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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.
Pre and Para Clinical Phases:
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 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.
Learn Anatomical Position, Planes, Direction, Movements Test Anatomy Terminology Edit Test Anatomy Terminology
Embryology: journey From Cells to Human Beings
Cell Structure and function Nutrition and Oxygen to Energy, Secretion of waste, Multiplication and Protein Synthesis Video:
Learn Cell Structure and Function Test Cell Structure and Function Edit 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 Test Knowledge of Spermatogenesis Edit Test Spermatogenesis
Oogenesis
Learn Oogenesis Test Knowledge of Oogenesis Edit Test Oogenesis
Fertilization Zygote and Embryo
Learn the Zygote to Embryo to Fetus Journey Test Your Knowledge of Fetal Development Edit Test of Fetal Development
Pregnancy and Labour
Learn the womb to world journey
Mechanism of Labor Movement needed to come out
Test area
Test your knowledge on pregnancy and labor
Test Labor Pregnancy Knowledge
Tissues ( Collection of similar cells) Providing Movement to body
Bone
Describe composition of bone and bone marrow: Bone consists mainly of two components:
Inorganic mineral component (~60–70% of dry weight)
Mainly hydroxyapatite crystals, approximately:
Ca₁₀(PO₄)₆(OH)₂
Provides compressive strength and resistance to deformation.
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.
Test your knowledge on bone structure and function
Memorize this video on calcium metabolism
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.
Test your knowledge on Development of Bone
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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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Edit Test on Laws of Ossification
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.
Cartilage and Joint
Describe various types of cartilage with its structure & distribution in body:
Cartilage - Joint movement and Growth in Length of Bones
For integration with Orthope dics You may go to
Orthopedics Page Of this Telemedical Education Site
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.
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
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.
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.
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.
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.
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
Test your Knowledge on Muscle Contraction and Sacromere Syn
Edit Test on Muscle Contraction
Nerves making muscle Contract
Learn how nerves make muscles contract
Test your Knowledge of Nerve Function
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:
Test your knowledge on Skin and Dermatomes
Fascia
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.
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.
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.
Circulation- Blood, Lymph and CSF:
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.
Test your Knowledge on Heart Diseases
Clinical Approach To Mitral Stenosis
Mitral Stenosis 8th Semester Lecture
Nitric Oxide Vaso Dilation for Tissue Anoxia
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.
Test your knowledge on Arterial Pulse
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.
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.
Oxygen Transport: High Concentration in Alveoli 99 % of O2 carriage is by 4 O2 molecules binding to 1 Hb 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.
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.
Edit Test Vascular Response to Anoxia
Test Vascular Response to Anoxia
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.
Edit Test on Blood Carriage of CO2
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.
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
Test Your Knowledge on Type I Hypersensitivity
Edit Test on Type I Hypersensitivity
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.
Test Hypersensitivity Knowledge
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.
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.
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.
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
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.
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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Lymphatic Drainage Lymph nodes and spleen
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
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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Describe structure of lymph capillaries & mechanism of lymph circulation Described
Explain the concept of lymphoedema and spread of tumors via lymphatics and venous system
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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.
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.
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
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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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.
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.
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.
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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Transcript for the video.
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.
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.
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.
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
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.
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
Dissociative disorders — when dissociation is the predominant feature.
Somatic Symptom Disorder — when excessive thoughts, anxiety, or behavior related to physical symptoms are prominent.
Autonomic, Endocrine functions, Synapses, Neuro humeral Transmission, Nerve conduction.
