Last moment revision in Anatomy to Practice of Medicine

Dr Sajeev V
Medical Officer, Department of Homoeopathy
Govt. of Kerala

Cranial Nerves

12 pairs of Cranial Nerves
Part of Peripheral Nervous System
All cranial Nerves Except 1&2 arise from Brain Stem
All cranial nerves supply to same side except Trochlear
All CN have b/l upper control
Cranial Nerves carrying Parasympathetic Fibres –
Occulomotor, Facial, Glossopharyngeal,Vagus

Parasympathetic ganglions–

Ciliary ganglion associated with 3^rd nerve
Sphenopalatine/pterygo palatine ganglion- 7^th nerve
Submandibular ganglion– 7^th nerve
Otic ganglion– 9^th nerve

SURFACE ANATOMY
The horizontal plane passing through the disc that separates thoracic vertebrae T4 and T5 is one of the most significant planes in the body passes through the sternal angle anteriorly, marking the position of the anterior articulation of the costal cartilage of 2ndrib with the sternum.

The sternal angle is used to find the position of rib II as a reference for counting ribs (because of the overlying clavicle, rib I is not palpable);
Separates the superior mediastinum from the inferior mediastinum and marks the position of the superior limit of the pericardium
Marks where the arch of the aorta begins and ends
Passes through the site where the superior vena cava penetrates the pericardium to enter the heart
Is the level at which the trachea bifurcates into right and left main bronchi
Marks the superior limit of the pulmonary trunk

Openings in diaphragm
Venacaval opening-at T8 Vertebral level

Inferior venacava

Branches of rt phrenic nerve

Oesophageal opening- at T-10 level

Oesophagus
Rt &lt vagus nerve
Oesophageal branch of left gastric artery
Veins &lymphatics

Aortic opening – at T 12 Level

Aorta
Azygous vein
Thoracic duct

The hilum of the right lung is arched by- Azygos vein

Bochdalek hernia occurs in – Posterolateral part of diaphragm

Anteriorly, the costal cartilages of ribs 1 to 7 articulate with the sternum (true ribs)

The costal cartilages of ribs 8 to 10 articulate with the inferior margins of the costal cartilages above them.

Ribs 11and 12 are called floating ribs because they do not articulate

Centrally, the intercostal veins ultimately drain into theà azygos system of veins or into internal thoracic veins, which connect with the brachiocephalic veins in the neck.

The right costo-phrenic recess extends up to the 10th level of which rib in the mid-axillary line

The middle cardiac vein is located at the Posterior interventricular sulcus
The right coronary artery originates from the right aortic sinus of the ascending aorta

The left coronary artery originates from the left aortic sinus of the ascending aorta àbranches into LAD(anterior surface of the left ventricle) & LCx (courses toward the left )

Heart

Right border is formed by the right atrium
Left borderis formed by the left ventricle
Apex of heart is formed by left ventricle
Base of the heart is formed by the left atrium

Anterior surface is formed by right ventricle

The coronary sulcus circles the heart, separating the atria from the ventricles.

It contains the right coronary artery, the small cardiac vein, the coronary sinus, and the LCx

The large majority of cardiac veins drain into the wide coronary sinus

The sinus opens into the right atrium between the opening of the inferior vena cava and the right atrioventricular orifice;

The opening is guarded by an endocardial fold semilunar valve (eustachian valve)

BREAST

Location: (female breast)
Superior border: 2nd rib
Inferior border: 6th rib
Medial border: Sternum
Lateral border: Midaxillary line

Location: (male nipple)
Fourth Intercostal Space, Midclavicular line
Underlying muscle
Pectoralis major and minor
Part of serratus anterior, external obliques

Arteries
Lateral Thoracic Artery, branches of Internal Thoracic A., Post. Intercostals

Veins
Intercostal, Internal Thoracic, Axillary Veins

Nerve
Branches of Intercostal Nerve

Spleen lies obliquely along the long axis of the 10th rib.
Directed downwards, forwards & laterally making an angle of about 45 degree with horizontal plane.

