The Updated National Medical Commission (NMC) Competency-Based Medical Education (CBME) curriculum for MBBS focuses on early clinical exposure, practical skill labs, and integration with the NExT exam structure. The 4.5-year academic program plus 1-year internship is divided into distinct phases. Course Structure and Phases Foundation Course (1 month): Focuses on communication, basic IT, professional ethics, and sports.Phase I / First Year (Pre-Clinical): Covers Anatomy, Physiology, and Biochemistry with early clinical exposure. Phase II / Second Year (Para-Clinical): Covers Pathology, Microbiology, Pharmacology, and Forensic Medicine through applied case studies.Phase III Part I / Third Year (Clinical Basics): Introduces Community Medicine, ENT, Ophthalmology, and Forensic/Clinical postings.Phase III Part II / Final Year (Advanced Clinical): Covers General Medicine, General Surgery, Pediatrics, Obstetrics & Gynecology, Orthopedics, and Dermatology.Internship (12 months): Compulsory Rotating Medical Internship (CRMI).Core Focus Areas Competency Development: Applying medical knowledge to real-life patient care. Skill Labs: Training via simulation models alongside ward/hospital postings. Assessments: Logbooks, formative assessments, and alignment with national NExT guidelines. This page on Telemedical Education site attempts to facilitate students to generate the Should Be Able to (required ability)  prescribed in the curriculum, online, across space and time, accessing it by a simple device like a mobile as an add on to teaching in Medical Colleges using an innovative  Segment wise Learn and Test Technology. 

NMC Competency wise Video, Notes and Quiz Revision 

A few thoughts on Medical Education See Following Videos

Why Create ONLINE Education Content

Creating MCQ on Google Forms to immediately test the learnt

Why stick to NMC Curriculum (Learn What not to Teach)

Learning To use Google Class Room

Google Classroom

Making MCQ's in Google Class Room

Making MCQ on Google Classroom

Pre and Para Clinical Phases:

1. Normal anatomical position, various planes, relation, comparison, laterality & movement in our body. Since human body became biped from quadruped everything became Vertical instead of Horizontal except the brain. Thus Superior in brain is Dorsal and inferior Ventral.  In terms of position of thesis horror structures median/  Superficial-deep / internal-external, proximal-distal /  Directions can be combined like - anteromedial,   Clockwise positions (3 O clock 6 o clock  are used.  Also, adding Side, Right-Left, Para in names to suggest that the plane is not median Para Sagittal or Para median are used without specifying sides. Side Right Left is of the body not the visualizer. Special terms of movement used for Forearm (Pronation Supination), fingers (Palmer Dorsal), eyes (Elevation Depression, Jaw Opening-Closing), Eye (Winking), Spine (R/L Lateral flexion, Flexion-Extension, Right Left Rotation are also used. Besides Use links below to master the subject.

From Prof Ashok Sahai

Learn Anatomical Position, Planes, Direction, Movements                                                                                           Test Anatomy Terminology                    Edit Test Anatomy Terminology

Creation of Humans

Reproduction

Embryology

Initial Embryology

From Womb to the World

Neonatology Clinical Approach

Neonatology Reflexes

Neonatology Reflexes examination

Reflexes from Lying to Walking

Cells which are born, function and die to make us live a hundred Years 

Cell Structure and function Nutrition and Oxygen to Energy, Secretion of waste, Multiplication and Protein Synthesis Video: 

Learn Cell Structure and Function          

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Test Cell Structure and Function 

Heterosexual Reproduction: Sperms and Ova carrying n male Father female mother chromosomes but coming from 2n cells form Zygote having 2n chromosomes

Spermatogenesis

Learn Spermatogenesis                            

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Oogenesis

Learn Oogenesis                                        

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Fertilization Zygote and Embryo

Learn the Zygote to Embryo to Fetus Journey  

Test Your Knowledge of Fetal Development  

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Pregnancy and Labour

Learn the womb to world journey    

Mechanism of Labor Movement needed to come out

Test area

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Tissues ( Collection of similar cells) 

Locomotion Providing Movement to body

Bone 

2. Describe composition of bone and bone marrow: Bone consists mainly of two components:

1. Inorganic mineral component (~60–70% of dry weight)

   • Mainly hydroxyapatite crystals, approximately:
     Ca₁₀(PO₄)₆(OH)₂

   • Provides compressive strength and resistance to deformation.

2. Organic matrix (osteoid) (~30–40% of dry weight)

   • Mainly Type I collagen with ground substance.

   • Provides tensile strength and resistance to stretching/fracture.

Mineral HPO4 and Osteoid. Mineral provides compressional Strength  (prevents bending} and osteoid Tensile Strength (prevents breaking). The cells in the bone are Osteoblast: A stellate cell with a granular cytoplasm, which lays down osteoid and secrets Alkaline Phosphatase. This makes medium alkaline and increases concentration of HPO4. Alkaline medium unionizes calcium which binds to plenty of HPO4. 

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Memorize this video on calcium metabolism 

Calcium Metabolism Animation

3. Describe parts, blood and nerve supply of a long bone: Membranous bones are flat bones like those in skull, long bones in limbs short bones in hand and feet. Long bones have an articulating Epiphysis at both their ends and short bones only at the distal ends. Adjoining the epiphysis is the Physis, the cartilaginous growth plate which helps growth in length and fuses at maturity.  Adjacent to the Physis towards the center of long bones is Metaphysis cancellous and vascular in nature, fractures easily, suffers from demineralization in Rickets , Osteomalacia and osteoporosis. Connecting the two metaphysis is the Diaphysis which has a highly mineralized strong cortex with Trabeculae lying laid down to prevent bending or breaking. It has a nutrient foramen from which enters the nutrient artery accompanied by its veneconventes directed away from the growing end of the long bone, physis which will fuse later. Direction can be remembered by "To elbow I go, from Knee I flee". The vessels reach their, destination, the blood sinusoids through the Haversian canal system. Sinusoids are mainly  in the metaphysis where blood comes directly in contact of marrow without intervening endothelium, increasing the probability of infection there. Hair pin bends in arteries as they reach the physis,by slowing the blood stream also contributes for Osteomyelitis in the metaphysis. Muscle attachments yielding periosteal vessels piercing the bone surface also help the blood supply. The nerves accompany the vessels. Nerve supply of joints conveys position and rate of change of position whereas the nerve supply of muscles conveys their Tone.

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4. Enumerate laws of ossification: Bones develop from the parietal layer of intraembryonic mesoderm which forms the core of the limb buds as they bud from the wall of the embryo. The mesodermal bar first converts to membrane which if ossify directly is Primary or membranous ossification, yield Flat bones. In long or short bones the Membrane first chondrifies, yielding a cartilage bar. Arteries enter the centers of the diaphysis and epiphysis, endothelium transforms to osteoblasts, which lay down osteoid and cause its mineralization yielding ossification centers. Ossification gradually grows till Physis disappears and epiphysis and metaphysis fuse.  

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Enumerate special features of a sesamoid bone: Sesamoid bone develops in a tendon to act as a pulley where direction of force has to change. Example Patella in the Quadriceps. 

Sesamoid Bones

5. Cartilage and Joint

Describe various types of cartilage with its structure & distribution in body: 

Cartilage - Joint movement and Growth in Length of Bones

Chondromalacia Patellae

Osteoarthritis

Disc Degenerative Disease

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For integration with Orthopedics You may  go to 

Orthopedics Page Of this Telemedical Education Site

6. Describe various joints with subtypes and examples: Joints are where bones meet, articulate with each other to allow movement. If the connection between them is Fibrous they are called Fibrous Joints example-middle radioulnar joint, Sutures of skull.  If the connection is cartilaginous they are called symphysis - Pubic Symphysis, if there is synovial fluid in between they are called Synovial joints. Then depending on shape of articulating bones they can be ball and socket, hinge or saddle joints. 

7. Individual Joints are described by bones articulating, meniscus, cartilage, synovial membrane, capsule, ligaments, blood supply and nerve supply, movements and muscles producing them, surrounding soft tissue and special features if any 

8. Explain the concept of nerve supply of joints & Hilton’s law: The same nerve that supplies the joint, supplies the muscles moving it and the skin covering it. This helps sensory motor integration and is called the Hiltons Law. If a nerve supplies 2 or more joints disease in one can cause referred pain in the other.

9. Muscles The movers of joints

Classify muscle tissue according to structure & action 1. Skeletal → voluntary contraction through nerves, long multinucleated 2 Cardiac → involuntary & striated + intercalated discs, autonomous Rhythmic Contraction through conductive system by auto discharging Sinoatrial node. Rate and Force governed by Autonomous Nervous System and Catecholamines from the Adrenal medulla. 3 Smooth involuntary un-striated, maintain vasoconstriction, Bronchoconstriction, power the GUT movement, bladder and uterine contraction, pupil size control.

10.  Enumerate parts of skeletal muscle: Contractile central or proximal portion is called Muscle Belly and it can be attached to bone by strong inelastic shiny Tendon, Tendon may form a sheath called Aponeurosis which provides for insertion or origin from large linear expanse like Galea Aponeurotica of  Occipito-frontalis and and palmer and planter aponeurosis of palmaris longus and Plantaris. Look at Galea Aponeurotica and tendo-achallis to understand the difference.

11. Explain Shunt and spurt muscles: Consider Biceps Spurt muscle from far from joint, angular insertion, rotates the radioulnar joint in Pronation-Supination. Brachialis Shunt Muscle near the joint, parallel to bone stabilizes and compresses the joint. 

12. Muscle Contraction Voluntary Involuntary and cardiac: Mechanism of contraction is the same. Voluntary contraction occurs through nerve, Cardiac is initiated by the SA node discharges conveyed through a conductive system, Bowel, bronchial and vascular smooth muscle force of contraction or tone is maintained by a complex autonomic, hormonal and local level control and bladder, rectum and uterus have a contraction relaxation cycle where lost origin insertion distance si not restored even while relaxing by a mechanism called Ratchet mechanism. 

Learn Sacromere Syn and How muscle Contracts

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Nerves making muscle Contract

Learn how nerves make muscles contract

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13. Skin and Dermatomes

Types of skin: Skin can be classified histologically and clinically into Thin skin-Thin epidermis, no stratum lucidum; usually hair-bearing, in Most of the body and Thick Skin - Thick epidermis, prominent stratum corneum; has stratum lucidum; no hair follicles or sebaceous glands in Palms and soles.

Major sensory receptors in skin are: Free nerve endings conducting Pain, temperature, crude touch, Merkel discs conducting Fine touch, pressure, Meissner corpuscles-Fine/light touch, Pacinian corpuscles-Deep pressure, vibration, Ruffini endings-Skin stretch, Hair follicle receptors-Movement of hair/light touch

Dermatome - is an area of skin supplied mainly by sensory fibers from one spinal nerve      root, not a peripheral nerve.  Dermatome wise supply

Supra Trochlear nerve supplies the Frontal Sinus: Sinusitis can cause headache.

A branch from Vagus - Alderman's nerve supplies skin over mastoid process. Irritating used to cause vomiting allowing attendance in multiple parties in Greek rich men called Alderman.  

C2 Posterior scalp Occipital Head ache

C3 Neck Injury above C3 involves Phrenic Nerve paralyses Diaphragm is incompatible with Life

C4 Shoulder/clavicular region: Right Shoulder Right Sub  Left diaphragmatic, Liver Gall bladder pathology causes referred pain Boas sign and  Left shoulder pain in Splenic infarct or rupture - Kehr Sign. Cardiac pain is referred to Left shoulder jaw and C8 T1 distribution in left arm

C5 Lateral upper arm: Axillary nerve involvement - Regiment Badge Anesthesia

C6 Thumb

C7 Middle finger

C8 Little finger

T1 Medial forearm: Low Ulnar Median claw hand in Leprosy is distinguished from C8T1 involvement in Klumpkie's Paralysis by Medial arm forearm anesthesia because medial cutaneous nerve of arm and forearm arising from medial cord are involved

T4 Nipple

T6 Xiphisternum

T10 Umbilicus: Pain of Appendicitis and Pancreatitis Referred Here

T12 Suprapubic region

L1 Inguinal region

L2 Anterior thigh

L3 Medial knee

L4 Medial leg/medial malleolus: Disc presents with foot pain on lateral side

L5 Dorsum of foot / great toe L5 disc involves the great toe

S1 Lateral foot / little toe

S2 Posterior thigh

S3–S5 Perianal region ("saddle area"). Saddle anesthesia. Sacral Triad seenin S2-4 involvement refers to Neurogenic Bladder, Defecation problem and Erectile Dysfunction and decreases the probabilityof recovery in spinal cord involvement.

In short C6 → Thumb, C7 → Middle finger, C8 → Little finger, T4 → Nipple, T10 → Umbilicus, L4 → Medial malleolus, L5 → Great toe/dorsum of foot, S1 → Lateral foot, S3–S5 → Perianal/saddle region

     Dermatome disease causes Radiculopathy → dermatomal sensory loss, hyperaesthesia,  pain

Peripheral nerve injury causes sensory loss in the distribution of that particular nerve

After memorizing the above:

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14. Fascia

15. Describe superficial fascia along with fat distribution in body: Superficial fascia or subcutaneous tissue stores Fat is found just under the skin, Sometimes it is replaced by muscles - Panniculus Cornosus example Facial muscles, Platysma, Palmaris Brevis, Dartos and  Corrugator cutis ani. In abdomen it has the Campers fat bearing layer and fibrous Scarpa's Fascia. In the perineum, Scarpa's fascia bounds the superficial perrineal pouch, where leak of urine in urethral rupture will go in to abdomen but not in the thigh as Scarpa's fascia's attachment to the deep fascia of both thighs parallel to inguinal ligament prevents it.

16. Describe modifications of deep fascia with its function: Deep Fascia packs the muscles and creates compartments in the limb along with its attachment to bones. Edema under the fascia can lead to distal vascular insufficiency needing decompression by Fasciotomy or bone removal for example Fibulectomy can decompress anterior, lateral, Posterior superficial and posterior deep compartments of bone. Where tendons have to change direction fascia thickens to become Retinaculum. Flexor Retinaculum in front of the wrist forms a fibro-osseous tunnel, Carpal Tunnel, passing among tendons the Median Nerve. Swelling in the tunnel can compress the nerve initially causing pain in its distribution and then paralysis. Decompression by dividing the Retinaculum medial to Palmaris Longus may be needed. Another example is medial to calcaneum and Talus is the Flexor Retinaculum forming the Fibron osseousTunnel called Porta Pedis (gateway to foot) which passes The Doctors are not Here. Tibiais Posterior, Flexor Digitorum Longus, Posterior Tibial Artery and Nerve and Flexor Hallucis Longus. Involvement in leprosy or Congenital Talipes Equino Varus Surgery can damage the Posterior Tibial nerve causing a very disabling Anesthetic sole and neuropathic joints.

17. Explain principles of skin incisions:

1. Holding the Knife usually between thumb and middle finger, handle between Thenar and hypothenar eminence, tip to index finger distance as per depth of incision required, Enter vertical,  proceed 45 degree come out vertical.

2. Full layer in one go up to deep fascia, creating vertical edges.

3. Second hand stretches the skin.

4. Assistant follows with pressure through sponge.

5. Hemostasis one by one as sponge lifted gradually from one end to the other. If by cautery then it should not touch metal or skin edges.

6. Divide along Langerhan Lines.

7. Don't cross joint transversely as fibrosis perpendicular to joint line can cause contracture.

8. Count instrument and sponges before closing.

9. Check Hemostasis.

10. Consider drain.

18. Circulation- Blood, Lymph and CSF:

19. Heart: Development and developmental anomalies, Fetal to pulmonary circulation, Pericardium, Myocardium, endocardium, Cardiac Cycle and production of murmurs, Conduction system EKG and recognizing abnormalities of EKG. Enjoy seeing these videos for patient intent knowledge.

Cardiac Diseases

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Endocardial Defects

Mitral Stenosis

Clinical Approach To Mitral Stenosis

Understanding Mitral Stenosis

Mitral Stenosis 8th Semester Lecture

Nitric Oxide Vaso Dilation for Tissue Anoxia

20. Pulse waves: Systolic - S (Systolic) and D (due to elastic recoil of arteries during diastole). In between there is the Anacrotic notch. The D wave will disappear if arterial elastic recoil energy is wasted during aortic regurgitation or is less in atherosclerosis destroying the elastic collagen of the artery. Secondly as the D wave pressure maintains flow in coronary arteries during diastole this can cause cardiac ischemia. Also, decreased time for diastole in increased heart rate will also cause coronary ischemia as coronary arteries supply the haert only during diastole. A are generated by ventricular systole and travel at 5-10 m/s in healthy arteries towards the peripheral circulation. There is therefore a systolic component and a diastolic component sustained by the elastic recoil of the arteries during Diastole. In Aortic regurgitation since this energy is lost in regurgitation the pulse becomes Water Hammer. Examination of pulse records - Rate/minute High -Tachycardia, Low Bradycardia, Rhythm- Regularly irregular - Ventricular ectopic, Irregularly irregular- Atrial fibrillation, Volume high - Hypertension, Water hammer pulse ( volume increases on raising the upper limb above the heart.), Pulse volume low indicates shock. Increase in lowering of pulse volume during inspiration indicates - Pulsus Paradoxus, seen in pressure on the Heart by constrictive pericarditis, Cardiac Tamponade or pericardial effusion which decreases the end diastolic filling.  Different lowering of volume between two arteries of right and left indicates pressure- Cervical rib. Low or absent femoral pulse on one side- Vascular Sign of Narath is caused by posterior Dislocation of the Hip. Pulse confirms cardiac function. Absent at all sites indicates cardiac arrest. Absence in traumatic/other limb indicates ischemia ( causes - RESTED- Raynaud's, Embolic, Senile, Thromboangitis Obliterans and Takayasu's Disease, Ergot Alkaloid Poisoning, Diabetes and Traumatic.) This ischemia  may indicate pending gangrene and loss of limb.

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21. Venous Drainage: Veins return Blood from tissue to Heart, all carrying deoxygenated blood except pulmonary veins which carry oxygenated blood from Lung to Left atrium of the heart. They have unidirectional valves to prevent back flow and blood in them is maintained by suction by negative pressure during inspiration and  pumping by muscle contraction in limited fibro-osseous space like by Triceps Surae  (Calf muscle) called Peripheral Heart. Venous return from gut and spleen must be monitored and modified by liver before being let into the systemic circulation. This draining one organ into the other is called the portal system. Blockade at the liver level can cause Portal Hypertension when veins connecting the systemin and portal veins peripherally dilate - Esophageal varices and rupture causing Hematemesis. Higher pressure in them can lead to fluid leak into Peritoneum - Acitis and enlargement of the draining organ - Splenomagaly. Similarly, valvular failure at the sapheno-femoral junction causes dilated tortuous lower limb veins called  varicose veins. These varicose veins may also be compensatory due to thrombosed or incompetent drainage of the deep veins of calf.  Central  Venous pressure monitors blood returning to heart during shock as cardiac output depends on venous return, force of contraction and rate of contraction. If CVP is high despite shock it indicates restricted end diastolic filling due to the heart failing to dilate sufficiently due to external pressure by pericardium in Cardiac Tamponade (Blood), Pericardial Effusion (fluid) or Constrictive Pericarditis (Fibrosis of pericardium). In these conditions Normal pulse volume drop during inspiration increases (Not a Paradox) but Central venous pressure (CVP) during inspiration increases, should normally decrease, hence paradoxical. The venous waves are - a - Atrial Systole, X descent-Rapid inflow phase, C + Elastic recoil of arteries and Y descent.

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22. Blood: Contains  Cells and Plasma. Blood Cells are Red , White and Platelets. 

Red Blood cells (RBC)  4.7-6.1 X 10 to the power 12/ ml in  Men and 4.2-5.4 in women, maintaining Hb level 13.5-17.5 g/ml men and 12-15 in women  are biconcave, to increase the surface area for gaseous absorption, due to an enzyme G6PD, which if deficient causes Spherocytosis. Drugs  5 P's and Dapsone- Primaquin, Phenazopyridine, Probenecid, Pharmaceutical Sulfonamides and Prooxidant along with Fava beans, Moth balls and severe infections, sequentially decrease G6PD, NADPH, Glutathione causing inability to neutralize oxidants, producing Heinz bodies which bite RBC's to cause Hemolytic anemia of Spherocytosis. Hb S causes Sickle Cell Hemolytic anemia due to Sickling of cells in Anoxia- Hess's Finger Tourniquet test. Non replacement of Foetal Hb causes Hemolysis in Thalassemia. Oxygen binds to Hb and is carried by it from lung to tissue. Since Carbon mono oxide binding is stronger, in persons exposed to CO, Coal burning in close space to beat cold, oxygen carriage hy Hb is defeated by greater CO binding affinity and patient can die of Anoxia. Blood remains bright Red therefore this is called Happy Anoxia. Deoxygenated Hb presents as Cyanosis - Bluish discoloration of lips and skin.  However, if Hb is lower than 6 gm % then reduced Hb is insufficient for cyanosis to occur. This can occur in shock and anemia. Red blood cell can also be destroyed by extracellular Antibodies against the Rh + antigen present on their surface when Rh -ve mothers bear Rh +ve babies. These antibodies in mother are indicated by Indirect Coombs Test + and in baby by Direct Coombs Test +ve. Hemolysis (destruction of RBC) has two effects. Hemolytic Anemia described above  and Hemolytic Jaundice, because the Hb in plasma due to hemolysis    converts to indirect unconjugated Bilirubin, demonstrated by Indirect Vandenburg reaction. RBC destruction is compensated by increased production in bone marrow indicated by incre3ased Reticulocyte count. Another reason for reduced Hb is less formation by Bone marrow. Less function of Bone marrow, Aplastic Anemia is characterized by normocytic normochromic cells in blood where as cells become Microcytic Hypochromic in Iron Deficiency anemia and Megaloblastic in B12 deficiency anemia. B12 deficiency can be secondary to absent Castle factor needed for its absorption in Gastric insufficiency. B12 deficiency also produces Sub Acute Combined Degeneration of sensory motor neurons in the spinal cord (SACD). B12 and Iron can be measured in Blood. Red Blood Cells are also infested by Malaria Parasite. Parasite uses Duffy antigen (ACKR1) to enter RBC so Duffy negative RBC is resistant to P vivax Infestation. HbS and G6PD deficiency also protects.  Chloroquine enters the parasites digestive vacuole and binds ferriprotoporphyrin IX (pfcrt) preventing its detoxification into hemozoin, thus killing the parasite. This pfcrt mutates thus preventing Chloroquin action causing Chloroquine Resistance.  Exposure to low O2 or sometimes without cause RBC number increases causing Polycythemia.    

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Oxygen Transport: High Concentration in Alveoli 99 % of O2 carriage is by 4 O2 molecules binding to 1 Hemoglobin molecule. Lowering of O2 Concentration here, initially decreases Hb-O2 binding slowly, then steeply (Oxygen- Hemoglobin dissociation sigmoid curve), making low concentrations in lung dangerous to Hb-O2 binding and thus oxygen carriage. Same Low concentration in Tissue releases O2 there, aided by higher CO2 concentration+Acidic media, (Bohr Effect). Acidic because High O2 consumption in active tissue induces Anoxia, causing Pyruvic to Lactic acid conversion by Lactic Dehydrogenase and high levels of 2,3-bysphosphoglycerate (2,3-BPG), all being present in Highly active tissue.

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Vascular Response to Tissue Anoxia: Local Anoxia in Tissue is sensed by endothelium by increased Deoxygenated Hb. Endothelial Nitric Oxide synthase  eNOS (endothelial nitric oxide synthase) produces NO from L-arginine, with L-citrulline as the coproduct. Arginase competes with eNOS for L-arginine decreasing the availability of Arginine for NO synthesis to combat Anoxia. NO activates soluble guanylyl cyclase (sCG) which increase cGMP causing vascular smooth muscle relaxation causing vasodilation acting on  and restoration of O2 levels in tissue. Robert F. Furchgott, Louis J. Ignarro, Ferid Murad got Nobel prize for this discovery.  In elderly L Arginine levels decline with age causing perpetual vasoconstriction, increased peripheral vascular Resistance thus Hypertension. Arginase comes from L-Arginine needs Nitrites. Source of Nitrites is Nirate, found in Beetroot, stored in Saliva during good chewing and converted to Nitrites by nitrate reductase from Neisseria, Veillonella, Actinomyces and Rothia microbes residing in the mouth and nasal sinuses which may be destroyed by tooth paste, oral disinfectants like Listerine or Antibiotics. Interesting how mouth wash can produce Hypertension and importance of Beet Root Kanji in nutrition.

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CO2 Transport: 20% CO2 from Tissue to lungs is carried 1. bound to the globulin portion of Deoxygenated Hemoglobin yielding Carbaminohemoglobin . Deoxygenated Hb carries more CO2 than Oxygenated Hb, (Haldane Effect). In lung, as Hb Oxygenates, it releases CO2. 2. 70% CO2 reacts with water by Carbonic dehydrogenase yielding  H+ and HCO3-. H+ is buffered by the globulin component of deoxygenated HB. HCO3- goes out Cl- comes in (Chloride shift, Hamburgers  Phenomenon, Acid Shift) (70%), . In Lungs HCO3- yields CO2 (exhaled) and OH- stays. Alveolar Action Alkalizes. So when CO2 increases in Respiratory failure keeping O2 low allows more CO2 carriage by Deoxygenated Hb and improving alveolar ventilation insures more CO2 to exhale. 3. dissolved in plasma.(10%). Clinical effect of High CO2 are flapping tremors.Brain responds by Hypercapnea Deep fast Kusmauls breathing. This breathing is normal Respiratory system compensating Renal acidosis by respiration throwing out excess acidosis producing CO2. In Respiratory failure, however, Anoxia causes Respiratory depression. CO2 accumulation stimulates, result is Cheyne Stoke Breathing. Then Irregular- Bitot's and finally  Respiratory Arrest.