List components of nervous tissue and their functions
Describe parts of a neuron and classify them based on number of neurites, size & function
Describe structure of a typical spinal nerve
Describe principles of sensory and motor innervation of muscles
Describe concept of loss of innervation of a muscle with its applied anatomy
Describe various type of synapse
Describe differences between sympathetic and spinal ganglia
Bones joints movement and movers
Identify the given bone, its side, important features & keep it in anatomical position
Identify & describe joints formed by the given bone
Enumerate peculiarities of clavicle
Features of individual bones (Upper Limb)
Demonstrate important muscle attachment on the given bone
Regional
Upper Limb
Which Bones forming which joints provide for which movements General features and attachments
Identify and name various bones in articulated hand, Specify the parts of metacarpals and phalanges and enumerate the peculiarities of pisiform
Describe scaphoid fracture and explain the anatomical basis of avascular necrosis
Breast: Describe the location, extent, deep relations, structure, age changes, blood supply, lymphatic drainage of breast in relation to carcinoma breast, microanatomy and applied anatomy of breast, development of breast
Axilla: boundaries and contents
Axillary artery & vein
Brachial plexus Erb’s palsy and Klumpke’s paralysis
Lymphatic drainage of Breast Quadrant Wise - Staging of Breast Cancer
Muscles moving the Pectoral Girdle: Name Elevators, Depressors, Protractors, Retractors, Internal and External Rotators their Origin Insertion nerve supply action. Understand the biomechanics of the action
Describe the arterial anastomosis around the scapula and mention the boundaries of triangle of auscultation Describe and identify the deltoid and rotator cuff muscles
Muscles Moving The shoulder
Describe and demonstrate shoulder joint for– type, articular surfaces, capsule, synovial membrane, ligaments, relations, movements, blood supply, nerve supply and applied anatomy
Explain anatomical basis of Injury to axillary nerve during intramuscular injections
Muscles moving the Elbow Origin insertion nerve supply action Testing
Muscles moving the Radio ulnar joints Origin insertion nerve supply action Testing
Muscles moving the Radiocarpal Joints Origin insertion nerve supply action Passage under Retinaculum changing direction of pull - Example EPL and Brevis Testing
Muscles moving the Intercarpal Joints Origin insertion nerve supply action Testing
Muscles moving the Carpometacarpal Joints Origin insertion nerve supply action - Details of Opponens, Testing
Muscles moving the MP Joints Origin insertion nerve supply action Testing
Muscles moving the PIP/DIP Joints Origin insertion nerve supply action Testing
Muscles special to the thumb and little finger Origin insertion nerve supply action Testing
Nerves of upper limb Course Branches Testing Substitution if Paralyzed where are they entrapped
Blood Supply of upper limb Course Branches Testing Management if Compromised. where can they be entrapped and may need decompression
Lower Limb
Gait Normal Abnormal and How achieved
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
Pelvis Osteology - Borders, Inside, Outside
Inner Pelvis and exit of Urine, baby and feces
Movers of Pelvis : Mechanisms of Pelvic Tilt, Pelvic inclination, Pelvic Rotation there compensation if deficient
Movers of Hip : Flexors, extensors, adductors, abductors, Internal rotators, external rotators. How Trendelenburg sign and gait, How Ilio-psaos is an internal rotator in TB stage II but External Rotator in Fracture Neck of Femur.
Anatomy of surgical approaches to the hip
Soft Tissue Contracture Release around hip
Movers of Knee: Locking, Unlocking and compensation when locking fails, contracture release, approach to injured knee
Movers of Ankle: Planter and Dorsiflexion: Contracture and Paralysis, Recognition and management
Movers of Sub taloid Joint Inversion and Eversion
Movers of Mid tarsal Joint: Cavus and Planus
Movers of MP and PIP/DIP Complex
Ischemia in Lower limb Causes RESTED Decompression in Traumatic vascular insufficiency
Nerve involvement in Lower Limb Paralysis, Sensation loss Recognition and remedy
Varicose Veins
Thrombosis
Lymphedema in Lower Limbs
Orthopedic Integration Fractures, Dislocations, Contractures, paralysis, deformity and deficiency in lower limb, Arches of Foot - Planus and Cavus, Anatomy of Congenital Talipes Equino Varus
Thorax Inlet, Outlet, Wall, movement in Respiration
Contents Lung and Pleura how of Ventilation Perfusion Diffusion
Gaseous Exchange in Blood
Cellular Respiration
Conditions involving Respiration
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
Mediastinum Esophagus Tracheo-esophageal fistula Achalasia cardia Dysphagia
Paravertebral region
Tracheo-esophageal fistula ,Killian's Diverticulum Achalasia Cardia
Abdomen
Posterior Abdominal Wall
Lateral and Anterior wall Hernia Types and Anatomy
Peritoneum
Approach to Kidney and Psoas abscess
Viscera
Kidney and suprarenal
Duodenum and pancreas
Stomach stomach bed pseudo pancreatic cyst
Liver Gall Bladder Biliary drainage: Cirrhosis, faliure, hepatitis,
Colon
Urinary Bladder:
Urinary Bladder Placement and Anatomy
Uterus Vagina and Ovaries
Scrotum
Rectum and Anal canal
Perineum and Pelvis
Head and Neck
Skull how it houses the Brain, Orbit, Ears, Nose and paranasal sinuses,
Mouth, Tongue, Teeth, Tonsils, Cheek,
Temporal and Infra temporal region, Salivary glands, Mastication, Temporo-mandibular joint dislocation and ankylosis
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
Ear Hearing and Balance Petrous Temporal Bone
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
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
Lymphatic Drainage of Head and Neck - Cystic Hygroma
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
Histology of various Tissues
Reproduction: Male and female genitilia, oogenesis and spermatogenesis, fertilization, embryology of development, Normal and Abnormal mechanisms of Labour. Assessing problems antenatally, Examining a new born child for congenital anomalies and other potential problems , prematurity, asphyxia, jaundice
Immune System: Deficiency, Hypersensitivity, Transplant immunology
Gastro intestinal system: Ingestion, mastication, deglutition, Action in stomach, Bile, Pancreatic juice, absorption, fecal excretion, pathologies of GIT
Metabolic Diseases - Diabetes, Calcium Metabolism, Kidney Liver funtion and failure, Nutrition Deficiency and excess
Toxicology
Adverse Drug Reactions and interactions
Epidemiology and Research
Ethics
Communication and commitment
Security and Prudence
Community Medicine and Public Health
Define health The Health Model, Transition rates, monitoring and controlling them
Cause Effect Etiological factor - Disease (Agent, host and environmental), Prognostic factor- Outcome, Intervention - Result. establishing Cause effect relation and using it in Adverse outcome control.