PHYSIOLOGY
Conduction velocity

Purkinje fibres -4m/s

Internodal tracts -1m/s

Vent muscle fibres -.5m/s

Atrial m.f – .3m/s

Bundle of His -.12m/S

A.V Node – .05m/s

Rythmicity

SA Node-70-80 beats/min
A.V Node-40-60 beats/min
Atrial m.f -40-60 beats/min
Purkinje fibres-30-40beats/min
Vent m.f 20-40 beats/min

Systolic -cardiac output

Diastolic –total peripheral resistance

Blood will push into aorta –stretches aorta

More stroke volumeàMore stretchingà SBP increased

Diastolic BP

When diastole starts ventricular pressure drops- aortic valve closes

Elastic arteries recoil àblood tend to move forward&backwardàbackward movement is prevented by closed aortic valve

Blood flows out àflow regulated by the tone of arteries

BLOOD PRESSURE

CO TPR

S /v- heart rate
pre load contractility
EDV
venous return
venomotor tone — blood volume

Regulation of BP

SHORT TERM LONG TERM

neurological RAAA

NEUROLOGICAL

BP sensors in vessels

volume sensors in venous side
pressure sensors in arterial side

Pressure sensors

Carotid sinus
Aortic arch sinus

NTS (Nucleus Tractus Solitaris)

1)Stimulates cardio inhibitory centre – via rt vagus ànd SA node

2)INHIBITS cardio accelerator centre

3)vasomotor centre is inhibited

4)adrenal medulla is inhibited

5) JGA IS INHIBITED

Long term regulator : RAAS

Lung volumes

FORENSIC MEDICINE

Strong acids

Inorganic acids-sulphuric acid ,nitric acid,hydrochloric acid
Organic acids-carbolicacid ,oxalic acid,acetic acid,salycillic acid

Strong alkalies
Hydrates &carbonates of sodium,potassium &ammonia

MEDICAL ETHICS
Serious professional misconduct(infamous conduct)P

Moral principles which guide the members of medical profession
CENTRAL COUNCIL OF HOMOEOPATHY Act in 1973

Main cause of penal erasure(removal name from medical council register)

Any conduct which is considered as disgraceful

Dichotomy –(fee splitting) -receiving or giving commission to a professional colleague or trader,chemist etc

Adultery –voluntary sexual intercourse other than his or her spouse

Covering-assisting a person who has no medical qlfcn to attend, treat or perform an operation

Privileged communication – A statement made bonafied upon by a doctor to authority to protect the community

Professional negligence( malpraxis)- IPC 304 A,312

Absence of reasonable care and skill or willfull negligence of a doctor in tt of a patient which causes bodily injury or death

CIVIL NEGLIGENCE – If following conditions are present

Duty –existence of duty of care by the doctor

Dereliction-failure of the doctor to maintain care &skill

Direct causation -the failure to duty lead to death or damage

Damage – the damage which results must be reasonably anticipated

A civil wrong is known as TORT

NOVUS ACTUS INTERVINIENS
Unrelated action intervening

The responsibility for death or disability may pass from original incident to the negligent action of doctor

Criminal negligence-304A-IPC

If gross negligence leads to death of patient.

CONTRIBUTORY NEGLIGENCE
If absence of care on the part of personal attend or patient along with doctors’

Therapeutic misadventure

If patient injured or died due to unintentional act by the doctor/hospital

Vicarious liability

An employer is not only responsible for his own act but also for his employees negligence (respondant superior-let the master answer)

Euthanasia(MERCY KILLING) – producing painless death of a patient who suffers from incurable d’s – No legal sanction in India

CONSENT

Expressed
Implied

Oral consent-should be obtained in the presence of a third party

OBSTETRICS
a/c toxaemia of pregnancy

Pre-eclampsia may be mild or severe charecterised by oedema,albuminuria &hypertension

ECLAMPSIA is the above symptoms with convulsion or coma

Abortion – Termination of pregnancy before the uterus become viable

Can be due to

Foetal factors

Intrinsic defects of fertilised ovum
Cystic degeneration of chorionic villi
Haemorrhage into deciduous
Low quality sperm

Maternal factors

Infections
DM
Htn ,c/c nephritis
Trauma,stress

Uterine causes

Congenital malformation of uterus
Fibroid tumours of uterus
Retroversion of uterus
Ovarian tumours

Hormonal causes

Incompatibility of blood of husb & wife

Pregnancy

Changes in uterus &cervix

Weight -50à900 gms (GENERAL BODY WT gain-5-9 kg)