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White Blood Cells and Immunity: White Blood cells about 4 to 11 thousand per ml of blood are Polymorphonuclear, 40-70%, Lymphocytes 20-40%, Monocytes 2-8% Eosinophils 1-4% and Basophils 0-1% are Formed in bone marrow and are destroyed in spleen. They are the warriors of the body acting against other harmful chemicals or microbes  providing immunity or harmless others antigens - Hypersensitivity or Self antigen Autoimmunity. Tolerating self antigens is Immune tolerance provided by T (Thymus) cells which by circulating through the Thymus gland in Foetal life  get educated by it to distinguish between self and non self antigens.  The Y shaped receptor on Lymphocyte surface has a Fab 1 arm to recognize self/ non self,  intracellular Fc piece to relay attack information to nucleus to start multiplying in case of attack. The other Fab 2 arm attacks the adversary helps in killing  by injecting cytokines in them. Memory T cells Memorize this sef non self, store it and pass it to the next generation to Regulate  immune function by controlling Killer T cells and Regulating T cells. The IgG, IgM, IgA, IgD and IgE type antibodies made by B cell agglutinate, tag to help identify, initiate a compliment reaction (Series of explosive chemical transformation to  hole the cell membrane of the adversary) and form complex with the antigen deactivating it by changing its nature. Immunoglobulin, antibodies are stored in the Aner/ Myeloma bodies of B cell cytoplasm. B cells with such bodies more than 10 per high power field in marrow smear are diagnostic of Multiple Myeloma.  In blood increased immunoglobulin appear as Myeloma Band in Plasma Electrophoresis. Their Fc piece is secreted in urine as Bence Jones Proteins which cloud on heating and disappear on more heating.  Increase in WBC as a reaction to infection or suo-moto in malignancy Leukemia is Leucocytosis  Other Malignancies of B cells are Lymphoma,  Multiple Myeloma, Plasmocytoma.  Total Leucocyte count decrease is Leukopenia due to less formation in marrow Hypo or Aplastic marrow or increased WBC destruction (rare). Polymorphonuclear cells on activation stick to vessel wall-Margination, Flow out of it, Diapedesis, walk over fibrin mesh if present or simply swim the ECF and engulf the attacker, keeping and digesting it  or excreting it through excretory vacuole -Phagocytosis. Outside the blood vessels they are called Macrophages.  Lymphocytes perform the Immune function, T Lymphocytes-cells mediated and B Lymphocytes- antibody mediated. Eosinophils rise to combat mediators of inflammation in Type I hypersensitivity-Eosinophilia or sometimes in response to worm infestation. Monocyte rise is in infectious Mononucleosis. Little is known about Basophils. 

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Hypersensitivity: Failure of Immunotolerance is Hypersensitivity. It is of Type I, II, III and IV. Type I is initiated by IgE antibodies anywhere including the nasal mucosa, when they encounter harmless antigens recognized as non self either genetically, Atopy or acquired in other places - Anaphylaxis. Ige catching antigen on their FaB arms stimulate the Mast cell they reside on by their intracellular Fc arm causing release of chemical mediaters of inflammation like Histamine. Inflammation causes exudation, edema and spasm of smooth muscles like Bronchospasm. In nose - Rhinitis, Siunses - Sinusitis, Pharynx -Pharyngitis, Eustachian tube - Eustachian catarrh, Ear- Acute and Chronic Otitis Media, Conjunctiva - Conjunctivitis, Larynx- Laryngitis, Trachea - Tracheitis, Bronchus- Bronchial Asthma, Bronchitis and Bronchiectasis, Peri-Bronchial tissue- Broncho Pneumonia, Alveoli- Emphysema, Pulmonary arteries - Pulmonary Hypertension ( accentuated 2nd heart sound), Right Ventricular Hypertrophy - Parasternal Heave, Right ventricular failure - Prominent neck veins, Tender smooth hepatomegaly, splenomegaly, ascites, pedal edema. From pulmonary arteries heart involvement is called Cor Pulmonale. Respiratory present as Pink Puffers and cardiac as Blue Bloaters    

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In Type II Hypersensitivity IgG and IgM antibodies bind to cell surface antigens or extracellular matrix leading to death by complement activation, Opsonization- Phagocytosis, antibody dependent cell mediated Cytotoxicity by Natural Killer cells  inflammation or altered function by blocking or simulating cell receptors. Blood Transfusion Reaction, Rh+ fetus cells destroyed by antibodies of Rh- Mother, Basement Membrane of kidney - Good Pasteur Syndrome, Rheumatic Fever, Myaesthenia Gravis, Graves Disease, Idiopathic Thrombocytopenic Purpura. Presentation depends on organs involved. Investigation can be for specific antibody, Anti Rh Antibodies Coombs test, Compliment levels and histology. Treatment is remove antigen, steroids, immuno-suppressive, Intravenous immunoglobulin for IdiopathicThrombocytopenic Purpura and disease specific therapy.   

Type III hypersensitivity is Immune complex mediated like Type I and II Glomerulonephritis

Type IV hypersensitivity is by Cell Mediated Immunity important in Transplantation where the reaction can be Graft vs Host or Host Vs Graft.

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Platelets: Platelets or thrombocytes, 1.5–4.0 lakh/ml of blood, 2–4 µm in size, live 7–10 days from 

creation from megakaryocytes in bone marrow. Being a-nucleate cannot multiply. Function is primary hemostasis and secondary support of coagulation.

Structurally Granular they have α-granules containing

vWF, fibrinogen, Platelrt Factor 4, Platelet Derived Growth Factor. Causing respectively adhesion, coagulation, repair, extracted from patients blood and used therapeutically to cause repair in inflammation, injury or degeneration and Dense/δ-granules containing ADP, ATP, Ca²⁺, serotonin. Serotonin released in alveoli. This during the Covid Pandemic resulted in severe pulmonary vascular spasm, decreased lung perfusion and respiratory failure along with other effects of Serotonin. Platelet activation shows as aggregation, Lysosomes, Hydrolytic enzymes release of Platelet Factor 4 which neutralizes heparin allowing coagulation during hemostasis within vessel coagulation Thrombosis fuelled by Virchows Triad, stasis, endothelial injury and increased coagulability of the blood. This is the root of Heart Disease and Cerebrovascular Stroke. When blood vessel Injury  exposes subendothelial collagen, vWF binds collagen and platelet GpIb binds vWF. This they plug the breach arrest bleeding. Primary Hemostasis.Growth factors taken out from patients blood are used therapeutically specially in degenerative arthritis.

Activated Platelets change from disc to spiky shape releasing

ADP, TXA₂ Ca²⁺, Serotonin, ADP causing GpIIb/IIIa expression which releases fibrinogen binding adjacent platelets, platelet aggregation and plug the gap in bleeding vessels. TXA₂

causes vasoconstriction, Promotes platelet aggregation,

PGI₂ (prostacyclin) produced  by endothelial cells Causes vasodilation and Inhibits platelet aggregation. Thus Primary hemostasis means Platelet plug formation and

Secondary hemostasis, the Coagulation cascade,

Fibrin formation, Stabilization of platelet plug. Platelet disorders are due to decreased numbers or weak function. Thrombocytopenia or Thromboaesthenia. Low counts, seen in Dengue fever, too much use in Disseminated Intravascular Coagulation -DIC syndrome, marrow suppression, presents as spontaneous bleeding, and Prolonged bleeding time. Increased destruction in Hypersplenist contributes. In Thromboaesthenia function suffers because in

Bernard-Soulier syndrome - GpIb defect causes defective adhesion, In Glanzmann thrombasthenia there is GpIIb/IIIa defect, in von Willebrand disease defective platelet adhesion is due to decreased or abnormal vWF.

Vascular incompetence cause Vascular Purpura classified as Henochs-Schonlene purpura (HSP), current name IgA vasculitis is a small vessel leucocytoclastic vasculitis caused by IgA deposition affecting children having purpura, arthralgia, abdominal pain, renal involvement. and Purpura Simplex means easy Bruising with normal platelets and coagulation. Sometimes vessels fail due to Vitamin C deficiency-Scurvy. Drugs inhibiting platelets are Aspirin by COX-1 inhibion causes low TXA₂ decreased platelet aggregation. This has been used in reducing mortality in Coronary insufficiency by use within an hour of Heart Attack. Clopidogrel blocks P2Y12 ADP receptor decreasing GpIIb/IIIa activation.

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22. Immune deficiency can occur with Hematological malignancy Leukemia, Lymphoma and Myelomas and by marrow suppression by radiation or drugs. Virus AIDS insures its survival by creating deficiency. Immunity fails against  cancer cells See Cancer for Under Graduates,

which though being antigenically different, having tumor neoantigen, some of it also being at the surface, evade T cells by stimulating univalent antibody (Hapten ) production by B cells against surface tumour neoantigens which carpet the tumour surface antigen making it invisible to killer T cells - Eclipse Phenomenon. Next the Hapten antigen complex breaks from the tumour cell surface and circulating in the plasma blocks the self/non selfrecognizing FaB piece on the surface of the T lymphocyte blinding it for recognizing anything. Thirdly this complex inhibits lymphocyte production directly in the marrow of Tumor bearing patients.   CAR T Cells, Chimeric Antigen Receptor bearing T cells are patients lymphocytes, which are taken out, cultured with antigen specific to Tumor cell CD 5,19, 23 etc. not found on normal cell and then their self/nonself recognizing FaB is fused to killing Fab so that now when they are injected back they will seek and destroy only the specific antigen bearing cell, keep multiplying and doing it till the last cell is gone. Very effective in Hematological malignancies they are not so effective in solid Tumors. However, culturing Lymphocytes from Tumor tissue instead of blood seems to restore their ability. They are one of the most effective forms of immunotherapy yet. Thermo or cryo-coagulation of Tumor seems to expose cytoplasmic or nuclear tumor neo antigens triggering an effective immune reaction against the tumor. Resection of bone segment bearing the tumors, radiating it to kill all cells and exposing intracellular tumor antigens and re implanting seems to work on a similar principle.  that can recognizing  infected by a virus bearing  Immunotherapy. 

Management of Aplastic marrow is Transfusions to gain time, prevent exposure and Allogenic Hemo-poetic Stem cell Transplant protecting it from host vs graft reaction by controlled immuno-suppression horse ATG + cyclosporine.

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Plasma its constituents : Is  90 %  water,  decrease is dehydration and increase over hydration. Proteins 6-8 %, are Albumin 60%, which maintain colloid osmotic pressure, decrease causes extra vassation of fluid in the extra vascular compartment called edema/ anasarca. Causes of decrease are malnutrition and increased loss due to leaky Glomerulus in Nephrotic Syndrome. Globulin 40% AG ratio,6:4, are alpha and beta which transport like lipoprotein, transferrin and Gamma globulins having IgG, M, A, D, and E Immunoglobulins for the immune function. Other important functioning proteins are Fibrinogen 4-7% coagulation, Complement defense, clotting factors Homeostasis and regulatory proteins like hormones and enzymes. Functions are Transports nutrients, hormones, gases, metabolites, waste products and drugs. pH 7.35 to 7.45 maintained by buffer system of plasma proteins and Bicarbonate, supports coagulation, immunity, heat distribution, and blood Pressure.    

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Coagulation and coagulopathies: 

• Primary hemostasis → platelet plug

• Secondary Hemostasis-Coagulation is the process in which soluble fibrinogen converts to  insoluble fibrin, stabilizing the platelet plug and producing a stable blood clot. coagulation cascade → fibrin formation

• Fibrinolysis → plasmin breaks down fibrin after repair

Coagulation pathways: Extrinsic  Tested by VII PT/INR, 

Intrinsic XII, XI, IX, VIII Tested by aPTT, Common X, V, II, I Tested by 

PT and aPTT. 

Faliure to Clot: VIII deficiency Hemophilia, IX deficiency Christmas Disease. Acquired Vit K deficiency, Liver unable to synthesize Prothrombin. PT, PC decreased. Excess use DIC syndome Disseminated intravascular coagulation. Mnemonic: Extrinsic → 7, Intrinsic → 12 → 11 → 9 → 8, Common → 10 → 5 → 2 → 1, Both pathways converge at Factor X.

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Fluid and Electrolyte Balance and Ph Control: Fluid intake is oral and regulated by renal excretion balancing availability and absorption rate. Less intake, more loss as in Gastroenteritis - Fluid, Burns Plasma or internal or external blood loss may cause dehydration or shock. The principles are suspect dangerous dehydration or shock, don't wait for the cold clammy skin and a gasping patient with dilated pupils for then your diagnosis of shock  or dangerous dehydration for then it is for postmortem purposes only. Replace Blood by blood as soon as possible as fast as possible. Replace what is needed, Plasma in burns, Platelets, RBC's. Restore osmolarity by High Molecular weight Dextran and Low molecular weight Dextran increases Perfusion. Diagnose and restore electrolytes Sodium, Potassium, Calcium, maintain pH and blood gases and treat the cause. Hyponatremia due to prolonged use of diuretics to control Hypertension presents as disorientation in elderly. Sudden Lowering of  mineralocorticoids in Addisonian crises or Niesseria Meningitidis causing bilateral adrenal hemorrhage-Waterhouse-Friderichsen Syndrome has to be managed by substitution of electrolyte and Hormone. Hypocalcemia due to accidental Parathyroid removal during throidectomy presents as convulsion Chovostek sign, Carpopedal spasm, Accoucheurs hand, coagulopathy and convulsion. Hypocalcemia is also produced by Acid Citrate Dextrose used to prevent coagulation by chelating calcium in blood stored for transfusion. More than 6 units of transfusion  needs calcium substitution because excess ACD can chelate intravascular calcium.

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23. Lymphatic Drainage  Lymph nodes and spleen

24. List the components and functions of the lymphatic system

Spleen and lymph nodes: Lymphatic drainage prevents edema and returns excess interstitial fluid and proteins to the bloodstream, while also providing immune surveillance and transporting absorbed dietary fats and is thus created to augment Circulation. Besides this Lymph nodes contain and fight infection in the drainage area and house cancer cells spreading from the primary source. Lymph filters into blind ended lymphatic vessels, is squeezed towards draining lymph node by muscle  contraction and nearby pulsating arteries, backflow being restricted by unidirectional valves carrying, food, debris, fluid, microbes, Cancer cells which are filtered in Lymph nodes. Immunity destroys the undesirable microbes causing lympadenitis. Cancer cells start growing here causing secondaries. Lymph node enlargement is local or general. For local drainage area should be examined for infection or malignancy along with number, site, tender or not, matted or discrete and consistency. Tender enlargement associated with fever with chill and rigour and edema in the draining area with hydrocele in the scrotum with painful lymphatics may indicate filaria to be confirmed by demonstration of microfilaria in Night Blood Smear or Anti filarial antibodies in the blood. The treatment is Banocide forte 1 xTDS x 21 days. Matted lymphnodes indicate Tuberculosis, Shorty discrete Syphilis. Generalised lymphadenopathy could be Leishmaniasis, Malaria, Malignancy like Lymphoma or Leukemia where splenomegaly should be looked for. Spleen is palpated as firm lump from Left subcostal margin directed towards Right Iliac fossa, moving with respiration. it is not possible to insert fingers between it and the subcostal margin. Prehepatic, hepatic or post hepatic (Right sided Congestive Heart Failure), Portal Hypertension, Malaria, Filaria, Leishmaniasis, Subacute Bacterial endocarditis, Leukemia, Lymphoma can be thought of. As spleen is the graveyard of blood cells with associated Pan cytopenia is an effect - hypersplenism particularly in Idiopathic Thrombocytopenic Purpura. (ITP). Splenic Rupture can cause bleeding in the Left  paracolic gutter causing bluish discoloration around the umbilicus Grey Turners Sign D/D Pancreatitis and being sub diaphragmatic pain of splenic rupture is referred to Left shoulder Kehr Sign by phrenic and supraclavicular nerves sharing the root values of C3,4,5. Post Lymphnodes lymph travels to the Thoracic duct's Cysterna chyli crosses the spine from left to right, collects Lymph from Left side of Head and neck and drains into left subclavian vein.. Filtering lymph before drainge for harmful Lymphocytes in autoimmune Rheumatoid Arthritis is called Lymphapherisis

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25. Important Lymphatic Drainage: Head and Neck is drained by rings of Waldyer. The inner ( pharyngeal, tubal-Eustachian Tube, Palatine and lingual tonsils-PTPL)  and outer (submental, submandibular, pre and post auricular, and occiptal lymph nodes). The outer ring drains from submandibular into jugulo digastric, jugulo omohyoid and supraclavicular lymph nodes. Lymph nodes of neck are palpated from behind with neck flexed to relax the deep fascia. Cystic Hygroma is a transilluminant  cystic swelling in the posterior triangle of a child due to faulty blockade of connections between draining lymphatic channels.  The Supraclavicular lymph nodes (Stage III Breast cancer) drains the axillary lymph nodes (stage II Breast cancer) which drain the Axillary tail of spence of the breast. Lymph flows in the subcuticular layer of breast centripetally towards the nippel superficial to the subcuticular layer of skin. The skin is connected to pectoral fascia by arranged radially from the nipple, twin layered Ligaments of Astley Cooper which divide the breast into locules housing the breast fat, ducts and glands. Space in these ligaments allow subcuticular lymph to connect to sub pectoral fascia  lymphatics where it drains centrifugally, quadrant wise into axillary through the Axillary tail of Spence piercing the clavipectoral fascia and through the Rectus sheath, Falciform peritoneal fold into liver, the pathway of Retzius. Cancer breast spreads through these. It infiltrates the Ligaments of Cooper retracting the nipple and directing it towards the side of the malignancy. Testicular drainage is into para aortic lymph nodes, perineum and lower limb drains into Lymph node of Cloquet  medial to femoral vein, the femoral canal, site of strangulation of the femoral hernia needing very careful decompression as vein is lateral, inguinal canal anterior, pubis posterior and the Accessory Obturator Artery in the lateral margin of the lacunar ligament medial. Fracturing the pubic tubercle decompresses the femoral canal.  Filarial involvement of inguinal Lymph nodes causes Lymph edema of Lower Limb, the classical Elephantiasis, involvement of lymphatics of inguinal canal can cause Painful irreducible inguinoscrotal swelling without cough impulse - Filarial Funiculitis. Consequent Lymphatic Blockade can cause Hydrocele. 

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26. Describe structure of lymph capillaries & mechanism of lymph circulation Described

27. Explain the concept of lymphoedema and spread of tumors via lymphatics and venous system 

Integrate Cancer See Video

Cancer for Under Graduates

Metastasis: Cancer cells invade surrounding tissue by breaking through the basement membrane. Enzymatically Matrix Metalloproteinases extracellular matrix is broken. Their leaking into lymphatic or blood vessel is intravasion. They survive in circulation by eclipsing their surface neoantigens by Hapten univalent antibodies produced by B lymphocytes against them and by the immune complex thus created sticking to the Recognizing Fab piece of the T lymphocyte blinding them. Cells extravasate from lymphatics and blood stream into distant tissue. They survive, adapt, proliferate and multiply at new site (Colonization) and arrange blood supply - Angiogenesis. Their dedifferentiated nature helps survival and adaption. Spread is lymphatic, hematogenous and transcoelomic - Kruckenburgs tumor - Gastric cancer trancoelomic spread to ovaries. The spread through veins is to lungs and from lungs to bones and brain. From GIT drained by portal system it is to liver and prostatic portal system to vertebra. The metastasis usually retains the Primaries character and is sometimes are Primary dependent like Follicular Carcinoma of Thyroid and Hypernephroma of Kidney. Metastasis regresses with removal of Primary. Also removal of primary in follicular carcinoma of thyroid will allow most of the radioactive iodine given to irradiate and kill the cancer cells will deposit without competition into the metastasis.  

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28. Nervous System: Describe general plan of nervous system with components of central, peripheral & autonomic nervous systems

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Living (Conscious) beings  Perceive the change in their surrounding environment (Stimulus) - Perception, process to classify it into painful, pleasurable or neutral and Respond by thinking, feeling, acting to seek pleasure, avoid pain and ignore the neutral. This they do by the Nervous System. 1. Perception is by Senses : a. Special  - sight, smell, sound, taste and change in position (vestibular) and b. General: b1 External (outside the body through skin - Exteroceptive (Pain, Touch, Temperature and pressure), b2 Interoceptive - Internal organ and  b3  Proprioceptive - information about Position of joints  and it's rate of change 

2. Perceived Stimulus is processed by comparing it with past experience stored in memory which classifies it as Novel (No past experience) and Experienced. Novel is Experienced and the experience stored as memory to control future response -Learning. For Experienced stimuli memory is used to decide its painful pleasurable or neutral nature. Painful pleasurable are reinforced to reach consciousness, acquire attention shifting character and neutral suppressed -  Habituation.  Optimal thinking feeling or acting response is planned. If speed is needed Response is standardized so action occurs without bringing the perception into consciousness, becoming aware Reflex Action.

3. Responding body needs O2 and nutrition to reach the cells and end products rapid removal  for response to be optimal, provided for  by circulation and respiration rate being controlled by  the Autonomic - Sympathetic Accelerator and parasympathetic breaking systems.  Optimal state of the  responding body the maintained by hormones, (chemical influencers reaching their site of action through blood - Endocrine System) ; Enzymes which act where they are produced or reach the site in fluid called secretions through ducts, Exocrine System. Living Body is the Structure and function protocol that strives to achieve this from individuals creation to his demise. Responding optimally every time is intelligence. 

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This perceiving responding behavior can be normal or abnormal. Abnormal can harm self or others. Thinking excess, uselessly, imagining worrying about improbable future or regretting un change able past causes Anxiety Neurosis. Neurosis is when victim knows his problem, Psychosis when he does not know it. Acute anxiety needs Benzodiazepines like Diazepam antidote Flumazenil, chronic anxiety- Buspirone, SSRI's, SNRI's, Pregabalin and  performance (Exam) anxiety - Beta Blockers-Propranolol.   Mood Swings: Abnormal elation Mania and Depression (Depression) or alternating state of mania and depression is  Cyclothymic Personality. Excess and Psychotic is Maniac Depressive Psychosis. Manic-depressive psychosis, the older term for bipolar disorder, particularly bipolar affective disorder is treated by Lithium carbonate a long term mood stabilizer in Acute mania preventing both manic and depressive relapses. It reduces Suicide-risk. Having a narrow therapeutic index blood lithium levels and renal/thyroid function need monitoring. Adverse effects are tremor, polyuria, polydipsia, weight gain, hypothyroidism and GI upset. Toxicity is coarse tremor, vomiting/diarrhea, ataxia, confusion, dysarthria, seizures. Interaction is with Thiazide diuretics, NSAIDs. ACE inhibitors/ARBs can increase lithium levels. Lithium can cause Ebstein anomaly if given in first-trimester. Persona is others estimate of individuals nature ego is his own estimate. Persona Problems include responding to or fearing (Paranoid) the unreal - is Hallucination and Unpredictable shifts in reaction, persona type being good Dr Jekyl sometimes and bad Mr Hyde, Split (Schitz) personality (Phrenos), Schitzophrenia. This is attributed to Dopamine Excess and responds to Major Tranquilizers like Phenothiazine which inhibit Dopamine. Associate this with that Dopamine formation by Substantia Nigra can cause Parkinsonism. Electric induction of Grand Mal Seizures (ECT) has been used. May be Epileptics have less chance of being Schtzophrenics. can  

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29. Supportive Motor and Supportive Sensory Reflex action system headed by cerebellum: Cerebellum heads the reflex  - Afferent from Tecto (Vision), Vestibulo (speed and direction of body movement recorded by semicircular canals of the internal ear) and Spino (muscle tone, joint position, rate of change) cerebellar tracts. Afferent. Center Cerebellum finding intention of Cerebral cortex through Cortico-ponto-cerebellar tracts Processing for Intended minus expected position. and the correction needed is done through the extrapyramidal system- Efferent constituting ( area 4S in cortex, Basal ganglion-Caudate, Lentiform, Claustrum, subthalamic nuclei, Substantia Nigra, Red nucleus, Reticular formation, Vestibular nucleus - extensor tone and inter-nuntial neurons of the spinal cord - Flexor Tone regulation). This is  by controlling the tone of terminal muscles of the nucleated intrafusal muscle fibers through gamma neurons. The center of this nucleated intrafusal fiber is a coiled annulo spiral ring sensor, coil distance decides at which length the muscle tone will equalize antagonistic muscle tone and control the resting angle achieved by the joint. Spinal Tone causes Universal Flexion, Vestibular nucleus  Rigid Extension (Spinal Rigidity- Moros Startle Reflex. Substantia Nigra by Nigro-strial pathways provides Dopamine, which if deficient causes bradykinesia, resting tremor, lead pipe rigidity and consequent instability and inability to stop in time and reach where they want to reach.  Since Dopamine can not cross Blood Brain barrier, L Dopa is used. Bilirubin deposit in basal ganglion  in Icterus neonatorum among other causes can cause Chorea sudden, involuntary jerking movements and Athetosis, slow sinuous writhing movement.  Reticular Formation generates electrical impulses  and directs them appropriately to controls electrical activity of brain. This activity is measured by EEG. Excessive un controlled activity of local area of brain causes Focal or Jacksonian epilepsy and generalized activity causes Grandmal Epilepsy. Normally by ascending Reticulo-Cortical Tracts, electrical activity increase causes wakefulness and decrease sleep. The Reticulo-thalmico- cortical tracts power the thalamus to selectively increase the electrical activity of a specific area in the Hippocampus to re feel experienced important event Memory  and use it in wakefulness in Sleep this appears as Dream. Descending Reticulospinal tracts maintain activity in the internuncial neuron system of the spinal cord, the center of the stretch reflex. Annulospiral ring around the intrafusal fibers of muscle if stimulated by gama neurons from the extra pyramidal system will stretch the ring coils generate afferent activity in the corresponding internuntial area and cause extrafusal fibers to contract till the coil distance is restored at the desired length of that muscle. This is the Stretch Reflex. or Deep Reflex (initiated by Deep muscle sensation). Tapping the tendon increases muscle length unexpectedly and muscle contracts to control it. Superficial reflex is initiated by Superficial sensation like Touch or pain. In sudden section of the reticulospinal tracts the stretch reflex is oblierated till the internuntial neurons can revive causing temporary absence of Tone - Spinal Shock. In uterus the spinal Flexor tone is high and the fetus is in the position of universal flexion, floating in the amniotic fluid without effect of gravity or weight, Archimedes principle. With Birth whether higher centers will be able to provide antigravity extension tone or not is tested by the Moros or Startle reflex when the baby stretches on being suddenly dropped and caught experiences gravity. Head holding when, prone, using extensors to propel like a lizard, crawling, standing and bipedal walking are all indicators of the gradual development of  extensor tone superiority and development of antagonistic, horizontal, diagonal, forward backward straight walking and caudate nucleus mediated turning to opposite side be decreasing stride length on that side.

