
hypoglycemia and hypercalcemia
In Addison’s, pigmentation involve palmar crease,sites of pressure and friction like knuckles, scars,oral
mucosa,gums,conjunctiva and areola of nipples
Patients with primary aldosteronism (Conn’s syndrome) characteristically donot have edema since
they exhibit an ‘escape’ phenomenon from the sodium retaining aspects of mineralocorticoids
Criteria for diagnosis of Conn’s syndrome are diastolic hypertension without edema, hypersecretion
of aldosterona and low renin levels
Bartter’s syndrome is characterised by a defect in sodium-potassium cotransport resulting in
defective renal conservation of sodium and chloride, and a normal to low blood pressure
 ANEMIA
Heriditary spherocytosis, Sickle cell anemia and Fanconi’s anemia are associated with normocytic
normochromic anemia
Anemia of chronic disease may present with normocytic normochromic anemia , or less commonly
with microcytic hypochromic anemia
Lead poisoning causes inhibition of enzyme ALA synthetase and causes sideroblastic anemia with
microcytic hypochromic picture
Red cell distribution width is a measure of anisocytosis and normal value is <14.5%
Normal amount of hemoglobin HbA2 is 1.5-3.5% and HbF is <2% of total hemoglobin
Most commonly used red cell index is Mentzer index=MCV/red cell count which is <13 in thalassemia
minor and >13 in iron deficiency anemia
Hemangioma and DIC are characterised by high reticulocyte count
In chronic renal failure, peritoneal dialysis improves anemia while hemodialysis causes associated iron
deficiency anemia
Free erythrocyte protoporphyrin and red cell distribution width are typically normal in thalassemia
trait (increased in other forms of microcytic hypochromic anemia)
Thalassemia minor is characterised by normal or elevated RBC counts while it is reduced in iron
deficiency anemia
The most common mutation in beta thalassemia involves the intervening sequence1(IVS-1) or the
intron-1
Osmotic fragility is decreased in thalassemia and sickle cell anemia
Protein defects causing hereditary spherocytosis are ankyrin>protein3>spectrin>palladin
In sideroblastic anemia; serum iron,ferritin and percentage saturation of transferrin receptors are
often increased
Copper deficiency causes normocytic hypochromic blood picture
 ARTHRITIS
Juxta articular osteoporosis is the characteristic radiographic change in Rheumatoid Arthritis
Serum Rheumatoid factor refers to an IgM antibody directed against the Fc fragment of IgG and is
present in the sera of >75% of rheumatoid patients
Anti CCP antibodies are the most specific blood test for Rheumatoid Arthritis while Rheumatoid
factor is only of prognostic significance
Rheumatoid Arthritis is most strongly associated with Class II MHC allele HLA DR4 and seronegative
spondyloarthropathies with HLA-B27
Non Steroidal Anti Inflammatory Drugs are the drug of choice in seronegative spondyloarthropathies
and indomethacin is preferred among them
Recurrent aphthous ulceration is a sine quo non for diagnosis of Behcet’s syndrome
HLA-B5 and not HLA-B27 is associated with Behcet’s syndrome in which recurrent bilateral hypopyon
is a characteristic feature
Keratoderma Blenorrhagica is the characteristic skin lesion of Reactive Arthritis or Reiter’s Syndrome,
and consists of vesicles which become hyperkeratotic and forms crusts
Chlamydia is a commonly implicated agent in Reactive Arthritis
Sparing of wrist and metacarpophalangeal joint with involvement of base of thumb (carpometacarpal
joint) is very characteristic of Osteoarthritis
Allopurinol should never be used in acute gout as it may actually precipitate an acute attack
Tophi appear as characteristic punched out cysts or deep erosions with overhanging bony edges
(Martel’s or G’ sign)
 ASTHMA
Asthma involves both large and small airways but not alveoli
Particles of size<2.5mm can be carried to lower airways
IgE levels are increased in extrinsic asthma
Idiosyncratic asthma (intrinsic asthma) is associated with normal IgE levels
Aspirin-associated asthma usually begins with perennial vasomotor rhinitis that is followed by a
hyperplastic rhinosinusitis with nasal polyps
Hypoxia is a universal finding during acute exacerbation of asthma
Hypocapnia and respiratory alkalosis are seen in most asthmatic patients
In acute severe asthma, peak expiratory flow rate (PEFR) is <50%
Silent chest in asthma indicates grave prognosis/impending respiratory failure (life threatening
asthma)
Propranolol can precipitate life threatening attack of asthma as it increases bronchial resistance by
blocking beta2 receptorsleukotriene modifiers have no role in aborting an attack of asthma
Morphine is contraindicated in asthma because it causes constriction of bronchial muscle by causing
histamine release
 BLEEDING AND COAGULATION DISORDERS
Von Willebrand disease is characterised by impaired platelet aggregation in response to Ristocetin
Bleeding time and PTT are prolonged while prothrombin time is normal in Von Willebrand’s disease
Wiskott-Aldrich Syndrome(X linked recessive disorder) is a disorder of platelet secretion and signal
transduction
Thrombotic Thrombocytopenic Purpura is characterised by the clinical pentad (MAHA, TCP, decreased
renal function, disturbed neurological function, fever) and normal coagulation tests
Spontaneous hemarthrosis and spontaneous muscle bleeds are a hallmark of moderate and severe
factor VIII and IX deficiency (Hemophilia)
Hemophilia is associated with a defect in the intrinsic pathway and hence PT is essentially normal
Russel Viper Venom assay is done to establish the presence of lupus anticoagulant in APLA Syndrome
where APTT alone is prolonged
The mainstay of treatment of Antiphospholipid Syndrome is Warfarin
The most common hereditary blood coagulation disorder is Factor V Leiden and is the commonest
congenital cause of venous thrombosis
Homocysteinemia is associated with increased risk of arterial thrombosis
The extrinsic and intrinsic pathways in coagulation converge at the Stuart factor X
Absence of clinical bleeding even after major surgery like tonsillectomy suggests a classical deficiency
of factor XII
The most sensitive test for DIC is elevated FDP levels but fibrinogen levels and PTT is increased
Coomb’s test is characteristically negative in patients with Hemolytic Uremic Syndrome
 BRONCHOGENIC CARCINOMA
The most common presenting symptom of lung cancer is cough
Most common bronchogenic carcinoma worldwide is Adenocarcinoma and is the commonest in
women and non-smokers
Association with clubbing and a peripheral location suggests a diagnosis of non small cell variant like
Adenocarcinoma
In females with adenocarcinoma histology who have never smoked, Gefitinib is the most effective
drug
Squamous cell carcinoma is the commonest in India and the commonest type among smokers
Cavitation is a feature of Squamous cell carcinoma and large cell variants
Small cell carcinomas are the most commonest type associated with ectopic hormone production
The most common type of lung cancer associated with SVC syndrome and widespread metastasis is
small cell carcinoma
Hilar lymphadenopathy is a typical feature of small cell variant
The term Oat cell carcinoma is synonymous with Small cell carcinoma and respond best to
chemotherapy
ACE levels are not elevated in bronchogenic carcinoma
Bronchoscopy together with a bronchial/transbronchial biopsy is the investigation of choice
The treatment of choice for stage I disease is surgery (pulmonary resection)
 CIRRHOSIS LIVER
Alpha and Beta globulins are produced primarily by hepatocytes
Gamma globulins are produced by B lymphocytes and not in hepatocytes
Positive anti-mitochondrial antibody is sensitive and specific for primary biliary cirrhosis
Asymptomatic elevation of GGT is the earliest finding in primary sclerosing cholangitis
Smoking is associated with a decreased risk of developing primary sclerosing cholangitis and
ulcerative colitis
Post necrotic cirrhosis is characterised by a shrunken liver with reduced liver span
Non cirrhotic portal fibrosis (NCPF) is the most important cause of intrahepatic non cirrhotic portal
hypertension in India
Chronic ingestion of arsenic has been incriminated in the causation of NCPF
Extra hepatic portal vein obstruction (EHPVO) is the commonest cause of portal hypertension in
Indian children
When cirrhosis is complicated by portal hypertension, the increased resistance is usually sinusoidal
Hepatic encephalopathy is precipitated by hypokalemia and metabolic alkalosis
Hepatorenal syndrome is associated with urine osmolality greater than plasma osmolality
Clinchy criteria is a prognostic criteria used in liver failure, which uses Factor V levels
 CONGENITAL HEART DISEASES
The strongest genetic tendency is known in ‘Holt Oram Syndrome’ is Atrial Septal Defect with bony
abnormalities
The strongest environmental factor known in the causation of congential heart disease is high altitude
Palliative treatment in TOF includes Pott’s shunt involving anastomosis between descending aorta and
pulmonary artery while Waterson shunt is between ascending aorta and pulmonary artery
ASD Ostium Primum has left axis deviation in ECG while Ostium Secondum has right axis deviation
Ellis Van Crevald Syndrome is associated with ASD with single atrium
Endocarditis is the commonest complication of VSD and VSD is the commonest congenital lesion
complicated by infective endocarditis
Intermittent claudication, dizziness and headache are suggestive of coarction of aorta
The most common associated cardiac anomaly with coarctation of aorta is bicuspid aortic valve and
usually presents during infancy or early childhood
In coarctation of aorta, inferior rib notching and ‘3’ sign due to enlargement of left subclavian artery
above the coarctation
Neurofibromatosis is associated with superior rib notching
Symptoms of restlessness, irritability and diaphoresis on feeding and an increased risk of MI suggests
a diagnosis of Anomalous Coronary Artery
Sustained severe hypertension in children is most commonly caused by renal parenchymatous disease
 DEMENTIAS AND EXTRA PYRAMIDAL DISORDERS
Alzheimer’s Disease is the most common cause of dementia in elderly
Alzheimer’s predominantly affects the temporo-parietal cortex although frontal lobe is also
frequently involved
Amyloid Precursor Protein on chromosomes 21 and Trisomy 21 (Down’s)who survive beyond the age
of 40 years are risk factors for Alzheimer’s
Accumulation of beta Amyloid (leading to neuritic plaques and amyloid angiopathy) and
hyperphosphorylated tau protein (leading to neurofibrillary tangles) mostly in Entorhinal cortex-
Hippocampus occurs in Alzheimer’s
Decreased levels of Acetylcholine, its synthetic enzyme choline acetyltransferase and nicotinic
cholinergic receptors is the primary biochemical abnormality observed in Alzheimer’s Disease
The primary target in Parkinson’s Disease is Subthalamic Nucleus (Globus Pallidus Internus is the
second most common site)
Manganese ion exposure is implicated in the free radical damage of the basal ganglia causing
Parkinsonism
The main biochemical characteristic of Parkinson’s Disease is the reduction of dopamine and
dopamine synthesizing enzymes including Tyrosine Hydroxylase and Tetr ahydrobiopterin cofactor
The only drugs effective in phenothiazine/drug induced extrapyramidal symptoms are central
anticholinergics like Benzhexol, Procyclidine and Benztropine
Huntington’s Disease is caused by a Triplet Repeat Expansion mutation and predominantly affects
striatum and cause atrophy of caudate nucleus
The triad of Normal Pressure Hydrocephalus is ataxic gait, dementia and urinary incontinence
Steel Richardson Syndrome is a degenerative disorder of supranuclear gaze palsy characterised by
paralysis of voluntary down gaze alongwith nuchal dystonia
Small petechial hemorrhages in the mammilary bodies are characteristic of Wernicke’s Korsakoff
Syndrome but amnestic effect is related to lesion in dorso-medial nucleus of thalamus
Pick’s disease mainly affects fronto-temporal cortex and is caused by tau protein accumulation
 DIABETES MELLITUS
In type I DM, insulin levels and C-peptide levels are both reduced while both are increased in type II
DM
HbA1c measurements are unreliable in certain conditions like uremia
Prerenal azotemia is characteristic of hyperosmolar non ketotic coma
Renal glycosuria is characteristized by urinary excretion of glucose at normal blood glucose
concentrations
The most reliable indicator for diabetic nephropathy is presence of overt proteinuria
The most characteristic lesion in diabetic nephropathy is nodular glomerulosclerosis
Microalbuminuria is associated with long term cardiovascular mortality
Urinary infection may cause false positive microalbuminuria
The most common form of diabetic neuropathy is distal symmetric sensory polyneuropathy
Hypoglycemia unawareness can be due to autonomic neuropathy or due to loss of catecholamine
response to hypoglycemia
ACE inhibitors and ARBs are the first line agents for management of hypertension in diabetes
The treatment of choice for diabetic ketoacidosis is insulin
 ESOPHAGEAL CONDITIONS
Dysphagia to both solids and liquids is suggestive of esophageal motility disorders like achalasia and
diffuse esophageal spasm, where manometry is the investigation of choice
Achlasia cardia is characterised by an increased pressure of lower esophageal sphincter and absence
of esophageal peristalsis due to Auerbach’s plexus degeneration
Postganglionic cholinergic fibres are spared in achlasia and barium swallow
Tertiary contractions of esophagus are responsible for the corkscrew appearance in barium swallow,
characteristic of diffuse esophageal spasm
Intermittent chestpain is the most common symptom in diffuse esophageal spasm(>dysphagia)
Non progressive dysphagia only for solids is characteristic of Schatzki’s rings in the lower esophagus,at
the squamo-columnar junction
Schatzki’s ring is often associated with hiatus hernia and treatment involves esophageal dilatation or
endoscopic diathermy or laser
Progressive dysphagia for solids occur in pepic stricture and carcinoma esophagus and the
investigation of choice is endoscopy
Intermittent dysphagia for solids, regurgitation of food consumed days back and halitosis are
suggestive of Zenker’s Diverticulum
The most frequent complication of Zenker’s Diverticulum is aspiration into tracheobronchial tree
leading to pneumonia and lung abscess
Most common site of squamous cell carcinoma is middle third of esophagus and adenocarcinoma is
lower third
Scleroderma increases the risk of esophageal adenocarcinoma through the development of Barret’s
esophagus as the collagen deposits in distal esophagus cause LES dysfunction
The most important toxicity of cisplatin used in esophageal carcinoma is renal impairment
 GENETIC DISORDERS
The most common Mendelian mode of inheritance is autosomal dominant (65%)
Familial combined hyperlipidemia is transmitted as an autosomal dominant disorder
Retinoblastoma presents dominant inheritance with variable penetrance
In accordance with an autosomal recessive inheritance pattern, all offsprings will be carriers and none
will be affected
The risk of abnormal offspring for a carrier of balanced translocation of 21:21 is 100%
Brushfield’s spots are whitish speckling on iris seen in light skinned people in Down’s syndrome
Triple test used in prenatal diagnosis of Down’s syndrome includes Maternal Serum Alpha Feto
Protein , Human Chorionic Gonadotropin and Unconjugated Oestradiol
Mental retardation is seen in Down and Klinefelter’s syndrome but not in Turner’s syndrome
Presence of pulmonary stenosis and male child with features of Turner’s syndrome leads to a
diagnosis of Noonan’s syndrome
In Noonan’s syndrome, females show normal sexual maturation but it is delyed two years on an
average
Congenital hypoplasia or absence of vagina with abnormal or absent uterus is called Meyer-
Rokitansky-Kuster-Hauser Syndrome
The most common cause of primary amennorrhea is gonadal dysgenesis
About 95% of patients with coeliac sprue express HLA-DQ2 allele
CEA is an oncofetal antigen and may be used as a tumour marker in adenocarcinoma of colon,
pancreas, lung, breast and ovary
 IMMUNE DISORDERS
IgM and IgG fix complement via the classical pathway
Fetal infection is characterised by an elevated IgM and not by IgG
NK cells express CD3, CD16 and CD56 and less commonly CD2 and CD8
CD19 is a marker for B lymphocytes
IL-1 is secreted by phagocytes in response to injury and increases T lymphocyte activation
IL-2 is produced by T-helper cells (CD4 cells)
Casoni’s test is immediate type of hypersensitivity reaction (Type I)that detects positive reaction in
response to intradermal injection of hydatid fluid
Langerhan’s cells are the antigen presenting cells of skin
Paracortical area of lymphnode is thymus dependent and has collection of T-lymphocytes
Thymoma is associated with hypogammaglobulinemia
Pneumocystis carini infections are associated with deficient cell mediated immunity and not humoral
immunodeficiency
The most common cause of autosomal recessive severe combined immunodeficiency (SCID) is the
deficiency of enzyme Adenosine Deaminase (ADA)
 JAUNDICE
Absent levels of urobilinogen suggest a diagnosis of obstructive hyperbilirubinemia
The rate limiting step in bilirubin metabolism is the excretion of conjugated bilirubin into the bile from
where it reaches the GIT
Initial investigation of choice in a case of obstructive jaundice is ultrasonography
The enzymes that reflect damage to hepatocytes are ALT, AST and LDH
ALT is found only in liver disease and hence more specific than AST
Enzymes that reflect cholestasis are ALP and 5’nucleotide which are more specific than GGT
Dubin Johnson syndrome is characterised by defect in hepatic excretory function across the
canalicular membrane of hepatocyte
Deposition of melanin like pigment in liver causes the liver to appear dark or completely black in
Dubin Johnson syndrome
Criggler Najjar syndrome is primarily an autosomal recessive disorder and is of two types
Kernicterus is a characteristic feature of type I Criggler Najjar syndrome
Phenobarbital is extremely useful and effective in reducing bilirubin levels in type II Criggler Najjar
syndrome
 LEUKEMIAS
Myeloperoxidase (MPO) is a marker for myeloid lineage
Myeloblastic cells are Sudan black positive
Auer rods by definition are absent in AML-M0
All-trans-retinoic acid is used in the treatment of M3 subset (Acute Promyelocytic Leukemia) of AML
Hyperploidy, female sex and translocation t(12;21) are associated with good prognosis in ALL
Fetal hemoglobin levels are elevated in most cases of juvenile CML
In CML, the Philadelphia chromosome is present in all the cell lineages and remain positive even after
remission of the disease
Leukocyte Alkaline Phosphatase (LAP) levels are characteristically low in Chronic Myeloid Leukemia
(CML)
‘Sokal index’ is the prognostic index used in CML and spleen size is one among the five criteria in it
The treatment of choice and the only curative treatment in CML is allogenic bone marrow
transplantation
The drug treatment of choice for CML is Imatinib mesylate (earlier it was Interferon alpha)
Diffuse effacement of lymphnodes by a predominant population of small lymphocytes is the
histological feature of Chronic Lymphoblastic Leukemia (CLL)
When present, proliferation centres are considered pathognomic of CLL
The most common genetic abnormality in CLL are deletions on long arm of chromosome13 (13q14)
 LYMPHOMAS
CD19 is a marker for B lymphocytes while CD2 and 3 are pan T cell markers
In Hodgkin’s Disease, the most common subtype worldwide is Nodular Sclerosis while the Mixed
Cellularity type is the commonest in developing countries
In Classical Hodgkin’s Disease, the characteristic immunophenotype is CD15 and CD30 positive
In Lymphocyte Predominant type of Hodgkin’s Disease, CD45 is positive while others are negative
Lymphocyte Predominant type of Hodgkin’s Disease has the best prognosis
Hodgkin’s lymphoma is associated with paraneoplastic cerebellar degeneration
ABVD (Doxorubicin, Bleomycin, Vinblastine, Dacarbazine) is the chemotherapy regimen of choice in
Hodgkin’s lymphoma
Mycosis fungoides is synonymous with Cutaneous T cell lymphoma
The histological hallmark of Mycosis fungoides are Sezary-Lutzner cells which are T helper cells
The Sezary-Lutzner cells form band-like aggregates in dermis and invade epidermis as clusters called
Pautrier’s Microabscesses
Angiocentric lymphoma is a type of T cell lymphoma that has been linked to Epstein Barr virus
Presence of t(8;14) or one of its variants t(2;8) or t(8;22) is the hallmark of Burkitt’s lymphoma
t(11;14) translocation is characteristic of Mantle cell lymphoma
 NEPHROLITHIASIS
Oxalate stones are the most common type of renal calculi and are radiopaque
Phosphate stones are formed in alkaline urine and cystine stones in acidic urine
Urinary tract infection with urea splitting bacteria (like proteus, klebsiella and pseudomonas) produce
triple phosphate stones
Magnesium ammonium phosphate(struvite) stones are often solitary and form staghorn calculi
Most stones are radiopaque except pure uric acid stones and xanthine stones
Drugs leading to stone formation include indiavir and triamterene
Ureteric colic pain is due to hyperperistalsis and spasm of the smooth muscles of the ureter and is
referred to groin via genitofemoral nerve(L1)
In upper ureteric stone, pain radiates to the testicles(T11,T12)
Extracorporal shockwave lithotripsy is used for proximal ureteric stones <2-2.5 cm
Uric acid stones are most responsive to lithotripsy while cystine stones are most resistant
Low protein,low sodium,normal calcium diet is recommended for patients with calcium
nephrolithiasis
Nephrocalcinosis is a feature of medullary sponge kidney disease, primary hyperparathyroidism and
distal renal tubular acidosis
Oxalosis typically causes both cortical and medullary nephrocalcinosis
 PANCREATIC DISORDERS
Serum amylase doesnot form any criteria for prognosis in acute pancreatitis
Serum lipase elevation is the most specific laboratory test for establishing a diagnosis of acute
pancreatitis
Eradication of gallstone disease prevents further attacks of pancreatitis
Purtscher’s retinopathy is a complication of acute pancreatitis which manifests by sudden and severe
loss of vision
Pseudocyst is the most common complication of acute pancreatitis which occurs after 2-3 weeks
Most common site of pancreatic pseudocyst is the body and tail of pancreas
Percutaneous aspiration is the initial management of pseudocyst but the treatment of choice is
surgical internal drainage (cystojejunostomy)
Most common site of Zollinger Ellison Syndrome is the duodenal bulb
Peptic ulcer disease with diarrhea may suggest Zollinger Ellison Syndrome
Secretin stimulation test is the most sensitive and specific test to diagnose Zollinger Ellison Syndrome
The gold standard test for diagnosis of insulinomas is a supervised “72 hour fast’ test
Pancreatic cholera is a pancreatic endocrine tumour most commonly of Delta cells
Pancreatic cholera is also known as VIPoma, Verner-Morrison Syndrome or WDHA Syndrome
 PULMONARY EMBOLISM AND ARDS
Acute pulmonary embolism is the most common cause of preventable hospital death
Dyspnea is the most frequent symptom of pulmonary embolism and tachypnea is the most frequent
sign
The most common source for pulmonary emboli is proximal vein of lower extremity (pelvic /femoral
veins)
The most common site for deep vein thrombosis is calf vein but isolated calf vein thrombosis poses a
lower risk of pulmonary embolism
Sinus tachycardia is the commonest ECG abnormality in pulmonary thromboembolism
CT scan with intravenous contrast (Multidetector CT Angiography) is the test of choice for diagnosis
of pulmonary embolism
The D-dimer assay is most sensitive for pulmonary embolism with a sensitivity of greater than 95%
D-dimer values are falsely decreased in patients receiving anticoagulant therapy
Pulmonary edema with normal pulmonary capillary wedge pressure suggests a diagnosis of ARDS or
non cardiogenic pulmonary edema
‘Shock lung’ is a synonym used for Acute/Adult Respiratory Distress Syndrome
Diffuse Alveolar Damage is the histopathological hallmark of ARDS
Pulmonary hypertension may be caused by hypoventilation and not by hyperventilation
 RENAL FAILURE
By definition, renal parenchymal tissue is not damaged in prerenal acute renal failure
Urinary sodium excretion of more than 20mmol/L suggests intrinsic renal failure such as acute tubular
necrosis
Uremic complications and electrolyte complications occur in oliguric phase of acute renal failure
Oliguric acute renal failure is associated with hypocalcemia and not hypercalcemia
Muddy brown granular casts are typical of intrinsic acute renal failure
Fractional excretion of sodium ions <1 is characteristic of prerenal azotemia while value >1 suggests
intrinsic renal failure
Plasma urea:creatinine ratio >20:1 is suggestive of prerenal acute renal failure while value <10-15
occurs in intrinsic acute renal failure
Isosthenuria and broadcast sediment in urine are common in chronic renal failure
In renal osteodystrophy, serum phosphorus is either high or normal (there is hypophosphatemia in
osteomalacia)
Iron deficiency and uremia of chronic renal failure may cause restless leg syndrome
Intravenous insulin is the fastest way to lower serum potassium levels
Diabetes and analgesic abuse (NSAIDS) are the most common predisposing factors of renal papillary
necrosis
 SEIZURES
Absence of postictal confusion is a feature of absence seizures/Petitmal seizures
EEG in absence seizures show bursts of bilaterally symmetrical and synchronous 3Hz spike and wave
activity
Myoclonic seizures are most frequent in the morning
Juvenile Myoclonic Epilepsy is a generalized seizure disorder and not a focal one
Valproic acid is the drug of choice in Juvenile Myoclonic Epilepsy (also Ethosuxamide)
Carbamazepine and Phenytoin may aggrevate myoclonus in Juvenile Myoclonic Epilepsy
The hallmark of second stage of Subacute Sclerosing Pan Encephalitis (SSPE) is massive myoclonus
Subtle seizures are the most common subtype of neonatal seizures
The term post traumatic epilepsy should be used if seizures occur after first week post injury and are
recurrent
Lymphadenopathy pseudolymphoma is a complication associated with use of phenytoin
Phenobarbitone is a microsomal enzyme inducer and so its administration induces the metabolism of
Carbamazepine
 SYSTEMIC LUPUS ERYTHEMATOSIS
Anti-double stranded DNA and anti-smith antibodies are specific for SLE
The best screening test and the most sensitive test for SLE is demonstration of anti-nuclear
antibodies (ANA)
Diagnostic criteria for arthritis in SLE includes non erosive arthritis involving two/more peripheral
joints characterised by tenderness, swelling or effusion
Shrinking lung syndrome characterised by diaphragmatic weakness or dysfunction is a pulmonary
manifestation of SLE
Wire loop lesions and proteinuria >0.5g/dl are seen in lupus nephritis
Wire loop lesions are most characteristic of diffuse proliferative glomerulonephritis (class IV WHO)
but may also be seen in focal proliferative glomerulonephritis (class III WHO)
Immune thrombocytopenia may be seen in a variety of collagen vascular diseases but is most
characteristic of SLE
Presence of anti-LA (SSB) in SLE suggests concomitant Sjogren’s syndrome
Drug induced lupus is associated with anti-histone antibodies commonly
Persons with HLA-D and 4 allele are of greater risk of developing lupus after administration of
Hydralazine
Propyl thiouracil is the anti thyroidal drug which can cause drug induced lupus
APLA syndrome is associated with thrombotic disorders and not bleeding disorders
APLA syndrome is associated with thrombocytopenia and not thrombocytosis
Anti centromere antibodies are characteristic of CREST syndrome
Non-erythematous malar rash in a woman of child bearing age suggests diagnosis of chloasma
 TUBERCULOSIS
Lungs are the most commonly involved organ in both congenital and acquired tuberculosis
Most common primary site of infection of congenital tuberculosis (caused by transplacental route) is
liver
Diagnostic criteria for congenital tuberculosis are the Beitzke’s criteria and the revised criteria by
Cantwell
Fibrocaseous lesion, phlyctenular conjunctivitis, erythema nodosum are characteristic of primary
tuberculosis
Cavitory lesions are a feature of post primary or secondary tuberculosis and not primary tuberculosis
cases
Military tuberculosis may occur following primary infection or secondary reactivation
Tuberculin test is negative in 20-30% of patients with military tuberculosis
Infection with atypical mycobacteria are associated with false positive tuberculin tests
Most common cause of necrotic lymph nodes with peripheral rim enhancement is tuberculosis
In sarcoidosis, lymph nodes show no necrosis and no calcification
Bronchial arteries are the most common source of bleeding in hemoptysis(>90%cases)
Rasmussen’s aneurysm refers to an aneurysm of the pulmonary artery within or adjacent to a
tuberculous cavity and is a pseudoaneurysm.
 URINE ANALYSIS
White cell casts suggest interstitial injury and are seen in interstitial nephritis
Broad casts are characteristic of chronic renal failure
Albuminuria is the hallmark of glomerular proteinuria
Tomm Harsfall protein in urine is a feature of tubular proteinuria
Bence Jones proteinuria may be seen in ‘Mu’ heavy chain disease due to excretion of kappa light
chains in urine
Presence of dysmorphic RBC casts suggests hematuria of glomerular origin
Alport’s syndrome and IgA nephropathy are characterised by recurrent episodes of gross hematuria
Currently, the most convenient method of estimating renal function is by isotope renography
Inulin clearance is more accurate than creatinine clearance in assessing GFR as Inulin is not secreted
by tubular cells
Presence of beta2 microglobulin in urine indicates tubular injury and not glomerular injury
Water Deprivation Test is used to assess distal tubular function
Paraaminohippurate (PAH) clearance is used to assess renal plasma flow
 VALVULAR HEART DISEASES
In mitral stenosis, the duration of mid diastolic murmur correlates with the severity of stenosis
The severity of mitral stenosis can be clinically judged by the gap between the opening snap (OS) and
the aortic component of second heart sound (S2)
The severity of mitral regurgitation is indicated by the presence of left ventricular S3 or an inflow
rumble at the apex
Progressive LV dysfunction and an LV ejection fraction declining below 60% is an indication for mitral
valve repair/replacement in severe MR
Presence of midsystolic click in an asymptomatic female suggests a diagnosis of mitral valve prolapse
(MVP)
Myxomatous degeneration of mitral valve leaflets (less commonly in tricuspid or aortic valves) is the
pathological finding in MVP
ST and T wave changes in ECG favour severe aortic stenosis
Positive exercise stress test or mean pressure gradient >/=60mms of Hg is an indication for aortic
valve replacement in severe aortic stenosis
Peripheral pulmonary stenosis is often associated with various conditions like Williams syndrome,
Ehler Danlos syndrome and Rubella
Most commonly, tricuspid regurgitation is functional and secondary to marked dilatation of RV and
the tricuspid annulus
Systolic pulsations of liver and marked hepatomegaly are characteristic features of tricuspid
regurgitation
Carcinoid syndrome may cause valvular heart disease, commonly right sided, due to endocardial
fibrosis
 VIRAL HEPATITIS
Most common cause of sporadic hepatitis in children is Hepatitis A
Piecemeal necrosis and bridging necrosis are typically seen in lobules in case of chronic active
hepatitis or periportal hepatitis
Portal tract infiltration with minimal portal tract fibrosis is typical of portal hepatitis or chronic
persistent hepatitis
In Hepatitis B virus, reverse transcriptase activity is a property of DNA polymerase which is coded by
‘P’ gene
The only marker detected in the window period of Hepatitis B infection is IgM type anti-HBc and is the
most reliable marker of acute infection
After Hepatitis B infection, the first virological marker detectable in serum is HBsAg
HBV DNA is the most sensitive and specific marker of active Hepatitis B virus replication (HBV DNA >
HBV DNA polymerase > HBeAg)
Antiviral therapy is indicated in patients with active HBV replication
Evidence of chronic active Hepatitis B suggested by elevated liver enzymes in patients with detectable
HBV DNA but negative HBeAg suggests a diagnosis of precore mutant chronic Hepatitis B
HDV superinfection of a patient with chronic Hepatitis B has the worst prognosis with high likelihood
of fulminant hepatitis and death
HCV RNA levels in the setting of elevated antibodies to HCV for 6 months determine the serological
diagnosis of chronic Hepatitis C
Essential Mixed Cryoglobulinemia(EMC) is an extrahepatic manifestation in chronic HCV infection
rather than HBV infection
Anti LKM(Liver Kidney Microsomal ) antibodies against cytochrome P450 enzymes are seen in chronic
Hepatitis C and autoimmune hepatitis (anti LKM 1),drug induced hepatitis (anti LKM 2)and chronic
Hepatitis D (anti LKM 3)
Most common cause of epidemic hepatitis and sporadic hepatitis in adults is Hepatitis E
 Scientists Discovery
Antony Van Leeuwenhoek First to observe and report bacteria
Louis Pasteur Germ theory
(Father of Microbiology) Sterilization techniques
Hot air oven, Coined the term vaccine
Vaccine for rabies, Anthrax
Disproved theory of spontaneous generation
Joseph Lister Antiseptic techniques in surgery
Robert Koch Discovered TB bacilli, V.cholera
(Father of Medical Microbiology) Staining techniques
Edward Jenner Small pox vaccine
Hansen Leprosy
Ogston Staphylococci
Loeffler Diphtheria
Nicolaire Tetanus
Fraenkel Pnemococci
Hoffman Syphilis
Beijernick Coined the term Virus
Knoll and Ruska Electron microscope
Ehrlich Acid fast stain