Size-7.5x5x2.5 cmà30x23x20

Endometrium &myometrim undergo hypertrophy

Endometrium of pregnant uterus is called Decidua

Cervix become softer 7secrete tenacious mucus

Irregular ,painless contractions-Braxton—Hicks contractions

In Vagina
Blood supply increases –with bluish discoloration-Jacquemier’s sign/chadwick’s sign

Vaginal Ph becomes acidic 3.8-4.4

In Breast

Oestrogen acts more on glands &ducts
Progesterone acts on the secretory functions of Breast
Prominent tubercles in the areola-Mont-Gomery tubercles

IN SKIN – Main changes are due to MSH

General changes

Total blood volume increases by 30 %
A/G ratio decreases
Fibrinogen level increases
ESR increases
Cardiac Output RISES BY 40%

Foetal heart beat can be heard from 16^th week

Qty of amniotic fluid-

At 12 weeks -50 ml

20 weeks-400ml

35 weeks -1L

UMBILICAL CORD- 50 CM

2 arteries 1 vein

Labour

Stages of labour

Stage 1

Onset of true labor pain to full dilatation of cervix

Stage 2

Dilation of cervix to expulsion of foetus

Stage 3

Expulsion of foetus to expulsion of expulsion of placenta and its membranes

Mechanism of labor

Engagement
Flexion of head
Internal rotation of head
Crowning
Delivery of head by extension
Restitution
External rotation
Delivery of shoulders by lateral rotation
Caulophyllum,arnica,puls,phos,ipecac,secale cor,sabina

GYNAECOLOGY
Amenorrhoea –absence of menstruation

Kallman’s syndrome -hypogonadotropic hypogonadism-

Dec:GnRH+ dec LH&FSH

LH (N)&FSH Inc-PCOD

LH inc &FSH inc- Ovarian failure

Sheehans syndrome -ischemia due to venous thrombosis

Dysmenorrhoea –painful menstruation

Menorrhagia –excessive menstruation in excess of amount &duration

Metrorrhagia –acyclical intermenstrual bleeding

Polymenorrhoea-frquent menstruation at regular intervals

Uterine fibroids

Subserous
Intramural
Submucous
Symptoms depend on the size of tumour

SURGERY

Types of fracture are:

Complete fracture: A fracture in which bone fragments separate completely.
Incomplete fracture: A fracture in which the bone fragments are still partially joined. In such cases, there is a crack in the osseous tissue that does not completely traverse the width of the bone.
Linear fracture: A fracture that is parallel to the bone’s long axis.
Transverse fracture: A fracture that is at a right angle to the bone’s long axis.

Oblique fracture: A fracture that is diagonal to a bone’s long axis.
Spiral fracture: A fracture where at least one part of the bone has been twisted.
Comminute fracture: A fracture in which the bone has broken into a number of pieces.
Impacted fracture: A fracture caused when bone fragments are driven into each other.
Avulsion fracture: A fracture where a fragment of bone is separated from the main mass.

RENAL STONES

Calcium oxalate 80% when urine is acidic (low pH)
Calcium phosphate _5-10 % when urine is alkaline (high pH)
Uric acid 5-10% when urine is persistently acidic

Diets rich in animal proteins and purines: substances found naturally in all food but especially in organ meats, fish, and shellfish.
Struvite 10-15% infections in the kidney( “infection stones“) Preventing struvite stones depends on staying infection-free. (ammonium magnesium phosphate, NH4MgPO4·6H2O
Cystine 1-2% rare genetic disorder

PATHOLOGY
Inflammation is part of the complex biological response of vascular tissues to harmful stimuli, such as pathogens, damaged cells, or irritants

Vascular changes : vasodilation, increased permeability and increased blood flow,

Increased permeability -results in àallows leukocytes to marginate (move) along the endothelium(margination)àdiapedisis-the passage of blood cells through the unruptured wall of a blood vessel into the surrounding tissues.

Chemotaxis-Movement of leukocytes within the tissue via

Classical signs

Redness – Rubor
Swelling –Tumor
Heat – Calor
Pain – Dolor
Loss of function –Functio laesa

The first four (classical signs) were described by Celsus

While loss of function was added later by Galen

Cells in inflammation

Macrophages
Mast cells
Neutrophils
Basophils

The plasma contains four interrelated systems of proteins—

Complement ,
Kinins,
Coagulation factors,
Fibrinolytic system—that generate various mediators of inflammation.