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You Tube on Cerebellum for detailed Explanation of Above

SENSORY SYSTEM

Special Senses:  Vision, Audition, Smell, Taste and Vestibular Function:

Vision Eye: Light falls on the object to be seen and is reflected refracted towards the Eye. It crosses the transparent media - Cornea, aqueous humor in anterior chamber, pupil, lens vitreous and falls on the retina. Amount of light  reaching the retina is controlled by the pupillary size decreasing to avoid excess and increasing to compensate for low light. In Vitamin A deficiency night/low light vision is lost. Refraction by cornea air interface, is corrected by lens shape change by ciliary muscle tone to form a sharp image of the viewed object on the retina. Two together are called Accommodation and errors are called Refractory Errors, more power Myopia Less power Hypermetropia and unequal power in different planes Astigmatism.     Macular area is more adapted to perceive such image so it is kept aligned to get the best by extra ocular muscles.  Total area of the outside that eyes can see is the field of vision. Temporal Eye looks the nasal field and impulses travel in the optic nerve, in the lateral side of optic chiasma and same side optic tract to the superior colliculus of the midbrain.  From there to lateral geniculate body, optic radiations and the calcarine sulcus in the occipital lobe. Superior part of the sulcus , in parietal  lobe, Myers area looks at the inferior field and inferior temporal  part at the superior field. The macular area casts its information in the posterior angle of the calcarine sulcus supplied by the Posterior Cerebral Artery. So when rest of the calcarine area is damaged in Middle cerebral artery thrombosis macular area Brodman's area area 17  is spared. Macular Sparing. The nasal area of retina looks at the temporal field and the fibers cross to the opposite side in optic chiasma lying anterior and susceptible to be pressed by adenoma Pituitary  causing Bilateral temporal loss of the field of vision. One eye sharing its information with both cortices allows fusion of the two images of 1 object in two eyes. Binocular function. Similarly ear shares its information with both side auditory areas and the fibers cross at lateral lemniscus before the inferior colliculus to medial geniculate body to auditory cortex area 41,42.   Superior Colliculus passes information to Edinger Westphal Nucleus to coordinate pupillary reflex of both eyes ipsilateral Direct and contralateral Consensual and accommodation to insure optimal fusion. 

Visual loss means 1. Media opacity- Cornea, Aqueous Humor, Pupil, Lens (Cataract) Vitreous hemorrhage. 2. Retina malfunction - Detachment, retinopathy, Central retinal artery thrombosis. 3 Optic nerve unable to transmit, injury or neuritis. 4 Chiasma Pressure Pituitary adenoma, Bitemporal Hemianopia, 5. EWN - Argyll Robertson's Pupil ( Loss of light reflex direct and consensual present accommodation Reflex- Tabes Dorsalis, Tract disorder contralateral upper, lower or complete visual epilepsy or loss. 6. Cortex- Middle cerebral artery ischemia contralateral field with macular sparing because that area escapes because it is supplied by the posterior cerebral artery.

Corneal Transplant for corneal opacity, Management opacity in  Anterior Chamber, insuring normal functioning pupil, Replacing opaque lens, replacing opaque vitreous, treating retinopathy, retinal detachment and preventing conduction or perception loss of impulses from Retina can be done to restore save vision. 

Refractory Error: Besides media opacity diminished  vision can be because of Refractory Error - Myopia, Hypermetropias or Astigmatism which needs diagnosis and correction.

Pressure of Aqueous Humor may rise due to blockade of its drainage through corneo iris angle  Close angle Glaucoma or  Blockade in Canal of Schlem bounded towards anterior chamber by Desmet's membrane extension towards scleral spur and endothelium lining the gap between extensions. Open Angle Glaucoma. Production decrease by carbonic anhydrase inhibiters Diamox and opening of blockade in canal of Schlem constitute the treatment. Prolonged pressure besides painful red eye with circumciliary congestion can damage visual acuity. Corneal ulcer, Uveitis and iridocyclitis is the differential diagnosis.

Anatomy of formation and Drainage of Aqueous Humor

Inadequate darkness in the eye is seen in Albinism where light coming from all sides prevents macular development, may present as Nystagmus and poor focus in vision.

Squint: Inability to align both eyes is Squint which is due to imbalance between Lateral, Medial, Superior, Inferior Rectus and Superior Inferior oblique muscles. It can be corrected by accommodation Phoria or not Tropia. Deviation lateral, medial, superior, inferior, intorsion or extorsion. The weaker image is ignored and the vision of that eye may become poor Amblyopia.

Ptosis: Eyes lie in the orbit and can be closed by the upper and lower eyelids - Orbicularis Oculi or Opened - Levator Palpebri Superioris. This muscle has a motor, 3rd nerve and a Sympathetic Mullers muscle supply. Thus, Sympathetic blockade of the stellate ganglion of the neck to restore blood supply to ischemic arm causes Ptosis upper eyelid drooping, meiosis, pupil constricted, enophthalmos - Horner's part of lacrimal part of orbicularis oculi pulling eyeball out paralyzed  along with vasodilation in half of face Flag sign and inability to sweat in the affected 1/2 Anhidrosis. This is Horner's Syndrome. Eyelid may fail to remain open in Myesthenia Gravis or not open due to mechanical weight or fusion between two lids. Besides eye lash disease Blepheritis may make eylids itch or stye - painful or Challession swollen,

Paralytic Failure to close: If orbicularis oculi is paralyzed in facial nerve entrapment in stylomastoid foramen the palpebral fissure between lids fails to close, exposure keratitis and opacity occurs in the cornea. Temporalis is used as transfer to restore lid closure as both are synphasic muscles Jaw wink reflex or Marcus Gunn's Phenomenon. Jaw closure causes eye to close. 

Mechanical Failure To close: Eyelids may not close because the eyeball is protruded Proptosis- Big Eyeball Retinoblastoma (yellow pupillary reflex) , Retroorbital Tumour or abscess -Unilateral or Bilateral Exophthalmos of Hyperhyroidism, smooth symmetrical thyroid swelling - Primary or Graves Disease and Nodular - Secondary Thyrotoxicosis. If this stretches the optic nerve and causes blindness then unilateral decompression can be done through Zygomatic component of lateral, or medial, inferior wall of orbit or bilateral removal of orbital plate of frontal bone. Steroids to decrease edema may be tried First.

The Conjunctival sac connecting the eyeball to lids contains tears secreted by the lacrimal gland, collected in the lacrimal sac and pushed into nose by the nasolacrimal duct. Conjuctiva may start growing onto cornea from medial side - Pterygium. On removal tip area will produce opacity so removal should be before or after it crosses the pupillary area. Conjunctivitis is itchy red eye with exudative discharge. Cause allergic or infected need treatment.  Congestion is away from cornea -Peripheral. 

Painful Red Eye:  Caused by Corneal ulcer by foreign body, inwards directed lid, or disease, Iridocyclitis and Uveitis showing ( aqueous flare)  or Glaucoma showing high tension has to be managed as per the cause.

Excessive Tears are due to poor drainage or excessive irritation in the conjunctival sac. Drainage is through the puncta in the in the lower and upper lids, which collect tears and drain it into lacrimal sac. Lacrimal part of orbicularis oculi squeezes the sac to empty into the nose through the nasolacrimal duct. Congenital non canalization and dacrocystitis (sac infection) impede the process. Dacrocysto-Rhinostomy - Sac to nose connection operation bypasses the Nasolacrimal duct. 

Hutchinsons Pupil in one sided supra-tentorial intracranial extradural hematoma is irritative same sided constriction followed by compressive dilation the same sequence being repeated on the opposite side. So unequal pupil in Head Injury means extradural hematoma on the side that constricted dilated first.

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Head Injury and Eye: In Supratentorial Space occupying lesion Tentorium cerebelli in pressed inferiorly along with cerebellum, mid brain, pons and medulla. The 6 th Abduscent nerve as it rises in the inferior petrosal sinus - Canal of Dorella, hooks into the cavernous sinus below the petrosphenoid ligament of Guber on the petrous temporal bone, bend of Wolf, is stretched and paralyzed paralyzing the lateral rectus demonstrated by absence of lateral deviation of eye as head is rolled to the opposite side as a result of fixation reflex. This test is Dolls Eye Movement Test and positive means supra-tentorial space occupying lesion or loss of Brain Stem integrity.   Skull base fractures can cause carotico cavernous fistula and pulsating Exophthalmos. Arterial Bruit may be auscultated over the eye in this condition.

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Hearing:  See this video on Hearing and Vestibular system of the Ear.

Overview of Ear Anatomy and Sound Transmission

• External Ear: The auricle (the visible outer ear) concentrates incoming sound waves and funnels them through the ear canal to the tympanic membrane (the eardrum) [01:16].

• Middle Ear and Ossicles: When sound hits the tympanic membrane, it vibrates. This vibration is most intense at its center (the umbo) and is mechanically transmitted through a chain of three tiny cartilaginous bones: the malleus, incus, and stapes [01:54].

• Protective Mechanism: To protect the delicate inner ear from extremely loud sounds, muscles attached to these three small bones can contract. This tightens the bony arch and dampens the transmission of excessive vibrations [09:59].

The Middle Ear Cavity and Surrounding Structures

• Anatomy: The middle ear functions like a localized box containing a roof, floor, anterior, posterior, medial, and lateral walls [04:40].

• Pressure and Infections: The anterior wall contains the eustachian tube, which connects to the pharynx to equalize air pressure in the ear with atmospheric pressure, protecting the eardrum [07:11]. If this tube is blocked (like during an allergy), pressure builds up and can cause infections like acute otitis media [07:59]. Infections can sometimes travel through a hole in the posterior wall into the mastoid air cells in the skull.

• Facial Nerve Path: The video also outlines how the facial nerve (the 7th cranial nerve) travels near the middle ear space, bending down to eventually supply the facial muscles and accompanying the nerves that serve the salivary glands [10:59].

Inner Ear: Hearing and Balance

• Cochlea (Hearing): The stapes conveys the vibrations into the inner ear through the oval window. This causes fluid inside the snail-shaped cochlea to vibrate [17:50]. The vibrating fluid bends tiny hair cells, which catch the movement and transmit the signal as sound to the brain via the cochlear nerve.

• Semicircular Canals (Balance): For balance, the ear relies on three fluid-filled semicircular canals that track the head's movement in different directional planes  When your head moves, the fluid moves inside the canals, causing small calcium concretions (otoliths) to shift and bend specific hair cells. This motion data is transmitted through the vestibular nerve to the brain, allowing you to perceive how fast and in what direction your head is moving.

• Corrections the ossicles are bones, not cartilages; the protective reflex involves tensor tympani and stapedius; and otoliths are mainly associated with the utricle and saccule, whereas semicircular canals detect angular acceleration through their cristae ampullares. Otoliths in semicircular canals can cause Benign Positional Vertigo and are restored to Ampula by Apley's Maneuver

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Smell:  Odor molecules stimulate the olfactory epithelium in the roof of the nose. 20-40 olfactory nerves on each side pass through the cribriform of the ethmoid into the olfactory bulbs having Mitral and Tufted cells. Olfactory Tract ends in olfactory trigone from which lateral olfactory stria to Primary olfactory cortex (pyriform, Periamygdala and Hypothalamus for autonomic response. Secondarily, Amygdala creates the emotional response, Hippocampus memory and orbito frontal cortex via thalamus for reaching the cortex. It is the only sensory pathway bypassing the thalamus.

Taste: From anterior 2/3 of tongue, lingual, chorda tympani geniculate ganglion of facial, Posterior 3rd Glossopharyngeal Vagus both into Nucleus of Tractus Solitarius. 2nd order neurons go to the VPN nucleus of the Thalamus and third order neurons to the primary Gustatory cortex in the insula and its frontal operculum. 

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General Sensations To Cerebral Cortex and Cerebellum:

Pain received by (nociceptive pathway) at the site of origin travels to the brain by

1. Transduction: Painful stimuli (mechanical, thermal, or chemical) activate nociceptors (free nerve endings). The stimulus is converted into an electrical impulse.

Chemicals such as prostaglandins, bradykinin, histamine, serotonin, and substance P sensitize (make more or less receptive the nociceptors).Prostaglandin Inhibiters are analgesic anti-inflammatory drugs. 

2. Transmission Pain impulses travel through 

First-order unipolar neuron, Cell body in the Dorsal root ganglion for body and  trigeminal ganglion for face. The Aδ fibers carry  Fast, sharp, well-localized pain and C fibers slow, dull, aching, burning pain. They enter the spinal cord via the dorsal root and synapse in the substantia gelatinosa of the dorsal horn. The Second-order neuron crosses (decussates) to the opposite side through the anterior white commissure within 1–2 spinal segments,

Ascends as the lateral spinothalamic tract. It's closeness to spinal canal during the decussation involves it in spinal canal in the dilation of spinal canal in syringomyelia so that pain temperature are selectively lost whereas touch pressure, anterior spinothalamic tract are preserved - Dissociate Anesthesia. ST tract terminates mainly in the ventral posterolateral (VPL) nucleus of the thalamus.

Third-order neuron travels from the thalamus to the primary somatosensory cortex postcentral gyrus for conscious 

3. Perception and localization of pain. Additional projections reach the insula, anterior cingulate cortex, and limbic system, contributing to the emotional Fight, Flight, Fright perception  of pain. Thus the brain interprets the intensity, location, and emotional significance of the pain. It also 

4. Modulates excessive pain through

Descending pathways from the periaqueductal gray (PAG), raphe nuclei, and locus coeruleus inhibiting pain transmission in the dorsal horn through Endorphins and enkephalins, Serotonin (5-HT). Norepinephrine (NE) released in crises reduces neurotransmitter release substance P and suppress pain signals.

Temperature: Thermoreceptors in skin to Aδ fibers Transmit cold (especially rapid cooling), C fibers transmit warmth and slow temperature sensation to Dorsal root ganglion (1st-order neuron) to relay in Dorsal horn of spinal cord, Cross to opposite side through anterior white commissure and rise in Anterolateral / spinothalamic tract to VPL of Thalamus. Third  order Thalmico-cortical through internal capsule reach Primary somatosensory cortex (postcentral gyrus) for Conscious perception of temperature.

Clinical point: Because temperature fibers cross in the spinal cord, a lesion of the anterolateral tract can cause opposite side loss of pain and temperature, usually beginning a few segments below the lesion.

Touch: Fine discriminative touch -  localization, two-point discrimination, texture is received by Skin Receptors carried to cord by First order neuron which are unipolar with cell in Dorsal root ganglion. Clinically lesion proximal to the Dorsal root ganglion can obliterate the Triple response to scratching the skin - Red line due to Histamine generated dilation of small capillaries, Flare widening of the line by the arteriolar dilation by Axon reflex mediated by vasodilators like CRPG and substance P and Wheal due to increased permeability and extravasation mediated by Histamine. In spinal cord tracts ascends ipsilaterally in posterior columns, Fasciculus gracilis from lower limb/lower trunk and Fasciculus cuneatus from upper limb/upper trunk to Nucleus cuneatus and gracilis in medulla. There, some aimed for cortex Cross as internal arcuate fibers and Medial lemniscus to the

VPL nucleus of thalamus relay and 3Rd order reaches the 

Primary somatosensory cortex (postcentral gyrus). Others, aimed for cerebellum go as posterior external arcuate fibers to ipsilateral cerebellum and anterior external arcuate fibers to contralateral cerebellum. These augment the muscle tone and joint position and rate of change -  Proprioceptive sensation needed by the cerebellum carried to it by Anterior Spinocerebellar tracts rising to mid brain, decussation and reaching cerebellum of opposite side through the superior cerebellar peduncle and Lateral Spinocerebellar passing through the inferior cerebellar peduncle to the cerebellum of the same side. Crude / non-discriminative touch perceived by Skin receptors through  cell in Dorsal root ganglion, Synapse in dorsal horn of spinal cord, Crosses through anterior white commissure ascend as Anterior spinothalamic tract to VPL of Thalamus. The 3rd order neuron through internal capsule reaches the Somatosensory cortex. 

Key: Crude touch crosses in the spinal cord. and fine touch in the medulla.

Pressure is mainly carried through mechanoreceptors and uses pathways similar to touch. Vibration is a fine/discriminative sensation and travels mainly through the Dorsal Column–Medial Lemniscus (DCML) pathway.

Fine discriminative touch -  localization, two-point discrimination, texture is received by skin Receptors carried to cord by First order neuron unipolar with cell in Dorsal root ganglion. Clinically lesion proximal to the Dorsal root ganglion can obliterate the Triple response to scratching the skin - Red line due to Histamine generated dilation of small capillaries, Flare widening of the line by the arteriolar dilation by Axon reflex mediated by vasodilators like CRPG and substance P and Wheal due to increased permeability and extravasation mediated by Histamine. In spinal cord tracts

Ascends ipsilaterally in posterior columns, Fasciculus gracilis from lower limb/lower trunk and Fasciculus cuneatus from upper limb/upper trunk to Nucleus cuneatus and gracilis in medulla. There some aimed for cortex Cross as internal arcuate fibers and Medial lemniscus to the VPL nucleus of thalamus relay and 3Rd order reaches the Primary somatosensory cortex (postcentral gyrus). 

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Supportive Reflex System for Locomotion Afferent Center and Efferent

Transcript for the video.

Brain Anatomy and the Role of the Cerebellum

• Basic Structure The video begins with a structural breakdown of the brain, identifying the corpus callosum, pituitary gland, fornix, pineal gland, and parts of the midbrain, pons, and medulla oblongata. The Cerebellum's Core Function: The cerebellum acts as the "secretary" to the brain's cortex. The cortex is responsible for determining the intended position of the body at a specific time. Calculating the Correction: To coordinate movement, the cerebellum figures out the body's current position and its rate of change to determine the "expected" position. It then calculates the difference between the intended and expected positions to find the exact movement correction needed. Executing the Movement: This necessary correction is executed via the extra-pyramidal system, which adjusts flexor and extensor muscle tone through the stretch reflex.

How the Cerebellum Gathers Information

To make these precise calculations, the cerebellum receives sensory input from three primary sources:The Eyes: Visual information regarding the "artificial horizon" is sent to the brain through the tectocerebellar tracts. Semicircular Canals: Information about the head's current position and its rate of movement is conveyed via the vestibulocerebellar fibers.The Spinal Cord: Pathways from the spinal cord transmit crucial data regarding joints and muscle tone. Specific Spinal Pathways: The lecturer explains that the fasciculus cuneatus tracks joint position, the fasciculus gracilis monitors the rate of change in joint position, and the spinocerebellar tracts carry information regarding muscle tone.

The Extra-Pyramidal System and Motor Pathways

• Deep Brain Structures: The video maps out the connections to the extra-pyramidal system, sketching a coronal section of the brain that highlights the thalamus, caudate nucleus, lentiform nucleus, and internal capsule. Descending Structures: Important control centers are discussed, including the red nucleus and substantia nigra in the midbrain, and the reticular formation which extends down into the spinal cord. The Reticular Formation: This structure uses an oscillatory neuronal circuit. Because of the way these neurons loop, they can create a perpetual electrical impulse at a fixed frequency. Voluntary vs. Corrective Movement: The nervous system utilizes pyramidal fibers for voluntary movements, and extra-pyramidal fibers for the cerebellum's corrective, involuntary muscle adjustments.

The Mechanism of the Stretch Reflex

Muscle Anatomy: Muscle fibers consist of extrafusal fibers (which are responsible for bulk movement) and intrafusal fibers (which contain an annulospiral ring that acts as a stretch sensor). Motor Neurons: Alpha motor neurons innervate the extrafusal fibers, while Gamma motor neurons control the intrafusal fibers. How the Reflex Adjusts Tone: When the extra-pyramidal system aims to move a joint, it stimulates the gamma neurons, which contracts the intrafusal fibers. This stretches the annulospiral ring, sending a signal down to the spinal cord. Final Execution: The spinal cord responds by activating the alpha motor neurons, causing the extrafusal fibers to contract. This restores the length of the annulospiral ring and successfully adjusts the joint to the new, precise angle intended by the brain.

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Motor Tract:

Draw the Brain with this Video Saggital Section

Key Anatomical Structures Covered:

• The Sagittal Section & Core Structures: The instructor begins by identifying central brain components, pointing out the Corpus Callosum [00:41]. From there, the lesson moves to the Fornix, the Septum Pellucidum, the Thalamus, and the Hypothalamus [01:09].

• The Brainstem & Cerebellum: The pathway from the midbrain down to the brainstem is mapped out, specifically detailing the Pons and how it transitions into the Medulla Oblongata [02:16]. The instructor also highlights the cerebellar peduncles that connect the brainstem to the cerebellum [02:26].

• Glands & Ventricles: The video points out the location of the Pituitary Gland resting in the hypophyseal fossa [03:33], the Pineal Gland [04:09], and the position of the Fourth Ventricle [02:55].

• Cranial Nerves: There is a detailed look at the junction of the pons and the medulla, specifically tracing the path of the Abducens nerve and how the Facial nerve loops around it to form the facial colliculus [04:59].

• Deep Brain Nuclei & Capsules: In the latter half of the video, the focus shifts to a horizontal or coronal perspective to explain the relationship between the Caudate Nucleus and the Lentiform Nucleus [05:55]. The instructor illustrates how the Internal Capsule passes between these nuclei like a "bunch of flowers" [07:14], and briefly identifies the external capsule and claustrum on the outer periphery 

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Draw the Brain to Recognize its Parts Coronal Section

Introduction to the Nervous System: The lecture begins with a philosophical overview of the nervous system, describing how it helps humans navigate the "world of objects, emotions, and thoughts." It explains that learning and memory are fundamentally processes of developing appropriate emotional, cognitive, and physical responses to external events [00:11].

Drawing the Brain's Core Structures: The instructor emphasizes that drawing the nervous system is crucial for properly identifying its parts and their spatial relationships [02:37]. The anatomical diagram starts with the corpus callosum and septum pellucidum [03:22], followed by the mapping of the fornix, thalamus, and the third ventricle [04:07].

Basal Ganglia & Matter Distribution: The video details the location of the caudate nucleus relative to the ventricles [05:07], as well as the lentiform nucleus and putamen [06:03]. The instructor points out the distinction between the gray matter (which forms these nuclei) and the surrounding white matter tracts [07:30].

Cerebral Lobes and the Insula: The diagram expands laterally to define the frontal lobe, the temporal lobe, the lateral sulcus, and the insula [08:19].

The Midbrain: Moving toward the brainstem, the instructor illustrates the midbrain structures, focusing on the corpora quadrigemina—which includes the superior and inferior colliculi—and the cerebral aqueduct [10:38].

Capsules and Cerebellar Connections: Using a new perspective, the video highlights the internal capsule (situated between the thalamus/caudate and the lentiform nucleus), the external capsule, the claustrum, and the fibrous connections extending to the cerebellum [12:12].

Brainstem and Motor Tracts: The lecture maps the lower brainstem, detailing the pons, medulla oblongata, and spinal cord [14:28]. In the final segment, the instructor traces the descending pathway of the motor tracts from the cerebral cortex, passing down through the internal capsule, the cerebral peduncles, the pons, and finally into the medulla [15:35].

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Upper Motor Neuron of motor Pyramidal  Cortico Spinal tracts start from Precentral Gyrus with human hanging with the knee bent on the upper border, foot and leg on the medial side and the thumb lowermost. The lowest portion of the precentral gyrus of the dominant hemisphere, mostly the Left has the speech  Broca's area. Ischemia or irritative lesion of cortex can cause focal epilepsy, inability to recognize objects by palpation - Astereognosis, and loss of two point discrimination.  Then they descend through Corona Radiata, being held by the Caudate nucleus as hand holds the Bouquet. Hemiplegic Stroke is due to thrombosis of the supplying Middle Cerebral Artery, lying in the lateral sulcus involving the internal  capsule which is  indented by lentiform nucleus into a medially directed bend - Genu and an Anterior and Posterior Limb. Rotating continuously, upper tracts becoming lateral they reach the Cerebral peduncle of the mid brain  and supply ipsilateral 3rd, 4th nerve nuclei (occular movements), then the Right and left tracts lie adjacent in the anterior pons supplying the 5th nerve, muscles of mastication. 6th the lateral rectus, 7th lies at the pontomedullary junction supplies the facial muscles, its parasympathetic part from the superior salivary nucleus supplies  salivary and lacrimal glands and sensory part carries taste sensation from anterior 2/3rd of Tongue through lingual and chorda tympani. 8th the vestibular and the cochlear of the ear. 9th, taste and sensation of posterior 3rd tongue and stylopharyngeus which lifts the thyroid cartilage during deglutition. 10th whose motor supplies the laryngeal muscle, rest is parasympathetic, 11th supplies Trapezius and Sternocleidomastoid and 12th the muscles of the Tongue. Cranial nerve origin level helps in horizontal localization of the lesion.  Above midbrain is Hemiplegia, In the brain stem as per the nerves involved, above Brachial plexus Quadriplegia and below it Paraplegia.  At medulla  3/4th cross and 1/4th  will cross in spinal cord. The hemi-section of spinal cord will cause ipsilateral motor and proprioceptive loss but contralateral spinothalamic loss. Brown Sequard Syndrome. They relay in the anterior horn cell of the spinal cord. The Stellate Anterior Horn cell with central nucleus and granular cytoplasm has many Dentrides - afferent and one Axon which traverses through, cauda equina, ventral rami, nerve root, nerve and ends in the myoneural juncion of the nerve. Disruption of the pathway results in partial or complete loss of the power of the muscle supplied.   
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Signs of Upper Motor Neuron (UMN) Involvement

A lesion of the corticospinal/upper motor neuron pathway produces a characteristic pattern Weakness / paralysis often in groups of muscles, Muscle tone shows Clasp knife Spasticity, distinguish from lead pipe rigidity of Parkinsonism and Cog Wheel Rigidity of Ataxia, Deep tendon reflexes are exaggerated, Clonus especially ankle/knee, Plantar response Extensor (Babinski positive), Superficial reflexes (abdominal, cremastric, anal ) decreased or absent, Mild/disuse atrophy; Fasciculations in Motor Neurone Disease, Loss of fine, skilled voluntary movements. Important exception Immediately after an acute severe UMN lesion, there may be a period of flaccid paralysis with depressed reflexes (“spinal shock”). The typical spastic UMN picture develops later.