Exceptions to Koch’s postulates Æ M. Leprae, T. Pallidum

 Materials and sterilization
Material Method of sterilization / disinfection
Chemical thermometer Isopropyl alcohol
Fungal spores Methyl alcohol
Bacterial spores Autoclaving
Fumigation of theatres, lab, ward Beta propiolactone >> formaldehyde
Cystoscope, Bronchoscope, Plastic ETT, face 2% glutaraldehyde (CIDEX)
masks
Heart lung machines, Respirators, Dental Ethylene oxide
equipment
Glass syringes, test tubes, forceps, scalpels, Hot air oven
liquid paraffin
Bacterial vaccines Filtration (Seitz filters)
Culture media, dressings, gloves, all Autoclaving
instruments except sharps, suture materials
except catgut
Heat labile culture media with egg, serum, Tyndallization
sugar
Catgut, grafts, plastics, swabs, catheters Ionizing radiation
Sharp instruments 5% cresol
Contaminated cloth, animal carcasses, plastics Incineration
like PVC and polythene
 Types of Culture media
Type Example
Simple (basal media) Nutrient broth
Complex media Added ingredients
Synthetic / Defined media From pure chemical substances
Eg: peptone water

Enriched media (solid media) Blood, serum, egg added to basal media
Eg: blood agar, chocolate agar

Enrichment media (liquid Substance which have stimulating effect on the bacteria to be
media) grown and inhibitory effect on others
Eg: tetrathionate broth for S.typhi
Selenite F broth for Shigella
Selective media Inhibiting substance added to solid medium
Eg: deoxycholate citrate medium for Salmonella and Shigella
LJ medium for TB bacilli

Indicator media Changes colour when particular bacteria grows

Eg: Wilson and Blair medium, McLeod’s medium

Differential medium To bring out different characters of bacteria

Eg: MacConkey;s media
 Immunoglobulins

Immunoglobulins Features

IgG - Major serum Ig

- Least carbohydrate content
- Only Ig that crosses placenta
- Late antibody, appears after initial response by IgM
- More effective than IgM in neutralization of toxins and viruses
- Four subclasses with IgG1 in maximum concentration

IgD - Normal serum level : 3mg / 100 ml

- Recognition molecule on the surface of B lumphocytes

IgA - Major IgG of colostrum, saliva, tears

- Secretory IgA is formed by two monomers joined by J chain
- IgA does not fix complement but activates alternate complement
pathway

IgM - Also known as ‘Millionaire molecule’

- Pentameric structure
- Mostly intravascular
- First to appear following infection
- Earliest Ig synthesised by fetus
- More effective than IgG in opsonisation, bacterial agglutination and
bactericidal activity

IgE - Only heat labile Ig

- Shortest half life
- Does not ix complement
- Responsible for anaphylactic type hypersensitivity
- Main defence against helminthic infections
- Homocytotrophic Æ species specific
 Complement system

Constitutes 5% of mormal serum protein

Does not bind to antigens or antibodies but only to antibodies that have combined with their antigens
IgG4, IgE, IgA, IgD do not fix complement
C3 is the most abundant complement in the body

Complement components Complement inhibitors Complement inactivators

- Major serum opsonin – C3b - C1 esterase - Factor I, Factor H

- Membrane attack complex: inhibitor - Anaphylotoxin
C5-C9 - S protein inactivator
- Anaphylotoxins: C5a, C3a - C4 binding protein

Deficient complement Disease

C1 esterase inhibitor Hereditary angioneurotic edema

C2 deficiency Most common, no significant effect

C1, C2, C4 SLE and collagen vascular diseases

C3, properidin and Factor D Recurrent pyogenic infections

Immune complex mediated glomerulonephritis

C5, 6, 7, 8, 9 Recurrent Neisserial infections

Toxoplasmosis
 HLA and disease associations

HLA B27 Ankylosing spondylitis

Reiter’s syndrome
Psoriatic arthritis
Spondyloarthopathies

HLA B14 Hemochromatosis

HLA B8 Myasthenia gravis

Grave’s disease

HLA B51 Behcet’s disease

HLA B47 Congenital adrenal hyperplasia

HLA CW6 Psoriasis vulgaris

HLA DR2 Multiple sclerosis

Narcolepsy
SLE
Goodpasture syndrome

HLA DR3 Sjogren’s syndrome

Diabetes Mellitus type I
Primary biliary cirrhosis
Grave’s disease (and B8)
Myasthenia Gravis (and B8)

HLA DR4 Rheumatoid arthritis

Type I Diabets mellitus

HLA DR5 Pernicious anemia

Hashimoto’thyroiditis

HLA DQ2 Gluten sensitive enteropathy

HLA DQ7 Bullous pemphigoid

 Staphylococcus
Anterior nares are the most frequent site of human colonization
MCC of pyomyositis, surgical wound infection, spinal epidural abscess, septic arthritis
Staphylococcus aureus is the most common cause of endocarditis in IV drug abusers
Staphylococcus epidermidis is the most common cause of early prosthetic valve endocarditis
In nutrient agar there is oil paint appearance of colonies
Selective media used is Ludlam’s media
Most common association with virulence is production of coagulase > mannitol fermentation
Exfoliative toxin produces Ritter’s disease in neonates and Toxic Epidermal Necrosis in adults
The test to differentiate between micrococci and staphylococci is the Hugh and Leifson’s oxidation-
fermentation test

Penicillin sensitive Penicillin G

Methicillin sensitive Methicillin, Nafcillin, Oxacillin

MRSA Vancomycin or Daptomycin

VRSA Quinipristine, Linezolid, Dalfopristine

Food poisoning No antibiotics, supportive treatment

Toxic shock syndrome Clindamycin

 Bacillus anthracis
First pathogenic bacteria to be observed under microscope
First bacillus to be isolated in pure culture and shown to possess spores
First bacillus to be used for the preparation of an attenuated vaccine
It has a polypeptide capsule
Bamboo stick / box car appearance in culture
M’Fadyean’s reaction – when stained with polychrome methylene blue shows shows capsule
Frosted glass appearance in agar plate
Microscopic appearance of colonies – Medusa head appearance
Inverted fir tree appearance in Gelatin stab culture
Growth in solid media containing penicillin – string of pearls reaction
Selective media – PLET media
Duckering – destruction of spores by formaldehyde
Anthracoid bacilli – motile, non capsulated, not susceptible to gamma phage, no medusa head colony
Ascoli’s thermoprecipitin test – demonstration of anthrax antigen
 Congenital syphilis
Early congenital syphilis Late congenital syphilis

Within 2 years Olympian brow

Snuffles / rhinitis (earliest feature) Hutchinson’s triad
Bullae (syphilitic pemphigus) - Hutchinson’s teeth
th
HSM, Lymphadenopathy - 8 nerve deafness

Osteochondritis - Interstitial keratitis

Parrot’s pseudoparalysis Mulberry molars

Mucocutaneous rash Saddle nose, perforated nasal septum

Condylomatous lesions Sabre shins

Clutton’s joint (bilateral knee effusion)
Wimberger sign (destruction of medial
aspect of proximal tibial metaphysis)
Rhagades
 Culture media

Bacteria Selective medium

Staphylococcus Ludlam’s

B. cereus MYPA

B. anthrax PLET

Legionella BYCE

Borrelia BSK

H. influenza Flide’s

Pseudomonas Cetrimide agar

Nocardia Paraffin bait

V. parahemolyticus Wagatsuma agar

Neisseria Thayer Martin medium

Mueller Hinton agar

Clostridium Robertson cooked meat medium

Corynebacterium Loeffler’s serum slope

Campylobacter Skirrow’s

Mycobacteria LJ media

Shigella Deoxycholate citrate agar

 Urease positive Oxidase positive Catalase negative

Proteus Hemophilus Streptococci

Klebsiella Vibrio Pneumococci
S. Aureus Neisseria Enterococci
H.pylori Legionella Almost all other organisms are
Nocardia Pseudomonas catalase positive
Yersinia Brucella
Cryptococcus Pasteurella

Bacteria Transport medium

Streptococcus pyogenes Pike’s media

Gonococci Stuart’s media

V. cholera Cary blair medium

Shigella Sach’s buffered glycerol saline

 Organism and culture appearances

Culture appearance Organism

Golden yellow colonies Coagulase positive staphylococci

White colonies / oil paint Coagulase negative staphylococci

Glossy colonies Avirulent streptococci

Spidery colonies / Sunray Actinomyces

Jet black colonies Salmonella

Satellitism H. influenza

School of fish / rail track H. ducreyi

Stormy fermentation Cl. Perfringens

Thumb print / Aluminium paint / Bisected pearl / Mercury drops Bordetella

Fried egg colonies Mycoplasma

Draughtsman / carom coin Pneumococci

Fish in stream / swarm of gnats V. cholerae

 Organism Other name

H. aegypticus Koch Week’s bacillus

H. influenza Pfeifer’s bacillus

Pseudomonas pseudomallei Whitmore’s bacillus

M. paratuberculosis Jone’s bacillus

M. intercellulare Battey’ bacillus

C. diphtheriae Kleb’s Loefler’s bacillus

C. pseudodiphthericum Hoffman’s bacillus

C. pseudotuberculosis Prisch – Nocard bacillus

Klebsiella pneumonia Friedlander’s bacillus

Klebsiella rhinoscleromatis Frisch bacillus

Klebsiella ozaeane Perez or Abel’s bacillus

Mycoplasma pneumoniae Eaton agent

C. tetani Nicolaire’s bacillus

Organism Growth factors

E.coli Arginine

Gonococci Glutathione

S. typhi Tryptophan

Legionella L- cysteine

Mycoplasma Cholesterol

M. tuberculosis Niacin

Ricketssia Sulfonamides

H. influenza Factors X and V

H ducreyi Factor X

Vibrio parahemolyticus NaCl

Rotavirus Trypsin

Organism Virulence factors

Staph aureus Coagulase

Streptococci M protein

Pneumococci Capsular polysaccharide

Gonococci Pili

Cl perferingens Lecithinase

M. tuberculosis Cord factor

Bacteria Type of motility

Campylobacter, V. cholerae Darting

Listeria Tumbling

Mycoplasma Gliding

Clostridia Stately

Borrelia Lashing

Trichomonas Twitching

T. pallidum Cork screw

Fusobacterium Spinning motility

 Test / Reaction Organism

Dick test, Schultz Charlton test Scarlet fever

Schick test Diphtheria

M’ Fadyean reaction, Ascoli thermoprecipitin Bacillus anthracis

test

Diazo reaction Salmonella typhi

Diene’s phenomenon Proteus

String test Vibrio

Nagler reaction Cl. Perfringens

Quellung reaction Pneumococcus

Frei’s test LGV

Eiken’s precipitin test ETEC

Anton test Listeria

 Fever Organism

Shanghai fever Pseudomonas

Undulant / Malta fever Brucella

Brazilian purpuric fever H. aegypticus

Haverhill / Rat bite fever Streptobacillus moniliformis

Soduku Spirillum minus

Cat scratch disease Bartonella henslae

Oraya fever / Carrion’s disease Bartonella bacilliformis

Goal fever / Epidemic typhus R. prowazekii

Weil’s disease Leptospira

 Acid fast organisms Intracellular organisms Capsulated bacteria

- Mycobacteria - M. Leprae - Meningococci

- Isospora belli - M. Tuberculosis - Pneumococci
- Cryptococcus cyst - Legionella, listeria - H. Influenza
- Rhodococci - Pneumococci - Klebsiella
- Bacterial spores - Meningococci, Gonococci - E. Coli
- Legionella micdadei - Salmonella, Shigella - Yersinia
- Y. Pestis - Bordetella
 Miscellaneous
Gram negative organisms producing exotoxin
- Vibrio
- E. Coli, Salmonella
- Bordetella