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.
Planning interventions
Public Participation in interventions: Health promotion and Education, Monitoring Knowledge Attitude and Practice change to assess learning-change in KAP
Demographic profile of India and discuss its impact on health
Effective Communication skills in health in a simulated environment
Demonstrate the important aspects of the doctor patient relationship in a simulated environment
Socio Cultural interventions:
Clinico-socio-cultural and demographic assessment of the individual, family and community S SH Y Lecture. Developing comprehensive, precise and valid data collection instruments on factors under study. Using those instruments on representative sample. Analyzing data to determine cost effective risk free group of interventions to change harmful clinico-socio-cultural behavior at policy program and practice levels.
List common socio-cultural factors affecting health.
Family types there role in staying healthy, getting diseased and response to the disease and interventions.
Barriers to good health and health seeking behavior
Poverty and resilience in response to disease. Planning social security measures and its relationship to health and disease
Health hazards: Air, water, noise, radiation and pollution
Safe Water: sanitary sources of water, water purification processes, water quality standards, concepts of water conservation and rainwater harvesting Water borne diseases /jaundice/hepatitis/ diarrheal diseases
Pollution Prevention: Solid waste, human excreta and sewage disposal
Housing How housing affects health
Vectors Borne diseases. National Vector Borne disease Control Program
Identify and describe the identifying features and life cycles of vectors of Public Health importance
Describe the mode of action, application cycle of commonly used insecticides and rodenticides
Describe various methods of health education with their advantages and limitations for vector control
Social participation in Health Care: Organizing health promotion and education and counselling activities at individual family and community settings
Program Evaluation
Health Promotion and Education: Importance, methods, comparison
Nutrition: Assessment of individuals, families and the community, Identifying nutrition deficiency and preventing strategy - Supplementation, early detection and management.
What is needed. Which food it is found. How cooked, how much, how many times, what else sunlight, air water food adulteration/ pollution free to stay healthy. Nutrition deficiency related health disorders (including macro-PEM, Micro-iron, Zn, iodine, Vit. A), their control and management
Plan and recommend a suitable diet for the individuals and families based on local availability of foods and economic status, etc.
Describe the methods of nutritional surveillance, principles of nutritional education and rehabilitation in the context of sociocultural factors.
Enumerate and discuss the National Nutrition Policy, important national nutritional Programs including the Integrated Child Development Services Scheme (ICDS)
Describe food hygiene
Describe and discuss the importance and methods of food fortification and effects of additives and adulteration
Research Statistics and Epidemiology
Formulate a research question for a study
Data is Collection of Variables. Variable Types. Central tendency and dispersion, frequency distribution, magnitude and significance of difference, choosing tests of significance, Introduction to computerized analysis of data
Data Collection: Source study and target Populations, Sample, sampling techniques, sample size, statistic and parameter, point and interval estimates, confidence intervals, magnitude and significance of difference, confidence interval and p value.
Define Epidemiology Distribution and determinants of event of interest. Health model to describe possible events of interest, Transition Rates. Time distribution, place and person distribution of EOI, Determinants of EOI - Cause effect studies. What of interest is happening, when, where, how, why and then what.
Prevention and control of communicable and noncommunicable diseases
Burden of Disease concept of DALY -Disability Adjusted life years lost, Cost to save 1 DALY as measure of cost effectiveness of any preventive or curative strategy
Study designs
Diagnostic Tests When specificity when sensitivity, tests in series tests in parallel, deciding cutoffs
Response to Epidemic and endemics
Causality studies, Cause effect association, sources of error in universe-Confounding and Study design - selection and measurement bias, contamination, cointervention, cross over, inadequate follow-up time, all outcomes not measured, loss, measurement errors, analysis errors, inadequate dissemination
-Describe and demonstrate the application of computers in epidemiology
Designing at policy level what investigation to be available at what level of health care to maximize sensitivity and specificity, prevent overuse, duplication for communicable diseases and noncommunicable diseases - diabetes, Hypertension, Stroke, obesity and cancer etc.
Enumerate and describe disease specific National Health Programs.
Describe the principles and enumerate the measures to control a disease epidemic
Describe and discuss the principles of planning, implementing and evaluating control measures for disease at community level bearing in mind the public health importance of the disease
Educate and train health workers in disease surveillance, control, treatment and health education
Information systems
Demography, Demographic cycle, Vital statistics
Define, calculate and interpret demographic indices including birth rate, death rate, fertility rates
Enumerate and describe the causes of declining sex ratio and its social and health implications
Population explosion and population dynamics of India.