Lower Motor Neuron Constitution and Signs: constituting anterior horn cell, motor nerve root, peripheral nerve, neuromuscular junction, or motor nerve endings. Muscle may be paralyzed directly. Weakness / paralysis often affecting individual muscles or specific nerve/root distribution, Hypotonia Hyporeflexia or absent, Muscle wasting, muscle atrophy, Fasciculations Present, Fibrillations on EMG, Plantar response Usually flexor/normal, Superficial reflexes, Reduced or absent if the relevant motor arc is involved, Clonus Absent, Babinski sign Absent, Fine movements Impaired due to weakness.

Differential Diagnosis of Motor weakness complete "plegia", partial "pareisis" is Acute Spastic - All T's Trauma (Spinal Cord Injury), Transverse Myelitis, Thrombosis of anterior spinal artery (Meningo vascular syphillis), Acute Flaccid: Spinal Shock with all P's Polio, Porphyria, Polyneuritis, Phosphorus (Organophosphorus poisoning). Disseminated Sclerosis and Hysteria can be both. Chronic spastic paraplegia is seen in Lathyrism. Syrigomyelia and MND are combinations of Upper and Lower Motor Neurone, Syringomyelia showing dissociate anesthesia ( lost pain temperature present Touch pressure), MND being pure motor. 

Chronic Flaccid are best remembered by site - Anterior Horn cell Polio, MND, Nerve Root, Pressure by Disc, spin bifida or spondylolisthesis, Nerve injury, entrapment and distribution wise Mononeuritis ( lead poisoning), Mononeuritiis Multiplex ( Leprosy) Polyneuritis Symmetrical stocking Glove progression of anesthesia (Diabetes). Myoneural Junction- Myaesthenia Gravis and Muscle Muscular Dystrophy. Let us briefly describe each of the Differential Diagnosis. 

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Acute Spastic

Acute Cord Compression: Trauma or Tubercular abscess can cause acute compression. The third T Tumor can cause insiduous cord compression. On Lumber Puncture there is dry tap or Albumino-cytological Dissociation with Xanthochromia - Froin Syndrome, also seen in infective Polyneuritis (Gullian Bare Syndrome) an  acute ascending but unlike this group lower motor neuron paralysis. Another finding in cord compression on Lumber Puncture is absence of rise in CSF pressure rise on LP when Coughing, Queckenstedt's test. These tests are now not done as Contrast MRI can non-invasively demonstrate the site and nature of compression. 

Transverse myelitis is Acute Spastic sensory motor paralysis with bladder Bowel involvement with no evidence of cord compression. 

Thrombosis of Anterior Spinal artery: Meningovascular Syphilis or unpaired Anterior Cerebral Artery is rare.

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Acute Flaccid: Besides the spinal shock of the Acute spastic group which is darkness when like goes off before the generator, local spinal internuntial neuron system can switch on causes are 4 P's.

Poliomyelitis, by Leon, Landing and Brunhilde entero (gut residing) RNA virus, spreading through feco-oral route, grows in the intestine. If live (kept live by cold chain carriage), attenuated, non disease producing all 3 viruses are given in children disease producing virus can not enter because the infected cell produces Interferron. Also, Attenuated virus moving in the body creates immunity against it which immunises by cross reacting with wild virus too. Excreted in faeces the attenuated virus infects other non immunises children in the community immunizing them too, Herd Immunity. Thus a wall of immune children is created leaving none in the nearby population to get infected provided the process occurs everywhere at the same time. Pulse Polio Vaccination Program with immunizing every child  en mass by Saben Vaccine, 3 times at monthly intervals and giving oral vaccine to every newborn irradicated Poliomyelitis. After using protein synthesis mechanism of intestinal cells to synthesize the virus the wild virus reaches the anterior horn cell through Blood Viremia producing influenza like sickness, through lymphatics general and perineural. The stellate cell on infection becomes swollen and round, clear cytoplasm cloudy, and central nucleus Pyknotic and peripheral. The glial interstitial tissue in the cord becomes edemetous, interfiber distance increasing, vessels become surrounded by Lymphocytes-perivascular cuffing. This causes increasing pure motor, patchy, proximal paralysis with acute muscle tenderness and aggravation by trauma eg. injection. At medulla oblongata level this is bulbar polio. It is treated by Hotel Saline Fermentation- Sister Canies treatment and splinting the lower limbs in functional position by long liston splint with foot piece. As immunity kills the virus edema subsides allowing some cells to recover -Decreasing Paralysis or recovery phase, the dead cells cause residual paralysis. Incubation Asymptomatic 2 days, Influenza like fever with acute muscle tenderness 2 weeks, increasing paralysis 2 months, decreasing paralysis 2 years is the time distribution of the infection. In the recovery phase preventing deformity by moving all joints through their complete range every day, splint or orthosis in functional position and maintaining muscle tone by Galvanic/Faradic electricity induced contraction, Active assisted, active and resisted Physiotherapy. Residual paralysis is treated by correction of deformity, compensating power loss by orthotic stabilization of paralyzed joints in functional position in case hip, knee, ankle and foot involved or incase of 1 or 2 joint involvement, Restoration of power by tendon transfer or stabilization of painless stable joints by bone block and painful unstable ones by fusion is done.

Porphyria is Genetic Defect in heme biosynthesis pathway causing increase in Porphyrins (Porphrobilinogen) secreted in urine, turns it portwine red on standing. Presents with Neuro (acute flaccid muscle weaknesses), visceral (autonomic tachycardia and hypertension, photo sensitivity) and skin blisters without photosensitivity-Pupillary reflex problem, Triggered by Fasting, drugs, Alcohol overdose, hepatitis, estrogen or unknown factors, treated by removing trigger, IV heme, chloroquine, glucose. May require Phlebotomy to take away altered blood and replace with normal one if needed- Exchange transfusion.

Infective Polyneuritis, Gullian Bare Syndrome: .Acute ascending symmetrical paralysis + areflexia + albuminocytologic dissociation = Guillain–Barré syndrome. IV immunoglobin or Plasma exchange (Plasmapheresis) only one of them needed to save Respiratory paralysis and life.

Organophosphorus Poisoning: These used in pesticides compounds are acetylcholinesterase (AChE) inhibitors causing accumulation of acetylcholine at muscarinic, nicotinic and CNS synapses. Presents as DUMBBBLESS - D iarrhea, U rination,  M iosis, B radycardia / B ronchorrhea / B ronchospasm, E mesis, L acrimation, S alivation,  S weating. Atropine is given for muscarinic effect, and Pralidoxine as soon as possible to revive Choline Esterase before it ages to become non revivable.

Disseminated sclerosis is an older medical term for multiple sclerosis (MS), a chronic autoimmune disease that affects the central nervous system (brain and spinal cord) where. the immune system mistakenly attacks the myelin sheath, affecting saltatory non insulated axolemma (node of Ranvier) to node of Ranvier conduction in nerves reducing  nerve conduction, causing communication problems between the brain and the rest of the body. Over time, nerve fibers themselves may also be damaged. It presents as recurring attacks of  Blurred or double vision, Numbness or tingling in the limbs, Muscle weakness, Difficulty walking or maintaining balance, Fatigue, Muscle stiffness or spasms, Problems with bladder or bowel control, Dizziness and Cognitive difficulties (memory, concentration).Depending on progression it is Relapsing-remitting MS (RRMS), Secondary progressive MS (SPMS): Begins as RRMS and gradually worsens over time, Primary progressive MS (PPMS): Symptoms gradually worsen from the beginning without distinct relapse. MRI of the brain and spinal cord show plaques or lesions, Lumbar puncture shows oligoclonal bands in cerebrospinal fluid, Evoked potential tests to assess nerve conduction. Disease-modifying therapies (DMTs) such as interferon beta, glatiramer acetate, ocrelizumab, and others, Corticosteroids in acute relapses, Medications and physiotherapy to manage symptoms such as spasticity, pain, and fatigue, Regular exercise, rehabilitation, and lifestyle support, Non Fatal. Hysteria now called Functional Neurological Disorder a person develops neurological-type symptoms without a structural lesion that can explains them. Unlike Malingering not deliberately produced. Weakness or paralysis, Abnormal gait or inability to walk, Tremor or abnormal movements, Loss of sensation, Blindness or deafness despite intact sensory pathways, Non-epileptic/dissociative seizures, Episodes of altered consciousness or dissociation are normal presentations.

Hysteria is an older term that is now largely avoided in modern medicine because it was used to describe several unrelated psychiatric and neurological symptoms. “Hysteria” historically referred to a condition with physical/neurological symptoms without an identifiable organic lesion, often associated with psychological factors. Manifesting as 

• Paralysis or weakness

• Loss of sensation or blindness

• Abnormal movements

• Aphonia (loss of voice)

• Seizure-like attacks

• Fainting

• Emotional outbursts

it is now called Functional Neurological Symptom Disorder (FND) — neurological symptoms inconsistent with recognized neurological disease.

• Dissociative disorders — when dissociation is the predominant feature.

• Somatic Symptom Disorder — when excessive thoughts, anxiety, or behavior related to physical symptoms are prominent.

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Autonomic Nervous System:

The Autonomic Nervous System (ANS) is the part of the peripheral nervous system that regulates involuntary functions of the body—such as heart rate, blood pressure, digestion, sweating, pupil size, and bladder function.

Sympathetic

“Fight or flight”

↑ heart rate, pupil dilation, bronchodilation, ↓ GI activity

Parasympathetic

“Rest and digest”

↓ heart rate, ↑ digestion, pupil constriction, bladder emptying

Enteric

Controls gastrointestinal tract

Intestinal motility and secretion

Important pathway

Most ANS pathways have two neurons:

CNS → Preganglionic neuron → Autonomic ganglion → Postganglionic neuron → Effector organ

Neurotransmitters 

• All preganglionic sympathetic & parasympathetic neurons: Acetylcholine (ACh) → Nicotinic receptors

• Postganglionic parasympathetic: ACh → Muscarinic receptors

• Postganglionic sympathetic: usually Noradrenaline → α/β receptors

• Exception: Sympathetic fibers to sweat glands release ACh → muscarinic receptors

• Adrenal medulla: acts like a modified sympathetic ganglion and releases mainly adrenaline and noradrenaline into blood.

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30. Describe various type of synapse 

Synapses connect Neurons to neurons and Neurons to muscles.

They are broader portions of end of Axons containing the Neuro humeral transmitter which is discharged into the Synaptic cleft on being excited by a depolarizing repolarizing wave of Action Potential, + to - Depolarizing and - to + repolarizing. The Neurohumoral Transmitter acts on the receptor and the concerned transmission or muscle contraction is produced. See Muscle Contraction. 

Synapses connect Neurons to neurons and Neurons to muscles or other end organs like glands. Neuron to muscle synapse, mechanism of muscle contraction, Myesthenia Gravis and Organo phosporus compound poisoning have been covered.

Synapses are broader portions of end of Axons containing the Neuro humeral transmitter which is discharged into the Synaptic cleft on being excited by a depolarising repolarising wave of Action Potential, + to - Depolarizing and - to + repolarizing. The Neuro-humeral Transmitter acts on the receptor and the concerned transmission or muscle contraction is produced.

Neuron to Neuron connection of Synapses are between 1st to 2nd to 3rd order neurons in sensory and supportive sensory system, Upper and Lower Motor Neuron in Motor and Supportive motor extra pyramidal system. Cortico ponto cerebellar tracts connect at pons conveying the desired position of body information to the cerebellum. Substantia Nigra to Basal ganglion has Dopamine as Neurotransmitter deficiency of which causes Parkinsonism. Excess causes Schizophrenia. Reticular formation has oscillatory arrangement A to B to C to D to E to A of neurons so that when impulse returns to A it is no longer refractory and the impulse starts going round and round in the circuit. at one point in the circuit there is an electric Action Potential at fixed frequency depending on length of circuit, not changing and Synaptic Delay, changing or variable. From the Reticular formation, the generator of the Nervous System, impulse discharge ascend to Cortex directly Reticulo Cortical (RC) and through Thalamus, Reticulo Thalmico Cortical pathway (RTC). Increased activity of RC leads to a wakefulness pattern and decreased activity to Sleep. The Thalmico Cortical beam of RTC pathway increases electrical activity of specific areas in Hippocampus where memory is stored giving rise to experiencing the stimulus without the stimulus being there. This occurring during sleep are possible explanations of how we dream. For example if Stimulus X causes Action Potential in A-B-D-F neurons then if it is painful or pleasurable the Synaptic Resistance in the circuit will decrease allowing even less strength of stimulus cause a discharge across the specific memory circuit -Reinforcement. If the stimulus is neutral Synaptic Resistance will increase, the information will never reach consciousness- Habituation. Thus only painful pleasurable or Novel (first Time received stimuli have an attention shifting character, are reinforced rest are stopped from reaching consciousness Habituated, ignored, not perceived. In case of long absence of stimulus the synaptic resistance in the circuit normalises leading to Forgetting the stimuli. Synaptic Resistance appears to be controlled by number of receptors for the Neuro-humeral Transmitter on the end organ. Like decrease in insulin receptors on cell surface decrease the cell response to same amount of insulin. Analysis of stimuli into Novel, painful or pleasurable is learning. Beta receptors in the Hypothalamus initiate the Sympathetic response through the Sympathetic and Sympathetico-Adrenal pathways. Through the Adrenal medulla Adrenaline spreads all over the body through Blood -Hormone. Through the Sympathetic system the Nor Adrenaline Mediated Affects are more Localized. Parasympathetic Through Muscarinic Atropine stimulated ganglionic and Acetyl choline stimulated Nicotinic receptors in end organs reverse the Sympathetic effect.

Electrical Activity generated by the Reticular Activating System is recorded by ELECTRO ENCEPHALO RAPHY (EMG). Sensory stimulation in anesthetized patients cause changed in EEG called Evoked Sensory Potentials are used to monitor intactness of sensory pathways when patient is unconscious. 

Descending Reticular Activating System energizes the Internuncial neuronal component of RAS in the spinal cord. Incase of sudden loss of connection seen in Acute Spinal Cord Injuries, for sometime electrical activity in spinal cord below the lesion becomes zero - Spinal Shock ( Temporary Flaccid Paralysis in Upper Motor Neuron Section). Same Zero activity  happens down stream in bladder -Neurogenic Retention and Bowel Paralytic Ileus. Initially bladder wakes up, evacuating only to clear over distension by a dribble having large more than 100 cc residual always,, Autonomous Bladder. Then Spinal reflex recovers causing automatic evacuation in a stream, leaving less than 100 cc residual, with no information or control by brain. Next information returns - Sensate bladder, then Partial control - Hesitant (can't initiate micturition) or Precipitant ( Can't hold it ) and finally Normal.

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Chemicals that act causing effects near by enzymes and far away are

• Paracrine: acts on nearby cells

• Endocrine: Chemical Hormones act through Blood

• Autocrine: acts on the same cell that released it

• Neurocrine: neurotransmitter released by neurons

• Juxtacrine: requires direct cell-to-cell contact

Chemicals that act causing change are

• Paracrine: acts on nearby cells

• Endocrine: Chemical Hormones act through Blood

• Autocrine: acts on the same cell that released it

• Neurocrine: neurotransmitter released by neurons

• Juxtacrine: requires direct cell-to-cell contact

Endocrine functions, 

The endocrine system consists of glands and tissues that secrete hormones into the bloodstream. These hormones act on distant target organs to regulate major physiological processes.

Posterior Pituitary Neuro Hypophysis secrets Antidiuretic Hormone (Vasopressin) and Oxytocin

Anterior Pituitary Secrets 1. Growth Hormone Increase - Acromegaly Decrease Pituitary intelligent Dwarf.

2. Prolactin Milk production as estrogen progesterone drop after delivery and Oxytocin for Milk Ejection and Ejecting the baby by uterine Contraction during labor.

3 Stimulate other glands - TSH- Thyroid, ACTH- Adrenal Cortex, FSH- Ovarion Follicle, LH - Corpus Leuteum Formation after ovulation.

Thyroid: T3 Triiodothyronine, T4 Thyroxine both iodine dependent, increase Basic Metabolic rate. Excess with smooth thyroid - Graves Disease or Primary Hyperthyroidism- Weight loss, tachycardia, palpitation, tremors, exophthalmos, sleeplessness. With nodular thyroid it is secondary hyperthyroidism minus exophthalmos. Hypothyroidism in child can cause a mentally retarded obese toad skinned sleepy dwarf, in adult add metabolic syndrome substract dwarf. Iodized salt is used to prevent Goiter but looses iodine on heating. So it's use should be post cooking as table salt rather than with cooking. Levothyroxine for Hypo and Anti thyroid drugs Thionamides ( PTU inhibits TPO + peripheral T4-T3 conversion Carbamizole inhibits TPO only) , Lugol iodine and KI in salt, Radioactive iodine I-131, Beta blocker and anion inhibiter Potassium perchlorate are used for Hyperthyroidism. Thyroid Storm PTU + iodide + B Blocker + Steroids to prevent Blindness due to Exophthalmos. No response - Decompress orbit by Naffgigers removal of orbital plate of frontal Bone.

Calcitonin secreted by parafollicular cells of Thyroid decreases blood calcium by inhibiting osteoclastic activity. Bisphosphonates, Denosumab (Anti Rankly Monoclonal Antibody prevents osteoclast formation), Calcitonin and SERMs reduce bone resorption by stimulating estrogen receptor are used to treat Osteoporosis.

Parathyroid:  Secrets Parathormone which increases blood Calcium by  increasing absorption from Gut, Bone and Kidney. Primary Hyperparathyroidism due to Adenoma in parathyroid causes Hypercalcemia leading to calcium deposit in Veins - Phlebolithiasis, Kidney Nephrtolithiasis and nephrocalcinosis. Adenoma parathyroid is associated with Adenoma of the Delta cells of the islet of Langerrhans of pancreas which secret Gastrin causing indolent acid peptic disease or duodenal ulcer. Together it is called Pluriglandular Syndrome, and isolated pancreatic Zollinger Ellison's Syndrome. After Thyroidectomy the specimen must be inspected for accidental removal of 4 parathyroids. Incase removed they must be implanted on sternomastoid before closure. Otherwise there can be fatal hypocalcemia causing CCC - Coagulopathy, convulsion and congestive cardiac failure. Convulsions are preceded by hyper irritability of muscles- Face Chovostek sign, Devils grin (Risus Sardonicus) on tapping the facial nerve  and Carpopedal spasm due to lumbricals MP flexion PIP, DIP extension called Accouchers (Male Obstetricians hand)

Adrenal Medulla:  Secrets Adrenaline to prepare circulation to face crises, which travels through blood (Hormone), acts through beta receptors to increase the force and rate of cardiac contraction, dilates the Bronchi and with Noradrenaline and dopamine from the sympathetic endings  increases blood pressure by selective peripheral vascular constriction except in Heart, Lung, Brain and Kidney area. 

Adrenal Cortex: Secret Glucocorticoids and Mineralocorticoids. Glucocorticoids stabilize vascular endothelium, preventing extravasation, fluid loss, loss of blood volume, drop in cardiac output, fall of BP, less perfusion and anoxia. They stimulate Gluconeogenesis so that more glucose becomes available for cell energy. They inhibit hypersensitivity reactions and are therefore crucial in their control both topically and systemically. They cause Cushings syndrome and Metabolic Syndrome in excess.

Mineralocorticoids - In response to poor Blood Supply to the Glomerulus of the kidney Renin is secreted by juxtaglomerular cells, while macula densa cells, sense tubular NaCl and regulate renin release. Renin stimulates Aldosterone increasing tubular absorption of Sodium, obligatory volume of water increase blood volume and increase blood pressure. Excess causes Renal Hypertension and Lowering in Adrenal insufficiency (Addison's Disease) or in Neisseria Meningitidis Meningitis,  Disseminated Intravascular Coagulation causes coagulopathy characterized by  hemorrhage in Adrenals - Waterhouse Fredriksson Syndrome. Dangerous Hyponatremia and Hypotension ensue. Fludrocortisone Mimics Aldosterone and can be given in these conditions.

Pancreas Secret Glucagon alpha cells increases blood Glucose by glycogenolysis, neoglucogenesis and Lipolysis. Insulin acting through Insulin receptor stimulates Hexokinase which binds Po4 to 6th position of the Glucose molecule helping to retain it intracellular and use it for ATP energy generation. Primary insulin deficiency Type I diabetes and Secondary insulin receptor deficiency induced by fat signaling due to obesity causes non retention of glucose in cell thereby by increasing blood glucose resulting in  polyphagia, polyuria, Glycosuria and polydipsia and creates a energy crises in the cell where Acetoacetic acid from fat burns instead of glucose causing dyslipidemia and atherosclerosis. Gastrin from delta cells of the islet of Langerhans causes acid secretion in the stomach. Delta cell tumors produce severe indolent peptic disease Zollinger Ellison's Syndrome, when combined with parathyroid adenoma it is called Pluriglandular Syndrome.

Sex hormones Estrogen by Follicular cells of the Ovarion Follicle develops the endometrium for implantation. Progesterone from remnant of Follicle post ovulation  called Corpus Leuteum Maintains implantation till Progesterone secretion is taken over by Placenta. Incase there is no fertilization, zygote formation, implantation and thus no placenta to take over, the Corpus Leuteum disintegrates, progesterone drops and menstruation occurs.  From Pituitary, Follicle Stimulating Hormone (FSH) causes development of Follicle, Luteinizing Hormone (LH) Causes Ovulation and formation of Corpus Leuteum. Oxytocin Induces and maintains uterine contraction during labor and ejects milk post delivery. Prolactin released due to post pregnancy drop in estrogen progestrone induces milk formation. Testosterone develops secondary sexual characters in male and promotes Spermatogenesis. Androgen effect.

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31. List components of nervous tissue and their functions Nervous Tissue Consists of supportive Glial Tissue with vasa nervosa as its blood supply supporting Neurons. Neurons have a stellate cell with clear cytoplasm and Nissl Granules. Afferent fibers to them are Dendrites and efferent from them the Axons. Conduction of information in both differ only in direction, Dendrites towards and Axons away from the cell. 

32. Describe parts of a neuron and classify them based on number of neurites, size & function If there is 1 dendrite and axon from one pole of the cell neuron is unipolar,  if 1 each from two poles neuron is bipolar and if multiple dendrites from multiple sites but one axon then the neuron is multipolar. Unipolar example Dorsal Root Ganglion, Bipolar connect the dorsal and ventral horn of the spinal cord and poly dendritic in the brain where information from various sites has to be collated.

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33. Functions of neuron are Irritability and Conductivity. Irritability, is Response to a stimulus- Physical, chemical, electrical, mechanical change in its environment. Stimulus must be of sufficient strength and duration measured as Rheobase (minimum current needed) and Chronaxie ( the minimum duration for which twice the Rheobase should be given to produce a response). Response (Action Potential), For some time nothing happens - Latent period. Then the -70 mV charge across axolemma - Resting Potential, reverses to + 20 mV because the Sodium Pump, responsible for actively maintaining higher Na+ ions, thus ++ outside, stops and Sodium Rushes in - Depolarization. Then  K+, initially more inside gushes out to maintain the surface negativity, sodium pump starts and takes over, keeps working till -90 mV is achieved, Hyperpolarization. The pump slows down and -70 mV Resting potential is restored. Repolarization. At surface +ve -> -ve Depolarization -ve -> +ve Repolarization, Combined - Action Potential is a single similar response to sufficient strength and duration of any stimulus - All and None Law. Another stimulus for some duration elicits no response - Absolute  Refractory Period, higher strength can elicit Period of Partial Refraction, Lower strength duration can elicit during Hyperpolarization -90 mV period.  

Conductivity: The point of depolarization acts as stimulus for the adjacent point so the wave of depolarization starts spreading away from the point of stimulus followed by the wave of repolarization. This travelling of response away from the site of stimulus is conduction. On the nerve surface as +-> -ve (Line of depolarization) reaches the proximal galvanometer sensor it deflects proximally, stays till the depolarized segment passes, deflects distally as it crosses the distal sensor creating a Biphasic Mirror Image Potential. Incase of conduction block between electrodes the distal deflection does not occur, Biphasic becomes monophasic allowing recognition of site of conduction Block. Also, if distance between sensors is divided by the time between proximal and distal deflections it gives the Nerve Conduction Velocity. In the peripheral nerves the axolemma is insulated by the Myelin sheath except between Nodes of Ranvier. The action potential thus jumps from node to node increasing speed and decreasing energy expenditure, Saltatory Conduction.  In only function loss in a particular segment, Neurapraxia,  proximal segment will demonstrate biphasic, non conducting segment monophasic and distal segment Biphasic again. In Axon loss sheath intact state, Axonotmesis, from proximal biphasic, to across monophasic, to distal no conduction due to Wallerian degenerated fiber, is observed. In axonotmesis this point with march distally with time Motor March but in complete section Neurotmesis, disruption of the sheath too, the Motor March can only occur after Surgically suturing the nerve. Sheath has Endoneurium, Perineureum and Epineurium Parts. On section it gives Faggot appearance. Since it is elliptical placing corner sutures first, allows suturing without rotation. Suturing without tensioning is achieved by bone shortening, rerouting or using nerve grafts.