Gram negative cocco bacilli

- Hemophilus
- Bordetella
- Legionella
- Brucella

Gram negative coccobacillary rod - Acinetobacter

Pleomorphic bacteria
- C. Diphtheria
- H. Influenza
- Ricketssiae
- Streptobacillus moniliformis

L forms are seen in:

- Mycoplasma
- Mycobacterium tuberculosis
- Staph aureus (in the presence of penicillins)
 HIV
The virus belongs to lentivirus subgroup of retroviridae
For contaminated medical instruments, 2% glutaraldehyde is used for disinfection
Subtype C of HIV 1 is the most common form worldwide
Binding of virus to CD4 is facilitated by gp 120 and fusion of virus to cell is facilitated by gp41
Coreceptors required for binding include CCR5 and CXCR4
As per NACO guidelines, clinical AIDS sets in when CD4 count < 250 / microlitre
ELISA is the best screening test and Western Blot is the confirmatory test
P24 is the earliest viral marker
PCR is the gold standard of diagnosis of HIV infection
HIV in newborns is diagnosed by PCR (ELISA not done before 18 months due to interference by
maternal antibodies)
Persistent generalised lymphadenopathy is the presence of enlarged nodes atleast 1 cm in diameter,
in two or more non contiguous extrainguinal sites, that persist at least 3 months, in the absence of
any current illness or medication that may cause lymphadenopathy
 Most common in AIDS
MC opportunistic infection : Pneumocystis pneumonia
MC pulmonary disease : Pneumonia
MC intracranial space occupying lesion : Toxoplasmosis
MC malignancy : Kaposi sarcoma
MC cause of blindness : CMV retinitis
MC haematological abnormality : Anemia
MC fungal infection : Cryptococcus
MC electrolyte abnormality : Hyponatremia, SIADH
MC endocrinological abnormality in HIV infected men: hypogonadism
MC variety of lymphoma : B cell immunoblastic lymphoma
MC HIV drug causing myopathy : Zidovudine
 Adenovirus
Virion has the appearance of space vehicle
Can be associated with mesenteric adenitis and intussusception in children
Used as carrier in recombinant vaccine production
Potential vectors for gene therapy

Syndromes associated with Adeno virus Serotypes

Respiratory disease 1,2,5,6

Follicular conjunctivitis 3, 7
Pharyngoconjunctival fever

Epidemic Keratoconjunctivits 8, 19, 37

(Shipyard eye)

Diarrhea 40, 41

Hemorrhagic cystitis 11, 21

Acute respiratory disease in military recruits 4, 7, 14, 21

 Cytomegalovirus
- Owl eye appearance of infected cells
- MC organism causing intrauterine infection
- MC organism complicating organ transplantation
- Periventricular calcification in newborn is a characteristic feature in intrauterine infection
- Ganciclovir or Valganciclovir are the first choice drugs for CMV retinitis
- AIDS patients are at risk for CMV retinitis when CD4 count < 100 /microlitre

Ebstein Barr virus

- Associated with Hodgkin disease, Oral hairy leukoplakia, CNS lymphoma, lymphoid interstitial
pneumonia in AIDS etc
- CD21 is the cellular receptor for EBV
- Paul Bunnel test is the standard diagnostic test for Infectious mononucleosis
- Atypical lymphocytes in IMN are mostly CD8 lymphocytes
- Patients with Duncan’s disease (X linked lymphoproliferative disease) are extremely susceptible for EBV
infection
 Maternal pelvis

Normal female pelvis : Gynaecoid pelvis

Least common type of pelvis : Platypelloid pelvis
The only pelvis with AP diameter more than transverse diameter : Anthropoid pelvis
Face to pubis delivery most common in Anthropoid pelvis
Persistent occipito posterior is most common in Android pelvis
Deep transverse arrest / Non rotation is most common in Android pelvis
Super sub parietal diameter instead of Biparietal diameter engages in Platypelloid pelvis
Naegele’s pelvis : one ala of sacrum absent
Robert’s pelvis : Both ala of sacrum absent
Longest diameter of pelvis : transverse diameter of inlet and AP diameter of outlet
Shortest major diameter of pelvis : Interspinous diameter (10 cm)
Longest AP diameter of inlet : Diagonal conjugate
Shortest AP diameter of inlet : Obstetric conjugate
Only AP diameter measured clinically : Diagonal conjugate
Critical value of obstetric conjugate : 10cm
 Fetal head

Smallest diameter of fetal head is Bitemporal diameter (8 cm)

The longest diameter of fetal skull is Mentovertical diameter (14.5 cm)
Second longest diameter is Submentovertical = Occipitofrontal = 11.5 cm
Commonest type of presentation is vertex

Diameters Attitude of head Presentation

Suboccipito-bregmatic Complete flexion Vertex

Suboccipito-frontal Incomplete flexion Vertex

Occipito-frontal Marked deflexion Vertex

Mento-vertical Partial extension Brow

Submento vertical Incomplete extension Face

Submento bregmatic Complete extension Face

Brow presentation is not suitable for vaginal delivery, hence caesarean section is mandatory
 Events following fertilization

‘0’ hour - Fertlization

th
4 day - 16 celled stage
Morula enters uterine cavity

th
5 day - Blastocyst
th
7 day - Interstitial implantation
st nd
21 -22 day - Placenta fully established/Fetal heart and circulation
formed
8 weeks - Internal gonads formed
10 – 12 weeks - Swallowing starts
11 weeks - Fetal breathing movements
12 weeks - External genitalia formed
12 weeks - Urine formation occurs
 Placenta and Umbilical cord

Placenta

Placenta has a diameter of 15 – 20cms

It has a thickness of 2.5 cm at the centre
Weighs around 500 gm
Divided into 15-20 cotyledons
Maternal surface is formed by deciduas basalis
Fetal surface is covered by chorion frondosum and chorionic plate
Hofbauer cells are the phagocytic cells in the stroma of placenta
th th
Formation of placenta begins in the 6 week and is completed by 12 week
Nitabuch’s layer: zone of fibroid degeneration where trophoblast and deciduas meet
At term, fetus extracts 20-30 ml of oxygen per minute from maternal circulation

Umbilical cord
Normal length is around 50 -55 cm
At term, it contains 2 arteries and one vein (left)
Whartons Jelly is the connective tissue of the cord
Folds of Hoboken are the transverse intimal folds of umbilical arteries across their lumen

Abnormalities

Battledore placenta - cord attached to margin of placenta

Furcate placenta - blood vessels divide before reaching the palcenta
Velamentous insertion - blood vessels are attached to the amnion where
they ramify before reaching placenta

Succenturiate placenta - small part of placenta separated from the rest

Circumvallate placenta - deep insertion of placenta into the deciduas
Maternal changes during pregnancy
Blood volume and plasma volume increases by 40%
Hemoglobin concentration and peripheral vascular resistance decreases
All clotting factors increase except Factor 11 and 13
Renal blood flow and GFR increases by 50%
Serum urea, uric acid and creatinine decreases due to their increased clearance
Albumin: Globulin ratio decreases from 1.7:1 to 1:1
Respiratory rate and vital capacity remains unchanged whereas tidal volume increases
Cardiac apex shifts upward and outward with ECG showing left axis deviation
Third heard sound and systolic murmurs upto Grade II can be normally heard
Serum ferritin decreases and Total iron binding capacity increases
Thyroxine binding globulin, Total T4 and T3 increases while Free T3 and T4 remain unchanged
There is maternal fasting hypoglycaemia and postprandial hyperglycemia and hyperinsulinemia
 Clinical signs during early pregnancy

Jacquemier’s / Chadwick sign: dusky hue of vestibule and anterior vaginal wall
th
(from 8 week; in pelvic tumors also)
Osiander’s sign : increased pulsation felt through the lateral fornices
th
(from 8 week; also in acute PID)
th
Goodell’s sign : softening of cervix (6 week onwards)
Hegar’s sign : apposition of vaginal and abdominal fingers below the
body
of uterus due to softening of isthmus(6- 10 weeks )
Palmer’s sign : regular and rhythmic contraction of uterus felt on
bimanual
Examination (4- 8 weeks)
Ladin’s sign : Uterus softens in anterior midline along utero cervical

Junction
McDonald sign : Uterus becomes flexible at uterocervical junction at 7-8
wks
Von Fernwald sign : Softening of fundus at 4-5 weeks
 Amniotic fluid

nd
Source of amniotic fluid: maternal plasma in early weeks, fetal skin in 2 trimester, fetal urine from
20 weeks onwards
Quantity
o 12 wk : 50 ml
o 16 wk : 200 ml
o 20 wk : 400 ml
o 36 wk : 1000 ml
Specific gravity : 1.008 – 1.010
Osmolality : 250 mOsm/L
Fluid replaced every 3 hours
Contains 99% water; rest by protein, glucose, lipids
Phosphate / Zinc ratio in the amniotic fluid is the predictor microbial inhibitory activity
Normal Amniotic fluid index: 5-25 cm
AFI < 5cm is oligohydramnios and >25 is polyhydramnios
Normal Single Deepest Pocket (SDP) Æ 2-8 cm
SDP > 8cm in polyhydramnios and < 2cm is oligohydramnios
 Named criteria and classifications

MaCafee and Johnson regime - Expectant management of placenta previa

Page classification - Abruptio placenta
Sher classification

Clarke’s classification - Cardiac disease in pregnancy

Caldwell and Mohoy classification - Tpes of pelvis
Whites classification - Diabetes in pregnancy
Lytic cocktail regime
Pritchard regine - Eclampsia
Rotterdam criteria - PCOD
Amsel criteria - Bacterial vaginosis
De Lancey levels - Uterine supports
Baden and Walker classification - Grading of pelvic organ prolapsed
Spiegelberg criteria - Ovarian ectopic pregnancy
Rubin’s criteria - Cervical ectopic pregnancy
Studiford’s criteria - Abdominal ectopic pregnancy
 Ultrasound in Obstetrics

Ectopic pregnancy - live embryo outside the uterus

- free fluid in pouch of douglas
- increased endometrial thickness
- adnexal mass seen

Blighted ovum - embryonic development arrested in fertilised ovum

- no fetal parts or yolk sac in a sac > 20mm

Ovulation - Collapse of follicle

- fluid in pouch of douglas
- echo free zone around endometrium

Twin peak sign / Dichorionic – diamniotic twins

Lambda sign

T sign Monochorionic pregnancy

Double decidual sign Present in early intrauterine pregnancy; distinguishes it

from pseudogestational sac

Double bleb sign Intrauterine pregnancy

Interstitial line sign Interstitial ectopic pregnancy

Tubal ring sign (Bagel’s Tubal ectopic pregnancy

sign)

Empty amnion sign Pregnancy failure

 Ovarian tumors

Feature Associated tumor

Call Exner body Granulosa cell tumor
Coffee bean nuclei Granulosa cell tumor
Schiller Duval body Endodermal sinus tumor
Reinke’s crystal Hilus cell tumor
Psammoma bodies Serous epithelial tumors
Walthard cell nest Brenner tumor
Signet ring cell Krukenberg tumor
Hobnail cell Clear cell tumor
Polygonal cell with fibrous Dysgerminoma
septa and lymphocytic
infiltration
Skin, teeth, cartilage Teratoma

Ovarian tumor Tumor marker

Serous cystadenoma CA 125
Mucinous cystadenoma CA 19-9, CEA
Endodermal sinus / Yolk sac tumor AFP
CHoriocarcinoma HCG
Dysgerminoma LDH, Alkaline phosphatise
Granulosa cell tumor Inhibin
 Endometriosis and Adenomyosis
Sampson’s theory postulates the origin of endometriosis by retrograde menstruation and Halban’s
theory describes the vascular or lymphatic embolization of endometrial tissue
Smoking is protective for endometriosis
Most common site of endometriosis is ovary followed by Pouch of Douglas
Powder burn / Gun shot appearance is the characteristic appearance of peritoneum in endometriosis
Chocolate cyst of ovary is a true cyst with columnar lining containing brown coloured fluid with
hemosiderin
The classical symptom triad of endometriosis is dysmenorrhea, dysparunia and infertility
Tender nodularity of uterosacral ligament and cul de sac is the classical examination finding
Gold standard for diagnosis is Laproscopy for direct visualisation of endometritic deposits
Drugs used in endometriosis is aimed at producing a pseudo pregnancy state resulting in
decidualization or pseudo menopause state
Endometriomas < 3cm is managed by laproscopic aspiration and for those > 3cm, laproscopic
cystectomy is done
Adenomyosis is also termed ‘endometriosis interna’
Halban’s sign of adenomyosis is tender, softened uterus on premenstrual bimanual examination
 Urogynaecology
Retroversion is the first step in uterovaginal prolapse
Enterocele is the only true hernia of the pelvis
Congenital prolapse is associated with conditions like Spina bifida and connective tissue disorders like
Marfans and Ehler Danlos syndrome
Gold standard surgery for vault prolapse is Transabdominal sacral colpopexy
Surgery performed in congenital prolapse / a young nulliparous female who desires future pregnancy:
Sling surgery / Cervicopexy
Female < 40 years who does not desire future pregnancy but wants to retain menstrual function:
Manchester / Fothergill’s operation
Female > 40 years and does not desire future pregnancy and does not want to retain menstrual
function: Ward Mayo’s vaginal hysterectomy
Female > 60 years and medically unfit for hysterectomy: LeFort’s repair
Prolapse during pregnancy / puerperium: Ring Pessary
Most common urinary fistula: Vesicovaginal
MCC of Vesico vaginal fistula: Obstructed labor
MCC of Uretero vaginal fistula: injury to ureter after Wertheim’s hysterectomy
MCC of Vesico Uterine Fistula: Caesarean section
MCC of Rectovaginal fistula: Caesarean perineal tear
Bonney’s test and Marchetti test are used to detect stress incontinence
 Infections of Genital tract
Trichomonas vaginalis is the most common organism causing vaginitis
Strawberry vagina is a feature of Trichomonas vaginalis
Definitive diagnosis is made by culture on Feinberg Whittington media
Metronidazole is the drug of choice in pregnancy
Candidiasis is the most ommon vaginitis during pregnancy
Cottage cheese like vaginal discharge is characteristic
Whiff test with 10% KOH is done for the diagnosis of Bacterial vaginosis
Amsel’s criteria is used in the diagnosis
Metronidazole is the drug of choice
Fitz Hugh Curtis syndrome is the perihepatitis occurring as a complication of Chlamydia trachomatis
Violin string like adhesions in the pelvis and around the liver suggests PID caused by Chlamydia
Gonococcus is the most common cause of acute cervicitis and salpingitis in young females
Most common cause of genital ulcers is Herpes virus
Human Papilloma virus is the most common viral STI
Most common site for Genital TB is fallopian tube (ampulla) followed by cornu of uterus
Lead pipe appearance, Beaded appearance, Golf club tube etc are HSG appearance of TB fallopian
tube
 Disorders of Menstruation

Primary menorrhea: female has not attained menarche by the age of 14 years in the absence of
secondary sexual characters or no menarche by 16 years regardless of presence of normal growth and
secondary sexual characters
Oligomenorrhea is irregular episodes of bleeding occurring at intervals of more than 35 days
In Polymenorrhea, episodes of bleeding occur at intervals of 21 days of less
Mean blood loss per menstrual cycle is 35 ml
Metropathia hemorrhagica is a special form of DUB with swiss cheese appearance of endometrial
glands and cystic glandular hypertrophy
Most common cause of Primary Amenorrhea is Turner syndrome and the second most common cause
is Mayer Rokitansky Kuster Hauser syndrome
Cryptomenorrhea is occurrence of menstrual symptoms without external bleeding and the most
common cause is Imperforate hymen
Kallmann syndrome is a genetic condition characterised by hypogonadotropic hypogonadism and
anosmia
Premature menopause is amenorrhea associated with depletion of oocytes before the age of 40 yrs
Ashermann’s syndrome is amenorrhea due to intrauterine synechiae commonly caused by vigorous
curettage in post partum period
In Ashermann’s syndrome, HSG shows a honey-comb appearance and the treatment of choice is
Hysteroscopic adhesiolysis
 Eyeball
AP diameter : 24 mm
Vertical diameter : 23 mm
Horizontal diameter : 23.5 mm
Circumference : 75 mm
Volume : 6.5 ml
Weight : 7gm
Anterior chamber : 2.5 mm deep; contains 0.25 ml of aqueous humor
Posterior chamber : contains 0.06 ml of aqueous humor
Diopteric power of reduced eye : +60 D (cornea 43D, lens 17D)
In newborn, power of eye is hypermetropic by +2 to +3D
Refractive index
- Cornea: 1.376
- Aqueous and Vitreous humor: 1.336
- Lens: cortexÆ 1.386, coreÆ 1.406
 Fundus appearances
Hypermetropia - Silk shot retina
CRAO - Cattle trucking appearance
CRVO - Blood and thunder fundus
Pars planitis - Snow banking
Xerophthalmia - Uyemura’s fundus
Tuberous sclerosis - Mulberry tumor (retinal astrocytoma)
Best disease - Scrambled egg / Egg yolk appearance
Oguchi disease - Mizuo phenomenon
Morning glory syndrome - Deficient lamina cribrosa
CMV retinitis - Cottage cheese and ketchup / Pizza pie retinopathy
Angioid streaks - Peau de orange appearance of retina
(Pseudoxanthoma elasticum, Ehler Danlos, Paget disease..)
VKH syndrome - Sunset glow fundus
Purtscher retinopathy - Bilateral multiple cotton wool spots and superficial haemorrhages
(Acute pancreatitis, Air / Fat embolism, after bone marrow
transplant)
Sickle cell anemia - Sea fan retinopathy, Rising sun appearance
Sarcoidosis - Candle wax drippings, Lander’s sign (sarcoid nodules in retina)
Toxoplasmosis - Headlight in fog appearance
Salt and pepper fundus - Congenital syphilis, Leber’s amaurosis, Congenital rubella
Terson syndrome - Intraocular hemorrhage + Subarachnoid hemorrhage
 Uveitis
Koeppe’s nodules seen at the pupillary border and smaller in size
Busacca’s nodules in the surface of iris away from the pupil
Iris bombe: forward bowing of iris in Ring (annular) synechiae
Festooned pupil: irregular dilatation of pupil with mydriatic due to posterior synechiae
Arlt’s triangle: inflammatory cells wandering in the aqueous get arranged in a base down triangular
area at the lower part of cornea
Snow ball opacities in vitreous seen in intermediate uveitis (pars planitis)
White eye (Uveitis with no congestion) seen in JRA associated uveitis and Posner Schlossman
syndrome
Fuch’s heterochromic iridocyclitis:
- Affects young people unilaterally
- Iris heterochromia
- White stellate keratic precipitates
- Amsler’s sign: bridging vessels in the eye bleed during paracentesis
- Prone to develop cataract and Primary Open Angle Glaucoma
VKH syndrome
- Vogt koyanagi: skin changes and anterior uveitis
- Harada disease: encephalopathy, deafness, tinnitus, exudative retinal detachment
- Sunset glow fundus and depigmented limbal lesions (Sugiura sign)
- Alopecia, Poliosis, Vitiligo
Sympathetic ophthalmia
- Earliest symptom: decreased accommodation
- Earliest sign: retrolental flare / anterior vitreous cells\
- Dalen Fuchs nodules seen on hisopathology
 Conjunctivitis
Epidemic keratoconjunctivitis is caused by the adenovirus serotypes 8, 19, 37
Phlyctenular conjunctivitis occurs as a result of Type IV hypersensitivity reaction to endogenous
tuberculoprotein or staphylococcal blepharitis
Treatment of phlyctenular conjunctivitis is with topical antibiotic ointment and corticosteroid
drops
Giant papillae are ones with size > 1 mm and is associated with mechanical trauma from exposed
sutures, prosthesis or filtering blebs
Vernal keratoconjunctivitis / Spring catarrh occurs due to Type I hypersensitivity response
against extrinsic allergens
Features of spring catarrh include stringy / ropy discharge (Maxwell Lyon sign), cobble stone
papillae on some abnormaundersurface of eyelid, Horner Trantas spots at limbus,
pseudogerontoxon, shield ulcers of cornea and alkaline tears
The presence of woody membrane over conjunctiva is suggestive of Ligneous conjunctivitis
probably due to abnormality in coagulation pathway
Angular conjunctivitis is classically due to gram negative diplococcus Moraxella lacunata and by
Staph aureus
Treatment of the former is with zinc oxide containing eye drops
Superior limbic keratoconjunctivitis is characterised by superior bulbar conjunctival congestion,
corneal pannus, filamentary keratitis and is associated with Grave’s disease
Parinaud’s oculoglandular conjunctivitis is characterised by granulomatous nodules on palpebral
conjunctiva, fever, pre auricular and submandibular lymphadenopathy and is associated with
Bartonellae henslae infection (Cat scratch disease)
Actinomyces israeli infection is characterised by with chronic unilateral congestion of medial
angle of eye with infection of lacrimal system
 Keratitis
Bacteria that can invade intact corneal epithelium – Neisseria gonorrhoea, Neisseria meningitides,
tCorynebacterium diphtheria
Characteristic hypopyon corneal ulcer produced by Pneumococcus - Ulcus serpens
In bacterial corneal ulcer, hypopyon remains sterile as long as Descemet’s membrane is intact
Peritomy is a process of severing perilimbal conjunctival vessels when excessive corneal
vascularisation is hindering the healing process
Best treatment of a perforated corneal ulcer – therapeutic keratoplasty
Most common cause of mycotic corneal ulcer: Aspergillus
Features of fungal corneal ulcer:
- Signs out of proportion to symptoms
- Feathery finger like extensions
- Sterile immune ring
- Small satellite lesions
- Big non sterile hypopyon
- Absent corneal vascuolarisation
Herpes simplex keratitis
- Dendritic ulcer with terminal knobs are classical
- Can coalesce to form geographical ulcer
- Corneal hypoesthesia present in recurrent infection
- Disciform keratitis presents with folds in Descemet’s membrane, KPs, Wessley’s immune
ring without stromal necrosis
Psudodendrites, Nummular keratitis, Disciform keratitis, Mucous plaque keratitis are features of Herpes
Zoster keratitist
Hutchinson’s rule: ocular involvement is frequent if the side or tip of nose presents vesicles (involvement
of nasociliary nerve)
Acanthameba keratitis:
- Pain out of proportion to signs
- Limbitis
- Radial keratoneuritis
- Pseudodendrites
- Ring abscess
 Corneal dystrophy and degeneration