Describe the methods of population control Contraception
National Population Policy
Census, SRS, NFHS, NSSO
Reproductive, maternal, newborn and Child Health
Enumerate and describe the methods of screening high risk groups and common health problems like high risk pregnancy
Describe local customs and practices during pregnancy, childbirth, lactation and child feeding practices
Describe the reproductive, maternal, newborn & child health (RMCH); child survival and safe motherhood interventions
Describe Universal Immunization Program; Integrated Management of Neonatal and Childhood Illness (IMNCI) and other existing Programs.
Enumerate and describe various family planning methods, their advantages and shortcomings
Adolescent Health
Gender Issues and Women Empowerment
Family welfare program
Occupational Health: Ergonomics to prevent occupational health hazards (OHH), Time place and person distribution of OHH, Management at Policy, Program and Practice level
Geriatric Health: Problems, prevention (fall in bathroom and osteoporosis osteoarthritis), early detection and management, epidemiological burden Time place and person distribution
Hospital Waste Management: Laws, Types, collecting, transporting and disposal methods to be followed. Inspections, early detection and management of errors
Mental Health: Problems, early detection and management, epidemiological burden Time place and person distribution. plan of care
Health Management: Policy, Plan, Program levels, monitoring optimizing executing for most benefit at least cost and risk. Reaching out to problem dense areas. Examples of successful health management programs.
Pharmacology: Drug, discovery, testing by trial, Safe drug list, demand supply, Insuring optimal drug distribution right drug, right place, right quantity right time, Pharmacovigilance - Monitoring, detecting, managing and Preventing adverse drug reactions or interactions.
Health care Community Level: Define and describe concept, community diagnosis, primary health care components and principles. Educate about health care, primary health care, its components and principles, National policies related to health and health planning and millennium development goals, Describe health care delivery in India.National policies related to health and health planning and millennium development goals. Heath care delivery in India - SWOT analysis.
Recent in community medicine: Public Health events in 5 years, Outbreaks and lessons from their management, important success or failure in health care effort its SWOT analysis. Compare Indian response with other country responses
Clinical Phase
Approach to the Patient: Should be able to:
Collect, record and fluently present a comprehensive, precise and valid data of the patient (identity and demography) and his health problems, chronologically arranged since he was alright. While doing this he should understand what anatomical site in his body is suffering from what (congenital, traumatic, inflammatory (immune, infective or infestive) pathology, neoplastic, degenerative, metabolic, paralytic, genetic or developmental or other nature of disease and how the pathology has advanced till date-pathogenesis. Complete the history by asking relevant, rule in or rule out information, for the specific primary possibility and its secondary effects or other possibilities in decreasing order of probability, Clinical Diagnosis and Differential Diagnosis. Then he should be able to Perform comprehensive, precise and valid elicitation of physical signs (Examination), relevant to the problems being suspected. He should Demonstrate the ability to interpret this bed side clinical data to arrive at a Clinical diagnosis and differential diagnosis and demonstrate the ability to defend these. Next he should suggest rationale and relevant investigations (Imaging, biochemistry, immunology, microbiology, pathology, electrodiagnosis) and demonstrate the ability to read and interpret them correctly to arrive at a final diagnosis describing the site, nature, cause, effect and association of the pathology Next he should be able to suggest - Cost-effective safe and logically doable treatment and explain the prognosis to the relatives of the patient showing compassion, credibility, ethics and competence. This he should be able to do for common diagnosis in medicine listed below.
Additionally expectations from him are:
Legal and Forensic Component: All patient related activity constitutes Practice of Medicine and should always be performed keeping patients interest uppermost with his informed consent for every decision related to him. Deviation from this ethical practice is Malpractice which should be avoided and the legal knowledge of defending against challenge of malpractice should be acquired by the budding doctor. Incase of criminal activities in society he should be able to assist the courts in arriving at a correct decision.
Public Health Component: With his knowledge of community medicine he should be able to lead the community towards Healthy mind, body and spirit for all, towards the goal of सर्वे भवन्तु सुखिनाः सर्वे संतु निरामयः। सर्वे भद्राणि पश्यंतु । मा कश्चिद दुःख भा भवेत्।
Pharmacology Component: He should be fully aware of all therapeutic, side and toxic effects of drugs he prescribes including their pharmacokinetics and interactions. Same is required for all the operations, interventions, implants or devices he prescribes. He should do only the doable with the skill and infrastructure he has and should have the skill and attitude of appropriate reference with full information in patients . interest.
Create and Use Research Based Evidence: He should be a good user and producer of Research and should be able to keep updated and advise decisions in an Evidence based manner. If he doesn't know he should find out and decide by consultation or appraisal of Literature. Reference to literature in solving real problems is a great way to keep learning. He should be able to use all sources of information in decision making including computers and Artificial intelligence.