Nerve Tissue Structure and Function with Animation

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Detailed Teaching Video on Nerve Function Tests

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34. Describe structure of a typical spinal nerve: Section of the Spinal cord has a central canal which can dilate in Syringomyelia affecting the lateral spinothalmic tract carrying pain and Temperature sensation while sparing the anterior spinothalmic tract carrying touch and pressure- Dissociate Anesthesia. Its grey matter consist of posterior (Sensory) and anterior motor horn, a lateral horn carries sympathetic fibers. Upper motor neuron synapses with lower motor neuron here. Into Dorsal Horn goes the Dorsal Root with a ganglion on it which contains the cells of the unipolar sensory neuron. From Ganglion to Horn are Axons of the first order neuron. Lesion here leads to loss of the Line, flare and wheal of the Triple Response. The flare - Axon reflex is absent. Dorsal Root is sensory and ventral root from anterior horn is motor plus sympathetic. Both join to form the mixed spinal nerve in the intervertebral foramen with articular process posterior, Bodies and disc anterior and Pedicles superior and inferior. Disc degeneration and prolapse here causes pressure on the nerve causing referred pain along the Root. The nerve divides into anterior and posterior Rami which may or may not form plexus before reaching the muscle or sensory receptors of the skin. The ventral rami gives pre synaptic neurons to the sympathetic ganglion post synaptic of which reach the end destination along nerves and vessels.

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35. Describe principles of sensory and motor innervation of muscles:Describe concept of loss of innervation of a muscle with its applied anatomy:  Nerve enters the muscle at the motor point, used for electric stimulation and divides in Nerve Fibers. Muscle Fibers supplied by one nerve fiber is called Motor unit. Nerve fibers come in contact with muscle myolemma by swelling into a synapse which contains synaptic vescicles having Acetyl choline. Acetyl Choline is formed by Choline acetyl Transferase (CHAT) acting on choline. When action potential negativity travelling down the nerve hits the synapse, acetyl choline is released into the synaptic cleft by the synaptic vesicles. It acts on Nicotinic Nm Receptors on the myolemma  opens Ligand-gated Cation Channels producing an end plate potential. In resting stage Sodium pump maintains more Na+ outside the myolemma creating Resting potential difference across the membrane of -70 mV.  Sodium pump stops momentarily, sodium rush inside to maintain the ionic balance pushing  calcium with it. Ca++ binds to Troponin C positively charging Actin inducing negative charge on myosin.  Contraction occurs by Actin-Myosin cross bridge cycling powered by ATP.  The Acetylcholine in the cleft is destroyed by AcetylCholine esterase (ACHE) thus removing the block to sodium pump and allowing the muscle to Relax. Also,  antibodies against postsynaptic Acetylcholine receptors in Myaesthenia Gravis aggrqvating Acetylcholine efficiency. This causes premature relaxation of muscle. Fatigue Paralysis. Pyridostigmine, Physostigmine, Neostigmine and Edrophonium inhibit Choline esterase and are used for relieving Myaesthenia Gravis.  Organophosphorus Compounds used as pesticides cause poisoning by irreversible Choline Esterase inhibition allow acetyl choline induced muscle contraction and N1 receptor mediated Parasympathetic activity to persist. Early reversal of Choline Esterase inhibition before it ages and activation becomes impossible by Pralidoxime is life saving along with use of atropine to block unwanted Parasympathetic effects.

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36. NM Junction Applied: Rheobase is the minimum current required to cause an Action Potential (AP). Minimum duration for which twice the Rheobase should be given to cause an AP is Chronaxie. Chronaxie of muscle is  greater than 3 msec. So only greater than 3msec Galvanic current can stimulate a denervated muscle. State of Galvanism. Only through an intact nerve supply less than 3msec current can cause muscle contraction. State of Farradism. This is tested by putting a stimulating electrode at motor point and recording response by first determining Rheobase at more than 3 msec Galvanic current and then using twice the Rheobase and progressively decreasing duration to determine Chronaxie. Less than 3 msec means Innervated muscle. Charting it gives us the strength duration (SD) curve. Right shift of the curve indicates denervation or Reaction of Degeneration and Left Shift Reaction of Regeneration.

37. Muscle Fiber Applied: In an Electromyography (EMG) individual muscle fiber contraction is recorded as Fibril (Fibrillation). When motor unit (One nerve fiber along with all the muscle fibers it supplies) fires then it is recorded as collection of higher amplitude fibrillations called Action Potentials (AP). In resting there is predominantly fibrillation with few AP's. With contraction there is a congregation of AP's. Denervated muscle shows only fibrillation. As innervation occurs 1 nerve fiber commands many more muscle fibers than normal so the graph has fibrillation with less frequent but Giant AP'S. Reaction of Regeneration. In Myaesthenia Gravis Contraction AP can not sustain due to premature clearing of Ach causing tapering of the contraction wave. Sound representation of the wave is referred to as the Dive Bomber Sound). In Myotonia Congenita reverse occurs. This is besides the Nerve Conduction Velocity assessment by EMG.

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38. Describe differences between sympathetic and spinal ganglia 

Feature

Sympathetic ganglion Dorsal Root Ganglion, DRG

Autonomic nervous system Sensory nervous system

Postganglionic sympathetic Primary sensory neurons

Carries motor/autonomic signals to  Carries sensory information 

viscera, blood vessels, periphery to CNS

sweat glands 

Location

Along sympathetic chain anterior On the dorsal root 

to vertebral column

Synapse present Absent

Yes — preganglionic neuron synapses with postganglionic neuron

Multipolar Neurons Mainly pseudo-unipolar

One process that divides into        peripheral and central branches

Neurotransmitter at ganglion Absent

Acetylcholine (nicotinic receptor)

Efferent Afferent

Receptor → CNS

Satellite cells Present                           Prominent and closely surround                                                                  neuronal cell bodies

Example Cervical ganglion, Dorsal root ganglion 

sympathetic chain ganglion

Summary:

Sympathetic ganglion = synapse + multipolar neuron + autonomic motor

Spinal/DRG = No synapse + pseudo - unipolar neuron + sensory

Bones,  joints, movement and movers

39. Head and Neck: Learn how

40.  Skull  how it houses the Brain, Orbit, Ears, Nose and paranasal sinuses, 

41. Mouth, Tongue, Teeth, Tonsils, Cheek,  

42. Temporal and Infra temporal region, Salivary glands, Mastication,  Temporo-mandibular joint dislocation and ankylosis

43. Eye ball vision, focusing, coordination, light and accommodation reflexes, ocular movements. Lacrimal apparatus, Hutchinson's and Argyll Robertson's pupil, Doll eye testing in Head injury, Pathogenesis of cataract, squint and Glaucoma

44. Ear Hearing and Balance Petrous Temporal Bone

45. Neck - Bones, Viscera, Muscles, fascia,  spaces and Triangles - Boundaries, Roof, Floor, Contents, Cervical spine its articulation with skull, cervical vertebra and cervical rib, movements and movers and joints on which movement on which movements occur

46. Neck viscera - Nasopharynx, oropharynx, Laryngo-pharynx, Trachea, esophagus, Larynx and phonation, Thyroid and Parathyroid, Arteries and Veins of Head and neck, Cranial Nerves in Head and Neck

47. Lymphatic Drainage of Head and Neck - Cystic Hygroma

 See Draw and memorize these through the Following videos 1 by 1. See only 1 of the repeat videos

48. SCALP

49. Head and Neck  Housing the Brain, Nose, Eyes, Ears and Mouth with arrangement for mastication salivation and deglutition

50. Name the Facial muscles that do the 10 movements asked

51. Can You Recognize these muscles

52. Cervical Spine Movers

53. Skull to cervical spine

54. Neck Muscles

55. Torticollis

56. Edit Quiz on Cervical Spine Movement and Deformity

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58. Base of Skull Interna

59. Base of skull Interna 2

60. Base Skull Interna 3

61. Skull base inside 1

62. Skull base Inside 2

63. Base of skull inside and outside

64. Edit Quiz on Basis Cranii Interna

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66. Nervous System Response to events around you

67. Nervous System

68. Nervous System

69. Brain

70. Brain 2

71. Horner's Syndrome

72. Sagittal Section Brain 

73. Neuroanatomy 1

74. Neuroanatomy 2

75. Edit Brain Quiz Form

76. Do Brain Quiz 

77. Norma Lateralis

78. Base of Skull Externa

79. Skull Base from outside by Prof DR Singh my Guru

80. Skull base outside 1

81. Skull base outside

82. Skull base outside 2

83. Skull base outside 3

84. Edit Quiz on Norma Lateralis and Base of Skull Externa

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86. Cranial Nerves

87. 9th Nerve Glosso ( Taste plain sensation posterior 1/3rd Tongue and lifts the Thyroid in Deglutition-Pharyngeal)

88. 7th Nerve - Fascial Muscles Motor Lacrimal, Parotid Secretomotor

89. 1st to 6th nerve 1 smell, 2 vision 3,4,6 eye movement, 5th sensory face and muscles of mastication.

90. 10th is vagus secretomotor to gut, bladder, Heart The nerve activates in rest slows down fight, flight, fright reactions

91. 11th cranial part through Vagus supplies the extrinsic cricothyroid of Larynx by external laryngeal and intrinsic muscles of Larynx by Recurrent Laryngeal can be damaged during Thyroidectomy. the spinal part supplies the Trapezius and Sternocleidomastoid. The 12th nerve supplies the forward - Genioglossus, backward- Styloglossus, up- Palatoglossus and down Hyoglossus along with intrinsic AP, SS and superior inferior muscles of tongue.

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92. Hearing and Balance

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93. Orbit and Eye

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94. Nose

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95. Mouth

96. Tongue Movers

97. Mastication Deglutition

98. Mastication and Deglutition

99. Parotid, Sumbandibular, Sulingual and Lacrimal glands

100. Edit MCQ on oral cavity Structure and Function

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102. Larynx

103. Larynx 2

104. Edit MCQ on Larynx and Speech

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106. Pharynx

107. Edit MCQ on Pharynx

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108. Viscera of Neck and Thyroid

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Thorax the inlet, outlet, walls and contents visceral, Vessels, Thoracic duct and Paravertebral, respiratory movement. Thorax Inlet, Outlet, Wall,  movement in Respiration

Thorax inlet, outlet walls

109. Contents Lung and Pleura how of Ventilation Perfusion Diffusion

110. Gaseous Exchange in Blood

111. Cellular Respiration

112. Conditions involving Respiration

113.  Heart and Pericardium: Coronary Circulation, Cardiac Cycle, Heart sounds and murmurs, Pulse Rate volume rhythm types, Venous Waves, EKG, Arteries, Veins, Pulmonary and Systemic, Congestive cardiac failure, LVF, Arrythmia, arrest, corpulmonale

114. Mediastinum Esophagus Tracheo-esophageal fistula Achalasia cardia Dysphagia

115. Paravertebral region

116. Tracheo-esophageal fistula ,Killian's Diverticulum Achalasia Cardia

Chest Functional Anatomy Very Comprehensive but Brief Video

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Chest Injuries, Chest Injuries 2

Regional Injuries Spine 

117. Abdomen: Clinical Examination

118. Posterior Abdominal Wall: Abdomen Wall and Diaphragm

119. Lateral and  Anterior wall Hernia Types and Anatomy: Inguinal Canal

120. 3D visualization of Abdominal Wall

121. Abdomen 1 Walls

122. Inguinal Canal

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123. Approach to Kidney and Psoas abscess: Approach to Kidney and Psoas Abscess

124. Viscera sequence of placement posterior to anterior - Kidney and suprarenal, Duodenum and pancreas, Colon, Stomach stomach bed pseudo pancreatic cyst, Liver Gall Bladder Biliary drainage: Cirrhosis, failure, hepatitis,  Watch - Viscera placement Posterior to Anterior, Abdominal Viscera 2 Abdomen 2 

125. EDIT MCQ on Abdominal Viscera

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126. Viscera in Abdomen and Pelvis

127. Peritoneum: Peritoneum in Pelvis, 

128. Abdomen  3 Peritoneal Reflections

129. Peritoneal Reflections

130. Folds of Peritonuem

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131. Perineum and Pelvis: Uterus Vagina and Ovaries, Scrotum, Rectum and Anal canal Inside of Pelvis, Perineum

132. Reproduction, Initial Development of Embryo, From Womb to World Journey, Labor Being Pushed into the world

133. Urinary Bladder Placement and Anatomy

134. Perineum

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135. Acute Abdomen

136. Upper Limb

137. Which Bones forming which joints provide for which movements General features and attachments: 

Pectoral Girdle Sternum to clavicle in coordination with Acromioclavicular joint :

Anatomy: Scapula

138. Scapula

139. Clavicle

140. Pectoral Girdle attachment to Trunk

141. MCQ on Pectoral Girdle Thoracic Articulation

142. Scapulothoracic Movements and Movers (Memorize) Protraction Serratus Anterior Long Thoracic Nerve from 5,6,7 roots, Retraction Trapezius, Accessory, Rhomboidus- Major and Minor- Dorsal scapular or nerve to Rhomboids- C5, Elevation Trapezius and Levator Scapulae-Dorsal Scapular, Depression: Trapezius and Pectoralis Minor- Lateral Pectoral nerve, External Rotation - Trapezius and Serratus Anterior, Internal Rotation - Levator Scapulae and Pectoralis Minor.

Pectoral Girdle

Scapulothoracic Movements and Movers

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143. Breast: Breast in Females is larger than males. Abnormal  Enlargement of breast in males is called Gynecomastia.   Breast makes milk post pregnancy by Prolactin hormone from Pituitary and Secrets it under influence of Oxytocin post pregnancy. It is situated Anterior to pectoral fascia covering the Pectoralis Major and its Axillary tail of Spence on the anterior axillary fold gives lymphatics to axillary Lymphodes (cancer Spread).  Its front has a pinkish to brownish areola and a nipple structure, age changes, blood supply, lymphatic drainage of breast in relation to carcinoma breast, stage II to III. The subcutaneous tissue of breast is divided by radially arranged Ligaments of Astley Cooper dividing the breast into radially arranged lobules. Lobules of Breast by Ligament of Cooper. Lymphatic  drainage of Breast Quadrant Wise - Staging of Breast Cancer, The Superficial centripitally directed lymphatics between the skin and  tenea subcutenia goes into the subareolar lymph plexus of Sappy. From Superficial lymphatics passes to deep behind pectoral fascia through folds in the ligaments of Cooper they reach the sub fascial plane of the pectoralis major. From here they are directed centrifugally, depending on the four quadrants.  Upper lateral Lymphatics pass  through tail of spence into Axillary then supraclavicular lymph nodes. Lower medial area of Right breast pass through the Rectus sheath into the falciform ligament of Liver into Liver.  The locules of breast contain glands, ducts from which drain into lactiferrous sinuses or Ampula. This occurs under influence of prolactin released by the Pituitary due to progesterone withdrawal post pregnancy. On Suckling the baby the lactiferrous sinuses contract ejecting the milk in the babies mouth. Adenocarcinoma of Breast spreading through and contracting lymphatics can lead to nipple retraction and pointing towards the lesion. The growth of cancer is fanned by the Hormonal Status. Pregnancy and lactation Highly Malignant inflammation look Mastitis Carcinomatosa. Non pregnant menstruating, Middle level of malignancy, post menstrual More fibrosis less cancer - Atrophic Scirrhous.

Benign Breast Disease: This hormone mediated growth of glandular tissue, limited by fibrosis and fat causes mastalgia, bilateral breast pain+/- nodularity - Fibroadenosis, where glands can't drain Galactocoel, contain milk or Blue domed cyst of blood good contain bluish fluid. Mastitis, and Breast abscess are infections may need drainage by sub-pectoral cosmetic incisions. Nearest to malignance is Fibroadenoma.

NMC provides more emphasis on Breast Cancer given below

Breast cancer is commonly staged using the AJCC TNM staging system, which is based on:

• T (Tumor): Size and extent of the primary tumor

• N (Nodes): Spread to regional lymph nodes

• M (Metastasis): Presence or absence of distant metastasis

TNM Classification

T – Primary Tumor

• Tis: Carcinoma in situ (DCIS, LCIS, Paget disease without invasive cancer)

• T1: Tumor ≤2 cm

  • T1mi: ≤1 mm

  • T1a: >1–5 mm

  • T1b: >5–10 mm

  • T1c: >10–20 mm

• T2: >2 cm to ≤5 cm

• T3: >5 cm

• T4: Tumor of any size with direct extension to chest wall and/or skin

  • T4a: Chest wall

  • T4b: Skin edema/ulceration/satellite nodules

  • T4c: Both T4a and T4b

  • T4d: Inflammatory breast cancer

N – Regional Lymph Nodes

• N0: No regional lymph node metastasis

• N1: 1–3 movable ipsilateral axillary lymph nodes

• N2: 4–9 axillary nodes or clinically positive internal mammary nodes

• N3: ≥10 axillary nodes, infraclavicular, supraclavicular, or combined axillary/internal mammary node involvement

M – Distant Metastasis

• M0: No distant metastasis

• M1: Distant metastasis present

Stage Grouping

Stage 0

Tis N0 M0

Non-invasive (DCIS/LCIS)

Stage I

T1 N0 M0

Small invasive tumor, no nodal spread

Stage IA

T1 N0 M0

Tumor ≤2 cm, node-negative

Stage IB

Small tumor with microscopic nodal disease

Minimal lymph node involvement

Stage II

T0–T2 with N1, or T2–T3 N0

Larger tumor and/or limited nodal spread

Stage IIA

T0–T1 N1 or T2 N0

Stage IIB

T2 N1 or T3 N0

Stage III

Any locally advanced disease without distant metastasis

Extensive nodal disease and/or chest wall/skin involvement

Stage IIIA

T0–T3 N2 or T3 N1

Stage IIIB

T4 any N (except M1)

Chest wall/skin involvement

Stage IIIC

Any T N3 M0

Extensive regional nodal disease

Stage IV

Any T, Any N, M1

Distant metastasis

Prognostic Staging (AJCC 8th Edition)

In addition to TNM, modern breast cancer staging also incorporates:

• Histologic grade

• Estrogen receptor (ER) status

• Progesterone receptor (PR) status

• HER2 status

• Multigene assays (e.g., Oncotype DX in selected patients)

Easy Mnemonic

• Stage 0: In situ

• Stage I: Small, localized

• Stage II: Larger tumor and/or a few lymph nodes

• Stage III: Locally advanced (skin, chest wall, or extensive nodes)

• Stage IV: Distant metastasis

Early detection is crucial to Public Health and Teaching Breast Self Examination an important part of Public Education. Mammography or Ultrasound examination are used as screening tests

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144. Axilla: boundaries and contents  Clavicle anterior and scapula posterior grasp the trunk and hang by muscles from the neck posterior triangle and muscle of anterior and posterior axilarry fold from below. The intervening space with apex the cervico-axillary canal connecting the two is bounded by the clavicle scapula and Ist rib.The medial boundary is the Thoracic Cage covered by Serratus Anterior. Anterior is from above downwards clavicle, clavipectoral fascia pierced by cephalic vein, thoracoacromian artery, lateral pectoral nerve and lymphatics from axillary tail of spence of breast. Then is pectoralis minor from coracoid process to ribs and finally the suspensory ligament of Axilla. Superficial to this is pectoralis major. Posterior boundary is subscapularis and between scapula and humerus the Periscapular spaces. Contents are the Brachial Plexus after division level, Axillary Artery and vein and Lymphatics.

145. Axillary artery & vein 

146. Brachial plexus Erb’s palsy and Klumpke’s paralysis

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147. Muscles Moving The shoulder: Deltoid is Flexor, Abductor, Extensor. Additionally Pectoralis major Flexes, adducts internally rotates and Lattismus Dorsi Extends, adducts externally rotates. Rotator - Subscapularis adducts internally rotates, Supraspinatous abducts first 15 degree, holds the head down against the force of deltoid, insufficiency causes subacromial impingement UE humerus being higher than normal. Infraspinatous and Teres minor plane exits the axillary nerve is used for posterior approach to shoulder.

Upper limb in humans is not for walking it is for Pinch, grasp, hook of hand and prehensile      function for the rest of the limb

Upper Limb attaches to trunk by the Pectoral Girdle, (Clavicle to Sternum) and muscles that move it: Trapezius, Levator Scapulae and Rhomboids from posterior Trunk, Serratus Anterior, Pectoralis minor from anterior Trunk. Memorise the video below and test your memory

Scapula moves over thorax by Clavicle at Acromioclavicular and Sternoclavicular joints

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Scapula Osteology

Clavicle Osteology

Humerus and Shoulder

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148. Describe and demonstrate shoulder joint for– type, articular surfaces, capsule, synovial membrane, ligaments, relations, movements, blood supply, nerve supply and applied anatomy 

149. A ball and socket joint between upper end humerus having head, anatomical and surgical neck, greater and lesser tuberosity and pear shaped Glenoid of scapula, with the glenoid labrum and supra and infra glenoid tubercles. Head and glenoid are covered with cartilage lubricated by a synovial cavity and attached by capsule which leaves the anatomical neck attachment where long head of biceps originating from intracapsular supraglenoid tubercle winds round the lesser tuberosity and lies in the Bicipital Groove extending into the transverse bicipital ligament. Next its extension inferiorly encloses the medial part of surgical neck forming Lax part of capsule to allow for abduction of shoulder. It is strengthened anteriorly by superior, middle and inferior Gleno-humeral ligament. Rotator Cuff consisting of Subscapularis, Supra, infra spinatous and Teres Minor Strengthen it. Inferior to it between inferiorly diverging borders of scapula and humerus are periscapular spaces. Quadrangular space bounded superiorly by Lax part of capsule sandwitched between Teres minor and subscapularis, inferiorly by Teres Major, Medially by long head of Triceps originating from extracapsular infraglenoid Tubercle and laterally by surgical neck of humerus. It passes the Axillary nerve and posterior circumflex humeral artery  whoch supplies the Teres Minor (branch has a pseudoganglion} deltoid and regiment badge area skin in the upper outer arm. The lateral triangular space bounded by Lattismus Dorsi winding round lower border of Teres major, shaft of humerus and long head of triceps passes the radial nerve and profunda Brachii Artery. Nerve supply of all muscles around the joint also supply the joint (Hiltons law). Blood supply of head can be damaged in anatomical neck fractures leading to Avascular necrosis and needing Total Shoulder replacement. This is called Reverse Total Shoulder Replacement because concave glenoid is replaced by a convex prothesis and convex head by concave replacement. Thus axis of movement always passing through ball moves away from Deltoid increasing its lever arm and power to abduct. 

150. Explain anatomical basis of Injury to axillary nerve during intramuscular injections: Axillary nerve is 5 finger away from the lateral border of Acromion. Any intra muscular injection in deltoid must be given well below it. 

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151. Muscles moving the Elbow Origin insertion nerve supply action Testing: Elbow is a hinge joint between Olecranon and coronoid process of upper end of Ulna and Trochlea of lower end of humerus providing flexion 140 degree to extension 0 degree. The larger and more vertical medial Trochlea gives the elbow its valgus carrying angle of 5-7 degrees men and 7-15 women.   The capitellum on lateral side of Trochlea with the radial head - Radio humeral articulation allowing flexion extension at elbow. Radial head also rotates in the socket of upper end ulna forming the superior radioulnar articulation which with middle and lower RU articulations provide for supination and pronation of forearm. Triceps extends, Anconeus representing the popliteus of lower limb is vestigial, does nothing. Brachialis flexes, Biceps flexes but supinates the flexed forearm as needed in tightening a screw. Brachio radialis flexes in mid prone position, Common flexors from medial epicondyle flex. 

152. Muscles moving the Radio ulnar joints Origin insertion nerve supply action Testing Pronator Teres and Pronator Quadratus Pronate, Supinator in extended elbow and bicep in flexed. Brachioradialis will pronate from supine and supinate from prone forearm becoming stable only in mid prone position.

153. Muscles moving the Radiocarpal Joints Origin insertion nerve supply action Passage under Retinaculum changing direction of pull - Example EPL and Brevis Testing

Radius lower end is quadrangular having a lateral styloid and a anterior, posterior and medial border. The concave medial surface articulates with the convex head of ulna which is disallowed articulation with wrist by a triangular disc. Only Scaphoid directed obliquely forward to align with the thumb and lunate with the rest of the hand articulate with the lower end of radius allowing Flexion and Extension. Carpi means this joint So Flexor Carpi Ulnaris and Radialis Flex, Extensor Carpi Radialis longus, Brevis and Ulnaris extend the radio carpal joint. 

154. Muscles moving the Intercarpal Joints Origin insertion nerve supply action Testing: Intercarpal joint is around the central convex Capitate (head like). It radially and ulnar ward deviates in the socket by Scaphoid, Lunate and Triquetral. Pissiform is a sesmaoid bone in the tendon of Flexor Carpi Ulnaris which continues upto the hook of the Hammate as the pissio hammate ligament. Under the ligament is the Guyons canal passing the deep branch of the ulnar nerve which gets entrapped here if swollen in leprosy and has to be decompressed by dividing the pissio hammate ligament. Radial Deviation is by the radialis group (flexor carpi radialis + extensor carpi radialis longus and brevis flexor and extensor component cancelling out in desired FE position of wrist and radial deviation produced. Similarly Ulnar deviation is produced by combined action of Flexor and extensor carpi ulnaris. 

155.  Muscles moving the carpometacarpal Joints: Opponens possible for the thumb and little finger is internal rotation of the two metacarpals over the carpals hammate and Trapezium cupping the hand and allowing the thumb to move in a plane opposing the flexion of the fingers thus the name Opponens. Muscles Opponens Pollicis and Opponens Digiti minimi.  