Vogt’s limbal girdle: age related change; opacity at the level of Bowman’s membrane
Arcus senilis: starts in superior and inferior quadrants, ring of opacity is separated from limbus by a
clear zone called lucid interval of Vogt
Hassal Henle bodies:
- Most common senile change in cornea
- Drop like excrescences of hyaline material projecting into AC from corneal periphery
- Larger ones invade central cornea: Cornea guttata
Band shaped keratopathy: deposition of calcium salts in Bowman’s membrane, superficial parts of
stroma; In children may be a presenting sign of chronic uveitis as a result of Juvenile Idiopathic
arthritis
Most common anterior corneal dystrophy: Epithelial Basement Membrane dystrophy
Most common stromal corneal dystrophy: Lattice dystrophy
Least common stromal corneal dystrophy: Macular dystrophy
Most common posterior / Endothelial corneal dystrophy: Fuch’s endothelial dystrophy
Material accumulated in Lattice dystrophy: Amyloid (stain used is Congo red)
Material accumulated in Macular dystrophy: Mucopolysaccharides (stain used is alcian blue)
 Special types of cataract

Sunflower cataract - Wilson’s disease

- Chalcosis

Snow flake or Snow storm - Juvenile Diabetes mellitus

cataract - Down syndrome

Rosette cataract - Blunt trauma

Christmas tree cataract - Myotonic dystrophy

Oil droplet cataract - Galactosemia

Blue dot cataract - Hypoparathyroidism (Vit D deficiency)

Shield cataract - Atopic dermatitis

Glass blower’s c - Infrared rays exposure

Anterior capsular Anterior subcapsular Postrior subcapsular cataract

cataract cataract

- Gold - Diabetes - Myotonic dystrophy

- Chlorpromazine - Miotics - High myopia
- Vossius ring - Electric shock - DM
- Hypoparathyroidism - Radiation cataract
- Galactosemia - Neurofibromatosis 2
- Hereditary fundus dystrophies
 Lens and Cataract surgery
Smoking is associated with nuclear cataract
Lamellar / Zonular cataract is the most common type of cataract presenting with visual impairment;
occurs in the zone of fetal nucleus
Absolute contraindication of ECCE: Markedly subluxated or dislocated lens
Most dreadful complication of ECCE: Expulsive choroidal hemorrhage
First IOL implantation was done by Harold Ridley
Commonly used material for preparation of IOL : PMMA
SRK formula: for calculating the power of IOL (P = A – 2.5L – 0.9K )
Windshield wiper syndrome: IOL related complication when a small IOL is placed vertically in the
sulcus
After cataract is the posterior capsular opacity which persists or develops after ECCE characterised by
Elschnig’s pearls and Soemerring’s ring
In patients with Marfan syndrome, there is superotmporal dislocation of lens and in Homocystinuria
there is inferonasal dislocation of lens
Weil Marchesnani syndrome patients have spherophakia and lens with forward subluxation
Anterior lenticonus is seen in Alport syndrome and Ehler Danlos syndrome
Posterior lentconus is associatd with Lowe syndrome (oculo cerebro renal syndrome)
 Glaucoma
Normal IOP: 10 -21 mmHg
IOP is higher in the morning and lowest in the late evening
Photophobia, blepharospasm, lacrimation with corneal enlargement, corneal edema and Haab’s striae
are the features of Primary Developmental Glaucoma
Axenfeld anomaly: posterior embryotoxon characterised by prominent Schwalbe’s ring
Bayonetting sign and Lamellar dot sign are indicators of significant fundal involvement in primary
open angle glaucoma
Small wing shaped paracentral scotoma is the earliest clinically significant field defect
Ocular hypertension is raised IOP with no optic disc or visual field changes
Hypermetropic eyes with shallow anterior chamber are at risk for developing angle closure glaucoma
Coloured halos due to primary angle closure and cataract can be differentiated by Emsley- Fincham’s
stenopaeic slit test
Vogt’s triad refers to the sequelae of PAC glaucoma with glaucomaflecken, iris atrophy and slightly
dilated non reacting pupil
Angle recession glaucoma is a unilateral open angle glaucoma occurring years after blunt trauma and
the term refers to the rupture in the ciliary body face between sclera spur and iris root
Pigmentary glaucoma occurs commonly in young, myopic males and is characterised by Krukenberg’s
spindle (pigment deposition in posterior part of cornea) and Sampaolesi’s line.
Cogan Reese syndrome and Chandler’s syndrome are examples of irido corneal endothelial
syndromes that predisposes to glaucoma
 Vitreous
4ml in volume
Hyaloid / Clocquet’s canal: runs down the centre of vitreous body from the optic disc to the posterior
pole of lens
Vitreous base: attachment across the ora serrata, where vitreous attachment is strongest
Weigert ligament: attachment to the back of crystalline lens
Synchisis: liquefaction of vitreous; most common degenerative change in vitreous
Syneresis: vitreous collapse
Weiss ring: ring like opacity representing the ring of attachment of vitreous to the optic disc and is
pathognomonic of Posterior Vitreous detachment
Muscae volitantes: physiological opacities which indicate residues of primitive hyaloid vasculature
Asteroid hyalosis: small white rounded bodies in vitreous gel due to accumulation of calcium
containing lipids
Synchisis scintillans: cholesterol containing crystalline bodies; appears as beautiful shower of golden
rain on ophthalmoscopy
Diabetic retinopathy is the most common cause of vitreous hemorrhage in adults and in trauma is the
MCC in young
Examples for vitreous substitutes include Sulfur hexafluoride, Octafluropropane, silicone oil, Perfluro
carbon liquid
 Lesions in visual pathway

Site of lesion Features

Optic nerve - complete blindness of affected eye

- central / paracentral scotoma

Central chiasma (Pituitary tumors) Bitmeporal hemianopia

rd
Lateral chiasma (3 ventricle distension) Binasal hemianopia

Optic tract - Contralateral homonymous hemianopia

Geniculate body - Contralateral Wernicke’s pupil (optic tract)

Optic radiations in temporal lobe Superior quadrantic hemianopia (pie in the sky)

Optic radiations in parietal lobe Inferior quadrantc hemianopia

Optic radiations Homonymous hemianopia

Anterior occipital (visual) cortex Congruous homonymous hemianopia sparing

macula
Tip of occipital cortex Congruous homonymous macular defect
 Pupillary reflex abnormalities
Amauratic light reflex
- Absence of light reflex on the affected side
- Absence of consensual reflex on the normal side
Efferent pathway defect
- Absence of both direct and consensual light reflex on the affected side
- Near reflex is also absent on the affected side
- Sphincter paralysis can occur in atropine use, internal ophthalmoplegia, III nerve palsy
Wernicke’s hemianopic pupil
- Site of lesion is the optic tract
- Light reflex is absent if light is thrown on the temporal half of the retina on the affected
side and nasal half of the retina on the normal side
Marcus Gunn pupil
- Relative afferent papillary deficit
- Earliest feature of optic nerve involvement
- While performing swinging flash light test, in one eye the affected pupil will dilate when
the flash light is moved from the normal eye to the abnormal eye
Argyll Robertson pupil
- Accomodation reflex present, Pupillary reflex absent
- Classically seen in neurosyphilis
- Lesion is at tectum (internuncial neurons between pretectal nucleus and EW nucleus)
Holme Adie’s tonic pupil
- Light reflex absent, near reflex is slow and tonic
- May be associated with absent knee jerk
- Adie’s pupil constricts with 0.125% pilocarpine while normal people does not
Hutchinson’s pupil
- Due to oculomotor nerve involvement as in transtentorial herniation
rd
- Initially 3 nerve irritation causes miosis, later increasing compression cause paralysis
resulting in fixed and dilated pupil
 Eyelids
Meibomian glands: modified sebaceous glands which secretes the oily layer of tear film
Glands of Zeis are modified sebaceous glands and Glands of Moll are modified sweat glands
Coloboma of lid is usually in the nasal side of upper lid
Epicanthus is the most common congenital anomaly of the lids; a semicircular fold of skin which
covers the medial canthus
Cryptophthalmos: eyelids fail to develop
Epiblepharon: horizontal fold of tissue ridges above the lower eyelid margin
Euryblepharon: horizontal widening of palpebral fissure
Internal hordeolum is the suppurative inflammation of the meibomian gland
External hordeolum is the acute suppurative inflammation of glands of Zeis or Moll
Trichiasis: inward misdirection of cilia with normal position of lid margin
Distichiasis: extra row of cilia
Papillomas are the most common benign tumor
Basal cell carcinoma is the most common malignant tumor of lids (most involves inner canthus of
lower lid)
 Osteomyelitis
Staphylococcus is the most common causative organism overall and in immunocompromised and post
traumatic / post surgical patients
Salmonella is the commonest organism in sickle cell anemia patients
Pseudomonas aeroginosa is the commonest in drug abusers
Anaerobes in diabetic ulcer
Most common location in children in lower end of femur > upper end of tibia; and in adults it is
thoracolumbar spine
Infection always starts in metaphysic because of rich blood supply, hair pin bend vessels and defective
phagocytosis
First change in Xray is loss of soft tissue planes (Xray in <24 hours is normal)
nd
First bony change in Xray is Periosteal reaction seen on 2 week
Detected earlier in MRI (marrow changes in metaphysic)
Morrey and Peterson’s Criterion used for diagnosis of acute osteomyelitis
Cierney and Miller classification is used in chronic osteomyelitis
Sequestrum: Avascular piece of bone surrounded by granulation tissue, pathognomonic of chronic
osteomyelitis
Involucrum: dense sclerotic new bone surrounding the sequestrum
Brodie’s abscess: long standing pyogenic abscess in the bone gets walled off with sclerotic margins;
most common site is upper end of tibia
Garre’s osteomyelitis: non suppurative, sclerosing, chronic osteoyelitis characterised by marked
sclerosis and cortical thickening
 Disease and joint involvement
Disease Joint involvement
1. Diabetes - Midtarsal (most common) > tarsometatarsal > MTP
2. Tabes dorsalis - Knee (most common) > hip
3. Leprosy - Hand and foot joints
4. Syringomelia - Shoulder, elbow
5. Myelomeningocele - Ankle and foot
6. Amylodosis - Peroneal muscle atrophy
7. Septic arthritis - Knee
8. Hemophilic arthropathy - Knee (ankle in children)
9. Actinomycosis - Mandible
10. Pseudogout - Knee
11. Gout - MP joint of big toe
12. Ankylosing spondylitis - Sacroiliac joint
13. Osteochondritis dissecans - Knee
 Nerve Trauma Effect

Axillary nerve Dislocation of shoulder Deltoid palsy

(Anterior and inferior) Regimental badge palsy

Radial nerve Fracture shaft of humerus Wrist drop

(lower third)

Ulnar nerve Fracture medial epicondyle of Claw hand

humerus

Sciatic nerve Posterior dislocation of hip Foot drop

Common peroneal nerve Knee dislocation / Fracture of Foot drop

neck of fibula

Posterior interosseous nerve Monteggia fracture Finger drop

Anterior interosseous nerve Supracondylar fracture of Kiloh nevin sign

humerus

Median nerve Supracondylar fracture of Pointing index finger

humerus
Entrapment syndrome Nerve involved
1. Carpal tunnel syndrome - Median nerve (at wrist)
2. Pronator syndrome - Median nerve
3. Cubital tunnel syndrome - Ulnar nerve (between two heads of flexor carpi ulnaris)
4. Guyon’s canal syndrome - Ulnar nerve (at wrist)
5. Thoracic outlet syndrome - Lower trunk of Brachial plexus (C8, T1)- between clavicle
st
and 1 rib

6. Piriformis syndrome - Sciatic nerve

7. Meralgia paraesthetica - Lateral cutaneous nerve of thigh
8. Cheralgia parasthetica - Superficial radial nerve
9. Tarsal tunnel syndrome - Posterior tibial nerve (behind and below medial malleolus)
rd th
10. Morton’s metatarsalgia - Interdigital nerve compression (usually of 3 and 4 toe)
 Plaster casts and their uses

Name of the cast Use

1. Minerva cast - Cervical spine disease
2. Risser’s cast - Scoliosis
3. Turn-buckle cast - Scoliosis
4. Shoulder spica - Shoulder immobilization
5. U slab / Hanging cast - Fracture of humerus
6.Hip spica - Fracture of femur
7. Cylinder cast / Tube cast - Fracture of patella
8. Patellar Tendon Bearing cast - Fracture of tibia
9. Colle’s cast - Fracture lower end of radius
10. Glass holding cast - Fracture scaphoid
11. Thumb spica splint - Scaphoid fracture / Metacarpal fracture / Game keeper’s
thumb
 Common Splints / Braces and their uses
Name Use
1. Thomas splint - Fracture femur and knee immobilization
2. Bohler-Braun splint - Fracture Femur, Knee, Tibia
3. Dennis Brown splint - CTEV
4. Cock up splint - Radial nerve palsy
5. Knuckle bender splint - Ulnar nerve / Median nerve palsy
6. Volkmann’s splint / - Volkman’s ischemic contracture
Turn buckle splint

7. Aeroplane splint - Brachial plexus injury

8. Figure of 8 Bandage - Clavicle

9. Lumbar corset - Backache
10. Dunlop, Smith traction - Supracondylar fracture of humerus
11. Buck’s traction - Conventional skin traction
12. Gallow’s tracton - Fracture shaft of femur in children <2years
13. Perkin’s traction - Fracture shaft of femur in adults
14. Gutter splint - Phalangeal and metacarpal fractures
15. Crutch field traction - Cevical spine injuries
16. Buddy strapping - Phalangeal injuries
 Bursitis

Student’s elbow / Miner’s elbow - Olecranon bursitis

Housemaid’s knee - Prepatellar bursitis (commonest)
Clergyman’s knee - Infrapatellar bursitis
Weaver’s bottom - Ischial bursitis
Tailor’s ankle - Lateral malleolus bursitis
st
Bunion - Medial side of great toe (1 metatarsal head bursitis)
th th
Bunionette - 5 toe of foot (5 metatarsal head bursitis)

- Tubercular bursitis: Trochanteric bursa > Bursa anserine > Compound palmar bursa
- Morrant Baker cyst / Popliteal cyst
Pressure diverticulum of synovial membrane
Prominent on extension and reduced on flexion
Secondary to Osteoarthritis / Rheumatoid arthritis / Meniscal injury
Soft and fluctuant swelling with no transilliminancy
 Orthopaedics Oncology - I
Most Common

Most common bone tumors - Secondaries

Most common cause of secondaries in children - Neuroblastoma
Most common primary malignant bone tumor - Multiple myeloma
Second most common primary malignant bone tumor - Osteosarcoma
Commonest malignant bone tumor of flat bone - Chondrosarcoma
Commonest tumor of skull vault - Ivory osteoma / Compact osteoma
Commonest true benign tumor - Osteoid osteoma
Most common benign tumor of spine - Hemangioma (striated vertebra seen)

Classical radiological features

Sun ray appearance / Codman’s triangle - Osteosarcoma (not specific)

Onion peel appearance - Ewing sarcoma
Soap bubble appearance - Osteoclastoma, Adamantinoma
Ground glass appearance - Fibrous dysplasia
Patchy calcification - Chondrogenic tumors
Homogenous calcification - Osteogenic tumors

Enneking classification system is used for bone tumors

 Orthopaedics Oncology – II

Location of Bone tumors

Epiphyseal
- Chondroblastoma
- Osteoclastoma / Giant cell tumor
- Articular osteochondroma
- Clear cell chondrosarcoma

Metaphyseal
- Chondrosarcoma
- Osteosarcoma
- Ostoblastoma
- Enchondroma
- Osteochondroma

Diaphyseal
- Ewing’s sarcoma
- Adamantinoma
- Multiple myeloma
- Osteoid osteoma
 Orthopaedics Oncology – III
Most common sites:
Unicameral bone cyst - Upper end of humerus
Aneurysmal bone cyst - Lower end metaphysis (Tibia and femur)
Osteochondroma - Distal femur
Osteoid osteoma - Femur > Tibia
Osteoblastoma - Vertebrae
Osteoma - Skull and facial bones
Enchondroma - short bones of hand
Adamantinoma - Tibia
Ameloblastoma - Mandible
Osteoclastoma - Lower end of femur
Fibrous dysplasia - Craniofacial (polyostotic); Upper femur (monostotic)
Multiple myeloma - Lumbar vertebra
Ewing’s sarcoma - Femur
Chondrosarcoma - Pelvis
 Orthopaedics Oncology – IV
Benign bone tumors

Tumor Features

Osteoid osteoma - Affects diaphysis of long bones

- Commonest benign true bone tumor
- Pain worse at night relieved by aspirin
- Xray shows radiolucent nidus surrounded by
sclerosis

Osteochondroma - Arises from metaphyses of long bones

(Exostoses) - Mature bone with cartilaginous cap seen
- Treatment if indicated is extra periosteal resection
of the tumor
- Trevor’s disease: Osteochondroma on epiphyseal
side of growth plate

Enchondroma - Most common tumor of small bones of hands and

feet
- Arises from remnants of epiphyseal cartilage
- Ollier’s disease: nonfamilial multiple enchondromas
- Mafucci syndrome: familial multiple enchondroma
with cavernous hemangiomas and phlebolith

Osteoclastoma - Affects epiphysis of long bones (MC – distal femur)

- Egg shell crackling on palpation
- Soap bubble lesion on Xray
- Goltz syndrome: Multiple Giant cell like bone tumor
- Malignancy in GCTÆ Osteosarcoma / Malignant
fibrous Histiocytoma / Fibrosarcoma
- Tumors with giant cells: Non ossifying fibroma
(MC), Brown tumor, Aneurysmal bone cyst,
Fibrosarcoma, MFH, Clear cell chondrosarcoma

Chondroblastoma - Arises from epiphysis of a long bone

- Calcification present giving ‘chicken wire
appearance’
 Orthopedics Oncology V
Malignant bone tumors

Tumor Features
nd
Osteosarcoma - 2 MC primary malignant bone tumor
- Predisposing factors: Paget’s disease of bone, Familial
Retinoblastoma, Bone infarcts, Radiotherapy
- Affects metaphysis of long bones
- Xray appearances
o Lytic lesion with moth eaten appearance
o Sunburst appearance
o Codman’s triangle
- Extremely radioresistant
- Rosen T-10 protocol used in chemotherapy

Ewing’s sarcoma - Affects boys <15 years

- Arises from diaphysis of long and flat bones (pelvis)
-

Enchondroma - Most common tumor of small bones of hands and feet

- Arises from remnants of epiphyseal cartilage
- Ollier’s disease: nonfamilial multiple enchondromas
- Mafucci syndrome: familial multiple enchondroma with
cavernous hemangiomas and phlebolith

Osteoclastoma - Affects epiphysis of long bones (MC – distal femur)

- Egg shell crackling on palpation
- Soap bubble lesion on Xray
- Goltz syndrome: Multiple Giant cell like bone tumor
- Malignancy in GCTÆ Osteosarcoma / Malignant fibrous
Histiocytoma / Fibrosarcoma
- Tumors with giant cells: Non ossifying fibroma (MC), Brown
tumor, Aneurysmal bone cyst, Fibrosarcoma, MFH, Clear cell
chondrosarcoma
 Osteochondritis of different bones
Kienbock - Lunate
Kohler - Navicular
Perthes - Femoral head
Scheurmann - Ring epiphysis of vertebra
nd
Frieberg - 2 metatarsal head
Osgood Schattler - Tibial tuberosity
Sever’s - Calcaneum
Blount’s - Tibia
Haas - Head of humerus
Panner’s - capitulum of elbow
th
Islene - 5 metatarsal base
Prieser’s - Scaphoid
Johansen-Larsen’s - lower pole of patella
 Eponymous fractures