Complement proteins serve as chemotactic factors for neutrophils, increase vascular permeability, and stimulate the release of histamine from mast cells

The kinin system, which is activated by coagulation factor XII, produces substances that increase vascular permeability.

The most important of the kinins is bradykinin

The coagulation system converts the plasma protein fibrinogen into fibrin

The fibrinolytic system contributes to inflammation primarily through the formation of plasmin

Chemical mediators

Histamine, which triggers vasodilation and increases vascular permeability. Stored in granules of circulating basophils and mast cells,

Prostaglandins are a group of fatty acids, increase the effects of other substances that promote vascular permeability ,aggregation of platelets,

Prostaglandins are associated with the pain and fever of inflammation.

Acute phase proteins – C-reactive protein, serum amyloid A, and serum amyloid P

Repair

Granulation tissue
Endothelial cells give rise to new blood vessels
Fibroblasts grow to form a loose framework of connective tissue.
This delicate vascularized connective tissue is called granulation tissue

As repair progresses, new blood vessels establish blood circulation in the healing area, and fibroblasts produce collagen that imparts mechanical strength to the growing tissue

Eventually a scar consisting almost completely of densely packed collagen is formed.

Necrosis
A form of cell injury that results in the premature death of cells in living tissue

1. Coagulative necrosis – characterized by the formation of a gelatinous substance in dead tissues

Seen in hypoxic (low-oxygen) environments, such as infarction.
Coagulative necrosis occurs primarily in tissues such the kidney, heart and adrenal glands

2)Liquefactive necrosis (or colliquative necrosis)-characterized by the digestion of dead cells to form a viscous liquid mass.

Hypoxic infarcts in the brain

3) . Caseous necrosis -a combination of coagulative and liquefactive necroses, typically caused by mycobacteria (e.g. tuberculosis), fungi and some foreign substance

4) Fat necrosis is specialized necrosis of fat tissue- acute pancreatitis

Two pathways

1) Oncosis (swelling of the cells)àblebbing, àpyknosis (nuclear shrinkage).In the final step of this pathway karyorrhexis (nucleus is dissolved into the cytoplasm)

2) Karyolysis .Nucleusbreaks into fragments

Infarction
Tissue death (necrosis) caused by an obstruction of the tissue’s blood supply

divided into 2 types according to the amount of blood present:
White infarctions (anemic infarcts) affect solid organs such as the spleen and kidneys
Red infarctions (hemorrhagic infarcts), generally affect the lungs or other loose organs (testis, ovary, small intestines).

Neoplasia
Abnormal proliferation of cells.

Anaplasia        – Lack of differentiation
Aplasia            – when an entire organ or a part of an organ is missing
Hypoplasia     – inadequate or below-normal number of cells
Hyperplasia   – physiological proliferative increase in number of cells
Neoplasia      – abnormal proliferation
Dysplasia        – change of phenotype (size,shape and organization   of tissue)
Metaplasia     –conversion of cell type
Prosoplasia    – cell type develops new function
Desmoplasia – connective tissue growth

Neoplasms may be benign, pre-malignant (carcinoma in situ) or malignant .

Adeno – Epithelial glands-Adenoma-Adenoscarcinoma
Fibro- Connective tissue- Fibroma- Fibrosarcoma

BACTERIOLOGY
Staphylococcus + + + + + + + + + + + +

Gram + bacteria, round (cocci), and form in grape-like clusters
Staphylococcus spp. are facultative anaerobes (capable of growth both aerobically and anaerobically).

Streptococcus ++++++++++++++

Spherical Gram-positive bacteria
The most common of these infections include streptococcal pharyngitis (strep throat) and impetigo,scarlet fever ,rheumatic fever and acute glomerulonephritis

Mycobacterium

The genus includes pathogens known to cause tuberculosis (Mycobacterium tuberculosis) and leprosy (Mycobacterium leprae)
Mycobacteria are aerobic and nonmotile bacteria that are characteristically acid-alcohol-fast.
Mycobacteria do not contain endospores or capsules and are gram-positive
Ziehl-Neelsen stain

M. tuberculosis
First discovered in 1882 by Robert Koch,
M. tuberculosis is highly aerobic and requires high levels of oxygen.