156. Muscles moving the MP Joints MP joints flex by Lumbricals which simultaneously extend the PIP/DIP joints through extensor expansion- Intrinsic Plus position. Opposite is claw hand. Try it out on your hand. MP Joints extensor is Extensor Digitorum aided by Extensor indices and digiti minimi for index and little finger. Thumb Extensor Pollicis Longus extending in abducted and brevis extending in adducted thumb are supplied by the posterior interosseous branch of the radial nerve which is damaged in surgical excision of the radial head causing finger drop and thumb drop clinical picture characteristic of these muscles paralyzed. In contrast high radial nerve damage above elbow in the radial grove by injection or fracture paralyzes the wrist extensors too causing wrist drop. Besides flexing extending they adduct and abduct too. PAD DAB helps remember that Palmer interossi are adductors and Dorsal interossi are abductors. Since all movements towards middle finger are adduction only 3 Palmer Interossi can achieve this. Since lateral or medial movement of middle finger are abduction 4 Dorsal interossi are needed. Imp for MCQ

157. Muscles moving the PIP/DIP Joints Extensor of PIP DIP are Lumbricals. PIP flexor is Flexor Digitorum Superficialis and DIP Flexor Flexor Digitorum Profundus. Test for FDS is asked in Examination. Hold the other fingers extended locking the FDP. Now only proximal PIP joint of the free finger will flex. 

158. Muscles special to the thumb and little finger: Thumb Flexes MP joint Flexor pollicis Brevis, IP joint Flexor Policis Longus. Extends in Abducted thumb Extensor Policis Longus, Adducted Extensor Pollicis Brevis. Extensor Pollicis Longus winds round the Listers tubercle on dorsal border of radius to achieve extending an abducted thumb, ruptures in Colle's fracture leading to a drum stick deformity. Abducts Abductor Pollicis Longus (abducts metacarpal)  and Brevis (Proximal Phalynx) and Adducts Adductor Pollicis.

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Below Elbow Muscles How to remember

159. Identify and name various bones in articulated hand, Specify the parts of metacarpals and phalanges and enumerate the-  peculiarities of pisiform Scaphoid Lunate Triquetral Pissiform Proximal Row. Trapezium, Trapezoid, Capitate Hamate. Metacarpals, Phalanges. Pissiform is a sesmaoid bone in the tendon of Flexor Carpi Ulnaris while it continues as the Pissiohamate ligament to attach to the hook of hamate. Ulnar nerve and artery are medial and distal to it and can be compressed in the canal of Guyon under the pisio-hamate ligament.

160. Describe scaphoid fracture and explain the anatomical basis of avascular necrosis 

Scaphoid has a proximal head, neck and a distal body. It is directed forward to align with the thumb and to provide for it to move in coronal plane at 90 degree sangital plane movement of the fingers. Additional 40 degree rotation at scaphoid Trapezium and Trapezium metacarpal puts the plane of thumb movement to oppose the movement of fingers - Opponens. The dorsal and palmer arterial supply enters the body and moves proximally through the neck into the head. It is endangered in the neck fracture causing nonunion and avascular necrosis of the head. This necessitates Scaphoid fractures with tenderness in the snuff box to be immobilized by plaster in pen holding position for 10 weeks or by Herbert's headless compression screw.

Peculiarity of Scaphoid and its blood supply. See to clarify the concept above

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Myo fascial structure of hand

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13 Video play list to conceptualize placement of movers of the Upper LImbs

161. Nerves supplying upper limb Course Branches Testing Substitution if Paralyzed  where are they entrapped 

162. Brachial Plexus, Brachial Plexus Supra clavicular, Erbs Palsy  Nerve Entrapment Upper Limb, Testing Nerves of Upper Limb, Testing Nerves of Upper Limb 1, Ulnar Nerve Approach, Clinical Approach to Paralytic Hand, Nerve Physiology and Function Tests

163. Blood Supply of upper limb Course Branches Testing Management if Compromised. where can they be entrapped and may need decompression

ARTERIAL SUPPLY OF UPPER LIMB The Subclavian Artery branch of innominate L aorta R arches round the 1st rib behind scalenus anterior divided by it into parts 1,2 and 3. Here it can be entrapped by cervical rib or scalenus anticus syndrome. 1st part gives Vertebral and internal mammary and  2nd part Costo cervical and Thyrocervical trunks  COSTO CERVICAL trunk gives 1st Intercostal and Ascending cervical. Thyrocervical trunk gives Inferior Thyroid (must be tied away from Tracheoesophageal groove in thyroidectomy as there it is accompanied by Reccurent Laryngeal nerve, ligating which can cause intrinsic Laryngeal muscle paralysis). The other 2 from Thyrocervical trunk are Suprascapular and Transverse cervical which through the periscapular anastomosis with circumflex scapular branch of axillary artery provide collateral circulation incase of block in the 3rd part Subclavian or 1st part Axillary artery. Accompanied by the brachial plexus it continues as the Axillary artery behind the clavicle, through the cervico-axillary canal, then behind the clavipectoral fascia, pectoralis minor which again divides the Axillary artery into 1,2 and 3rd part. 1 branch from part 1 - Superior Thoracic 2   from part 2, Thoraco-acromian artery and lateral thoracic and 3 subscapular, anterior posterior circumflex humeral from part 3. Axillary divides into Brachial and Profunda Brachii. Both enter the ring made by proximal deep fascai of arm where it can be compressed by figure of 8 bandage given in fracture clavicle. Profunda Brachii passes with radial nerve through lateral triangular space into the radial groove giving ascending branches to the circumflex humeral anastomosis around the surgical neck of humerus. Around shoulder collateral. Brachial accompanied by median nerve initially lateral then crossing to become medial passes posterior to corachobrachialis, which may have an extended insertion from middle of medial border of humerus to humeral spur and the Ligament of Struther connecting it to the medial epicondyle. In this case both artery and nerve pass posterior to anterior between the Ligament and humeral border giving rise to entrapment causing pulsating neuralgia along median nerve with paraesthesia, paresis - along with vascular insufficiency-Struther Syndrome. Besides supplying muscle joint and bone the brachial gives Anterior and posterior Ulnar Collateral and Profunda Brachii anterior and posterior radial collateral anastamosing with corresponding Recurrent branches of the terminal Radial and Ulnar Branches of the brachial artery. Anastamosis around the elbow. At the level of the elbow the bicipetal aponeurosis merging into deep fascia of forearm from biceps must be divided during fasciotomy to decompress the brachial artery and median nerve. The Ulnar artery passes posterior to Ulnar head of pronater teres crossing the median nerve which is between the two heads. Both require to be saved while releasing the Ulnar head of pronater teres in Maxpage's flexor pronater release for Chronic Volkmans Ischemic Contracture. Ulnar artery next gives common interosseous becoming anterior and posterior interosseous in relation to the radioulnar interosseous membrane. Anterior interosseous is an end artery supplying the Radial to it Flexor Pollicis Longue and medial to it Flexor Digitorum Profundus. Elliptical Ischemic necrobiosis of the two in Volkmans Ischemia can entrap the median nerve needing decompression - Seddons Operation. Supplying muscles and bone, lying deep to Flexor Carpi Ulnaris Ulnar artery emerges medial to pissiform dividing into superficial and deep branches. The radial artery accompanied by the Radial Nerve laterally passes on the supinator crest of radius on which supinator is inserted from radial side and Flexor Digitorum Superficialis on the medial side. The nerve is retracted laterally and artery medially to expose upper end of radius. Anterior Radial Recurrent artery must be secured before medial retraction of the radial artery. Supplying bones and muscles under cover of brachioradialis, at its insertion the artery winds around radial styloid giving palmer and dorsal carpal branches like the Ulnar, but these supply the scaphoid with a precarious blood supply. After giving the Arteria Princeps Pollicis and Arteria Radialis indices like the Ulnar Radial also divides into Superficial and deep terminal branches. Superficial and deep branches form the superficial and deep palmer arches superficial and deep to the long flexor tendons and give digital branches to the fingers.

Veins from upper limb lying as veneconnivantes of arteries giving them the rail track effect recognition during surgery even when they are not pulsating in a tourniqueted limb mainly connect to the basilic and cephalic venous system interconnected beneath the loose skin of dorsum of hand. In intravenous injection or drip deeper veins stabilized by surrounding subcutaneous tissue or through angles are easier to puncture. The cephalic and basilic veins connect through the cubital vein anterior to the elbow. Basilic becomes axillary Subclavian and innominate when Jugular drainage from head and neck combines. collect blood. Cephalic moving proximal helps identity the deltopectoral groove in shoulder surgery before it pierces the clavipectoral fascia to open into axillary.

Lymphatic drainage of breast and upper limb drain into anterior posterior lateral medial and central group of Axillary lymph nodes which through cervico-axillary canal drain into the supraclavicular lymph nodes

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164. Lower Limb in humans achieves

165. Bipedal Human gait, Climbing up and down stairs, Standing on one or both limbs, sitting on  chair, squatting and cross legged sitting is what lower limbs achieve throughout life.

166. Pelvis The basin shaped bone suspended by muscles of Abdomen, closing it from below, giving passage to urine, baby and feces and attaching the Lower limbs through Hip. Its movements compensate deficient Hip movement

Practice Names Around Pelvic Bone

Pelvis Medial Surface

Pelvis Medial Surface 2

Pelvic Anatomy and Fractures

Pelvic Osteology Inside and outside

Osteology of Pelvic Borders

Draw with me the medial surface of Pelvis

Pelvis whole class

Pelvis Posterior Anatomy

Attaching lower limb to Pelvis

Viva On the bone pelvis

Play List of Anatomy of Pelvis 12 videos

Pelvis Outer Surface

Coronal Section of Pelvis

Hip attachment and movers of the Hip

167. Anatomy of surgical approaches to the hip:

Surgical Approaches Around Hip

Surgical Approaches to hip

Anterolateral Approach to hip

Operation Chiari Pelvic Osteotomy

Evacuation of Cold Abscess

Around Hip Anatomy

Osteology of femur

Thigh Anatomy

Femur Surrounding Anatomy

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168. Soft Tissue Contracture Release around hip: Incision anterlateral vertically below ASIS. Circumflex Iliac cauterized, lateral cutaneousnerve of thigh saved. Deep fascia between Tensor fascia lata and Sartorius divided to expose the medial surface of Tensor Fascia Lata across IT band. Divided. Deep fascia parallel to inguinal ligamant divided till saphenous ring. sartorius straight head of Rectus femoris divided. Wound closed with drain. Corrective plaster given. 

Movers of Knee: Locking, Unlocking and compensation when locking fails, 

Locking of the knee

Bones Articulating - Lower end femur, lateral and medial condyle with intercondylar notch. Outside the condyles is the origin of medial and lateral collateral ligaments, medial injury causing Valgus instability in 30 degree flexion, when diseased and calcified is Pelligrini Steida's Disease. The intercondylar notch inserts the Anterior and posterior Cruciate ligaments LAMP means On lateral is ACL and Medial is PCL. ACL instability produces more anterior Sliding of tibia on femur in 30 degree flexion - Lachmann's Test and PCL instability permits greater posterior sliding Posterior draw Test positive. The medial condyle is larger so its movement is arrested before lateral condyle in extension of knee causing it to act as a Pivot in terminal extension so that the femur lower end rotates medially altering the flexion extension axis and preventing flexion unless this medial rotation lock is undone by the Popliteus ( de-rotating lateral condyle from lateral surface towards the popliteal line on posterior surface of Tibia. 

Contracture release: Tibia upper end flexes, externally rotates and subluxes in triple dislocation/ subluxation of knee due to overaction of the posterlateral triad of Biceps Femoris, Iliotibial band and Lateral Collateral ligament or prolonged immobilization in that position.

Leg Region

Leg and Foot

169. Movers of Ankle: Planter and Dorsiflexion: Contracture and Paralysis, Recognition and management

170. Sole

171. CTEV Play List to understand leg and foot

172. Ischemia in Lower limb Causes RESTED  Decompression in Traumatic vascular insufficiency

Vascular Insuffciency

Management of Vascular Insufficiency

173. Nerve involvement in Lower Limb  Paralysis, Sensation loss Recognition and remedy

Paralysis Lower Limb

Paralysis Lower Limb

174. Orthopedic Integration 

175. Visit Orthopedics Page for Orthopedic Integration

YOU LEARNT

176. Nervous System: Response - Voluntary  and Involuntary - Sensory, Supportive Sensory, Motor, Supportive motor, Cerebellum and Cerebrum, Cranial Nerves, Meninges and CSF, Arteries supplying and Venous drainage Applied anatomy. Autonomic Sympathetic and Parasympathetic. Endocrine  and Exocrine Glands, Sleep and wakefulness, memory, intelligence, Neuro-humeral transmitters and their abnormalities

177. Histology of various Tissues: Not covered Here

178. Reproduction: Male and female genitilia, oogenesis and spermatogenesis, fertilization, embryology of development, Normal and Abnormal mechanisms of Labor. Assessing problems antenatally, Examining a new born child for congenital anomalies and other potential problems , prematurity, asphyxia, jaundice

179. Immune System: Deficiency, Hypersensitivity, Transplant immunology 

180. Gastro intestinal system: Ingestion, mastication, deglutition, Action in stomach, Bile, Pancreatic juice, absorption, fecal excretion, pathologies of GIT 

181. Metabolic Diseases - Diabetes, Calcium Metabolism, Kidney Liver funtion and failure, Nutrition Deficiency and excess

182. Toxicology

183. Adverse Drug Reactions and interactions 

184. Ethics

185. Communication and commitment

186. Security and Prudence

Community Medicine and Public Health: 

When community Health becomes your Responsibility

1. Measurement Yielding Numbers are the Basis of credible understanding of what is happening. It is the basis of all Decisions in Clinical (individual based) or  (For Community) Medicine : Numbers convert Belief - Hypothesis into Credible Knowledge. So understanding DATA well is the first step to understand, use or create credible Data based Knowledge. 

2. Numbers result from the act of measurement. Good measurement is valid - Near the Truth, Precise - Repeated inter or intra observers yield same or near by values and Comprehensive - Measures everything needed to answer the question on the Event of Interest. DATA failing on above parameters belongs to the dust bin. Results being true for the study population is internal validity. Being true on the Target population is external validity or generalizability.  External validity is achieved because Measurements are on a representative ( Randomly selected Sufficient sample size) sample of the source population, the study population, Analysis of those measurements yields result -Statistic that are inferred to be true  for the target population value - Parameter, because both study and target population have been derived from the same source population and are therefore similar. Inferential Statistics.

3. Data: presents as a spread sheet. Each column is a variable. Variable because the measurement value of it,  recorded in subsequent rows, varies for each unit of the population represented by Rows.   Variable name is in the Ist header row and values for individual units of the population in the designated  variable column row intersection cells in subsequent rows. Data must comprehensively  measure all cause, effect, confounder values important to understand the Event of Interest.

4. Variables can be Numeric Continuous (having values after decimal like Temperature - 98.4 degree Fahrenhiet), Numeric Discrete (Number of indivisible units like number of students in the class), Ordinal (Suggest order - High Low but not actually numbers - 1+, 2+, 3+ urine sugar), Nominal or Category like A, B, AB, O blood groups. Numeric variable values are actual numbers obeying the laws of mathematics of can be added, sustracted, multiplied or divided but for nominal and ordinal variables only their number of times they appear in the column-frequency can be reported. Finally, variable values can have a numerator and a denominator. They are Ratio if denominator does not contain the numerator or Rate if denominator contains the numerator. 35/70 passing is a rate as 70 denominator includes 35 numerator. But 35 passing 35 failing - 35/35 is a ratio because the 35 denominator does not contain the 35 numerator. Therefore, rate can never be more than 1 as numerator can never exceed the denominator but ratio can be more than 1.    

5. Source Study and Target Populations: Sampling Strategy, Sample Size, Generalizability or External validity: PopulationNext ratio and rates derived from the sample - study population can be used to estimate the truth in the target or the source population. Since 70% passed in 26 batch, frequency or rate of passed in 26 batch 70% are likely to pass in the 27 batch or 26 batch in other colleges. The frequency of passing in 26 batch will be probability of passing in 27 batch or batches from other colleges provided the populations (student merit) and their exposure (determinants of passing) (teaching quality etc) are similar. Frequency to probability transition is inference about what has happened elsewhere or is about to happen in future.This is inferential statistics. One thing more. 70% probability of passing in 27 batch is a point estimate which like a Rifle Bullet may miss the target bird flying in the sky, reality, percent actually passed in the 27 batch. So converting the point estimate into an interval estimate 70 into 65-75 will increase the chance of hitting the bird, being correct, because the interval will include the truth if 66% actually passed in the 27 batch. By the measures of variance of individual values from central tendency in the study population like Standard Deviation, interval estimate likely to have 68, 95, 99 or X% chances of including the parameter - the real value can be estimated. For example 95% confidence for normal distributions is mean±1.96xSD is 95% confidence interval. 

6. Probability and Odds: Supposing 30 out of 100 will fail the final exam then 30% (Rate or frequency failed),  is the probability of failing. But  Passed:Failed 30/70 ratio is the Odds of failing. Relation between the twom is that Probability/100-Probability is the odds of failing in future or other similarly placed populations. 30/100 in the studied 26 batch is the frequency of failing  estimating that 60/200 in another similar college or in 27 batch will fail if determinants of failing like teaching quality and student merit is similar.  Frequency of the Event of Interest in the study population, Sample, is the probability of the EOI in the Target population since both are derived from the same source population. This science is. Inferential Statistics. Study population reading is Statistic and the truth we are trying to estimate by it in the Target Population is Parameter. 

7. Laws of Probability:  As more information becomes available about the determinants of  the event of interest (Causes of the effect, like from presence of fire smoke can be inferred) the probability of the event becomes higher. For example if we say to any person in the population you have TB we have a 2% chance of being correct as the prevalence of TB in the population is 2%. If we add that the person was from a TB chest disease OPD, probability will increase, if we further add the information that he has 2 months of cough, 1 episode of hemoptysis, feeling feverish in the evening, waking up with night sweats, weight and appetite loss, history of TB in the family, response to antitubercular treatment than the 2% probability has almost converted to 90% certainty, each peace of information adding to the original 2%. This is the Law of Addition of probability, which makes a good clinical examination more powerful than any MRI on grounds of maximum yield at least cost and risk. The Law requires an "or" connector between determinants. 2 months of cough or1 episode of hemoptysis or feeling feverish in the evening or waking up with night sweats or weight and appetite loss or history of TB in the family or response to antitubercular treatment. If "or"  is replaced by "and"  then the end probability is the multiplication of individual probability of occurrence of EOI, given the individual determinant is present. Law of Multiplication of Probability. Since probability being a rate is always a fraction where denominator exceeds numerator and thus requiring that A and B and C all be present to diagnose the EOI decreases the probability of diagnosis. A-0.3, B-0.2, multiplying 0.3x0.2 will give 0.06 which is actually lesser than the individual probability of EOI given presence of A or B.  "and"  connector requiring both connected determinants to be present actually decreases the final probability of the EOI.  

8. Ratio Rate Proportion: In Ratio denominator and numerator have same units for example 70/100 passed in both unit is student. In Rate denominator has a different unit than numerator like 70 Miles/Hr. Usually denominator is time but it can be different also. Like if 70 out of 1000 became diseased in 2 years then 35/1000 is the Annual incidence rate of disease and the unit of the denominator is Person Years. Relation between two ratios is proportion like Odds ratio, Risk ratio. Another relation between riks is Risk Difference or Attributable Risk. Supposing risk of accident between alcohol driving is 40% and  in alcohol free driving is 20% then Risk Ratio or Relative Risk is 40/20 = 2 and Risk difference is 40-20 that means 20 more accidents occurred due to driving after Alcohol  intake, 20 is Risk Attributable to alcohol intake Attributable Risk. If Ratio between accident and no accident is used 40 had accident and 60 did not the statistic is referred to as Odds and Ratio of 40/60 divided by 20/80 is Odds ratio.   Odds Ratio approximates Relative Risk if percentage affected in the study population approximates percentage affected in source or target population. Otherwise Odds Ratio should be used as it doesn't  change with prevalence of disease.

9. Summary Statistics: Columns in the Data set are summarized as follows:
   Numeric data: 

10. Measures of Central Tendency - Means, Median, Mode. Measures of Dispersion around central tendency - range, interquartile range, Variance,  Standard Deviation, Standard Error and Confidence intervals.

11. Dispersion and Type of Distributions of Dispersion around central Tendency: Frequency (Y Axis) Distributions around the central Tendency (X Axis) can be symmetrical sloping around it with base being twice the height (Kurtosis 2) - Normal curve or Asymmetrical decrease in frequency on R or L sides of the central tendency - Skewed Curve. Skewness pulls mode and median away from the mean in its direction and can thus be measured by difference between median and mean in a particular distribution. In a normal curve mean median mode must coincide.

12. Are Two Distributions Different: If Yes what is the magnitude and Significance of difference. If distribution of two Frequency curves is placed on the same Y axis the measures of magnitude of difference is the difference between the central tendencies of the two distributions. The significance of difference, p value, The chance of belonging to both the curves, numbers in the intersection area/total numbers under the two curves is measured by parametric tests if the curves are normal, - Student T test, Z test among 2 comparison groups and Analysis of variance (ANOVA) if more than 2 distributions are being compared. In case of non normal distributions recognized by Bartlett's Test for Inequality of Population Variances having p<0.05, Non parametric test p values like by Kruskal Wallis statistics are used. They are available in Epi Info analysis.

13. Categorical or Ordinal Data is summarised by: Number of units belonging to each category - Frequency, when divided by Total studied it becomes relative frequency and if category is arranged in order low to high or reverse like fail, 3rd division, 2nd division, 1st division and distinction then numbers below 1st division cut off will be called cumulative frequency. From Relative and cumulative frequencies of study population inference about values in Target populations (different but representative of the study population in place or period) can be drawn - Inferential Statistics. 

In one group Ratios are 1. passed/total - Probability (Risk if outcome being measured is adverse otherwise Chance), 2. Passed/failed Odds of passing. In odds Failed denominator does not contain the number passed the Numerator hence its value can be more than 1 and it is more stable when the marginal Total is not believable. 

Comparing two groups. Risk in group 1/ Risk in group 2 is Relative Risk or Risk ratio. Null value 1. Greater than 1 means that the exposure is increasing the probability of outcome and less than 1 means that exposure is decreasing the chance of outcome - Vaccination yes is protective of an adverse event like disease. Risk in group 1 - Risk in group 2 is Risk Difference - or so many cases had the outcome because they were exposed - Risk attributable to being exposed - Attributable Risk. 

If Odds are used as measures of occurence the measure of Association is called Odds Ratio. 

These measures of Association are point estimates- Relative Risk of Accident due to drunk driving 2. If they are converted into interval estimates like 1.5 to 7, then the confidence that it will include the truth increases though precision decreases. When the confidence that in 95% of subsequent trials the relative risk will be within the interval the interval is called 95% Confidence interval.

If the 95% Confidence interval includes the null value of 1 than the exposure can be an accelerator or brakes to the chances of having the EOI. Association is insignificant at 95% Confidence interval. p value is also documented to record the significance of cause effect association. p=0.23 means that in only 23/100 subsequent studies will the Risk ratio will be more extreme than is being shown in this study.

Data for Doctors

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1. Define health: Is a state of Physical, Mental, social and Spiritual well being and not merely the absence of Disease:

2.  The Health Model: Individuals in a population move from Health to Disease to cure, disability, death or loss to follow-up at different and varying Transition rates which need to be monitored, their causality- factors affecting them, accelerators and brakes determined,  modifiable modified at the level of policy, practice and program which define and implement who will do what all when where how and why so as to achieve maximum health at minimum cost and risk by practical implementable do's and Don'ts. monitoring and controlling them : Health and Disease Model In the Community

States in Health Model Transition rates between them, studying and controlling them by Cost effective Risk free doable strategies

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Health, Health Model, Transition Rates, Causality, and Planning to Accelerate the Good and Brake The Bad

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3. Cause Effect Etiological factor - Disease (Agent, host and environmental) Helped us solve AESJE Epidemic.

      AESJE Micromapping

4.  Prognostic factor- Outcome, Intervention - Result.  establishing Cause effect relation and using it in Adverse outcome control.

5. Causality Studies - CAUSE Etiological Factor --Disease, Prognostic Factor --Outcome Both cause effect are  only observed Observational  Studies

    Also Confounders the other explanation of results must also be recorded and controlled.

Cause Effect Relation

Cause Effect Analysis

Binomial Data Cause Effect Relation

Confounders The Other Factors explaining Effect

In observational studies confounding by known confounders is controlled by Restriction, Matching, Stratified Analysis, and Regression. Linear Regression id outcome  is in numbers, Logistic regression if outcome is Binomial - Yes/No and Cox Proportionate Hazard Model if outcome is time dependent. Selection bias is controlled by Random Selection over sufficient Sample Size and Measurement bias by objective measurement or Single, double and triple Blinding if outcome is being measured subjectively. 

Regression Controlling confounding by multiple known Confounders

In Experimental studies the best method to control confounding by  UNKNOWN besides known confounders is Random Allocation to  intervention groups over sufficient sample size. No other method can control confounding by unknown factors

Study Designs cause effect Association after confounder control

Paired Studies

Case Control Studies

Treatment Administered  Effect observed - Experimental studies.

Experimental Research

Why Random Allocation to Treatment Groups

Evidence Based Choice Of Treatment

Randomized Controlled Trials

Randomized Controlled Trial Analysis Utsav Data

Randomized Controlled Trials

6. Describe and discuss the natural history of disease. Pathogenesis what happens inside body - How does it manifest in symptoms, signs, investigations to facilitate a Diagnosis. Diagnostic Tests and combining them. Law of addition of probability. 