Aviator’s fracture - # neck of talus; due to sudden forced dorsiflexion

Barton’s fracture - intra articular # of distal articular surface of radius
st
Bennet’s fracture - oblique intra articular # of base of 1 metacarpal with subluxation
st
of 1 carpo metacarpal joint
th
Boxer’s fracture - ventrally displaced # through neck of 5 metacarpal
Bumper fracture - comminuted depressed # of lateral tibial condyle
Chance fracture - horizontal # through vertebral body
Chauffer’s fracture - # of radius just above the styloid process
Cotton’s fracture - trimalleolar # ankle
Pond’s fracture - depressed fracture in skull of infants
th
Jone’s fracture - avulsion # of base of 5 metacarpal
Pilon fracture - comminuted # of tibial articular surface with # of tibia
Pott’s fracture - bimalleolar # ankle
Galeazzi fracture - # distal third of radius with dislocation of distal RUJ
Monteggia’s fracture - # of proximal third of ulna with dislocation of head of radius
Smith’s fracture - reverse of Colle’s fracture
Piedmont fracture - closed # of radius at the junction of middle and distal thirds
Jefferson’s fracture - burst fracture of atlas
Hangman’s fracture - Traumatic spondylolisthesis of C2
Green stick fracture - bending of bone with incomplete # involving convex side of curve
only
 Tuberculosis of bones and joints
Most common site of skeletal TB: spine
Most common location of Pott’s spine: Dorsolumbar region
Paradiscal type > Central (vertebral body) > Anterior > Appendiceal / posterior
Earliest feature of spinal tuberculosis is reduction of intervertebral space
Most common clinical feature of spinal TB is kyphosis
Alderman’s gait is seen in TB affecting dorsolumbar spine
Tu'berculosis with polyarthritis is known as Poncet’s disease
Tuberculosis of shoulder is dry with no effusion – Caries sicca
TB dactylitis is also known as spina ventosa
Most common site affected in TB hip is roof of acetabulum
Radiological features of TB hip include mortar pestle appearance, wandering acetabulum, protrusio
acetabuli etc
Phemister triad of tubercular arthritis includes juxtaarticular osteoporosis, peripheral osseous
erosions and narrowing of joint space
Triple deformity is seen in Tuberculosis of knee which include flexion, posterior subluxation and
external rotation of tibia
 Platelets

Normal count : 1.5 to 4 lakhs/mm3

Life span : 7 -10 days
Disorders of Platelet function
- Adhesion disorders
ÆBernard Soullier syndrome (platelet membrane glycoprotein Ib-IX defect)
ÆVon Willebrand disease
ÆUremia
- Aggregation defects
Æ Glanzmann thrombasthenia (dysfunction of glycoprotein IIb-IIIa)
Æ Afibrinogenemia
ÆTiclopidine, GpIIb/IIIa inhibitors
- Disorders of granule release
ÆChediak Higashi syndrome
ÆGrey platelet syndrome
Æ Oculocutaneous albinism
ÆMyeloproliferative diseases
ÆCardiopulmonary bypass

Large platelets
- May Hegglin anomaly
- Fechtner syndrome
- Sebastian syndrome
- Epstein syndrome
Heparin Induced thrombocytopenia
- Due to antibodies against heparin- platelet factor 4 antibodies
- Increased risk of thrombosis
- Treatment Æwithdraw heparin, direct thrombin inhibitors (argatroban, lepirudin)
 Sickle cell disease
th
Point mutation at the 6 codon of beta globin chain leading to substitution of glutamine by valine
Sickle cell trait gives protection against falciparum malaria
In sickle cell trait, 40% is HbS and rest is HbA
HbF and HbC inhibit polymerization of HbS, hence protection from symptoms
Clinical features
- Vaso occlusive / pain crisis is the most common clinical manifestation
- Plugging of small vessels in bone – dactylitis (hand and foot syndrome)
- Autosplenectomy
- More prone for Pneumococcus, H.influenza septicaemia
- Avascular necrosis of femoral head, Osteomyelitis due to femoral head
- Extramedullary hematopoesis – prominent cheek bones and crew cut appearance of skull
- Occlusion of vertebral arteries – fish mouth deformity of vertebra
- Aplastic crisis due to Parvo virus B19
- Renal papillary necrosis leads to hyposthenuria
- Priapism
- Leg ulcers
Metabisulfate and sodium dithionate used for sickling test
Diagnosis in neonatal period : High Perfomance Liquid Chromatography
Hydroxyurea is the drug used in treatment which acts by increasing the synthesis of HbF
Quantitative estimation of HbF made by Kleihauer test
 Myocardial Infarction

rd
Subendocardial MI: ischemic necrosis limited to 1/3 of ventricular wall thickness due to
incomplete coronary occlusion
Following ischemia, the earliest physiological change is ATP depletion in the cell (starts within
seconds)
Loss of contractility occurs in <2 min and irreversible injury in 20-40 min
Morphological changes following MI
- Waviness of fibres at border (earliest change)
- Neutrophil infiltration in 12-24 hours
- Granulation tissue in 7 -10 days
- New blood vessels and collagen deposition in 10-14 days
- Dense collagenous scar by > 2 months
In infarcts < 12 hours old, area of necrosis can be identified by immersing tissue slices in Triphenyl
tetrazolium chloride (infracted area – unstained pale zone)
Characteristic microscopic change in reperfusion – necrosis with contraction band
Myoglobin is the earliest marker to raise following MI (not specific)
Elevated levels of CPK-MB and Troponins distinguish patients with NSTEMI from those with UA
CK-MB is the most sensitive early marker of MI
CK-MB is the test of choice to diagnose reinfarct (value falls to normal in 48-72 hours)
Rupture of ventricular free wall is the most common mechanical complication of MI
The antero-lateral wall at the mid ventricular level is the most common site of rupture
Ventricular aneurysm is the complication that occurs very late
Dressler’s syndrome is the immune mediated post MI pericarditis
 Tumor Markers

HCG - Trophoblastic tumors, Non seminomatous

testicular tumors
Calcitonin - Medullary carcinoma thyroid
Catecholamines - Pheochromocytoma
Alpha feto protein - Liver cell carcinoma, Non seminomatous germ
cell tumors
Carcinoembryonic antigen - Cancer of colon, pancreas, lung
Neuron specific enolase - Small cell cancer of lung, Neuroblastoma
CA 125 - Ovarian cancer, some lymphomas
CA 19 -9 - Colon, Pancreas, Breast
CA 15 – 3 - Breast cancer
S – 100 , HMB 45 - Melanoma
CD 30 - Hodgkin’s disease, Anaplastic large cell
lymphoma
PSA, P. Acid phosphatase - Prostate cancer
Immunohistochemical markers used in Carcinoma of Unknown Primary

Thyroid transcription factor - Thyroid, Lung

Chromogranin, Synaptophysin, CD56 - Neuroendocrine tumor
Calretinin, Mesothelin - Mesothelioma
HMB-45, Tyrosinase, Melan A - Melanoma
URO- III, Thrombomodulin - Bladder cancer
CDX – 2 - Gastric cancer
WT-1, estrogen receptor - Mullerian / Ovarian cancer
RCC, CD10 - Renal cell carcinoma
BRSR 1, Gross Cysstic Disease fibrous
Protein - 15 - Breast cancer
 Paraneoplastic neurologic syndromes

Syndrome Antibody

Encephalomyelitis, Subacute sensory neuronopathy Anti- Hu

Cerebellar degeneration Anti- Yo, Anti- Tr

Opsoclonus, cerebellar degeneration Anti Ri

Encephalomyelitis, chorea, optic neuritis, Uveitis, Anti CV2 / CRMP5

peripheral neuropathy

Limbic, hypothalamic, brainstem encephalitis Anti-Ma proteins

Cancer associated retinopathy, Melanoma associated Recoverin, Bipolar cell antibodies

retinopathy

Stiffman syndrome Anti- GAD

Lambert Eaton myasthenic syndrome Anti – VGCC

 COLLAGEN

Collagen type Tissue distribution Genetic disorders

Fibrillar collagen

I Adult skin, bones, soft tissues Osteogenesis imperfect, Ehler

Danlos syndrome
(arthrochalasis type)

II Cartilage, intervertebral discs, vitreous Achondroplasia,

Spondyloepiphyseal dysplasia

III Hollow organs, soft tissues, Vascular Ehler Danlos

V Soft tissues, blood vessels Classical EDS

IX Cartilage, Vitreous Stickler syndrome

Basement membrane collagen

IV Main component of basement Alport syndrome

membrane

Other collagens

VI Microfibrils Bethlem myopathy

VII Anchoring fibrils at dermal-epidermal Epidermolysis bullosa

junction

Keloid – excess Type III collagen

Most abundant glycoprotein in basement membrane - Laminin
 Tumor suppressor genes and their location

p53 - 17 p (Li Fraumeni syndrome)

RB - 13 q (Retinoblastoma)
APC - 5 q 21 (Colon cancer with polyposis)
PTEN - 10 q 23
NF1 - 17 q (Neurofibromatosis 1- Neurofibromin protein)
NF2 - 22 q (Merlin protein)
VHL - 3 p (Renal cell carcinoma, Hemangioblastoma,
Pheocromocytoma)
WT1 - 11 p (Wilm’s tumor)
BRCA 1 - 17 q (Breast cancer)
BRCA 2 - 13 q (Ovarian cancer, Male breast cancer)
DCC - 18 q (Deleted in Colon cancer)
INK4a - 9 p (Melanoma)
 Inflammation

The phenomenon of ‘Phagocytosis’ discovered by: Metchnikoff

Four cardinal signs of inflammation proposed by: Celsus
Fifth sign of acute inflammation (loss of function) put forward by Virchow
Earliest change in inflammation – transient vasoconstriction
Hallmark of acute inflammation – Increased vascular permeability
Hallmark of chronic inflammation – tissue destruction
Platelet Activating Factor (PAF) causes leukocyte priming
Nitric Oxide is synthesised from L-arginine by the enzyme Nitric Oxide synthase
Histamine dilates arterioles but constrict large arteries
Lipoxins are inhibitors of inflammation
Most effective bactericidal system in neutrophils: H2O2 – MPO – Halide system
Selectins are responsible for rolling of neutrophils and beta 2 integrins for neutrophil
adhesion
Delayed separation of umbilical cord : Selectin or CD 11a : CD 18 deficiency
The replication of hepatocytes after liver resection is mediated by TGF-alpha
 Stem Cells
Self renewal : ability to go through numerous cycles of cell division while maintaining
undifferentiated state
Potency : capacity to differentiate into specialised cell types
- Totipotent / Omnipotent Æ can form entire organism, eg: Zygote
- Pluripotent Æ can differentiate into cells derived from any of the three germ layers
- Multipotent Æ can form multiple lineages, but cannot form all cells, eg:
hematopoetic stem cells
- Oligopotent cells Æ form only a few lineages; eg: neuron stem cells, lymphoid /
myeloid stem cells
- Unipotent stem cells Æ produce only one cell type with property of self renewal, eg:
progenitor cells, muscle stem cells
Stem cells are present at special sites called niches

Stem cell Location

Oval cells Canal of Herring (Liver)
Satellite cells Basal lamina of myotubules
Limbus cells Canal of Schlemm
Ito cells Subendothelial space of Disse
Paneth cells Base of intestinal crypts
 Autoantibodies and diseases

Anti TSH receptor - Grave’s disease

Anti myeloperoxidase (p ANCA) - Microscopic polyangitis
Anti- proteinase 3 - Wegner’s granulomatosis
Anti ds DNA, Anti Smith Ab - SLE
Anti centromere - Limited scleroderma
Anti topoisomerase - Diffuse scleroderma
Anti Ach receptor, Anti MuSK - Myasthenia Gravis
Anti mitochondrial - Primary Biliary Cirrhosis
Anti histidyl t RNA synthetase - Inflammatory myopathies
Anti parietal cell ab - Pernicious anemia
Anti basement membrane - Goodpasture syndrome
Anti thyroglobulin - Grave’s disease
Anti SS-A, Anti SS-B - Sjogren’s syndrome
Anti gliadin, transglutaminase - Celiac disease
 Vasculitic disorders

Most common artery involve in Giant cell arteritis is superficial temporal artey
Jaw claudication is the most specific symptom
Most common association of Temporal arteitis is with Polymyalgia rheumatic
Takayasu arteritis is a granulomatous vasculitis of medium and large sized vessels
Most common artery involved is subclavian artery; also known as pulseless disease
Polyarteritis Nodosa causes segmental transmural, necrotizing inflammation of small and medium
sized arteries with characteristic involvement of renal and visceral arteries
Hepatitis B and Hairy cell leukemia are associated with PAN
Digital gangrene, renal hypertension, mononeuritis multiplex etc can occur but death is commonly
due to bowel infarcts and perforation
Classical PAN is p-ANCA negative while Microscopic PAN is p-ANCA positive
Kawasaki disease is mucocutaneous lymphnode syndrome
Associated with Staph aureus infection that releases TSST-1
Strawberry tongue, erythema and edema of hands and feet, non purulent conjunctivitis etcare
features
Associated with thrombocytosis and presence of anti-endothelial antibodies
Treatment is with Aspirin and IV Immunoglobulins
Wegener’s granulomatosis can present with nasal perforation, otitis media, subglottic stenosis, lung
cavitation etc
Treatment of choice of Wegners is Cyclophosphamide
Henoch Schonlein purpura is the most common vasculitic disorder of childhood
 Rheumatic Heart Disease

Most common form of acquired heart disease in the world

Mitral valve disease and chorea occurs more commonly in women, aortic valve involvement more
common in men
Associated with HLA-DR3 and B-cell alloantigen (Serum 883)
Pulmonary involvement in acute rheumatic fever is never seen
Diagnosis made using Modified Jones criteria
Migratory polyarthritis is the most frequent major manifestation and shows a dramatic response to
salicylates with no residual damage
Erythema marginatum is seen over the trunk and spares face
Abnormal movements of chorea are absent during sleep
Aschoff bodies are the most distinctive lesion in acute rheumatic fever
The characteristic cell is a plump macrophage called Anitschkow cells or caterpillar cells
MacCallum plaques are sub endocardial lesions usually found in left atrium
Fish mouth or button hole stenosis of of valves are due to fibrous thickening across the valvular
commissures
Vegetations are small and non friable and are seen along the lines of closure
 Special stains in histopathology

Periodic Acid Schiff - Glycogen, Fungi

Mucicarmine - Acid mucin
Masson Fontana - Melanin
Perl’s Prussian blue - Iron / Hemosiderin
Rubeanic acid, Orcein - Copper
Von Kossa, Alizarin red - Calcium
Von Gieson’s, Mason’s trichrome - Collagen
Phospho tungstic acid hematoxylin - Muscle and glial filaments
Bielschowsky’s silver - Axons
Luxol fast blue - Myelin
Oil red O, Sudan black, Osmium tetroxide - Lipid
Congo red, Thioflavin T,S - Amyloid
Acridine orange - DNA, RNA
Toluidine blue - Mast cell granules
Fite wade stain - M. Leprae
Shikata’s orcein - Hepatitis B surface antigen
Methenamine silver - Fungi
 Inclusion bodies in Infectious conditions

Negri body - Rabies

Henderson Peterson body - Molluscum contagiosum
Guarnieri body - Small pox
Haberstaedter Prowazek body - Trachoma
Bollinger body - Fowl pox
Torres body - Yellow fever
Lipshutz inclusions - Herpes virus
Donovan body - Granuloma inguinale
Babes Ernst granules - Coryne bacterium dipheriae
Warthin Finkelday giant cells - Measles
Miyagawa corpuscles - LGV
Citron body - Clostridium septicum
Coccoid X body - Psittacosis
Guarnieri body - Vaccinia
Levinthal Cole Lilly body - Psittacosis
Mooser body - Endemic typhus
Ross body - Syphilis
LD body - Kala Azar
Asteroid body - Sporotrichosis
Councilman body - Viral hepatitis
 Important bodies in non-infectious conditions
Asteroid body - Sarcoidosis
Ferruginous body - Asbestosis
Lafora body - Myoclonic epilepsy
Hirano body - Alzheimer’s disease
Michaelis Gutman body - Malacoplakia
Russel body - Multiple myeloma
Mallory body - PBC, Alcoholic hepatitis, Wilson disease
Heinz body - G6PD deficiency
Verocay body - Schwannoma
Zebra body - Metachromatic leukodystrophy
Rushton body - Odontogenic cyst
Sandstorm body - Parathyroid gland
Schiller Duval body - Yolk sac tumor
Call Exner body - Granulosa cell tumor
Reilly body - Hurler syndrome
Civatte body - Lichen planus
Aschoff body - Rheumatic fever
Psammoma body - Papillary carcinoma thyroid, ovary; meningioma,
Mesothelioma
 Bleeding and coagulation disorders

Von Willebrand disease is the most common inherited bleeding disorder on man
vWF is stored inside the endothelial cells in membrane bound organelles called Weibel Palade bodies
GP Ib-IX is the major receptor for vWF
Type 3 Von Willebrand disease is the most serious of the 3 types with extremely low levels of vWF
Acquired vWD is most commonly seen in Monoclonal Gammopathy of Unknown significance (MGUS)
Heyde syndrome is vWD with Aortic stenosis and GI bleeding due to colonic angiodysplasia
Bleeding time and aPTT are increased while Prothrombin time is normal and Ristocetin cofactor
activity is rduced
Classical Hemophilia is due to deficiency of Factor VIII
It is the most common congentital disorder associated with life threatening bleeding
Severe disease is indicated by < 1% of factor VIII activity
The characteristic clinical finding is the hemarthrosis which involves knee joint in adults and ankle
joint in children
Hemophilia B (Christmas disease) is due to decreased Factor IX activity
Hemophilia C is due to decreased Factor XI activity
Epidemiology of Cancer

Most common cancer in the world : Lung cancer

Second most common cancer : Breast cancer
MCC of cancer death in the world : Lung cancer
MC cancer in males : Prostate cancer
MC cancer in females : Breast cancer
Second MC in both males & females : Lung cancer
Most common cancer in < 20 yrs : Leukemia
MC cancer in females 20- 60 yrs : Breast cancer
MC cancer in females >60 yrs : Lung cancer
MC cancer in developing countries : Cervix, Liver
 Thyroid cancers

Most common thyroid carcinoma - Papillary

Least common thyroid carcinoma - Anaplastic
Least malignant - Papillary
Most malignant - Anaplastic
Most common cancer after radiation - Papillary
Cancer developing in Hashimoto thyroiditis - Lymphoma
Thyroid cancer developing in long standing MNG - Follicular
Type of thyroid cancer in MEN syndrome - Medullary
Thyroid cancer associated with amylodosis - Medullary
Psammoma bodies are associated with - Papillary
Orphan annie eyed nuclei seen in - Papillary
Carcinoma derived from ‘C’ cell of thyroid - Medullary
Carcinoma developing in thyroglossal tract - Papillary
 Cancers and Etiology

Etiology Cancer

Diethyl stilbestrol Vaginal clear cell carcinoma

Asbestos Mesothelioma

Aflatoxin Hepatocellular carcinoma

Prenatal alcohol, phenytoin Neuroblastoma

UV radiation Melanoma, basal and squamous cell carcinoma

Vinyl chloride Hepatic angiosarcoma

Cyclophosphamide Bladder cancer

Aniline dye Bladder cancer

Benzene Leukemia, Myelodysplasia

Human Immunodeficiency virus Leiomyosarcoma

Schistosoma hematobium Bladder carcinoma

Clonorchis sinesis Biliary tract cancer

Simian virus 40 Ependymoma, choroid plexus tumor

Epstein Barr virus Burkkit’s lymphoma, Nasopharyngeal carcinoma

HTLV 1 T cell lymphoma

 Neuromuscular disorders
Most neuronopathies are distal in distribution except Juvenile Spinal Muscular Atrophy
Most myopathies present with proximal, symmetric limb weakness with the exception of Myotonic
dystrophy which involves distal muscles
Botulinum toxin inhibits synaptobrevin and syntaxin and blocks release of acetyl choline from presynaptic
terminal
Vitamin deficiency causing myopathy – Vitamin E
Most common genetically determined neuropathy – Charcoat marie tooth disease
Most commonly biopsied muscle is Vastus lateralis
Kocher Debre Semelaigne syndrome – pseudohypertrophy of muscles seen in cretinism rarely
The three congenital myopathies presenting in adulthood are: Central core disease, Nemaline myopathy
and Centronuclear myopathy
Death in Duchenne Muscular Dystrophy occurs by 18-20 years and is mostly due to pulmonary insufficiency
Dilated Cardiomyopathy occurs in almost all patients with DMD with increasing age
Hatchet facies, Frontal baldness, Christmas tree cataract, heart block etc are features of Myotonic
dystrophy
Antimyotonia drug of choice is phenytoin and mexiletine
Muscle dystrophy associated with Coat’s disease of eye is Facio scapulo humeral dystrophy
An infant presents with hypotonia and areflexia. During his intrauterine period there was polyhydramnios
and decreased fetal movements. He has fasciculations of tongue and frog like posture of limbs. The
diagnosis is Spino muscular atrophy
 Thyroid disorders in children
Most common cause of congenital hypothyroidism is Thyroid dysgenesis
It has a prevalence of 1 in 3000 infants
Most common anomalies associated with congenital hypothyroidism is cardiac
X ray features of the former include:
- absence of femoral epiphyses at birth
- punctuate epithelial dysgenesis
th st nd
- beaking of 12 thoracic, 1 and 2 lumbar vertebrae
The two types of cretinism are neurological and myxedematous
Deccelaration of growth and goiter are usually the first clinical manifestations in children with
hypothyroidism
Younger children may present with galactorrhea or pseudoprecocious puberty
The most common cause of acquired goitre in the world is Hashimoto’s disease
Abnormal lab findings in hypothyroidism are hyponatremia, macrocytic anemia, hypercholesterolemia
and elevated CPK
Earliest signs of hyperthyroidism in children are emotional disturbances accompanied by motor
hyperactivity
The drug of choice for treating Grave’s disease in children is Methimazole
Adrenal disorders in Children
Congenital adrenal hyperplasia (CAH) is a family of autosomal recessive disorders of cortisol biosynthesis
nd
Most common type of CAH is 21 hydroxylase deficiency; 2 most common is 11 beta hydroxylase
deficiency
21 hyroxylase deficiency is characterised by elevated 17-hydroxyprogesterone
In males with 21 hydroxylase deficiency, external genitalia is normal at birth whereas females will be
virilised at birth itself
Males with ambiguous genitalia at birth: 3 beta hydroxysteroid deficiency, 17 hydroxylase deficiency,
Steroidogenic acute regulatory deficiency
Types of CAH with hypertension – 11 hydroxylase and 17 hydroxylase deficiency
Drug of choice for CAH in children is Hydrocortisone
Most common cause of endogenous cushing syndrome in children < 7years Æ Adrenocortical tumor
(ACTH producing adenoma is the MCC in children > 7years)
Loss of diurnal variation is the earliest biochemical marker of hypercortisolism
Confirmatory test for Cushing’s disease – Bilateral inferior petrosal sinus sampling
Combination of chronic mucocutaneous candidiasis, hypoparathyroidism and Addison disaease –
Autoimmune Polyglandular syndrome 1
Gold standard test for diagnosing adrenal insufficiency – Insulin induced hypoglycaemia
 Genetics of Congenital Heart Disease