Mycobacterium leprae
(Hansen’s coccus )

Bacterium that causes leprosy (Hansen’s disease).
It is an intracellular, pleomorphic, acid-fast bacterium.
M. leprae is an aerobic bacillus (rod-shaped)
Has been grown in mouse foot pads and more recently in nine-banded armadillos because they, like humans, are susceptible to leprosy

Virus
Human immunodeficiency virus (HIV)

Lentivirus (a member of the retrovirus family) that causes acquired immunodeficiency syndrome (AIDS)
Enveloped RNA viruses
HIV infects vital cells in the human immune system such as helper T cells (specifically CD4+ T cells), macrophages, and dendritic cells

Viral RNA genome is converted (reverse transcribed) into double-stranded DNA by a virally encoded reverse transcriptase that is transported along with the viral genome in the virus particle.

HIV-1 and HIV-2.

HIV-1 is more virulent

Malaria
Develops via two phases:

1) Involves the liver (exoerythrocytic phase), that 2) Involves red blood cells, (erythrocytic phase).

An infected mosquito pierces a person’s skin

Sporozoites in the mosquito’s saliva enter the bloodstream and migrate to the liver where they infect hepatocytes,àmultiplying asexually and asymptomatically for a period of 8–30 days

HELMINTHS

Cestodes (tapeworms)
Trematodes (flukes)
Nematodes (roundworms)

A. lumbricoides-causes ascariasis.

Is the largest intestinal roundworm and is the most common helminth infection of humans worldwide.

SPM

Water
Purest form of water –rain water

CHEMICAL IMPURITIES :dissolved gases(oxygen nitrogen etc),dissolved salt(chloride carbonate bicarbonate etc)
PHYSICAL IMPURITIES :suspended impurities, colloidal impurities
MICRO ORGANISMS :algae, fungi, bacteria etc

Water purification

Physical processes -filtration, sedimentation, and distillation,
Biological processes -slow sand filters or biologically active carbon
Chemical processes -flocculation and chlorination and the use of ultraviolet light.

Rapid sand filter
The most common type of filter is a rapid sand filter.

Water moves vertically through sand which often has a layer of activated carbon or anthracite coal above the sand.

The top layer removes organic compounds

NUTRITION

FORTOFICATION –increase nutrient value by adding small qty of nutrients to improve the qlty of food
Adulteration –prevented by PFA Act of 1954
Macronutrients-vitamins &minerals
Net protein utilization -wt gain per unit volume of protein consumed
Most common deficiency in india is IRON def anemia
Pastorization donot kill anthrax but kill TB bacilli

Family planning

Population
World more than 700 cr

India 122 cr

Most effective method of spacing between pregnancy is IUCD

Opinion of 2 doctors is necessary FOR mtp BEYOND 12 WEEKS OF GESTATION

MTP ACT ON 1971-alow MTP nly up to 20 weeks of gestation

Couple protection rate indicates prevalence of contraceptive use in the community

Pearl index-failure rate /100 woman yrs of exposure of contraception

Immunization schedule

Live attenuated vaccines

BCG,
Typhoid oral (Ty21A), Plague,
Oral Polio,
Yellow fever(17 D), Measles, Mumps, Rubella, Influenza,

Inactivated or Killed Vaccines

Typhoid(TAB),
Cholera,
Pertussis,
Rabies, ,
hepatitis B,
JE,
Diphtheria and Tetanus are Non- human antisera (immunoglobulins)
While hepatitis A & B,measles, rabies,mumps varicella are human immunoglobulins

Most effective vaccine is yellow fever vaccine

PRACTICE OF MEDICINE

JOINT DISEASES

Osteo Arthrosis
Most common form of arthritis

Kashin –beck disease is endemic OA

No acute phase response

Nodal OA

Heberden’s nodes -terminal interphalangial joint

Bouchards nodes -proximal inter phalangeal joint

X-Ray

Focal narrowing &osteophyte formation
Bone density is normal or increased

Rheumatoid Arthritis

Most common form of inflammatory arthritis in India
Most common form of arthritis below the age of 50

HLA DRW 4 &HLA DR 4 are ass with RA

HLA DR 4 is correlated with the severity of the disease

Anti globuln antibodies —acts on synovial membrane –

Last moment revision in Anatomy to Practice of Medicine

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