Example: Streptococcus hemolyticus Cardiogenic strain infects -Throat infection, antibodies develop against it and form complexus, complexes circulate in blood- Rheumatic fever, deposit in joints, Fleeting arthritis, deposit in mitral valve, edema causing Carycoomb Mitral Stenosis Murmur, cusps of valve adhere-Mitral Stenosis-Murmur, Forward less blood, Syncope, backward more blood, Left Atrium Enlarged, presses on esophagus-Dysphagia, Atrial Fibrillation, Stasis, thrombus, embolism, back pressure through pulmonary veins, fluid leaks in alveoli-Basal crepts, Breathlessness relieved on sitting-Orthopnoea, Heart failure cells in sputum, hemoptysis, pulmonary arteries constrict to save the lung, Pulmonary Hypertension, P2 accentuated, Right ventricle Hypertrophies, Parasternal heave, deep Q wave Lead 1, R wave Lead 3, ST depression T wave inversion, Right ventricle fails-Prominent neck veins, tender smooth hepatomegaly, Splenomegaly, ascitis ascites and pedal edema. ALL EFFECTS MUST BE LOOKED FOR BASED ON ABOVE UNDERSTANDING OF PATHOGENESIS. 

Pathogenesis Understanding the Natural History of Disease

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7. Planning interventions: Intervention has to have  . Proved efficacy higher than competing alternatives, Least toxicity risks, least cost and after informed consent Consent of recipient. It should be doable without complications in the settings where the intervention is planned. Or patient should be referred where it can be done better.

8. Public Participation in interventions: Intervention success is heavily deppendent dependent on public participation participation needing  skills to change both head and heart. Fight against Tobacco and  alcohol are glowing examples of failure and success stories on this front. Deaddiction efforts are important part. Example see this Health promotion video on world  tobacco day 2026.  Key Strategies to Combat Addiction

9. Demographic profile of India and discuss its impact on health Demographic Profile of India

The demographic profile of India describes the population in terms of its size, growth, distribution and composition. India is the world's most populous country, with an estimated population of approximately 1.464 billion (146.4 crore) in 2025 and a population density of about 492 persons per km². This automatically puts a strain on resources needed for health care amongst other needs. For example instead of required 21/10000 population of health care personel India has 6. Also, population effects environment causing pollution, effecting health. It creates poverty diminishing resilience to disease. It effects literacy affecting response to correct advice. It increases unemployment causing poverty depression and angry revolutionary self centred attitude. India has a very large and diverse population, with considerable variation in population density, age structure, sex ratio, literacy, birth rate, death rate and fertility across different states and regions. This strategies for health care have to take diversities into account like non vegetarian egg with essential aminoacids may not be acceptable to vegetarians. The last completed population Census was conducted in 2011, when India had about 1.21 billion people, a decadal population growth of 17.7%, a population density of 382 persons per km², a sex ratio of approximately 943 females per 1,000 males, and a literacy rate of 74.04%. Family Planning drive in India was launched for purpose of population control amongst which temporary measures like Condoms, Loops, Pills and permanent measures like Tubectomy and Vasectomy are programs that succeeded in partially controlling the population explosion. The population is influenced by fertility, mortality and migration, which are the three basic components of population change. India has undergone a substantial demographic transition, characterized by declining fertility and mortality and increasing life expectancy. The total fertility rate has fallen to approximately 2.0 children per woman, close to the replacement level of 2.1, although substantial interstate differences remain. States such as Bihar, Jharkhand and Uttar Pradesh continue to have relatively higher fertility, whereas Delhi, Kerala and Tamil Nadu have below-replacement fertility.

Demographic Profile of India its Impact on Health

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10. Effective Communication skills in health in a simulated environment:

Communication is the process of exchanging information, ideas, feelings and expectations so that both the health-care professional and the patient develop a shared understanding.

Patient is your examiner till the last patient you see in your life. He examines you on ABCDE - availability/ accessibility, behavior, competence, dexterity and empathy. Like all examinations communication is necessary to pass and secure high marks. Accessibility and availability demonstrates will be there when needed. Behavior reassures that you are a good human being committed to tender loving care who will always keep patients interest above your own. This particularly refers to " you will always look into the pocket of the patient not to pick pocket but prescribe accordingly." Competence spreads by success stories spread by word of mouth. It depends on practice of kanthahst vidya (adequate knowledge reflexively available in a time critical manner) sharpened by life long commitment to practice and experience. Dexterity shows by your appearance, your surroundings appearance and your works appearance. Having a wow effect is a resounding confidence building measure showing you pride in excellence. Empathy is crucial. It comes by never crossing the Laxman rekha of keeping patients interest above your own and the reputation of such a great persona spreading by word of mouth. Communication as described below  in busy settings of a 300 OPD patients of a Government Hospital in India is a reaching the sky dream. But try constantly we must. Some tricks are:

Make the patient fill the following fill in the blank proforma while waiting:

मैं ___ वर्षीय__(महिला/पुरुष), निवासी __(पिनकोड) __तिथि को बिल्कुल ठीक था । फिर मुझे ___ लक्षण, __ जगह पर महसूस हुए (हरेक लक्षण पहले से बाद तक विवरण करें ) । बीमारी की शुरुआत __ ( अचानक, धीरे धीरे) हुई । उसके लक्षण ___ (घट रहे,  बढ़ रहे, कभी बढ़ कभी घट रहे या स्थिर हैं । ) __ इलाज लिया । उसका __ असर हुआ (बीमारी बढ़ गई, स्थिर रही या घट गई) । मेरे ख्याल से इस बीमारी का कारण __ है । मुझे ___ अतिरिक्त बीमारियां, एलर्जी, दवा  से रिएक्शन हैं जिनका ___इलाज चल रहा है । इलाज से __( फायदा, कोई फर्क नहीं, नुकसान ) हुआ । मेरा व्यवसाय __ है । मासिक आय __ है । इसपर __ पेट पलते हैं ।

" I , _YEAR OLD, _(MALE/FEMALE), Resident of ___(pincode), WAS ALL RIGHT ON_(date). Then I had__(all Symptoms from 1st to last), at__(site from 1st to last). Onset was __( Acute, Subacute, Chronic, Course __(Progressive , regressive, Stationary , Recurring/Remitting),   Treatment taken __, Response (Improved, deteriorated, no response). Problem is aggravated by _, Relieved by __, Associated with_. I feel the cause of the problem is __. I Have __ Disease from the past (List all the diseases). I am on __ Drugs, I am allergic to __. My vocation is __. My Monthly income is_. I have to support __no. Of people in this income." 

Make him write what are the questions or concerns that are troubling his mind. That will make you address those comprehensively.

Pre information will make your data collection Targeted and save time. Use Recording and transcription for multiple languages. Generate diagnosis wise leading questionnaire which can be asked and filled before consultation.

Let all this be recorded on a Proforma electronically accessible by an Unique Identification number of the patient.

Respect patients or former opinion he has obtained and be careful to criticise.

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Communication is aimed to :

1. To understand the patient's problem

The patient's story is often the first and most important diagnostic investigation.

A patient may not present with a textbook description of disease.

The doctor must listen carefully to understand:

• What is the patient's main concern?

• When did it start?

• How has it progressed?

• What does the patient think is happening?

• What are the patient's fears?

• What does the patient expect from the doctor?

Good communication therefore improves history taking and diagnosis.

2. To build trust

Patients often meet doctors when they are frightened, anxious or vulnerable.

A doctor who listens attentively, shows respect and explains clearly creates confidence.

Trust encourages patients to:

• disclose relevant information,

• ask questions,

• follow advice,

• report problems early,

• and participate in decisions.

A useful principle is:

Before patients trust your treatment, they must first trust you.

3. To improve treatment adherence

Giving instructions is not the same as communicating.

For example:

Poor communication:

"Take this medicine twice daily for five days."

Better communication:

"Take one tablet in the morning after breakfast and one after dinner for five days. What time do you think will be easiest for you to remember?"

The second approach checks understanding and connects treatment with the patient's routine.

4. To reduce errors

Communication failures are an important cause of problems in health care.

Information may be lost:

• between doctor and patient,

• between doctor and nurse,

• during handover,

• during referral,

• or between different departments.

Clear communication can therefore improve patient safety.

5. To involve the patient in decision-making

Modern medicine is not simply:

Doctor decides → Patient obeys.

Instead, effective care increasingly involves:

Doctor + Patient → Shared decision-making.

The doctor provides medical knowledge.

The patient provides:

• values,

• preferences,

• circumstances,

• concerns,

• and personal priorities.

Together they arrive at an appropriate decision.

6. To communicate difficult information

Health-care professionals frequently have to discuss:

• serious diagnoses,

• cancer,

• complications,

• disability,

• poor prognosis,

• treatment failure,

• or death.

Technical knowledge alone does not prepare a doctor for these conversations.

The doctor must communicate honestly while maintaining:

truth + empathy + hope + dignity.

Effective communication can be understood through a simple sequence:

PREPARE → CONNECT → LISTEN → EXPLAIN → CHECK → AGREE → FOLLOW UP

1. PREPARE

Before entering the consultation:

• Know the relevant clinical information.

• Ensure privacy.

• Minimise distractions.

• Give the patient adequate time.

• Be mentally present.

Even before speaking, your behaviour communicates something to the patient.

2. CONNECT

Begin with a respectful introduction.

For example:

"Good morning, Mr Sharma. I am Dr Singh. How may I help you today?"

Use appropriate eye contact.

If culturally appropriate, acknowledge the patient respectfully.

Avoid immediately looking at the computer or writing notes while the patient is speaking.

The first few moments establish the tone of the consultation.

3. LISTEN

Listening is more than hearing.

Hearing is receiving sound.

Listening is trying to understand the meaning behind the words.

Allow the patient to explain the problem initially without unnecessary interruption.

Use open-ended questions:

"What brought you to the hospital today?"

"Tell me more about the pain."

"What concerns you most about this problem?"

Then use focused questions to clarify details.

4. USE ACTIVE LISTENING

Active listening involves:

A — Attention

Give the patient your attention.

B — Body language

Maintain appropriate eye contact and an open posture.

C — Brief responses

Use expressions such as:

"I understand."

"Go on."

"Tell me more."

D — Clarification

"When you say the pain is severe, what does severe mean to you?"

E — Summarisation

"So, if I have understood correctly, the pain started three days ago and has become worse since yesterday."

This confirms that you have understood the patient's story.

5. SHOW EMPATHY

Empathy means recognising and responding appropriately to another person's feelings.

Compare:

"Don't worry. It is nothing."

with:

"I can understand why this result is worrying you. Let me explain what it means and what we can do next."

The second response acknowledges the patient's emotion without giving false reassurance.

A useful formula is:

NURSE

N — Name the emotion

"You seem worried."

U — Understand

"I can understand why this is difficult."

R — Respect

"You have handled a very difficult situation well."

S — Support

"We will work through this together."

E — Explore

"Tell me what worries you most."

6. EXPLAIN IN SIMPLE LANGUAGE

Medical knowledge should be translated into language that the patient understands.

Instead of:

"You have hypertension with end-organ involvement."

Say:

"Your blood pressure is very high, and it is beginning to affect important organs such as the heart and kidneys."

Avoid unnecessary jargon.

Remember:

If the patient does not understand the explanation, the communication has not succeeded—regardless of how scientifically correct the explanation was.

7. GIVE INFORMATION IN SMALL AMOUNTS

Do not overwhelm the patient with information.

A useful sequence is:

What is the problem?

What does it mean?

What are the options?

What do we recommend?

What happens next?

Then pause and allow questions.

8. CHECK UNDERSTANDING

One of the most important communication techniques is teach-back.

Do not simply ask:

"Do you understand?"

The patient may say yes even when they have not understood.

Instead say:

"Just so I know that I have explained it clearly, can you tell me how you will take this medicine at home?"

This checks the effectiveness of our explanation, rather than testing the patient.

9. DISCUSS OPTIONS AND EXPECTATIONS

Patients often come with expectations.

Ask:

"What were you hoping we could do for you today?"

This may reveal an important concern.

For example, the patient may expect an injection when the actual treatment requires physiotherapy.

Understanding expectations allows the doctor to explain the reasoning behind the treatment.

10. SHARED DECISION-MAKING

When more than one reasonable treatment option exists, explain:

• the available options,

• benefits,

• risks,

• limitations,

• costs where relevant,

• and likely outcomes.

Then ask:

"Which of these options fits best with your priorities?"

This respects patient autonomy.

11. NON-VERBAL COMMUNICATION

Communication is not only words.

The patient also observes:

• facial expression,

• eye contact,

• posture,

• gestures,

• tone of voice,

• distance,

• speed of speech,

• and whether the doctor appears rushed.

A doctor saying:

"I'm listening."

while continuously looking at the computer is sending two contradictory messages.

12. COMMUNICATING BAD NEWS

When giving serious information:

Prepare the environment

Choose an appropriate private setting.

Assess what the patient already knows

"What have you understood about the tests so far?"

Ask how much information they want

"Would you like me to explain the findings in detail?"

Give information gradually

Avoid giving the entire diagnosis in one technical paragraph.

Respond to emotion

Pause.

Allow silence.

Acknowledge feelings.

Make a plan

End with:

"Here is what we can do next."

Patients may not remember every medical detail, but they often remember how the doctor made them feel.

13. COMMUNICATION WITH THE HEALTH-CARE TEAM

Effective communication is equally important between professionals.

During handover, communicate:

Who is the patient?

What is the problem?

What has happened?

What has been done?

What needs to happen next?

A structured approach such as SBAR can help:

S — Situation

What is happening now?

B — Background

What relevant information is available?

A — Assessment

What do you think is happening?

R — Recommendation

What needs to be done?

14. DEALING WITH ANGRY PATIENTS

Do not respond to anger with anger.

First:

Listen.

Then:

Acknowledge.

"I can see that you are very frustrated."

Then:

Clarify.

"Please tell me what has happened."

Then:

Explain what can be done.

The objective is not to "win" an argument.

The objective is to understand the problem, maintain dignity and find a safe solution.

15. CULTURAL AND LANGUAGE SENSITIVITY

Patients may differ in:

• language,

• culture,

• education,

• beliefs,

• health literacy,

• family structure,

• and expectations.

Never assume that the patient's beliefs are irrational simply because they differ from yours.

Ask.

Listen.

Explain.

Respect.

When necessary, use a trained interpreter rather than relying on children or untrained family members for important medical information.

16. DIGITAL COMMUNICATION

Modern health care increasingly uses:

• telephone consultations,

• video consultations,

• electronic medical records,

• messaging,

• email,

• and telemedicine.

The basic principles remain the same:

privacy + clarity + empathy + documentation + patient safety.

In a video consultation, pay particular attention to:

• identity verification,

• privacy,

• audio quality,

• visual cues,

• limitations of remote examination,

• and clear instructions about when an in-person assessment is required.

THE GOLDEN RULES OF HEALTH-CARE COMMUNICATION

Remember these ten principles:

1. Listen before you speak.

2. Ask before you assume.

3. Use simple language.

4. Show empathy.

5. Respect patient autonomy.

6. Pay attention to non-verbal communication.

7. Check understanding.

8. Involve patients in decisions.

9. Communicate clearly with colleagues.

10. Always end with a clear plan.

A SIMPLE MODEL TO REMEMBER

For every patient consultation, remember:

CONNECT

C — Create a respectful connection

O — Open the conversation

N — Notice the patient's concerns and emotions

N — Note and clarify the history

E — Explain clearly

C — Check understanding

T — Together agree on the plan

CONCLUSION

Effective communication is not simply about speaking well.

It is about:

understanding the patient,

being understood by the patient,

building trust,

sharing decisions,

and ultimately

improving patient care and safety.

A technically excellent doctor who cannot communicate may fail to deliver excellent care.

But a doctor who combines:

knowledge + clinical skill + communication + empathy

can transform the patient's experience of illness.

So, remember:

"The most important part of communication is not what we say. It is what the patient understands."

And perhaps the most important skill for every health-care professional is simply this:

Listen. Understand. Explain. Check. Connect.

Communication GK Singh

11. Demonstrate the important aspects of the doctor patient relationship in a simulated environment

Doctor–Patient Relationship

1. Treat every patient with respect

   • Remember that the patient is a person, not a disease or a case number.

   • Respect their dignity, privacy, culture and beliefs.

2. Listen before you speak

   • Allow the patient to describe the problem in their own words.

   • Do not interrupt unnecessarily.

   • Often, careful listening itself is therapeutic.

3. Show empathy

   • Try to understand what the illness means to the patient emotionally, socially and financially.

   • Simple statements such as “I understand that this must be difficult for you” can make a major difference.

4. Communicate in simple language

   • Avoid unnecessary medical terminology.

   • Explain the diagnosis, investigations, treatment and prognosis in words the patient can understand.

   • Check whether the patient has understood you.

5. Be honest—but compassionate

   • Never deliberately mislead a patient.

   • When discussing serious or uncertain information, communicate truthfully with sensitivity and appropriate support.

6. Protect confidentiality

   • Patient information must not become casual conversation.

   • Discuss patients only in appropriate professional settings.

   • Be particularly careful with photographs, WhatsApp messages and social media.

7. Respect patient autonomy

   • Explain reasonable treatment options and involve the patient in decisions.

   • Do not assume that the doctor should make every decision for the patient.

8. Never judge

   • Do not show contempt or blame because of a patient's lifestyle, socioeconomic circumstances, addictions, sexual history, obesity or previous non-compliance.

   • Your role is to help, not to punish.

9. Be aware of non-verbal communication

   • Eye contact, facial expression, posture and tone of voice communicate as much as words.

   • Avoid appearing rushed, distracted or uninterested.

10. Maintain professional boundaries

    • Be warm and approachable without becoming inappropriately familiar.

    • Avoid exploiting the patient's trust or developing relationships that compromise professional judgment.

11. Admit uncertainty and mistakes

    • No doctor knows everything.

    • Saying “I am not certain; let me check” is safer and more professional than pretending to know.

    • If an error occurs, follow appropriate professional procedures and communicate honestly.

12. Remember that time is part of treatment

    • A patient may remember how you made them feel long after forgetting the name of the medicine.

    • Even when you are busy, give the patient your full attention for the important moments.

A message I would give to medical students

“Before you become a good doctor, learn to become a good listener. Before you treat the disease, understand the person. Before you give advice, earn the patient's trust. And whenever you enter a patient's room, remember that you are entering the most vulnerable moment of another person's life.”

The foundation of a good doctor–patient relationship is simple:
Listen → Understand → Explain → Respect → Involve → Care.

Become an Available, Accessible, Caring, Competent, Dextrous Empathetic Communicative Clinician

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Socio Cultural interventions:

12. Clinico-socio-cultural and demographic assessment of the individual, family and community. Developing comprehensive, precise and valid data collection instruments on factors under study. PILOT TESTING, INTEROBSERVER WITHIN OBSERVER AGREEMENT Using those instruments on representative sample REPRESENTATIVENESS. Analyzing data to determine cost effective risk free group of interventions to change harmful clinico-socio-cultural behavior at policy program and practice levels.  

13. List common socio-cultural factors affecting health.  Health is greatly influenced by socio-cultural factors such as culture, customs, traditions, beliefs, religion, social values, education, occupation, income, family structure, social status, gender roles, food habits and housing conditions. These factors influence a person’s health behaviour, dietary practices, personal hygiene, use of health services, attitude towards disease and acceptance of treatment. Certain customs and beliefs may promote health, while others may contribute to malnutrition, infections, delayed treatment or harmful practices. Illiteracy, poverty, social discrimination, gender inequality and lack of awareness may further adversely affect health. Thus, understanding socio-cultural factors is essential for planning and implementing effective and culturally acceptable health programmes and interventions. Let us arrange this knowledge in an orderly understandable sequence. Loss of Health is an Event of Interest. For example since 1994 Encephalitis episodes involving 5000 children were occurring in Northern India, Pre monsoon west of Gandak and Post monsoon east of it. 3000 per year were disabled for life and 1000 died despite heavy cost incurred in trying to save them. AIIMS Patna, Rajendra Prasad Institute of Research and Bihar State Task Force responded to the Time place person distribution of the 2012 epidemic micromap plotted by AIIMS Patna and found that the epidemic was restricted to the North Bank of the Saryu River. It was hypothesised that an enterovirus residing in the intestine of infected carriers or diseased was Travelling from upstream  through the North stream of the Saryu River affecting the susceptible down stream population through oral consumption of infected water. The fast flowing mid stream of the river diluted the fecal contamination to a degree so that the south side population of the river was unaffected. Agent Transmission Host. Here Transmission was attacked by a clean water campaign in Muzzafarpur district. The 1347 affected count in 2014 became 64 affected count in 2015. Same was repeated in Gorakhpur. Now there is no Epidemic for perpetuity. First study Time when, place-where, person-who is affected. Here this much worked. Otherwise we would have gone to why, determining patient, place, habit characteristics peculiar to the diseased - Causality Studies and determining which modifiable risk factors could be modified achieving maximum effect at least cost or risk. Created a will to do it - Policy, Developed a program- who will do what when where how why with what Standard operating procedures (SOP's) and resource. Pilot tested, optimized and implemented that program. This is how specific problems are treated by specific measures to acheive maximum in minimum cost.

Sociocultural Interventions

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Family types there role in staying healthy,  getting diseased and response to the disease and interventions.  Families are the nearest exposure to the individual in the Health Model. They are nuclear, joint, extended, or broken/single-parent families. The family influences health body through nutrition, hygiene, sanitation, child care, and behavior through health education, emotional support and knowledge of optimal utilization of health services. Families also  can also contribute to body disease through poverty, education, poor housing, overcrowding, unhealthy dietary practices, inadequate sanitation, genetic factors and transmission of infections. They affect mental health by being combative, critical and an inimical selfish attitude.  When a member becomes ill, the family is usually the first source of care, recognizing symptoms, deciding when and where to seek medical help, providing treatment, nursing care and emotional support. The family also influences compliance with treatment, rehabilitation and prevention of complications.

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14. Barriers to good health and health seeking behavior: Addictions create difficulty in de-addiction. Lack of health education allows "All is well" in friendly harmless looking lumps in Breast delaying early detection of Breast Cancer. If problem is detected not knowing optimal response where will I get best at least price and risk causes decisions in not getting it adversely effecting outcome. Lack of Accessibility, Affordability, Receptivity, Rejecting Behaviour instead of Tender Loving Care), Competence, dexterity and Empathy are all barriers to health seeking behavior. Perpetual Disaster situation with demand constantly outrunning resource is a barrier.

Barriers to good health and health seeking behavior:

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For Example

Managing Tobacco Addiction

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15. Health hazards:  Air, water, noise, radiation, earth, space, microbes, vectors and humans.

AIR: AIR can damage health in many ways. It's contents can change O2 may decrease, Hypoxia on mountains, CO2 may increase, creating a ceiling disallowing infrared rays reflected from the surface of the earth to escape, causing Global warming, melting of glaciers, rising of sea levels and drowning of costal areas. The CO may be present, binding hemoglobin, decreasing oxygen carriage by blood and producing tissue anoxia. CCL4 from Air conditioners may cause holes in the Ozone protective layers in the stratosphere permitting Ultraviolet Radiation to affect life by skin allergies and cancer. Temperature may change, Global warming is not only making summers intolerable and disease producing, but glaciers are melting, sea levels rising, costal areas drowning, rivers not draining, rains producing stagnant water and stagnant water breeding vectors to cause diseases like malaria, filaria and dengue. Warmer Air's carries more water from sea, has more energy to flow causing storms, torrential rains floods in some areas and droughts in others. Rising sea levels prevent drainage in costal areas including drainage of rivers flooding them. Air may carry allergens causing allergy, particulate matter causing clogging of lungs, Pneumoconiosis or pathogens like Corona virus or TB bacteria causing Covid or TB. 

Trees are the greatest friends of healthy Air and Humans it's greatest enemies. So everyone plant trees and nurture them. Chipko protest against cutting trees in Nanda Devi Basin of Himalayas is an example of how illiterate but thoughtful loving women wrapped themselves around trees preventing greedy growth development hungry men from cutting them. Energy hungry humans Burn coal, oil, gas and biomass for cooking and keeping warm. Kangri in Kashmir is a container of burning coal bound to the body to keep heat out. Mushrooming Automobiles  burn carbon fuel ineffiently pushing large plumes of CO2 rich smoke into the atmosphere. Unlike steam engines who also burn coal but pulling many more people in public transport, they satisfy the need of only a few human beings. Do we really need to travel so much. Can't work places be near homes. Can't we work from homes. Can't we use Alternative sources of energy like electricity, solar energy, wind energy, water energy, geo thermal energy, hydrogen, ethanol, nuclear energy. Store energy and use it. Power the night side earth by day side solar energy production through electric grid. Make irrational exploitative methods of energy creation, preservation and use impossible by making it logically impossible, creating better alternatives like cooking gas, increasing vigilance and administering certain, immediate deterrent punishment to violators. Be vigilant, consider Air your friend and protect it against thoughtless exploiters. Health Sector besides this has the function of early detecting effects. Following the path of Air outside and then within the body. Beware of low oxygen, low atmospheric pressure, more Carbon mono oxide, SO2, Carbon dioxide in crowded areas where crop remains are being burnt, decrease or block the exposure, wear masks, decrease time of being exposed by moving away or avoidance. Point it out and insure deterrence. Within the body allergen, polluting particulate matter, or disease producing microbe can be protected against at agent in carrier level by identifying isolating, containing, confining. Transmission level by avoiding large numbers sharing same recirculated air, example aircraft, lifts, malls and metro's, masks. Host levels by immunizing, desensitizing, using protective drugs like Ivermectin which blocks ACE receptor where Corona virus bonds through its receptor binding site. Effects on lung, heart, blood vessels, blood, skin, pregnancy, foetus, child, nervous system, GIT, liver, kidney, Metabolism, locomotor system have to be known detected using comprehensive precise and valid data collection and managed cost effectively minimising risk and insuring accessibility. AIR quality has to be monitored and prominently displayed to create awareness and promote public opinion driven action. While humanity across national boundaries shares the responsibility and bears the effect. The whole world as 1, not a group of squabbling blaming nations should bury the hatchet and solve the problem urgently otherwise there will be no life for the coming generations. Aware, responsive, individuals, communities, industries, nations world have to act to achieve sustainable development.