Patient Expectation: ABCDE - Availability/accessibility/punctuality: Behavior inspiring confidence in patient that he will get Tender Loving Care, Egoless Competence, Dexterity and Empathy should become intrinsic parts of his Persona. Patients and community are his life long examiners.
Prehospital care and Disaster Management: He should be able to lead and train the community in pre hospital first response in time critical medical emergencies and disaster.
From Doctor to a Teacher: Incase he chooses to teach he should acquire the skills of a good teacher, who teaches by example, besides being an effective communicator of knowledge and mere emulation of whom can make a great doctor.
Administrative Management Business Financial Component: In positions of building, leading, institutions, policy or programs this Knowledge Attitude and skill is important
Skills of History taking, Examination, Discussing Diagnosis and Differential diagnosis, Investigating ( Image, biochemistry, microbiology, immunology, hematology, pathology or electrodiagnostic investigations), Treating, Handling the social economic environment about following common diagnosis in Health care practices.
REFERENCE AREA FOR CLINICIANS
AI Generated RMP modified Prescription Data on Real Patients
List of common Diagnosis to be mastered
MEDICINE AND SURGERY
Central Nervous System
Medicine and Allied: Higher Functions: Neuro-humeral Transmission in Brain defects - Schitzophrenia, Parkinsonism, Maniac Depressive Psychosis, Depression, Anxiety, Mental Retardation, Cerebral Palsy Congenital - Asphyxia Neonatorum, APGAR Score, Cerebral palsy, Icterus Neonatorum, Inflammatory Tubercular Meningitis, Encephalitis, Brain Abscess-Septicemia SABE, Disseminated Sclerosis, Epilepsy, Coma, Stroke, Parkinsonism, Chorea Athetosis, Ataxia., vertigo, blackout, UMN paralysis, Cranial nerves anatomy, supply testing and involvement. Trigeminal Neuralgia Spinal Cord: By level - Brown sequard syndrome, quadriplegia, paraplegia.-Acute, chronic spastic flaccid - Acute Spastic - T's Compression - Trauma, Tuberculosis, Thrombosis - Meningovascular Syphilis, Transverse Myelitis, Acute Flaccid- P's Polio, Porphyria, Polyneuritis (GB Syndrome),Organo-phosphrus poisoning-Irreversible Choline Esterase Inhibitor, Treatment -Atropine DAM MINA oximes Acute, chronic, recurrent Spastic Flaccid Mixed - Spinal Shock, Syringomyelia, Motor neuron Disease Chronic Spastic - Lathyrism, Syringomyelia (Dissociate Anesthesia) Chronic Flaccid Spinal cord- Tumours, Roots Disc prolapse, Spondylolisthesis, Nerves: Injury, entrapment, Mononeuritis,mononeuritis multiplex - Leprosy, polyneuritis- Diabetes, Myoneural junction: Myaesthenia Gravis, Muscle- Muscular Dystrophy. Other - Recurring Remitting - Epilepsy, Vascular- Hemorrhage and Thrombosis, Disseminated Sclerosis, Hysteria. Coma, Stroke, Parkinsonism, Chorea Athetosis, Ataxia, vertigo, Blackout- Transient Ischemic Attack (TIA). Cranial nerves anatomy, supply testing and involvement. Trigeminal Neuralgia. Special Senses and function: Smell, Taste, Vision, Audition, Speech, Cognition,
Sleep wakefulness - Consciousness, intelligence, memory, appropriate behaviour, Known mechanisms of abnormal behavior
Locomotion and balance: Cerebellum, Extrapyramidal System, Vestibular, Tectal, Position, tone, rate of change inputs
Autonomous Nervous System: Sympathetic and Parasympathetic: Salivation, Lacrimation, Cardiac function, GIT secretions and motility, Micturition and Neurogenic Bladder
Surgery and Allied Central Nervous System : Congenital - Hydrocephalous, Traumatic - Head injury, nerve Injury, Inflammatory Neoplastic - Intracranial space occupying lesions- Infective and Tumours UMN paralysis, Spinal Cord: Compression - Trauma, Tumour, Tuberculosis, Disc, Spondylolisthesis.
Autonomic Nervous System: Pheochromocytoma
Medicine Pediatrics Allied
Medicine Pediatrics Allied: Cardiovascular System: Congenital, Rheumatic, Infective SABE , Amyloid involvement. Cardiac Layer wise- Pericardium Pericarditis, Pericardial effusion, Cardiac Tamponade, Myocardium: Ischemia, Cardiomyopathy: Endocardium: Mitral, Tricuspid, Pulmonary, Aortic valve - Stenosis and Regurgitation, Right/Left Shunts - ASD, VSD, PDA Fallot's Tetralogy. Great Vessels - Aortic Aneurysm, Coarctation of the Aorta. Arteries: Injury, RESTED - Raynaud's, Embolic, Senile, Thromboangiitis Obliterans, Ergot Alkaloid Poisoning, Diabetes. Hypertension, Atherosclerosis. Aneurysm, Polyarteritis Nodosa, Migraine. Veins: Varicose veins, AV fistula.