Syndrome Cardiac lesion Gene and Other features

Chromosome

Cornutruncal defects 22q 11 Facial anomalies,

DiGeorge syndrome (Truncus arteriosus, TOF) hypoparathyroidism,
depressed cell mediated
immunity

Holt Oram syndrome ASD 12q2 Limb anomalies

TBX5 gene

Alagille syndrome Peripheral pulmonary artery 20p12 Bile duct anomalies,

stenosis butterfly vertebra

Noonan syndrome ASD, PS, Hypertrophic 12q24

cardiomyopathy

Down syndrome AV canal defect 21q22

Williams syndrome Supravalvular aortic stenosis, 7q11 Elfin facies, hypercalcemia

branch PS Elastin gene

Char syndrome PDA 6p12 Cranio-facial, limb defects

Ellis Van Creveld ASD, Single atrium 4p16 Polydacyly

syndrome

Marfan syndrome Aortic root dilatation 15q21 Connective tissue

Fibrillin weakness
 Classification of Congenital Cyanotic Heart Diseases

With increased pulmonary blood flow With decreased pulmonary blood flow

TGA with VSD or PDA Tetralogy of Fallot

TAPVC Pulmonary atresia

Truncus Arteriosus Tricuspid atresia with intact ventricular septum

Hypoplastic left heart syndrome Ebstein’s anomaly

DORV without PS DORV with PS

DORV with TGA (Taussig Biicleng anomaly) TGA with VSD and PS

Single vent
 Chest X-ray appearances in Congenital Heart diseases

Diagnosis Chest Xray appearance

D- TGA Egg on string appearance

L-TGA Straight left heart border

TOF Boot shaped heart

Non obstructive TAPVC Snowman of Figure of 8 appearance

Obstructed TAPVC Small heart with ground glass lungs

Ebsteins anomaly (severe) Box shaped heart

Right Axis Deviation Left Axis Deviation

TOF Tricuspid atresia

TGA Pulmonary atresia with IVS

TAPVC Ostium Primum ASD

Ostium secundum ASD VSD

PDA
 Congenital cyanotic heart diseases
Cyanosis noted since 6 months of life in a baby with typical dyspnea on exertion and squatting
episodes. History of cyanotic spells present. On examination, child has a prominent a wave in JVP,
loud S2 with ESM in pulmonary area. CXR shows oligemic lung fields with normal sized heart and
upturned apex. Classical ECG finding of pure ‘R’ wave in V1 and transition to R/S in V2
- Tetralogy of Fallot
New born presenting with severe cyanosis, massive cardiomegaly and long systolic murmurs.
Prominent V wave in JVP, association with WPW syndrome, Himalayan ‘P’ waves in ECG, intake of
lithium in the mother during antenatal period
- Ebstein anomaly

A cyanotic newborn is suspected of having CHD. She has a left ventricular impulse, with holosystolic
murmur, audible at left sterna border with single S2. CXR shows decreased pulmonary blood flow,
oligemic lung fields. ECG shows left axis deviation.
- Tricuspid atresia

A male neonate born to gestational diabetic mother presents with severe cyanosis and CCF at birth.
ECG shows right axis deviation and RVH. CXR shows cardiomegaly (egg on side app.) with plethoric
lung fields
- TGA
A baby presenting with minimal cyanosis and CCF, single loud S2, association with DiGeorge
syndrome, surgery indicated in the neonatal period to prevent development of pulmonary vascular
disease
- Truncus arteriosus
Baby presenting with CCF at 4 weeks of life, with minimal cyanosis, with all auscultatory features of
ASD, expected to have typical X-ray picture of Snow man appearance later in life.
- Supracardiac non obstructive TAPVC
Baby presenting with CCF with RV dilatation and progressive TR, shock and poor peripheral perfusion
associated with extra cardiac anomalies including renal and CNS anomalies
- Hypoplastic left heart syndrome
 Congenital Acyanotic heart diseases

A 3 year old girl, asymptomatic, incidentally found to have widely split, fixed S2, soft ejection systolic
murmur in the pulmonary area and short, rumbling MDM in the tricuspid area. ECG shows RVH and
RAD.
- Ostium secundum ASD
An asymptomatic girl with all auscultatory features of ASD + apical holosystolic murmur. ECG shows
LAD
- Ostium primum ASD
A child having all auscultatory features of ASD but cyanosis alos present:
- Supracardiac type of TAPVC
A 4 year old girl with large VSD and CCF on anti failure treatment recently presenting with
improvement in failure symptoms, as evidenced by improved exercise tolerance:
- VSD developing pulmonary hypertension
A adolescent diagnosed with VSD with PSM heard in mid to upper left sterna border, presents with
decrescendo diastolic murmur in aortic area.
- Supracristal type of VSD complicated by Aortic regurgitation
st
A 1 year old girl presenting with machinery murmur, beginning after the onset of 1 sound, reaching
nd
maximal intensity at the end of systole and waning in late diastole, localised in 2 left intercostal
space
- PDA
A newborn presenting with CCF on day 8 of life with systolic murmur in the left sternal border with
loud S2. The lower limb pulses are poorly felt with a weak femoral pulse:
- Severe coarctation of aorta presenting in the neonatal period; (ductus dependant
condition)
 Congenital Heart Disease and Management

CHD Management

Cyanotic Heart Disease

TOF - PalliativeÆ Modified Blalock Taussig shunt

- DefinitiveÆ Total repair (resection of RVOT obstruction and VSD
closure)

Ebstein’s anomaly Starnes procedure

Tricuspid atresia Modified Fontan operation (Total cavo-pulmonary connection)

TGA Rashkind balloon atrial septostomy

Jatene arterial switch operation

Truncus Arteriosus Rastelli repair

TAPVC Anastomosis of pulmonary veins to LA, ASD closure

HLHS Norwood procedure

Acyanotic heart disease

ASD Percutaneous catheter device closure

VSD (in indicated cases) Surgical closure of defect

PDA Preterm: Indomethacin

Term: surgical / catheter closure

Coarctation of Aorta Resection of coarctation with end to end anastomosis

Severe CoA Æ PGE1 infusion
 Down Syndrome
nd
The most common genetic cause of mental retardation (2 is Fragile X syndrome)
Most males with down’s are sterile but females have been able to reproduce
MCC of Down’s syndrome is non disjunction of maternal chromosome in meiosis I
The most common translocation in Down syndrome involves chromosomes 14 and 21
The only feature which tend to improve with age in Down’s is muscle tone
Hall’s criteria is used for clinical diagnosis
Presence of congenital heart disease (AV canal defects) is the most significant factor in determining
survival in Down’s syndrome
Quadruple test Æ Triple test (beta HCG, Serum estriol, AFP) + Inhibin A
Combined test Æ PAPP-A, beta HCG, Nuchal translucency (used in 1 trimester diagnosis)
st

Other USG markers or Down syndrome

o Short femur and humerus
o Duodenal atresia
o Absent nasal bone
The dermatological feature in Down’s is Cutis marmorata
The haematological abnormalities include Transient lymphoproliferative syndrome, Acute
lymphocytic leukemia and Acute Myelogenous Leukemia
 Other Aneuploidies

Edward syndrome - Second most common trisomy

rd
(Trisomy 18) - Index finger overlapping 3 digit and little finger overlapping
th
the 4 finger is a classical hand pattern
- Elongated skull and simple arches on all digits are classical
features
- CHD associated are VSD, PDA, ASD

Patau syndrome - The classical features include:

(Trisomy 13) - Ectodermal scalp defect
- ic Harelip
- Cleft palate
- Thin posterior ribs (missing ribs)
- Hypoplastic and hyperconvex nails

Turner syndrome - Bicuspid aortic valve and coarctation of aorta

(45 XO) - Horse shoe kidney
- Newborns with short stature, prominent ears, webbing of neck
and edema of hands and feet
- Anti thyroid antibodies in 50%
- Growth hormone replacement given
- Cubitus valgus, shield chest, congenital lymphedema

Noonan syndrome - Male turner’s syndrome

(45 YO) - Autosomal dominant disorder (chromosome 12)
- Pulmonary stenosis, Hypertrophic cardiomyopathy, ASD
- Short stature, shield chest, low posterior hair line
- Bleeding disorders, Dental malocclusion
 Some important chromosomal disorders
Syndrome Chromosomal Features
abnormality
Cri du chat syndrome Deletion 5p - Characteristic shrill cry
- Microcephaly, hypotonia, short stature
- High arched palate, epicanthic folds
Rett syndrome Duplication Xp28 - Deceleration of rate of head growth
(MECP2 gene region) - Repetitive stereotyped hand movements
- Autistic behaviour, Speech delay
Williams syndrome Deletion 7q - Elfin facies
- Supravalvular aortic stenosis
- Stellate pattern in iris, strabismus
DiGeorge syndrome Deletion 22q - Conotruncal cardiac anomalies
- Velopharyngeal incompetence
- Hypoplastic thymus and parathyroid
- Learning disability
- Facial anomalies
Alagille syndrome Deletion 20p - Bile duct paucity with cholestasis
- Peripheral pulmonary artery stenosis
- Posterior embryotoxon
- Butterfly vertebra
Prader Willi syndrome Deletion 15q - Short stature, obesity
Genomic imprinting - Hypogonadism
- Hypotonia, mental retardation
Angelman syndrome Deletion 15q - Inappropriate laughter
Genomic imprinting) - Severe mental retardation
- Poor or absent speech
- Seizures
- Feeding difficulties
 Breast milk
Human milk is the sweetest milk followed by ass milk
The most abundant proteins in human breast milk are lactalbumin and lactoferrin (Whey proteins)
PABA in breast milk give protection against and lactt malaria, Glycosaminogycans against HIV and
bifidus factor and lactoferin against E.Coli
Among the amino acids, glutamic acid is maximum and glycine is absent in human milk
Human milk is a good source of vitamins except Vitamin K and Vitamin D
The osmolality of cow’s milk is 221 mOsm/L as against 79 mOsm/L in human milk
Energy to protein ratio is 70 in human milk compared to 25 in cow’s milk
Contraindications to breast feeding include Congenital lactose intolerance, Galactosemia and
maternal intake of drugs like anti-cancer, anti-psychotic and anti-thyroid drugs
Cafeteria approach is associated with the breast feeding options of a working mother
The theme for World Breast feeding week 2014 (August 1-7) is “Breastfeeding: A Winning Goal – For
Life!"
Expressed breast milk can be stored at room temperature for 6 hours and can be refrigerated to be
used within 24 hours
The intake of Goat’s milk may predispose the child for folate deficiency and Brucellosis
Vitamins and Minerals
Hyperostosis, hepatosplenomegaly and pseudotumor cerebri are features of Hypervitaminosis A
Decreased levels of RBC transketolase and increased blood glyoxylate levels are diagnostic of
thiamine deficiency
Circumcorneal vascularisation, glossitis and peripheral neuropathy with decreased Erythrocyte
glutathione reductase activity – Riboflavin deficiency
Red vitamin – Vitamin B12
Pantothenic acid is Vitamin B5 and its deficiency is implicated in Burning feet syndrome
Both deficiency and excess of pyridoxine can produce peripheral neuropathy
Niacin is known as ‘Nature’s valium’ or Nature’s sleeping pill
Vitamin E is also called as ‘Shady lady of Nutrition’
Vitamin E excess may lead to necrotising enterocolitis in newborn
Pencil thinning of cortex, White line of Frenkel, Wimberger sign, Trummerfeld zone and Pelkan spur
are radiological signs of Scurvy
Selenium deficiency is associated with Keshan’s cardiomyopathy and Kashin Beck’s disease (endemic
osteoarthritis)
Chromium deficiency is associated with impaired glucose tolerance
Molybdenum deficiency can lead on to esophageal cancer and dental caries
 Normal findings in newborn

Length - 50 cm
Head circumference - 34 cm
Visual acuity in term infants: 20/ 150
Milia - distended sebaceous glands appearing as white dots over face and nose
Mongolian spots – bluish patches over buttocks and back; tend to disappear by 1 yr of age
Stork bites – vascular naevi presenting as pink macules over nape of neck, forehead and upper eyelids
Mastitis neonatorum – breast enlargement in first week of life due to maternal transfer of hormones
Epsteins pearl – whitish popular lesions seen over the palate and prepuce for a few days
Erythema toxicum – lesions with erythematous base on face, trunk and extremities
Harlequin colour change – division of body from forehead to pubis into red and pale halves; due to
abnormal vasomotor response and is transient
Sub conjunctival bleed, vaginal bleed and sub galeal bleed can be present normally in the neonatal
period
Abnormalities in new born

Third fontanelle is seen in Down syndrome and Hypothyroidism

Precocious dentition is seen in Ellis Van Creveld and Hallermann Steriff syndrome
Most serious complication of chronic oligohydramnios is pulmonary hypoplasia
Biggest risk factor for Necrotsing enterocolitis: Prematurity
Diagnostic finding of NEC: Pneumatosis intestinalis (presence of air in bowel wall)
Staging of NEC: Modified Bell’s staging
Staging of Respiratory Distress Syndrome: Silverman and Down’s syndrome
Staging of Hypoxic Ischemic Encephalopathy: Sarnat and Sarnat staging
Staging of gestational assessment: Expanded New Ballard score
Most commonly fractured bone during delivery: Clavicle
Commando crawl is seen in preterm asphyxiated babies resulting in spastic diplegia with the
pathological finding being periventricular leukomalacia
Polycythemia in newborn is hematocrit > 65%
 Fetal therapy

Erythroblastosis fetalis - Umbilical vein packed red cell transfusion

21 alpha hydroxylase deficiency - Dexamathosone
Bartter syndrome - Indomethacin
Severe Combined Immuno Deficiency- Fetal stem cell transplantation
Neonatal Hemochromatosis - Maternal IV Ig
Lupus anticoagulant - Maternal aspirin, Prednisolone
Supraventricular Tachycardia - Maternal digoxin, Amiodarone, Flecainide
Multiple carboxylase deficiency - Biotin
Immune thrombocytopenia - Umbilical vein transfusion, maternal IV Ig
Obstructive uropathy - Vesicoamniotic shunt plus amnioinfusion
Narcotic withdrawl symptoms - low dose methadone to mother
Twin Reversal Arterial Perfusion - Cord occlusion, Indomethacin
Neonatal Jaundice
1 gm Hemoglobin produces 35 mg of bilirubin
A bilirubin level of > 7mg/dl manifests as clinical jaundice or icterus in neonates
Contraindication of phototherapy: Direct hyperbilirubinemia
The light used for phototherapy is special blue light of wave length 420 to 480 nm
Baby is kept at a distance of 45 cm from the phototherapy unit
Structural isomerisation is the irreversible and most important mechanism of lowering bilirubin by
phototherapy
Indications of prophylactic phototherapy: ELBW babies and severly bruised infants
End tidal carbon monoxide has been thought of as a potential screening tool to detect
hyperbilirubinemia
The exchange transfusion done is called double volume exchange transfusion with 160 -170 ml/kg
Lucey Drsicoll syndrome: severe unconjugated hyperbilirubinemia in the first 2-3 days of birth due to
transplacental transfer of a glucuronyl transferase inhibiting substance
Phototherapy given to a neonate with conjugated hyperbilirubinemia will result in Bronze baby
syndrome
 Neonatal nomenclature
Late neonatal period - period from day 7 upto day 28 of life
Early fetal period - period of gestation upto 22 weeks
Intermediate fetal period - period of gestation from 22 to 27 weeks
Late fetal period - gestations greater than 27 weeks
nd
Perinatal period - 22 week of gestation to less than 7 days after birth
Preterm baby - baby born before 37 weeks
Post term - born at a gestational age of 42 weeks or more
Late preterm - babies between 34 and 38 weeks of gestation
Low birth weight baby - neonate weighing less than 2.5 kg irrespective of gestational age
Very low birth weight - neonate weighing < 1500 g
Extremely low birth weight- neonate weighing < 1000 g
Incredibly low birth weight baby- neonate weighing < 700 gm
 Most common in Pediatrics

Most common type of new born seizures : Subtle seizures

Most common cause of delayed puberty in boys : Constitutional delay
Most common inherited cancer in children : Retinoblastoma
Most common hereditary bleeding disorder : Von Willebrand disease
MCC of stridor at birth : Laryngomalacia
Most common cause of acquired hypothyroidism : Hashimoto thyroiditis
MCC of sensorineural deafness in children : Meningitis
MC type of nephritic syndrome assoc. With Renal vein thrombosis:
: Membraneous GN
MCC of congenital hydrocephalus : Aquductal stenosis
MCC of communicating hydrocephalus : Subarachnoid hemorrhage
MCC of severe obstructive uropathy : Posterior urethral valve
MCC of acute bronchiolitis : Respiratory syncitial virus
MC type of cerebral palsy in children : Spastic
MC benign tumors in children : Hemangioma
 Drugs of choice

Status epilepticus in children - IV Lorazpam

DOC for prevention of cyanotic spell - Propranolol
DOC for Methemoglobinemia - 1% Methylene blue solution
H. Influenza meningitis - Ceftriaxone
Maintaining patency of duct arteriosus - PGE1 infusion
DOC for Duschenne muscular dystrophy - Prednisolone
Listeria meningitis - Ampicillin
Acyclovir resistant varicella - Foscarnet
Sydenham’s chorea - Phenobarbitone
Infantile spasms associated with tuberous sclerosis - Vigabatrin
Neonatal seizures - Phenobarbitone
Alkaptonuria - Vitamin C + Nitisinone
Idiopathic hypercalciuria - Thiazide diuretics
Mycoplasma pneumonia - Macrolides
 Drugs concentrated in tissues

Skeletal muscle, Heart Digoxin , Emetine

Liver Chloroquine, Tetracycline, Mepacrine,

Digoxin
Kidney Digoxin, Chloroquine, Emetine

Thyroid Iodine

Brain Chlorpromazine, Acetazolamide,

Isoniazid
Retina Chloroquine

RBC Ethambutol, Chloroquine

Iris Ephedrine, Atropine

Bone and Teeth Tetracyclines, Heavy metals

Adipose tissue Thiopentone, Minocycline, DDT,

Clofazimine
Collagen Mepacrine
 Enzyme inhibitors
Competitive inhibitor Competes with Enzyme

Allopurinol Hypoxanthine Xanthine oxidase

Captopril Angiotensin 1 ACE

Moclobemide Catecholamines MAO-A

Sulfonamides PABA Folate synthetase

Physostigmine, Neostigmine Acetyl choline Choline esterase

Carbidopa Levodopa DOPA decarboxylase

Sulfadiazine PABA Folate synthase

Finasteride Testosterone 5 alpha reductase

Letrozole Androstenedione Aromatase

N on Competitive inhibitor Enzyme

Acetazolamide Carbonic anhydrase
Aspirin, Indomethacin Cyclooxygenase
Omeprazole H+ K+ ATPase
Statins HMG CoA reductase
Propyl thiouracil Thyroid peroxidise
Disulfiram Aldehyde dehydrogenase
Theophylline Phosphodiesterase
Digoxin Na+ K+ ATPase
 Drugs and their antidotes
Anticholinergics Physostigmine

Cyanide Sodium nitrite, sodium thiosulphate

Heparin Protamine sulphate

Iron Desferioxamine

Methanol Ethanol (competes with alcohol dehydrogenase)

Isoniazid Pyridoxine

Benzodiazepines Flumazenil

Paracetamol N- Acetyl cysteine

Lead Calcium sodium edentate

Digoxin Fab antibody fragment

Histamine Adrenaline

Opiates Naloxone

Heavy metals Dimercaprol or D-penicillamine

Warfarin Vitamin K
 Anti muscarinic drugs

Hyoscine induces ‘twilight sleep’, used as lie detector or truth serum drug in suspects
Central anticholinergic drugs (Benztropine, Benzhexol) are the drug of choice in treatment of drug
induced parkinsonism
Tropicamide is the shortest acting mydriatic
Pirenzepine and telenzipine is used in peptic ulcer disease
Glycopyrrolate is used as a preanesthetic medication
Darifenacin is a selective M3 blocker useful for irritable bowel syndrome and overactive bladder
Atropine is the antidote of choice for both oranophosphate and carbamate poisoning
Atropine’s effect declines rapidly in all organs except the eye
Tissues most sensitive to atropine are salivary and bronchial glands and the least sensitive ones are the
gastric parietal cells
Atropine is the DOC for early mushroom poisoning due to Inocybe species but is contraindicated in
poisoning due to Amanita muscaria
Atropine is the strongest cycloplegic agent, indicated for children
 Autacoids
Serotonin is a powerful vasoconstrictor except in skeletal muscle and heart
Ketanserin and Ritanserin are serotonin antagonists (5 HT 2A/2C) used in treatment of hypertension
5 HT3 antagonists like Ondansetron and Ganisetron are the DOC for chemotherapy induced vomiting
Sumatriptan (SC) is the DOC for aborting an acute attack of migraine
Frovatriptan is the longest acting and Rizatriptan is the most potent and fastest acting congener
Prolonged use of Methysergide can result in pulmonary, endocardial and retroperitoneal fibrosis
Betahistine is an oral histamine analogue used to control vertigo in Meniere’s disease
Rupatadine is an antihistamine with additional PAF antagonism
DOC for acute mountain sickness – Acetazolamide
DOC for sea sickness - Meclizine
Treatment of choice in beta blocker poisoning – Glucagon
Icatibant is a Bradykinin receptor antagonist
 Prostaglandins