See Summary of How to protect our Air

You Tube : Protect the Air GK Singh

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16. Water: Safe Healthy Water Is a scarce commodity.  Oceans, Sun evaporation, clouds, carried by winds, stopped by mountains and rain produces it, glaciers store it, rivers bring it to our vicinity. From earths surface water seeps through it being stored as underground water. Tree's by Transpiration send it back to the clouds.  We have learnt to tap the underground reservoir of water by wells which have to be very deep in mountains. We have also learnt to maximize the seepage by making water stand and not flow. Water Harvesting. But stagnant water is also a breeding ground for Vectors which should be prevented by making the surface unusable by larvae, spreading oxygen impermeable kerosene oil on it occasionally during vector excess cycles . This applies to all stagnant water like water in coolers. Rivers can be rerouted to water deficient areas. Flowing water can yield electricity through storage, dams and tunnels to power turbines as it falls. Hydroelectric power. Water can effect health by Dehydration, water borne disease producing microbes like Enterovirus causing AES JE spreading through feco oral route by wrong ussage of water from the North banmk of Saryu. Preserving clean drinking water is every ones responsibility from individual to mankind.  Water preservation, transportation to where it is needed, purification, quality control, and economic use are to be insured at all levels.   Water borne diseases spreading through feco fecal contamination by intestine borne entero microbes and oral intake by victims can be prevented at carrier transmission and host defense levels. AESJE, Infective hepatitis, Cholera,  Gastroenteritis, diarrheal diseases  are due to transmission of microbes. Underground water deficiency due to impossibility of well digging in high mountains and plateaus leads to Goiter due to iodine deficiency. River Ouch Ouch flowing through Cadmium rich mountains damaged the Distal Convoluted Tubules of the river side populations causing less extrusion of H ion - Acidosis and less re-absorption of Calcium, Potassium and Sodium, Hypo Calcemia, Kalemia, Natremia and dehydration due to sodium taking water out with it. This was Ouch Ouch Disease. Also, shallow wells tapped into Arsenic rich underground water usage caused deadly difficult to detect Arsenic poisoning necessitating marking by red cross hand pumps in the endemic areas to warn not to use water from them.

Heathy water availability preservation

You Tube: Water Safe or Toxic

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17. Solid Waste Management:  Pollution is Non usable Material where it should not be. There is an island of San Francisco sized plastic waste floating in the Pacific west of it. Important characteristics of such waste is its creation, its indestructibility, its inadequate disposal, its potential to adversely effect health, environment and earths beauty. Prevention is every ones responsibility and involves acceptance and enforcement of non polluting behaviour. Principles are create not. Use Paper or cloth bags instead of plastic or permanent reusable trash collectors. Not even paper because it causes cutting of trees. Use digital or verbal communication. If created Segregate to allow differential appropriate treatment. Color Code for correct identification : 🟢 Green, Biodegradable (Wet) Waste, Food scraps, fruit and vegetable peels, garden waste, 🔵 Blue, Dry Recyclable Waste, Paper, cardboard, plastic bottles, metal cans, glass, 🟡 Yellow, Biomedical/Infectious Waste, Human tissues, dressings, bandages, contaminated materials, 🔴 Red, Contaminated Recyclable Biomedical Waste, IV tubes, catheters, syringes (without needles), gloves, ⚪ White (Translucent), Sharps Waste, Needles, scalpels, blades, syringes with fixed needles, ⚫ Black, General/Non-recyclable or Hazardous Waste (depending on local rules), Dust, ash, sanitary waste, expired medicines, chemical waste. For house holds a simpler classification is 🟢 Green: Wet/organic waste, 🔵 Blue: Dry/recyclable waste, ⚫ Black: Non-recyclable/reject waste. Basic Classification seggregates dry, wet, infective/not infective, biodegradable or not. Store it at the right place where it can do no harm. Collecting Transporting system so it does not accumulate. Disposal by incineration, recycling, burying to create manure. Again everyone individual to mankind has to understand and contribute.

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18. Housing:

What makes a house a healthy home?

When a person spends a major part of their lifetime's earnings acquiring a house, the objective should be much more than four walls and a roof.

A healthy home should be:

Safe

• Structurally sound

• Fire safe

• Electrically safe

• Secure against intrusion

• Safe from falls

Healthy

• Adequate ventilation

• Natural light

• Safe water

• Good sanitation

• Effective drainage

• No stagnant water

• Good waste disposal

• Minimal pests and vectors

• Appropriate temperature control

• Low indoor air pollution

Comfortable

• Adequate space

• Privacy

• Appropriate furniture

• Safe, non-slip floors

• Facilities for cooking, eating, sleeping, working and recreation

Accessible

• Schools

• Hospitals

• Workplace

• Markets

• Parks

• Public transport

• Police and emergency services

Environmentally sustainable

• Solar/renewable energy where feasible

• Energy-efficient construction

• Green surroundings

• Trees and vegetation appropriately planned

• Efficient water and waste management

Resilient

• Earthquake-, flood-, fire- and other disaster-appropriate design according to local risk.

Socially healthy

• Peaceful neighbourhood

• Caring relationships

• Security

• Community interaction

• Freedom from violence and harassment

Legally and administratively sound

19. Compliance with local building regulations

20. Appropriate approvals

21. Clear ownership/tenancy arrangements

22. Adequate emergency access

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23. Vectors Borne diseases. National Vector Borne disease Control Program:

Vector-borne diseases are infections transmitted to humans or animals by living organisms (vectors) such as mosquitoes, ticks, fleas, sandflies and lice.

    Vector-borne diseases MD Chief Justice Lucknow Kanpur Patna Tata Lakhimpur

Learn Agent and Vector for each along with Clinical picture

Disease Causative agent Main vector

Malaria Plasmodium spp. Female Anopheles mosquito

Dengue Dengue virus Aedes aegypti

Chikungunya Chikungunya virus Aedes aegypti, A. albopictus

Japanese encephalitis JE virus Culex mosquitoes

Lymphatic filariasis Wuchereria bancrofti, Mainly Culex

   Brugia spp.

Kala-azar Leishmania donovani Sandfly (Phlebotomus)

Plague Yersinia pestis Rat flea

Typhus Rickettsia spp. Lice/fleas/ticks 

Lyme disease Borrelia burgdorferi Ixodes tick

Burkitts Lymphoma Epstein Barr Virus with MYC ? Aedes aegypti

gene activation by translocation

  at chromosome 8, 14

Prevention and control by Integrated Vector Management (IVM):

1. Source reduction – eliminate stagnant water and breeding sites.

2. Personal protection – bed nets, repellents, protective clothing.

3. Vector control – insecticides, larvicides and appropriate environmental measures.

4. Early diagnosis and treatment – reduces illness and, for some diseases, transmission.

Public Health 

5. Surveillance – monitor vectors, cases and environmental conditions.

6. Community participation – vector control cannot be sustained without household and community action.

Know:

Agent → Reservoir → Vector → Human host → Transmission → Disease About the disease.

For example:

Plasmodium → infected human → female Anopheles → another human → bite → malaria

Try out these theoretical Questions:

24. Identify and describe the identifying features and life cycles of vectors of Public Health importance  

25. Describe the mode of action, application cycle of commonly used insecticides and rodenticides  

26. Describe various methods of health education with their advantages and limitations for vector control  

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27. Radiation: Affects health by chronic unnoticed exposure or by Nuclear disaster leak or explosion through war. Nuclear explosion kills much before radiation by heat and shock wave deep underground being the safest places to escape in the survival zone because all travel straight and can't enter wells. The best option is prayer for sanity to prevail, deterrence to enforce peace the famous song O saare jag ke rakhwale, Nirbal ko bal dene wale, Balwanon ko, balwano ko dede gyan. Lets hope nuclear non proliferation is more widely accepted, deterrence is able to prevent misadventures, enforcers have more teeth and world survives this growing capability to destroy it. Leaks accidental or by misdirected attacks or mistakes affect everything in a growing circumference around the leak and must be managed by early detection, reporting,  containment, monitoring the exposed for effects and managing the effects ranging from sickness like nausea, vomiting, loss of appetite, skin burns to aplasia and malignancy like Leukemia. Refrigeration gases CFC -12  and HCFC-22 leaked from AC's and Refrigerators rose stably through troposphere into the stratosphere where UV radiation broke the molecule yielding Cl- ions. Cl- snatched the third O from O3 becoming CLO and depleting O3. Then Cl- freed itself regenerating from ClO and went for the next molecule of O3 thus creating a timeless perpetual mechanism of depleting O3. Through holes in O3  Ultraviolet radiation reached the earth causing pigmented dermatitis, sunburn, and increasing risk of skin cancer. Higher mountains are more affected. Finally, Hospitals using radiotherapy must monitor exposure to radiation and prevent overexposure. Radiation affects of electromagnetism use in communication has made sparrows extinct.  

Summary of Health and Radiation

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27. Pathogenic Microbes: 

Microbes causing infections are viruses, DNA and RNA,

Bacteria, fungus, parasites like amoeba, malaria parasite, filaria, kalazar, Fungus and worm infestations. 

BACTERIA

Gram + Cocci, Bacilli, Gram - Cocci, Bacilli. Below is a  brief introduction to them in relation to what they clinically cause. 

Among

Gram+ve Cocci

Staphylococcus cause Furuncles, wound infection osteomyelitis. Secrets Penicillinase to destroy penicillin and Methycillin Resistant Staphylococcus Aureus MRSA responds to Le vofloxacin.

Streptococcus Hemolyticus Cardiogenic strains cause Rheumatic fever and Nephrogenic strains Type I and II Glomerulonephritis.

Pneumococcus causes Pneumonia. 

Among

Gram - Cocci

Neiseria Gonohroea causes Gonorrhoea 

Nieseria Meningitidis Meningitis, complication Adrenal Hemmorrhage Water House Fredrichsons Syndrome. Among

Gram+Bacilli 

Coryne Bacterium causes Diptherie Diphtheria and Anaerobic spore bearing 

Clostridium Tetani Tetanus spastic convulsions, Clostridium 

Boutulinum Botulinism flaccid paralysis, Clostridium Septicum Oedemetins Welchi - Gas Gangrene. The anaerobic culture is on  Robertsons cooked meat medium. 

Plague is caused by Yersinia pestis. a Gram-negative coccobacillus transmitted by Rat flea (Xenopsylla cheopis), residing in Rodents, Bubonic - painful buboes in lymph nodes, Pneumonic plague: respiratory.  Transmission between humans possible. 

Gram +ve Bacilli: Gram positive spore bearing rod- Bacillus Anthracis with potential to be used in Biological Warfare produces cuteneous, respiratory intestinal Anthrax Epidemic if rained from Air.

Among

Gram -ve Bacilli

All Ellas are motile except Salmonella which causes Typhoid, cultured on Blood Culture Broth, antibodies demonstrated by Widal's Test against A, B and O antigens. Other ellas are 

Shigella causes Rieters Syndrome (Uveitis Urethritis Arthritis), capsulated

Klebsiella causes Ankylosing Spondylitis 

Legionella is Intracellular

Non Ellas 

Ecoli causes UTI grows in acid urine.

Proteus is cultured from wound infection.

Yersinia Enterocolitis causes Enteropathic Arthritis

Pseudomonas Aerogenosa causes- Wound infection with greenish pus due to pyocyanin needs Vinegar dressing

Acinobacter is a nosocomial hospital infection in Ventilator Associated Pneumonia ( VAP ).

Vibrio Cholrae causes Cholera, Campylobacter jejuni,

Gastroenteritis

Helicobacter pylori, indolent Peptic ulcer disease

Respiratory infection isolates are 

Haemophilus influenzae and

Meningitis. 

Whooping cough isolates are

Bordetella 

Pertussis

Brucella from unpasteurized milk causes undulating fever.

Acid fast Bacilli, Myco Bacterium Tuberculosis - Tuberculosis and Mycobacterium Leprae Leprosy  have mycolic acid in their cell wall that takes the stain, Thick smear on the slide is made of residue, supernatant thrown of NaOH centrifuged with sputum, Petroff's method, flame fixed, stained for 2 minutes with boiling Carbol Fuchcin, washed with Tap water, Excess AF Stain is removed by 3% HCL or H2SO4 solution for Lepra bacillus and 20% for Tuberculosis, Counter staining is done by  Malachite Green and bacilli seen under oil emulsion.  

 Lab diagnosis includes Gram Staining, Motility testing by hanging drop method, culture and colony characteristics, microscopic appearance spore bearing or not and biochemical reactions, To memorise biochemical reaction positivity just draw with me in the following video. Use it both ways to recognize diagnostic foot prints of Bacteria and to tell which bacteria are particular biochemical test positive.

Biochemical Reaction Positivity for Bacterial Diagnosis

Bacteria as Health Hazard

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Parasites: Parasitic infections in humans are broadly divided into protozoal and helminthic infections. Ectoparasites such as lice and mites are also important.

Parasite Disease / important manifestation Mode/vector

Entamoeba histolytica Amoebic dysentery, liver abscess Feco-oral

Giardia lamblia Giardiasis, malabsorption/diarrhea Feco-oral

Trichomonas vaginalis Trichomoniasis Sexual

Plasmodium Malaria Female Anopheles

Leishmania Kala-azar, Cutaneous Sandfly Leishmaniasis

Trypanosoma Trypanosomiasis Tsetse fly / reduviid bug

Toxoplasma gondii Toxoplasmosis Cat feces, undercooked meat

Ascaris lumbricoides Ascariasis Feco-oral

Ancylostoma / Necator Hookworm disease, anemia Skin penetration

Enterobius vermicularis Pinworm infection Feco-oral

Trichuris trichiura Trichuriasis Feco-oral

Taenia solium Taeniasis, cysticercosis Pork / eggs

Taenia saginata Taeniasis Beef

Echinococcus Hydatid disease Dog-associated

Filarial worms W Bancrofti Lymphatic filariasis Culex Mosquito

Brugia malayi Lymphatic filariasis Mosquito

Schistosoma Schistosomiasis Freshwater exposure

Fasciola hepatica Fascioliasis Aquatic plants

Sarcoptes scabiei Scabies Skin-to-skin contact

Pediculus humanus Pediculosis (lice) Direct contact

Pthirus pubis Pubic lice Sexual/direct co

Brief but Important

Malaria → Plasmodium → female Anopheles

Kala-azar → Leishmania donovani → sandfly

Filariasis → Wuchereria bancrofti → mosquito

Amoebic liver abscess → Entamoeba histolytica

Cysticercosis → Taenia solium eggs

Hydatid cyst → Echinococcus granulosus

Scabies → Sarcoptes scabiei

Hookworm → iron-deficiency anemia

Pinworm → nocturnal perianal itching

Giardiasis → foul-smelling diarrhea + malabsorption

Easy framework:

Protozoa → malaria, amoebiasis, giardiasis, leishmaniasis

Helminths → roundworms, tapeworms, flukes, filarial worms

Ectoparasites → scabies and lice.

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28. Fungal Infections 

Fungal infections (mycoses) can be classified according to the depth of tissue involved:

Type Common fungi Typical disease

Superficial mycoses Malassezia Pityriasis versicolor,Hortaea werneckii

Tinea nigra, Piedraia hortae, Black      piedra

Cutaneous mycoses Trichophyton Tinea/ringworm, onychomycosis Microsporum, Tinea corporis/capitis, Epidermophyton Tinea cruris/pedis

Subcutaneous mycoses Sporothrix schenckii Sporotrichosis Fonsecaea etc.

Chromoblastomycosis

Maduro mycosis Presenting with Swelling pain sinuses in Foot with sulphur granules discharged, on Gram staining Sunflower appearance with Gram -ve center and Gram +ve rays. Fungal Eumyecetoma Responds to Itraconazole plus surgical excision and Bacterial Actinomyecetoma (filamentous bacteria) to Cotrimoxazole and Amikacin

Systemic/endemic mycoses Histoplasma Histoplasmosis

    Blastomyces Blastomycosis

Coccidioides Coccidioidomycosis

Paracoccidioides Paracoccidioidomycosis

Opportunistic mycoses Candida Candidiasis

Aspergillus Aspergillosis

Cryptococcus neoformans Cryptococcosis, meningitis

Mucorales Mucormycosis

Pneumocystis jirovecii Pneumocystis pneumonia

In Short

Candida → oral thrush, vaginitis, systemic candidiasis

Aspergillus → allergic bronchopulmonary aspergillosis, aspergilloma, invasive aspergillosis

Cryptococcus → meningitis, especially in immunocompromised patients

Mucor → rhinocerebral mucormycosis; classically associated with uncontrolled diabetes/DKA

Sporothrix → lymphocutaneous “rose gardener's disease”

Malassezia → pityriasis versicolor

Dermatophytes → infections of skin, hair and nails

Key distinction:

Dermatophytes = keratin-loving fungi → skin, hair, nails.

Candida/Aspergillus/Cryptococcus/Mucor = important opportunistic fungi, particularly in immunocompromised patients.

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29. Viral Infections 

Viruses cause infections in virtually every organ system. For medical students, it is useful to remember them by clinical syndrome → virus.

Viral infection/disease Common causative virus

Common cold Rhinovirus, Coronavirus, Influenza, Influenza A, B

COVID-19 SARS-CoV-2

Measles Measles virus

Mumps Mumps virus

Rubella Rubella virus

Chickenpox / Herpes zoster Varicella-zoster virus

Herpes labialis/genital herpes HSV-1 / HSV-2

Rabies Rabies virus

Poliomyelitis Poliovirus

Dengue Dengue virus

Chikungunya Chikungunya virus

Yellow fever Yellow fever virus

Japanese encephalitis Japanese encephalitis virus

Hepatitis A HAV

Hepatitis B HBV

Hepatitis C HCV

Hepatitis D HDV

Hepatitis E HEV

HIV/AIDS HIV-1, HIV-2

Polio Poliovirus

Rotavirus Gastroenteritis

Norovirus Norovirus gastroenteritis

Warts Human papillomavirus (HPV)

Cervix cancer High-risk HPV, especially 16 & 18

Infectious mononucleosis Epstein–Barr virus (EBV)

Burkitts Lympnoma EBV Carried by Aedes Egyptia Fly causes transolocation 8,14 

CMV infection Cytomegalovirus

Parotitis Mumps virus

Important viral features

Obligate intracellular parasites — require living host cells for replication.

Contain DNA or RNA, but generally not both.

May be enveloped or non-enveloped. Capsomere. May have Receptor Binding Site ACE Receptor for Covid Virus

Antibiotics do not treat viral infections. Ivermectin has 3 level antiviral action, Receptor, Ribosome and Trans portin across nuclear membrane

Diagnosis may involve PCR/NAAT, antigen detection, antibody tests, or viral culture.

Exam mnemonic:

DNA viruses: “Herpes And Pox Are Big” → Herpesviruses, Adenovirus, Poxviruses, A? (Papilloma/polyoma), B? (Hepadnavirus).

More reliably: DNA viruses = Herpes, Adeno, Pox, Papilloma/Polyoma, Hepadna.

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29. Antibiotic misuse: Antibiotic misuse means using antibiotics in an inappropriate way, such as when they are not needed, using the wrong drug or dose, or not following the prescribed duration. Commonly: Taking antibiotics for viral infections such as common cold, influenza or most sore throats, Self-medication without medical advice, Using the wrong antibiotic, dose or duration, Stopping treatment early when symptoms improve, Using leftover antibiotics or sharing them with others, Unnecessary use of broad-spectrum antibiotics in Humans constitutes misuse.  In livestock and agriculture similar mistakes constitute miause.

Major consequences include Antimicrobial resistance (AMR) causing antibiotic failure, prolonged illness, prolonged treatment increasing risk of adverse effects and drug interactions. C. difficile infection and disturbance of normal microbiota, increased healthcare costs and hospitalisation, Spread of resistant organisms in the community and hospitals.

So: Antibiotics treat bacterial infections, not viruses. Use the right antibiotic, at the right dose, for the right duration, only when indicated.

29. Antimicrobial Resistance (AMR): Magnitude and Strategies to Control

1. Magnitude of the problem Antimicrobial resistance (AMR) occurs when microorganisms—especially bacteria—no longer respond adequately to medicines that previously worked against them. It is a major global public-health threat because: Resistant infections cause prolonged illness, disability and death. Routine infections and previously treatable conditions can become difficult or impossible to treat. Surgery, caesarean sections, cancer chemotherapy, transplantation and intensive care depend on effective antibiotics. AMR increases hospital stay and healthcare costs. Resistant organisms can spread between patients, communities, animals and the environment. Excessive and inappropriate antibiotic use is a major driver of resistance. A landmark global analysis estimated that bacterial AMR was directly responsible for about 1.27 million deaths in 2019 and associated with about 4.95 million deaths. Major causes/drivers are Human medicine- Unnecessary antibiotics for viral infections, Self-medication and over-the-counter access, Wrong antibiotic, dose or duration. Unnecessary broad-spectrum antibiotics, Poor infection-control practices.

Animal/agricultural use: Excessive or inappropriate antimicrobial use in livestock and aquaculture. Use for growth promotion or routine prevention where not justified. Environment Pharmaceutical and hospital waste. Sewage containing resistant organisms and antimicrobial residues. Contamination of water and soil.

Strategies to control AMR

1. Rational antibiotic use — Antimicrobial Stewardship

2. Right drug + right patient + right dose + right route + right duration

3. Do not prescribe antibiotics for viral infections.

4. Use culture and susceptibility testing whenever appropriate.

5. Prefer narrow-spectrum antibiotics when the organism is known.

6. Avoid unnecessary combinations and prolonged prophylaxis.

7. Review empirical therapy when microbiology results become available.

8. Establish hospital antibiotic-stewardship programmes.

9. Prevent infection by Hand hygiene, Vaccination, Safe water, sanitation, Proper food hygiene, Appropriate isolation of infectious patients, Sterilisation and disinfection, Infection-prevention programmes in hospitals.

10. Surveillance: Monitor Antibiotic consumption identify Resistance patterns, detect Hospital/community outbreaks, identify Emerging multidrug-resistant organisms, Use surveillance data to develop and regularly update antibiotic guidelines and antibiograms.

11. Regulation and education: Enforce prescription-only antibiotic policies, Control inappropriate pharmaceutical promotion, Educate doctors, pharmacists, nurses and students, Educate the public: "Antibiotics are not medicines for every fever." Discourage sharing or using leftover antibiotics.

12. One Health approach: Important Take Home-AMR cannot be controlled by human healthcare alone. Coordinate interventions across: Human → Animal → Food → Environment. This includes responsible antimicrobial use in veterinary practice, surveillance in animals and food production, and control of pharmaceutical/agricultural contamination.

13. Simple public-health message > PREVENT infection → DIAGNOSE correctly → PRESCRIBE only when needed → USE the right antibiotic correctly → PREVENT spread of resistant organisms → SURVEIL resistance.

14. For medical students: Remember “5 P's” — Prevent, Prescribe wisely, Practice infection control, Prevent environmental spread, and Participate in surveillance.

Video Summarising AMR

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30. Social participation in Health Care:  Organizing health promotion and education and counselling activities at individual family and community settings is the community involvement in Health care function of the Doctor. Chattisa Program of AIIMS Patna, Enlightened Empowered Citizen of BP Koirala Institute of Health Sciences Nepal, Sankat Sanket of AIIMS Patna  and Sankatmochan Nagrik of AROKA are examples of Job creation by increasing Accessibility to credible Health Care by making common people participate in Health care. This video summarises what Chattisa's with AIIMS Patna achieved.

Chattisa  named after the Common Barber helping society by 36 skills earned by online provision of credible health care from AIIMS Patna. Addon they were trained in being First Responders to Disaster and Medical Emergencies, Emergency victim Retrieval and providing lonely Elderlies with Shravan Kumar youngsters to take care of them round the clock. AIIMS Patna won the Socrates award for these activities. See this video in Chattisa's own words Computer Savvy functions connected health seekers in their vicinity to credible free health advice of AIIMS Patna, were trained as First Responders in Disaster and as Shravan Kumars for care of childless Elderlies

31. Health Programs and Program Evaluation: Being vigilant in practice of Health Care is Sentinel Surveillance which like Radars early detects health problems exceeding expected frequencies in a particular time, place and person distribution. Density or rate of increase cutoffs initiate reporting, monitoring and taking cognizance of at various levels of Health Care. At these levels decision to act becomes policy, which after approval by the competent authority goes to experts in Program development who document what is to be done by whom, with what training, when (in what situation), where, how, why, with what resource which constitute the Standard Operating Procedures and how will the program be evaluated, pilot tested, executed, monitored, optimised and publicized for use elsewhere. This is again approved by the competent authority and recurring and non recurring funds sanctioned. Monitoring and optimizing are parts of Program evaluation. They constitute identifying difference between expected and observed, determining causality, suggesting most cost effective doable methods to rectify the causality, report and get the modification implemented so that the program is now optimum and can be publicized for use elsewhere.

National Health Programmes in India can be listed as follows:

1. Communicable diseases

Programme Main focus

National Tuberculosis Elimination Programme (NTEP)     Tuberculosis

National AIDS Control Programme (NACP)     HIV/AIDS

National Vector Borne Disease Control Programme (NVBDCP)   Malaria, dengue,   chikungunya, kala-azar,   lymphatic filariasis,   Japanese encephalitis

National Leprosy Eradication Programme (NLEP)   Leprosy

Integrated Disease Surveillance Programme (IDSP)   Epidemic-   prone diseases

National Viral Hepatitis Control Programme (NVHCP) Viral hepatitis

National Rabies Control Programme (NRCP) Rabies 

National Programme for Prevention and Control of Snakebite Snakebite Envenoming

2. Non-communicable diseases

Programme     Main focus

National Programme for Prevention and Control of                    Diabetes, hypertension,     cardiovascular disease,     cancer and other NCDs

Non-Communicable Diseases (NP-NCD)     National Programme for        (NPCDCS) Earlier programme framework,       Prevention and Control of Now subsumed under NP-NCD     Cancer, Diabetes,     Cardiovascular Diseases     and Stroke