Surgery and allied Cardiovascular System: Valve stenosis and regurgitation: Management, Shunt closure- ASD, VSD, PDA, Coronary Circulation Restoration, Bypass, angioplasty. Removal of compression - Reduced end diastolic Volume- Constrictive Pericarditis, Cardiac Tamponed. Arteries: Ischemia: Stenting, Decompression, Bypass, Resection and reverse venous grafting for aneurysms, spastic thrombosed segments, arteriovenous fistulas, Sympathetic Blockade cervical (Horners Syndrome) and Lumber. Gangrene, Amputation and Rehabilitation
Medicine: Respiratory System: Pulmonary Component Ventilation: 1. Passages - Nose, sinuses, lacrimal duct Nasopharynx, eustachian tube and middle era, Oropharynx Tonsils, Larynx, Trachea, Bronchus - Obstruction Up o Trachea- Outside pressure - Thyroid Malignancy +/- Radiotherapy, Wall pathology - Type I hypersensitivity inflammation edema spasm, infection-Diphtheria, polyp, Lumen - foreign body, fluid, pulmonary edema, aspiration- (aspiration in new born - Tracheoesophageal fistula. 2. Movements - Paralysis quadriplegia, Costovertebral ankylosis- Ankylosing Spondylitis, Double fracture rib - Paradoxical Chest movements, Intrapleural space occupying lesion (IPSOL) - Transudate/exudate - Effusion, Blood- Hemothorax, Pus - Empyema thoracis. Diffusion - Alveoli: Congenitally absence of surfactant - fail to dilate at birth in premature - Asphyxia Neonatorum, Fluid - Pulmonary edema - Left ventricular failure, Distension - Emphysema. Perfusion: Pulmonary embolism, Fat embolism, Pulmonary Arterial spasm - Covid infection, Pulmonary Hypertension, periarterial fibrosis - Cor-pulmonale. Blood Carriage- Anemia, Shock, Carbon mono oxide poisoning. Cellular faliure - Acute - Cyanide Poisoning, Chronic - Deficient Glucose binding in Diabetes.
Surgery: Respiratory System: Thyroid, Thoracic Inlet Syndrome- Prevertebral Abscess. Double fracture rib stabilization, Managing Intrapleural space occupying lesion, Pneumonectomy
Surgery and Allied Gastro Intestinal System: Mouth Teeth - Congenital- Cleft Lip, Cleft Palate, Tongue Tie, Traumatic - Tongue/cheek Bite, Inflammatory - Ulcer, Glossitis infective, allergic nutritional, Neoplastic Pre cancerous and cancerous pathology of mucosa. Tonsillitis, peritonsillar abscess. Temporomandibular joint - Dislocation, ankylosis, Maxilla - Sinusitis, Burkitts Lymphoma, Carcinoma maxillary antrum. Mandible - Phossy jaw, osteomyelitis, Dental Cyst, Dentigerous Cyst Admantinoma, Giant cell Tumour.
Esophagus: Tracheoesophageal fistula, Kilian's diverticulum, Achalasia cardia, stricture, varices
Abdominal wall: Hernia : Inguinal, umblical, diaphragmatic femoral and pelvic, D/D inguinoscrotal swellings
Scrotal swellings- Possibilities detection and treatment
Passage upto stomach Esophagus - Dysphagia- External pressure- Killians Diverticulum, Thyroid, Left atrium in Mitral stenosis, In the wall- Achalasia Cardia, Corrosive Stricture, Carcinoma. Varices - Hematemesis.
Stomach- Hiatal Hernia, Pyloric Stenosis, Gastric Reflux Disease, Acid Peptic Disease, Gastric vs Duodenal ulcer, Indolent ulcer causes - Gastrin from Delta cells of Islet of Langerhans, Zollinger Ellisons Syndrome, Helicobacter Pylori Infection. Gastritis - absence of Castle factor for B12 absorption and lack of acidity decreasing calcium and protein absorption. Duodenum: Bleeding ulcer, Ampulla of Vater obstruction by stone causing obstructive jaundice and pancreatitis, pseudo pancreatic cyst. Abdominal Tuberculosis - Intestinal TB - Obstruction, peritoneal TB, lymphnode TB, Intussusception, Meckel's Diverticulum. Volvulus Colon: Amebic Tephelitis, Carcinoma cecum-colon, Appendicitis, Ulcerative Colitis, Polyposis, Congenital Megacolon, Sigmoid Volvulus, Benign malignant pathology of Rectum, Prolapse Rectum, Imperforate anus, Anal canal: Pile, fissure, fistula, Perianal abscess.