Epoprostenol (PGI2) & treprostenil (PGI2) Pulmonary hypertension

Alprostadil (PGE1) Keeps ductus arteriosus patent before surgery

Epoprostenol Anti platelet aggregator in hemodialysis, blood

storage and cardio pulmonary bypass

Dinoprostone (PGE2) Cervical ripening

Carboprost (PGF 2alpha) To control post partum hemorrhage

Misoprostol (PGE1) Induction of abortion

Aerolised PGE2 Acute attacks of asthma

Misoprostol NSAID induced gastric ulcer

Alprostadil (PGE1) Penile erectile dysfunction

Lantanoprost (PGF2alpha) Glaucoma

 NSAIDS
Paracetamol is a selective COX 3 inhibitor in brain
Fatal dose of paracetamol is > 250 mg/kg
Aspirin is used to prevent niacin induced flushing and pre eclampsia
Ketorolac is the only NSAID used as IV preparation
Nefopam is the NSAID that does not act by inhibiting PG synthesis
Aceclofenac has chondroprotective action by enhancing glycosaminoglycan synthesis
Diflunisal can cause pseudo porphyria
Sulindac is the NSAID used in Familial Adenomatous Polyposis and inhibit development of colon, breast
and pancreatic cancers
Etoricoxib is the longest acting coxib
Indomethacin is the analgesic causing headache
NSAID causing agranulocytosis: Phenylbutazone
Ketoprofen has additional lysosomal stabilising action
Adrenergic drugs
Beta blocker without local anesthetic effect: Timolol
Vasopressor of choice in pregnancy: Ephedrine
Drug used to perform stress ECHO: Dobutamine
In anaphylactic shock, adrenaline is given by intramuscular route
Most common dose related side effect of salbutamol is tremor
Urotensin II is the most potent known vasoconstrictor
Beta blocker which has K+ channel opening action: Tilisolol
Longest acting beta blocker: Nadolol
Longest acting ocular beta blocker: Betaxolol
Drug used for treatment of scorpion sting is Prazosin
Anti dyslipidemic drugs
Most potent statin is Rosuvastatin
Statins also have antioxidant, anti inflammatory and anti proliferative properties
Major side effects of statins are myopathy and hepatotoxicity
Risk of myopathy is increased if fibrates are used along with statins
Clofibrate is associated with gallstones and gallbladder malignancies
Fenofibrate has uricosuric action hence can be used in gout
Major effect of fibrates is to reduce triglycerides and to increase HDL
Among all hypolipidemic drugs, niacin has maximum HDL increasing property
Niacin is the only lipid lowering drug that reduces Lipoprotein (a) leves significantly
Avasimibe is an inhibitor of the enzyme ACAT-1 (acetyl coenzyme A: Cholestrol acetyl transferase1)
Red wine increases HDL, because of high content of anti oxidants
Anti diabetic drugs
Tolbutamide is the shortest acting while chlorpropamide is the longest acting sulfonyl urea
Chlorpropamide cause adverse effects like dilutional hyponatremia, cholestatic jaundice and
disulfiram like reaction
Lactic acidosis and Vitamin B12 deficiency can occur with Metformin therapy
Metformin is the only drug that reduces macrovascular complications in Type II DM
Thiazolidinediones act as agonists of PPAR gamma thus help in reversing insulin resistance in Type II
DM
Rosiglitazone is associated with increased incidence of MI and Pioglitazone with bladder carcinoma
Major adverse effect of Acarbose (alpha glucosidase inhibitor) is flatulence
Pramlinitide is an analogue of amylin that delays gastric emptying and suppresses glucagon secretion
Epalrestat is an aldose reductase inhibitor that reduces sorbitol accumulation and delays progression
of diabetic neuropathy
Bromocriptine mesylate alter insulin resistance byaacting on hypothalamus and bromocriptine targets
D2 receptors
 Corticosteroids

Features Steroid

Maximum glucocoticoid activity Dexamethasone, Betamethasone

Maximum mineralocorticoid activity Aldosterone

Glucocorticoid with maximum mineralocorticoid Hydrocortisone

activity

Maximum topical activity Triaminolone acetate

Least potent glucocorticoids Cortisone

Most potent glucocorticoids Betamethasone

Selective mineralocorticoid action (no glucocorticoid DOCA

action)

Selective glucocorticoid action (no mineralocorticoid Triamcinolone, Dexamethasone, Betamethasone

action)

Equivalent dose of corticosteroids

- 20 mg of hydrocortisone
- 5 mg of Prednisolone
- 4 mg of methyl prednisolone
- 4 mg of Triamcinolone
- 0.75 mg of Dexamethasone / Betamethasone
 Anticoagulants
Protein C has shortest half life among the factors associated with coagulation mechanism
Among clotting factors, first to disappear is Factor VII and last to disappear is Factor II
Treatment for warfarin overdose is Fresh Frozen plasma but the specific antidote is Vitamin K1
Contradi syndrome occurs due to teratogenic effect of warfarin Æ hypoplastic nasal bridge,
chondrodysplasia, CNS malformations
Heparin acts by activating antithrombin III in plasma
Fondaparinaux does not cause HIT because it does not bind to PF4
Direct thrombin inhibitors are hirudin, argatroban and ximelagatran
100 units of heparin in the patient is neutralized by 1 mg of protamine sulphate IV
Drotecogin alpha is the recombinant form of human activated protein C, decreases mortality in sepsis
Rivaroxaban: newer anticoagulant that acts by reversibly inhibiting Factor Xa
Anticoagulant of choice for HIT syndrome is direct thrombin inhibitors like lepirudin
 Selection of anti epileptic drugs

Drug First line of choice in

Ethosuximide Absence seizures in children

Valproate Absence seizures in adults, GTCS, Atypical

absence seizures, Atonic seizures, Tonic, Clonic
seizures

Carbamazepine Partial seizures

Vigabatrin Infantile spasms with tuberous sclerosis

ACTH Infantile spasms

Diazepam P /R Febrile seizures

Lorazepam IV Status epilepticus

Phenobarbitone Epilepsy in pregnancy

Magnesium sulfate Eclamptic seizures

 Antidepressants
Most potent blocker of 5-HT reuptake – Paroxetine
Least potent blocker of 5 HT reuptake – Bupropion
Most potent blocker of NA reuptake – Desipramine
Least potent blocker of NA reuptake - Mirtazapine
Most selective inhibitor of 5 HT reuptake – Escitalopram
Most selective inhibitor of DA reuptake – Bupropion
Most selective inhibitor of NA reuptake – Oxaprotiline
Maximum antimuscarinic activity – Amitryptiline
Maximum antihistaminic activity – Nefazodone
Maximum alpha 1 blocking activity – Doxepin
Maximum antimuscarinic, alpha 1 blocking and antihistaminic activity – Venlafaxine
Fluoxetine is the longest acting and Nefazodone is the shortest acting antidepressant
Amoxapine has mixed anti depressant and neuroleptic properties
 Anti epileptic drugs
Side effects of valproate include tremors, alopecia, obesity, hepatotoxicity, acute pancreatitis and
hyperammonemia
Gabapentin is used in diabetic and post herpetic neuralgia and pain associated with multiple sclerosis
Ganoxolone is a neurosteroid effective for absence seizures, infantile spasms and catamenial epilepsy
Topiramate and Zonisamide are implicated in causing renal stones
Felbamate is an NMDA blocker that is used in drug resistant epilepsies
Tiagabine, which is an inhibitor of GABA uptake is used as an adjunct in treatment of partial seizures
Lacosamide has a dual mode of action by blocking Na+ channels and CRMP-2
Adverse effects of rapid IV infusion of Fosphenytoin include cardiac arrhythmias and cerebellar
involvement
Steven Johnson syndrome and toxic epidermal necrolysis are rare side effects of Lamotrigine
Characteristic side effects of trimethadione is hamarlopia
 Neuro degenerative diseases
Alzheimer’s disease - Anticholinesterases (Donepazil, Rivastigmine,
Galantamine)
- Acetyl carnitine: anti oxidant and increases
cholinergic transmission
- Memantine: NMDA antagonist

Huntington’s chorea - D2 blockers (Haloperidol, Olanzapine)

- Tetrabenazine (dopamine deplete)
- Reserpine

Amyotrophic lateral sclerosis - Riluzole (NMDA antagonist)

- Idrocilamide (inhibit glutaminergic transmission)

Multiple sclerosis - Beta interferon, Glatiramer acetate: decreases

frequency of relapse
- Baclofen / Tizanidine : decreases spasticity
- Natalizumab: monoclonal antibody
- Fingolimod: sphingosine 1 phosphate receptor
modulator
- Dalfampridine: oral K+ channel blocker

Wilson’s disease - Trientine

- D pencillamine
- Aluminium tetrathiomolybdate
 Antibiotics and their mechanisms of action
- Tetracyclines (bind to 30S ribosomes, inhibit aminoacyl
Bacteriostatic tRNA)
- Chloramphenicol (binds to 50S ribosomes, inhibit
Protein synthesis inhibitors peptidyl transferase)
- Macrolides and Lincosamides (bind to 30S ribosomes,
inhibit translocation of peptide chain)
- Linezolid: binds to 23S fraction of 50S ribosomes

Drugs affecting DNA Nitrofurantoin, Novobiocin

Drug affecting metabolism Sulfonamides, Trimethoprim, Ethambutol

Protein synthesis inhibitors - Aminoglycosides (bind to 30S and 50S ribosomes,

misreading of mRNA)
Bactericidal - Streptogramins

Polypeptide antibiotics Polymyxin B, Colistin, Amphotericin B

Drug affecting DNA Quinolones (DNA gyrase inhibitor), metronidazole

Cell wall synthesis inhibitors Fosfomycin, Cycloserine, Bacitracin, Vancomycin,

Penicillins, Cephalosporins

First line ATT drugs Rifampicin, Isoniazid, Pyrazinamide, Streptomycin

(except ethambutol)
 Anti cancer drugs
Most common side effect of chemotherapy administration : Nausea
Peripheral neuropathy can occur with the use of: Vincristine, Cisplatin, Procarbazine
Pulmonary fibrosis occurs most commonly with: Bleomycin
Hemorrhagic cystitis is caused by cyclophosphamide
Anticancer drug causing cerebellar toxicity: Cytarabine
The primary target of chemotherapeutic drug is tumor stem cells
Anti cancer drug that inhibits dihydrofolate reductase: Methotrexate
Most widely used alkylating agent: Cyclophosphamide
Anticancer drug with prothrombotic potential: L-asparaginase
Most nephrotoxic anti cancer drug: Cisplatin
Anticancer drug causing blue urine: Mitoxantrone
Anti invasion agent used to reduce cellularity of tumor mass: Batibasat
Ennzyme used used as anti cancer agent: L-asparaginase
Most common side effect of vincristine: peripheral neuropathy
Anticancer drugs that inhibits mitosis: VInca alkaloids
 Body Fluid compartments
Total body water in an adult comes to around 60 % of total body weight (42 litres)
In infants, TBW = 75% of body weight
rd
Intracellular fluid constitutes around 2/3 of total body water (28 litres)
Extracellular fluid includes plasma and interstitial fluid
Interstitial fluid forms 75% of ECF and rest by plasma
Most abundant cation in the ECF is Na+ and the most abundant anion is Cl-
Most abundant cation in ICF is K+ and the most abundant anion is phosphate
ICF= 0.4 X bodyweight; ECF= 0.2 X bodyweight
Transcellular fluids include the fluid inside a cavity; eg: synovial fluid, pleural, pericardial fluid,
aqueous and vitreous humor etc.
Magnesium is the most abundant divalent cation intracellularly
 Cerebrospinal fluid
rd
Sugar : 2/3 of plasma (40-70mg/dl)

Proteins : 20-40mg/dl

Volume: 150ml

Rate of

- CSF formation – 550ml/day

- Turn over – 3times/day

pH : 7.33

Pressure : 70-180mmH2O,

At pressure of 112mmH2O, filtration = absorption

Below a pressure of 68mmH2O, absorption of CSF stops

All positive ions are less in CSF than in plasma except Mg2+

All negative ions more in CSF

Beta 2 transferrin assay to detect CSF

IL-6 levels in CSF are raised in Neuro Behcet’s

 Hypothalamus and its functions

Regulation Part of hypothalamus

Increased ECF osmolarity(Thirst) Osmoreceptors – Anterior hypothalamus

Response to heat Anterior hypothalamus

Response to cold Posterior hypothalamus

Sexual behaviour Anterior ventral hypothalamus, plus in males –

piriform cortex

Emotion Dorsal and posterior hypothalamus

Circardian rhythm Suprachiasmatic nucleus

GnRH secretion Arcuate nucleus

TSH(via TRH secretion) Paraventricular & neighbouring nuclei

Prolactin via PRH & PIH Arcuate nucleus

Oxytocin release Paraventricular nucleus(mainly)

ADH release Supraoptic nucleus(mainly)

Satiety centre Ventromedial nucleus

Feeding centre Lateral nucleus

 Electroencephalogram

Beta wave Alpha wave Theta wave Delta wave

Area of origin Parietal & Frontal Parieto-occipital Hippocampus

region area

Seen in Drowsiness, Awake subject at Children & in Deep NREM sleep

Children, Subjects rest with eyes drowsiness & Infants
awake with eyes closed
open, REM sleep

Frequency High(>14Hz) 8-13 Hz Low(4.7 Hz) Very Low(3 Hz)

Amplitude Low High Very High Maximum

- Alpha wave reflects synchronised brain activity

- Alpha block is when on eye opening, alpha rhythm is replaced by beta wave
- Desynchronisation is replacement of alpha waves by other waves
 Respiratory Volumes

MEASUREMENT TYPICAL VALUE DEFINITION

Tidal Volume(TV) 500ml Amount of air that enters or leaves lungs during
one inspiration or expiration (respiratory cycle)

Inspiratory Reserve Volume(IRV) 3000ml Maximum volume of air that can be inspired over
the normal TV

Expiratory Reserve Volume(ERV) 1200ml Extra volume of air expired by forceful expiration
after the end of normal tidal expiration

Residual Volume(RV) 1200ml Amount of air left in lungs after forced exhalation

RESPIRATORY CAPACITIES

Vital Capacity(VC) 4700ml IRV+TV+ERV, maximum amount of air that can

be exhaled after a maximum inspiration

Inspiratory Capacity(IC) 3500ml TV+IRV, maximum amount of air that can be

inhaled after a normal expiration

Functional Residual Capacity(FRC) 2400ml RV+ERV, amount of air remaining in the lungs
after a normal tidal expiration

Total Lung Capacity(TLC) 5900ml RV+VC, maximum volume to which the lungs can
be expanded
 BROADMANN AREAS

Primary motor area – precentral gyrus – Area 4

Premotor area – Area 6

Primary visual area – Area 17

Visual association area – Area 18,19

Primary auditory area(Wernicke’s area)- Area 41

Auditory association area – Area 42,22

Frontal eye field – Area 8&6

Broca’s area – Area 44

Primary sensory area – Area 3,1,2

Somato sensory association area(posterior parietal cortex) – Area 5,7

 COMPARISON OF MUSCLE FIBRES
Properties Skeletal muscle Cardiac muscle Smooth muscle

Histology Striated Striated Non striated

No intercellular coupling Synctium + Synctium +

Sarcomeres Well organised Well organised Absent

RMP -90mV -90mV(ventricles), - Variable,-50mV

55mV(S.A node)

Duration of AP 2-5ms 250-400ms Variable

Refractory period Short Long Short

Twitch duration 50-100ms 800ms Long tonus

Tetanus Possible Impossible Possible

Source of Ca2+ From SR ECF Mainly from ECF

Regulatory proteins Troponin-C & Actin Troponin-C Calmodulin & Myosin

Metabolism Aerobic & Anaerobic Aerobic Aerobic

glycolysis

Myosin ATPase rate Fast Slow Slowest

 Glucose transporters

Transporter Function Sites of expression

Secondary active transport

SGLT-1 Small intestines, renal tubules
Glucose Absorption
SGLT-2 Renal tubules

Facilitated diffusion

GLUT-1 Basal glucose uptake Brain, RBC, Kidney, Colon, Placenta,

BBB

GLUT-2 Beta cell glucose sensor, glucose transport in Beta cells of Islets, Liver, Intestinal
intestinal & renal epithelium & renal epithelium

GLUT-3 Basal glucose uptake Brain, Kidney, Placenta

GLUT-4 Insulin mediated glucose uptake Skeletal & Cardiac muscle, adipose
tissues

GLUT-5 Fructose transport Jejunum, Sperm

GLUT-7 Glucose 6 Phosphate transporter in ER Liver

 Important Principles in Physiology
- Bell-Megendie Law: In the spinal cord, Dorsal roots are Sensory & Ventral roots are motor
- Bernoulli’s Principle: The sum of the kinetic energy of flow and the pressure energy is constant
- Boyle’s law: At constant temperature, the Volume(V) of a given mass of gas varies inversely with its
absolute Pressure
- Charle’s law: The volume of given mass of a gas is directly proportional to the Temperature, at
constant Pressure
- Fick’s Principle: Cardiac Output = O2 consumption (ml/min)/ Arterio – Venous O2 difference
- Frank-Starling law: Within physiological limits, force of contraction is directly proportional to initial
length of muscle fibre
- Isohydric principle: All buffer pairs in a homogenous solution are in equilibrium with the same (H+)
- Labelled line principle: The specificity of nerve fibres for transmitting only one modality of sensation
- Law of Projection(Phantom limb sensation): No matter where a particular sensory pathway
stimulated along its course, the conscious sensation produced is always referred to the location of the
receptors
- Monre-Kellie doctrine: The volume of blood, CSF, and brain in the cranium at any time must be
relatively constant
- Muller’s law of specific nerve energies: When the nerve pathways from particular sense organs are
stimulated, the sensation evoked is that for which the receptor is specialised no matter how or where
along the pathway the activity is initiated
- Size principle: The orderly recruitment of motor units – motor units are recruited in order of motor
neuron axon size
- Weber-Fechner law : Magnitude of sensation felt is proportionate to the log of intensity of the
stimulus.
 Drugs Influencing Neuro Muscular Junction
Botulinum: prevents synthesis & release of Ach. Used in Rx of achalasia, torticollis, laryngospasm,
hemifacial spasm & removal of wrinkles in forehead. Calcium gluconate & guanide is used for treating
botulinism
Alpha-Bungarotoxin: irreversibly binds with receptor & cause muscle paralysis
d-tubocurarine: reversibly binds with receptor & cause muscle paralysis. Used in anesthesia
Succinyl choline & Decamethonium: produce persistent depolarization
Black widow spider venom: brief release of Ach at the nerve endings followed by permanent
blockade
Tetrodotoxin & Saxitoxin: blocks voltage gated Na+ channels
Nerve gas & Neostigmine: inhibits acetyl cholinesterase in post synaptic membrane
Strychnine: prevents IPSPs in spinal cord that inhibits contraction of antagonists.
 Numerical Classification For Sensory Fibres
Number Origin Fiber type
Ia Muscle spindle, annulo-spiral ending A alpha
Ib Golgi tendon organ

II Muscle spindle, Flower spray ending, Touch, A beta

Pressure

III Pain & Cold receptors, Some touch receptors A gamma

IV Pain, Temperature and other receptors Dorsal root C

Erlanger and Gasser classification

Fibre type Function
A alpha Proprioception, Somatic motor
A beta Touch, Pressure, Motor
A gamma Motor to muscle spindles

A delta Pain, Cold, Touch

B Preganglionic autonomic

C Dorsal Pain, Temperature, Mechanoception, reflex responses

root
C Post ganglionic sympathetic
Sympathetic

A and B fibres are myelinated, C fibres are myelinated

Highest conduction velocity and largest diameter : A alpha
Susceptability to pressure : A >B > C
Susceptability to hypoxia : B > A> C
Susceptability to local anaesthetics : C > B > A
Refractory period is minimum for A alpha and maximum for C
 Limbic system and Papez circuit
Limbic lobe includes cingulated gyrus, hippocampal gyrus, isthmus and uncus
Subcortical nuclei includes Amygdala, septal nuclei, hypothalamus and anterior thalamic nuclei
Hypothalamus and limbic system is responsible for the genesis of emotions
Sham rage is seen in animals with diencephalic lesion, i.e transaction of neural axis above the
thalamus
Persons with Bilateral pre frontal lobectomy shows marked deterioration of social behaviour, inability
to check emotions
Pre frontal leucotomy means cutting the connections between thalamus and frontal lobe
Frontal lobe syndrome: Euphoria, impaired recent memory, flight of ideas, emotional instability and
attention deficit
Kluver Bucy syndrome: Hyperphagia, Omniphagia, visual agnosia, increased oral activity,
hypermetamorphosis in patients with bilateral temporal lobectomy
Papez circuit is a closed circuit formed by the pre frontal lobe with the thalamus
It is responsible for resting EEG and plays an important role in emotional behaviour
Conducting system of Heart
Rate of conduction through different structures:
- Purkinje fibres ( 4 m/s)
- Bundle of His (1 m/s)
- Ventricular muscle (1 m/s)
- Atrial pathways (1 m/s)
- SA node (0.05 m/s)
- AV node (0.05 m/s)