Liver Portal Hypertension - Esophageal Varices- Splenectomy and Lieno Renal Shunt, Resection and transplant
Gall Bladder- Cholecystitis/Lithiasis, Empyema Gall Bladder, Carcinoma gall Bladder Obstructive jaundice, Bile duct stenting and bypass by Cholecysto jegenostomy
Pancreas: Pancreatitis, Ampulla of vater obstruction, Pseudo pancreatic cyst, Carcinoma Head of Pancreas, Pancreatico duodenectomy for Ca Head of Pancreas and Pancreatico jegenostomy- Whipplle's operation for ampulla of vater obstruction.
Medicine and Allied Gastrointestinal Tract: Paralytic- Difficult Mastication, Deglutition. Salivary Gland - Stones, bacterial and viral infections, benign and malignant tumors jejunum: Calcium Metabolism and Absorptive Rickets, Ileum - Regional Ileitis, Crohns Disease
Hepato Biliary System: Hepatitis - Viral, Amebic, Amebic Liver Abscess, jaundice, Liver function, Liver failure, Cirrhosis liver. Hepatic Toxicity.
Pancreas: Pancreatic deficiency, Adenoma of pancreas/ parathyroid both or one, Pancreas in digestion, malabsorption syndromes, Pancreas Endocrine function.
Protein Calorie Malnutrition
Specific Nutritional Deficiency: Vitamin- A, B (1, 6,12), C, D, E. Iron, Zn, Calcium, Magnesium
Kidney: Surgery and Allied Congenital - Polycystic Kidney, Horse Shoe Kidney, Absence, Unascended, Neoplastic Wilms Tumour, Renal carcinoma, Urinary Bladder: Retention: Neurogenic, Obstructive - Stone, prostate, stricture, Hematuria, Congenital: Urachal cyst, ectopia vesicae, Epispadias, hypospadias.
Kidney Medicine and Allied: Immunocomplex mediated - Brights Disease Type I and II Glomerulonephritis - Acute Renal faliure, Nephrotic and End stage Chronic renal failure stages, Nephrotic Large white kidney - Diabetes- Amyloid. Bacterial Pyelonephritis and UTI, Effects: Renal Hypertension, Renal faliure, Anemia and Renal rickets.
Reticuloendothelial System, Bone Marrow, spleen and Lymph nodes: Cell related - RBC - Anemia, Polycythemia, WBC- Leucopenia, Leucocytosis, Leukemia, Lymphoma, Spleen Enlargement cause- Blood congestive : RHF and Portal Hypertension, Reticuloendothelial infection - Malaria, SABE, Typhoid, Leukemia, Lymphoma, Myeloma, Leukemia, Lymphoma, Myeloma,
Bleeding and coagulation defects: Coagulopathy, Purpuras-Thrombo - cytopenic, aesthenic, vascular - scurvy
Immune System: Immune Deficiency, Hypersensitivity - I, II, III, IV types
Metabolic: Diabetes, Metabolic Syndrome, Gout and pseudo-gout , Calcium Metabolism - Rickets Osteomalacia, osteoporosis
Degenerative: Osteoarthritis, Disc Degenerative Disease, Alzheimer's Disease, Osteoporosis, Muscle Wasting
Paralytic: Hemiplegia, Paraplegia, quadriplegia, Monoplegia, nerve involvement, cerebellar, extrapyramidal and cerebellar system associated weakness in locomotion
Vascular: Ischemia RESTED and trauma, varicose veins, atherosclerosis, angiomas. polyarteritis nodosa,aneurysms and arteriovenous fistula.
Lymphatic: Lymphadenopathy - Localised, Generalised, Lymphedema
Presentations Acitis, Hepatosplenomegay, anasarca, pleral effusion
Orthopedics: Congenital- CTEV, Congenital Dislocation Hip, Limb deficiency states, Traumatic- Head, vertebral, Spinal Cord, Chest, Abdomen, Upper Limb, Lower Limb, Eye, Ear, Nerve, vascular, Infective: Osteomyelitis, Septic Arthritis, Tuberculosis, leprosy, Immune: Rheumatoid Arthritis, Ankylosing Spondylitis with variants, Neoplasms: Benign- Osteoma, chondroma, osteochondroma, fibroma, cysts, Malignant - Primary- Giant Cell Tumor, (Osteo, Chondro, Fibro and Ewing's sarcomas and Mulitple myeloma), Secondries from Thyroid, Breast, Lung, suprarenal, Kidney and prostate, Degenerative: Disc Degenerative Disease, Osteoarthritis, Osteoporosis; Metabolic: Calcium metabolism, Rickets Osteomalacia osteoporosis, Gout Pseudo Gout; Paralytic: Cerebral Palsy, Para/quadri/mono-plegia/pareisis, - Potts and Traumatic, Nerve injury, Leprosy, Diabetic insensate Foot Others: Disability: Cause, Reduction by physio, occupational, vocational, socio-medical therapies, orthotics and prosthetics and or surgery and rehabilitation with residual disability.