The intermodal tracts are Anterior (Bachman), Middle (Wenkebach) and Posterior (Thorel)
Conduction delay: A delay of about 0.1 sce, occurs in conduction through AV node, due to increased
number of gap junctions
This delay allows the atria to contract ahead of the ventricles
First portion of heart to get depolarised: left endocardial surface of the interventricular septum
Last portions to get depolarised are postero basal portions, pulmonary conus and upper most portion
of the septum
Taking the the heart as a whole, depolarisation occurs from endocardium to epicardium and
repolarisation occurs from epicardium to endocardium
In a single ventricular fibre, depolarisation occurs from endocardium to epicardium and repolarisation
occurs from endocardium to epicardium
 Electrocardiogram

Intervals Duration (Range) Events in the heart

P wave Atrial depolarisation

PR interval 0.12 – 0.2 sec Atrial depolarisation and AV

nodal conduction

QRS interval 0.08 – 0.10 Ventricular depolarisation and

atrial repolarisation

QT interval 0.40 – 0.43 Ventricular depolarisation and

ventricular repolarisation

ST interval 0.32 Ventricular repolarization

Einthoven’s law: Lead II = Lead I + Lead III

Kirchoff’s law: Lead I + Lead II + Lead III = 0
Normal cardiac axis in ECG: between -30 degrees to +110 degrees

Generalizations for leads in normal ECG

aVR All the deflections are negative

aVL /aVF Predominantly positive or biphasic

V1, V2 No Q wave, deep S wave

V3, V4 Biphasic

V5, V6 Small Q wave, Tall R wave

Lead I, II, III All positive deflection, largest in lead II

 Renal system
The glomerular filtration membrane is formed by fenestrated endothelial cells, glomerular basement
membrane and podocytes
Aquaporin I is present in PCT and Aquaporin 4 is present in Brain
Lacis cells are the agranular cells situated between afferent and efferent arteriole
Mesangial contraction decreases GFR whereas mesangial relaxation increases GFR
Kidneys have highest blood flow per gram tissue (300-400 ml /100gm/min)
Renorenal reflex: An increase in ureteral pressure in one kidney leads to a decrease in efferent nerve
activity to the contralateral kidney
In Proximal tubule, 80-90 % of filtered bicarbonate, 50-60% of water and 60% of filtered Na+ gets
reabsorbed
More than 50% of potassium that appears in the urine is derived from secretion by distal tubule
Renin is secreted from Juxtaglomerular cells
The segments of renal tubule impermeable to water are: thin and thick ascending limb of loop of
st
henle and 1 part of distal tubule
Acidification of tubular fluid occurs mainly in the collecting duct
Obligatory volume of urine is the minimum quantity necessary to remove all waste products with a
normal diet (500 ml / day)
Dent disease is a variant of Fanconi syndrome in which mutation of Cl- channels lead to hypercalciuria
and nephrolithiasis
 Levels of Motor integration

Level of integration Principal function

Spinal cord Control of spinal reflexes – stretch reflex

Medulla Anti gravity reflexes

Regulation of heart and respiratory rate
Tonic labyrinthine and tonic neck reflexes

Midbrain Righting reflexes

Vestibular placing reaction

Midbrain, thalamus Locomotor reflexes

Hypothalamus, limbic system Emotional functions

Cerebral cortex Initiation of voluntary movements

Conditioned reflexes
Optical righting reflexes
Placing and hoping reactions

Extrapyramidal tracts

Tracts Origin Functions

Rubrospinal Red nucleus Flexor muscle tone regulation

Tectospinal and tectobulbar Superior colliculus Postural movements in response to

visual and auditory stimuli

Reticulospinal Reticular formation (pons Regulate voluntary movement, muscle

and medulla) tone, BP, respiration

Vestibulospinal Lateral vestibular nucleus Facilitation of anti gravity muscles

Medial longitudinal fasciculus Medial vestibular nucleus Co-ordination of reflex ocular

movements and integration of eye and
neck movements
 Taste sensation

Taste modality Location of receptors Taste producing Mechanism of action

substances

Sweet Tip of tongue Organic chemicals Via a G protein,

gustducin

Salt Tip of tongue Na+ ions By ENaCs

Sour Sides of tongue Acids[H+ions] Blocking of K+ channels

Bitter Back of tongue Long chain organic Organic acids, most of

substances containing them blocks K+
N2 & alkaloids channels

Umami A variant of sweetness, acts by activation of

mGluR4

Sensory fibres from anterior 2/3 Æ chorda tympani of facial N Æ Geniculate ganglion
rd

Sensory fibres from posterior 1/3 Æ Glossopharyngeal N Æ Superior petrosal ganglion

rd

In,Sensory fibres from palate, pharynx Æ Vagus N Æ Ganglion nodosum

Miraculin: taste modifier protein, when applied, makes acid taste sweet
 Measurement of Body fluid compartments

VOLUME MEASUREMENT

TBW - By Heavy water(Dueterium oxide),Tritium oxide,

- By dilution principle

ECF - Can be called ‘SUCROSE SPACE’etc.

- Inulin(most accurate), Sucrose, Mannitol, radioactive
sodium, radioactive chloride, Thiosulphate

PLASMA VOLUME(PV) - By using Evans blue(T1824), Serum albumin labelled with

radioactive Iodine

RED CELL VOLUME - Volume occupied by all the RBC’s

- Determined by TBV-PV
- RBCs tagged with radioactive Chromium-51
- Phosphorous-32,Fe-55 or Fe59

ICF TBW-ECF (can’t be measured directly)

 Respiratory system signs

Garland’s triad(1-2-3 sign) Lymphadenopathy pattern in sarcoidosis: Right

paratracheal; Right hilar and Left hilar nodes
Bull’s eye lesion in lung Granuloma
Butterfly or Bat’s wing pattern CXR finding in pulmonary edema
Air Crescent sign/Meniscus sign Aspergilloma ball
Kerley B lines Seen when left atrial pressure exceeds 20mmHg
Popcorn calcification Hamartoma lung
Steeple sign Croup(Acute laryngo tracho bronchitis)
Thumb sign Acute epiglottitis
V sign of Naclerio Boorhaeve’s syndrome(indicates
pneumomediastenum + pneumothorax)
Vallecular sign Retention of barium in hypopharynx seen in Ca
larynx
Spinnaker(angel wing) sign Sign of pneumomediastenum seen on neonatal
CXR; refers to the thymus being outlined by air
with each lobe displaced laterally
S sign of Golden(reverse sign) Convexity of the medial aspect of the minor
fissure in patients with right upper lobe
atelectasis usually due to a large central mass(a
characteristic presentation of bronchogenic
carcinoma)
Felson’s Silhouette An intrathoracic lesion touching a border of the
heart aorta or diaphragm will obliterate that
border on the chest radiograph; valuable sign for
localising disease from the chest x-ray
Linguine sign MRI signs intracapsular rupture of a breast
implant
Reversed halo sign (atoll sign) Central ground glass opacity surrounded by
denser consolidation of cresentric(forming more
th
than 3/4 of a circle) or ring shape of atleast 2
mm in thickness; relatively specific sign for
cryptogenic organising pneumonia
Panda sign In sarcoidosis in a gallium-67 citrate scan; due to
bilateral involvement of parotid and lacrimal
glands in sarcoidosis
 Signs in CVS
Lambda sign Small ascending aorta seen in hypoplastic left heart
syndrome

Couer en sabot(boot shaped heart) Fallot’s tetralogy

Egg on side/string appearence TGA- transposition of great arteries

Pear heart Pericardial effusion (a.k.a flask, money bag, waterbottle)

Snowman(Figure of 8 heart) TAPVC – total anomalous pulmonary venous connection

Parchment right ventricle Uhl disease

Draped aorta sign Posterior aortic wall is unidentifiable and follows the
vertebral contour and associated with chronic contained
rupture of an abdominal aortic aneurysm with vertebral
erosion

Cobweb sign and Beak sign Arterial dissection

 Signs in GIT
Accordion sign In Pseudomembraneous colitis; oral contrast being trapped
between oedematous haustral folds and pseudomembranes
formed on the surface of the colon

Apple core appearence Carcinoma of sigmoid colon

Arc of Riolan Inconstant anastamotic A. Between middle + left colic A.

Bull’s eye lesion, liver Hepatic candidiasis

Bull’s eye lesion, stomach Melanoma is MC cause

Chain of lakes Chronic pancreatitis, appearance on ERCP

Chiladiti’s syndrome Interposition of colon between liver and right hemidiaphragm

causing elevation of right hemidiaphragm

Coffee bean sign, bird’s beak deformity or Sigmoid volvulus

‘ace of spade’ deformity

Corkscrew oesophagus Diffuse oesophageal spasm

Double bubble sign Duodenal atresia

Triple bubble sign Jejunal atresia

Floating membrane sign Liver in hyatid disease

Medusa locks sign Seen in children invested with round worms

“Mercedes Benz” sign/ Seagull sign Radiolucent gallstone with gas in it

Pearl necklace gall bladder Rokitansky Aschoff sinuses, Adenomatosis of gallbladder

“Rose thorning” of medial wall of Ca head of pancreas

duodenum

“Saw tooth” appearence Diverticulosis of the sigmoid colon on barium enema

Sandwich sign Mesenteric adenopathy

“Thumb printing” of colon Ischaemic colitis

“Tip of iceberg” sign on US dermatoid cyst of ovary

 RENAL SYSTEM
1. Adder head or cobra head deformity : Ureterocele

2. Flower vase appearance : Horseshoe kidney

3. Spider leg appearance : Polycystic kidney

4. Golf hole ureter : TB urinary bladder

5. Thimble bladder : TB urinary bladder

6. Fish hook(J shaped or hockey stick) ureter: BPH

7. Bladder diverticulum : Micturition may occur twice one after the other

8. Chalice (Bergman) sign : Dilatation of ureter distal to neoplasm, not seen with calculi or thrombi

9. Rim sign in nephrogram : Severe hydronephrosis

10. Bladder wall calcification resembling fetal head seen in : Schistosomiasis

 Skeletal system
“Corduroy cloth” appearence Haemangioma of vertebra, usually cavernous;
vertically striped orientation of bone trabeculae

“Double line” sign on MRI Avascular necrosis, commonly of the femoral head

H-shaped vertebra seen in Sickle cell disease

Heel pad sign seen in Acromegaly

Iliac horns are seen in Nail patella syndrome

Scottish dog appearence Inter-peduncular region in oblique view of spine, in a

normal vertebra

Schmori’s nodes Indentations of the IV discinto the end plates of the

vertebral bodies

Melorrhoestosis Candle bone disease

Metacarpal sign(short fourth meta carpal) Turner’s syndrome

Onion peel diaphysis seen in Ewing’s sarcoma

Optic foramen enlargement suggest Optic N glioma

Soap bubble appearance seen Osteclastoma

Plain X-ray finding of osteomyelitis develop 7-10 days after infection

“Sun ray” appearance, Codman’s triangle seen in Osteosarcoma

Tear drop sign(orbits) seen in Blow out fracture of floor of orbit

Tear drop sign(ankle) seen in Ankle effusion

Terry Thomas sign seen in Widened space between the scaphoid and lunate
bones on a frontal view of wrist secondary to
scapholunate dislocation

Trumpet sign(enlargement of nerve root secondary to Disc herniation

edema) seen in

Trumbling bullet sign seen in Post traumatic bone cyst

Wimbereger’s sign (seen in congenital syphilis) Symmetrical focal bone destruction of the medial
portion of the proximal tibial epiphysis

Fallen fragment’ sign solitary bone cyst

 HEAD AND NECK
1. Open ring sign : Specific for demyelination
2. “Winking owl” sign : Erosion of the pedicles, the earliest radiological sign of vertebral tumor /mets
3. Ballooning of pituitary fossa: Tumours of pituitary
4. Bare orbit appearance: Neurofibrimatosis
5. Blueberry muffin sign: Raised purple skin lesion, suggestive of dermal metastases of neuroblastoma
6. Chiari II malformation: Lemon sign (infolding of the frontal bones) and Banana sign(cerebellar
deformity)
7. Moth eaten skull: Syphilis
8. Rice grain calcification in brain: Neurocysticercosis
9. Suprasellar calcification: Craniopharyngioma
10. Tram track calcification: Sturge-Weber syndrome
11. Raised ICT signs are: Silver beaten appearance, posterior clinoid erosion in skull X-ray
12. Sunburst periostitis Midline subfrontal meningioma
13. Tuberculoma: MC site in brain is Posterior cranial fossa
14. Sail sign: Characteristic shape of thymus in young children
15. Panda sign: appearance of the midbrain, when the red nucleus and substantia nigra are surrounded
by high T2 signal; classically seen in Wilson disease
16. Ice cream cone sign: A medium sized(1.5 to 3cm)acoustic schwannoma typical appearance, with the
intracanalicular component representing ‘the cone’ and the cerebellopontine angle component
representing the ‘ice-cream’
17. Racing car sign : widely spaced lateral ventricles in agenesis of corpus callosum
Tumor classifications
Chang staging - Medulloblastoma
Masaoka staging - Thymoma
Shimada index - Neuroblastoma
Reiss and Ellsworth classification - Retinoblastoma
Esson Prognostic index
Bloom Richardson grading - ca breast
Naguchi classification - Adenocarcinoma lung
Sullivan modification of Macfalene system - Adrenocortical carcinoma
Gleason staging - ca prostate
Nevine staging - ca gall bladder
Duke staging - Colorectal carcinoma
Jackson staging - Ca penis
 Lymph nodes
Rotter’s nodes - Interpectoral nodes
Rouvier nodes - Retropharyngeal nodes (ca nasopharynx)
Delphian nodes - Pre cricoids / Pre tracheal / pre laryngeal nodes
Irish nodes - nodes in left axilla (ca stomach)
Sister mary Joseph nodes - Periumbilical metastasis (ca stomach)
Virchow nodes - Left supraclavicular node (GIT, testis malignancy)
Cloquet node - Femoral canal node
Lymph node of Lund - Cystic lymph node
Krouse lymph node - Jugular fossa lymph node

Most common lymph nodes involved

CA penis - Inguinal nodes
CA testis - inter aorto caval (right); paraaortic (left)
CA bladder - Obturator LN
CA prostate - Obturator LN
 Named triads

Triad Seen in Components

Virchow’s triad Thrombosis Hypercogulability + endothelial injury + stasis

Cushing’s triad Intracranial Hypertension + Bradycardia + Irregular respiraition

hypertension

Trotter’s triad CA nasopharynx Conductive hearing loss+ immobility of ipsilateral soft

palate + trigeminal neuralgia

Saint’s triad Hiatus hernia + Gallstones + Colonic diverticula

Quincke’s triad Hemobilia GI hemorrhage + biliary colic + jaundice

Borchradt’s triad Gastric volvulus Epigastric pain + inability to vomit + inability to pass a
nasogastric tube

Tillaux triad Mesentric cyst Fluctuant swelling in umbilical region, freely mobile
perpendicular to mysentry + zone of resonance all around

Mackler’s triad Boerhaave’s syndrome Thoracic pain + vomiting + cervical subcutaneous

emphysema

Rigler’s triad Gall stone ileus Small bowel obstruction + pneumobilia + ectopic gallstone

Whipple’s triad Insulinoma Symptoms of hypoglycaemia + S. Glucose < 45 mg/dl +

symptomatic relief on glucose ingestion

Murphy’s triad Appendicitis Pain + Fever + vomiting

Galezia’s triad Dupuytren’s contracture + retroperitoneal fibrosis +

Peyronie’s disease
 GI Malignanacy Chemotherapy
CA Esophagus ECF(Epirubicin + Cisplatin+5-FU)
CA Stomach ECF(Epirubicin + Cisplatin+5-FU)
CA Pancreas Gemcitabine
NET of Pancreas Streptozocin + 5-FU
Cholangiocarcinoma Gemcitabine + Cisplatin
CA GB Gemcitabine + Cisplatin
Small intestine adenocarcinoma 5-FU
Colorectal carcinoma FOLFOX-IV (5-FU + Leucovorin + Oxaliplatin)
CA anal canal NIgro Regimen : Chemoradiation(5-FU + Mitomycin C +
Radiation

Most Common Symptom

CA Esophagus Dysphagia >weight loss

CA Stomach Abdominal Pain >weight loss

Periampullary carcinoma(including CA head of Jaundice

pancreas)

HCC Abdominal Pain >weight loss

Cholangiocarcinoma Painless progressive jaundice

CA Gall bladder Bilary colic

CA Small bowel Abdominal pain

CA colon Abdominal pain

CA Rectum Bleeding PR

CA anal canal Bleeding PR

 NAMED HERNIA
Gibbon’s hernia Hernia with hydrocele

Berger’s hernia Hernia into pouch of Douglas

Beclard’s hernia Femoral hernia through opening of saphenous vein

Amyand’s hernia Inguinal hernia containing appendix

Ogilive’s hernia Hernia through the defect in conjoint tendon just lateral to where it inserts with
the rectus sheath

Stammer’s hernia Internal hernia occurring through window in the transverse mesocolon after
retrocolic gastrojejunostomy

Peterson hernia Hernia under Roux limb after Roux-en-Y gastric bypass

Littre’s hernia Content is Meckel’s diverticulum

Richter’s hernia Hernia sac contains a portion of circumference of intestine

Treitz hernia Duodeno jejunal hernia

Malgaigne’s hernia Infantile inguinal hernia prior to descent of testis

Kronlein’s hernia Preperitoneal inguinal hernia

Velpeau’s hernia Fermoral hernia where intestine is in front of blood vessels

Barth’s hernia Engagement of a loop of intestine between a persistent vitelline duct and
abdominal wall
 MOST COMMON SITES

Gastric ulcer Lesser curvature(near incisura angularis)

st
Peptic ulcer 1 part of duodenum
Gastric outlet obstruction

Small bowel adenocarcinoma Duodenum

Atresia

Polyps in PJS Jejunum

Pneumatosis intestinalis

Crohn’s disease
Fistula,perforation and carcinoma in crohn’s
disease Terminal ileum
Typhoid ulcer
Tubercular ulcer
Small intrestinal lymphoma
Gall stone ileus

Amoebic colitis
Bleeding in angiodysplasia Cecum and ascending colon
Bleeding in colonic diverticula

Ischemic colitis Splenic flexure

Colonic diverticula Sigmoid

Stricture after ischemic colitis
Volvulus

Ulcerative colitis Rectum

Colorectal cancer
Hirschprung’s disease
 CHARACTERISTIC RADIOLOGICAL APPERARENCES
Radiological Features Seen in

Apple core lesion on Ba enema Carcinoma colon

Claw appearance on Ba enema Intussuspection

Saw tooth appearence Colonic diverticula

Bird beak appearence Achalasia

Volvulus

Cork screw appearance

Rosary bead appearance Diffuse esophageal spasm
Pseudodiverticula appearence

String sign of Kantor Crohn’s disease

Tuberculosis

Thumb print sign Ischaemic colitis

Squeeze sign, Cushion sign, Tenting sign, Colonic lipoma

Naked fat sign

Rat tail appearence Achalasia

 ABDOMINAL EXAMINATION SIGNS

Sign Description Diagnosis

Aaron sign Pain or pressure in epigastrium or Acute appendicitis

anterior chest with persistant firm
pressure appled to McBurney’s
point

Bassler sign Sharp pain created by compressing Chronic appendicitis

appendix between abdominal wall
and iliacus

Blumberg sign Rebound tenderness Peritonitis

Carnetts’ sign Loss of abdominal pain when Intraabdominal source of abdomina
abdominal wall muscles are pain
contracted

Claybrook sign Accentuation of breath and cardiac Ruptured abdominal viscus

sounds through abdominal wall

Courvoisier’s sign Palpable gallbladder in presence of Periampullary tumor

painless jaundice
Cruveihlier sign Distended veins at umbilicus Portal hypertension
Danforth sign Shoulder pain on inspiration Hemoperitoneum
Fothergill’s sign Abdominal wall mass that does not Rectus muscle hematomas
cross midline and remains palpable
when rectus contracted

Ransohoff sign Yellow discolouration of umbilical Ruptured CBD

region

Ten Horn sign Pain caused by gentle traction of Acute appendicitis

right testicle
 Metastasis
Papillary carcinoma thyroid has lymphatic spread, follicular has hematogenous spread while
medullary carcinoma spread via both hematogenous and lymphatic routes
Papillary ca thyroid metastasises to lungs, follicular carcinoma to bones and medullary ca to liver
Pulsating secondaries are caused by Follicular carcinoma thyroid and Renal cell carcinoma
The tumors which metastasise to pancreas are Renal cell carcinoma and Malignant melanoma
Scalp is the most common site for cutaneous metastatic disease
Most common source of skin metastasis is ca lung in males and ca breast in females
Most common primary for leptomeningeal metastasis: ca breast
Tumor that has highest propensity to metastasise to heart: Malignant melanoma
Most common site of primary in penile metastasis : CA bladder
CA prostate is the tumor that most commonly metastasises to testis
Most common extra abdominal source of small bowel metastasis: Malignant melanoma
 Investigations of Choice
Acute mesenteric ischemia - Angiography
Mesentric vein thrombosis - CECT
Retropertitoneal fibrosis - CT scan
Diffuse esophageal spasm - Manometry
GERD - 24 hrs pH monitoring
Gall stone, Acute cholecystitis - Ultrasound
Medullary sponge kidney - IVP
Vesico ureteral reflux - MCU
Retrocaval ureter - MRI
Pelvi ureteric junction obstruction - DTPA scan
Renal surface assessment - DMSA scan
Carcinoid tumors - Somatostatin receptor scintigraphy
Colonic diverticula - Barium enema
Diverticulitis, Mesenteric cyst,
Chronic pancreatitis, Renal cysts, TB - CECT
CA bladder - Cystoscopy with biopsy