Ophthalmology: Lids: Ptosis, Proptosis, Orbital space occupying lesions, abscess, malignancy, carcinoma and Burkitt's Lymphoma of maxillary antrum, exophthalmos, Blepharitis. Inability to close Leprosy paralysis of orbicularis occulli - Exposure Keratitis, opacity, Treat by facial nerve medical surgical decompression, Temporalis transfer to orbicularis oculi Conjunctiva: Conjunctivitis, Pterygium, Lacrimal Apparatus: Tears deficiency- Paralysis of secretomotor supply; Nasolacrimal duct obstruction, Dacrocystitis; Cornea: Ulcer, Keratitis, Opacity; Anterior Chamber: Canal of Schlem- Glaucoma - Primary and Secondary, Iris and Uvea: Uveitis, iridocyclitis, synechia; Pupil: Meiosis, mydriasis, unequal Hutchinson's Pupil, Pupillary Reflex Problem - Argyll Robertson's Pupil (Edinger Westphal Nucleus in Tabes Dorsalis, Lens: Refractory Errors - Myopia, Hypermetropia, Astigmatism, Cataract. Vitreous: Hemorrhage, Retina: Retinopathy, Retinal Detachment, Central Retinal Artery Thrombosis. Optic Nerve: Optic Neuritis, injury compression, stretch, Optic Chiasma: Pressure by Pituitary Adenoma, Optic Cortex: Middle Cerebral Artery Thrombosis, mechanism of Macular Sparing. Binocular vision: Squint and Amblyopia
ENT: Ear: Deafness: Air and Bone Conduction, causes, investigation, treatment including hearing aids, External ear otitis, injury, fungal Infection wax; Tympanic Membrane : Perforation; Middle Ear: Eustachian Catarrh, Acute/ Chronic Suppurative Otitis media. Spreads to. Link with middle ear anatomy. Vestibular system balance and vertigo. Link with Cerebellum and Ataxia. Fascial and vestibulocochlear nerves, blood supply and drainage of inner ear. Nose: Congenital Cleft palate, deviated septum, Mucosal allergy, fungal infection, bleeding, Sinusitis, Polyp, Nasopharyngeal - Tumor, Mouth: Tonsillitis, Glossitis, ulcer, injury, precancerous, carcinoma, tobaco. Larynx: Laryngitis, Paralysis, Cancer.
Obstetrics: Male and female reproductive system - Infertility, Embryology and implantation - detection of fetal risk and abnormality, Antenatal evaluation and care, Prematurity, Antepartum Hemorrhage, Eclampsia, Rh incompatibility, Labor normal and abnormal mechanisms, Caesarian section when and how, Examining a neonate and managing asphyxia neonatorum and neonatal jaundice, Post partum hemorrhage, post partum care. Family Planning.
Gynecology: Anatomy and physiology of male and female reproductive system, Pathology: Congenital, Traumatic, Inflammatory Fungal infections, Neoplastic Adenoma, Polyp, Carcinoma cervix, Layers of Uterus Endometrioma, Endometriosis; Fibroid Uterus, Tubo-ovarian mass, ovarian cyst, carcinoma, Menstrual irregularities: Amenorrhea, Dysmenorrhea, Menorrhagia. Prolapse Uterus
Pediatrics: Development, Examining a Neonate for prematurity, congenital anomalies detection and management and managing conditions like Neonatal jaundice and Asphyxia Neonatorum. Mastery of Nervous, cardiovascular, respiratory, gastrointestinal, hepato biliary, Excretory, blood, metabolism as for medicine. Understanding monitoring growth and development. Fluid electrolyte nutrition IV alimentation in a child.
Dermatology: Impetigo, Herpes zoster & herpes simplex, Leprosy, Psoriasis, Atopic dermatitis, Contact dermatitis, Urticaria, Vitiligo, Alopecia areata, Lichen planus, Pemphigus vulgaris, Bullous pemphigoid, Stevens–Johnson syndrome / TEN, Alopecia areata → Mpox
Psychiatry: Bipolar I disorder, Bipolar II disorder, Persistent depressive disorder/dysthymia, Cyclothymic disorder, Premenstrual dysphoric disorder, Disruptive mood dysregulation disorder, Obsessive-Compulsive Disorder (OCD), Body Dysmorphic Disorder, Hoarding Disorder, Trichotillomania, Excoriation/Skin-picking disorder, Somatic Symptom & Related Disorders, Somatic Symptom Disorder, Illness Anxiety Disorder, Conversion Disorder / Functional Neurological Symptom Disorder, Factitious Disorder, Malingering, (not a psychiatric disorder)