1

FCPS-I
N O T E S
(Chapter-wise Tanveer Notes)

Arranged by:

DR. AHMAD RAZA

MO, THQ Hospital Daska
E-mail: kemcolian205@gmail.com

DR. IRFAN M IKRAM

MO, THQ Hospital Daska
E-mail: irfanikram@live.com
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1. ANATOMY
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UPPER LIMB

▌Bones & Joints:

1st bone to ossify=Clavicle
MC fractured bone in body=Clavicle
MC# in hand=Scaphoid
MC# in leg=Tibia
MC# face=Nasal bone
MC site of fracture clavicle=Junction of middle third and lateral third
Weight of UL transmitted to axial skeleton through=Clavicle
Greater part of weight of UL transmitted to clavicle through=Coraco-
clavicular ligament
Tip of scapula at the level of=T7 [Inferior angle of scapula marks the level of
Rib7 and spine of T7.]
Inferior angle of scapula ossification center appears at=15Y & fuse with rest of
scapula at=20Y
#Surgical neck humerus damages to=Axillary nerve
#Midshaft humerus=Radial nerve injury
#Shaft humerus=Profunda brachii artery damage
Nerves affected by #Humerus=ARM
Axillary nerve=#Surgical neck
Radial nerve=#Midshaft humerus
Median nerve=Supracondylar#
Head of humerus supplied by=Anterior humeral circumflex artery
Main supply of humeral head=Arcuate artery [Arcuate artery is terminal
branch of ascending branch of anterior humeral circumflex artery.]
Nerve injured in anterior dislocation of shoulder=Axillary nerve
A child had a blow at elbow, elbow joint is displaced and there is loss of
sensation over little finger, structure involved=Ulnar collateral ligament
XR Elbow of 12Y girl. Which 2˚ ossification center will appear last on
XR=Lateral epicondyle
Age of ossification in pediatric elbow=CRITOL
Capitellum=1Y; Radial head=3Y; Internal/medial epicondyle=5Y;
Trochlea=7Y; Outer/lateral epicondyle=9Y; oLecranon=11Y
#Scaphoid=Radial artery injury
#Hamate=Ulnar nerve& artery injury
Dislocation of lunate=Median nerve injury (Acute CTS)
1st CMC joint=Synovial saddle joint [rest of 4 CMC joints are synovial plane
joints.]

▌Muscles & Innervation:

Supraspinatus=Does not rotate humerus [Abduction of arm at shoulder joint]
Downward displacement of glenohumeral joint by following muscles
except=Latissimus dorsi
Pt. unable to abduct till 30˚, muscle responsible is=Supraspinatus
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Nutshell:
Supraspinatus Suprascapular Nerve Abduction 0˚-15˚
Deltoid Axillary Nerve Abduction 15˚-100˚
Trapezius Accessory Nerve Abduction >90˚
Serratus Anterior Long Thoracic Nerve Abduction >100˚
Regarding biceps brachii=arises from supraglenoid tubercle
Cause of extension of elbow while picking up stone from ground=Active
lengthening of flexors
Claw hand is produced by unopposed action of=Extensor digitorum and
flexor digitorum profundus
Attachment of 1st lumbrical=Extensor expansion of proximal phalanx [RJ
Last]
1 lumbrical=attached to radial side of index finger [Arises from
st

anterolateral/radial side of the tendon of flexor digitorum profundus to

index finger.]
Nerve supply to extensor of arm=Posterior cord
Nerve supply to latissimus dorsi=Thoraco-dorsal nerve
Nerve supply rhomboids=Dorsal scapular nerve
Dorsal scapular nerve supplies=Levator scapulae
Muscle causes flexion of elbow joint but supplied by radial
nerve=Brachioradialis
Flexor of arm but supplied by radial nerve=Brachioradialis
Flexor carpi ulnaris=Ulnar nerve
Flexor carpi ulnaris=Ulnar&Radial nerves
Pronator quadratus has same innervation as=Flexor pollicis longus
Nerve supply of extensor digiti minimi=Deep radial nerve [All extensors of
hand supplied by deep branch of radial nerve.]
Root value of biceps jerk=C6
Achilles reflex=S1, S2 (“buckle my shoe”)
Patellar reflex=L3, L4 (“kick the door”)
Biceps & brachioradialis reflexes=C5, C6 (“pickup sticks”)
Triceps reflex=C7, C8 (“lay them straight”)
Upper brachial palsy=Erb Duchenne palsy=Waiter’s tip hand (C5-6)—
Shoulder=Adducted; Arm=medially rotated; Elbow=Extended; loss of
sensation on lateral aspect of UL
Lower brachial palsy=Klumpke’s Paralysis (C8, T1)—Claw hand (ulnar
nerve); Ape hand (median nerve); Loss of sensation medial aspect of UL &
medial 1.5 fingers
2Y old child with medially rotated arm, lesion=Upper trunk
Crutch palsy=Posterior cord
Medial side of arm is supplied by=Medial cord
In RTA, injury to C5&C6 spinal nerves, muscle spared=Coracobrachialis
Loss of small muscles of hand=C8-T1 [if asked one, prefer T1]
Shoulder pain referred from pleura=C3,4,5 [Skin over shoulder is supplied by
supraclavicular nerve (C3,4,5); same roots as phrenic nerve. GB radiates to
right shoulder and splenic pain to left side.]
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Median nerve=Ape like hand [Loss of thenar eminence]

Ulnar nerve=Claw hand
Radial nerve=Wrist drop
Musician’s nerve=Ulnar nerve (fine movements of hand)
Laborer’s nerve=Median nerve
All movements lost in ulnar nerve injury except= Abduction of thumb
H/O trauma to UL, loss of sensation in little finger & paralysis of dorsal
interossei, lesion=Ulnar nerve
Paralysis of small muscles of hand, thenar muscles spared=Ulnar nerve
Cut on wrist in suicidal attempt, loss of adduction of fingers and
thumb=Ulnar nerve injury [Ulnar nerve & artery pass superficial to flexor
retinaculum.]
Patient lacerated ventral aspect of wrist accidentally, now facing difficulty in
adducting fingers and thumb; nerve damaged=Ulnar nerve
Ulnar nerve injury behind medial epicondyle=Loss of sensation in medial 1/3 of
palmar and dorsal aspects
Loss of abduction and adduction of fingers & adduction of thumb with intact
skin sensations. Lesion=Deep branch of ulnar nerve [Median nerve?]
No sensation in little finger with paralysis of dorsal interossei=Ulnar nerve
Wasting of thenar eminence with loss of sensation in index finger &
thumb=Median nerve
Carpal tunnel syndrome=Wasting of thenar muscles
Median nerve damaged, which action of median nerve will be
damaged=Opposition
 Flexion of thumb least affected in median nerve injury because of
dual innervation (median & ulnar nerves) of flexor pollicis longus.
 Extension not affected because extensors are innervated by radial
nerve.
 Abduction not affected because abductor pollicis longus is intact so
it compensates for paralysis of abductor pollicis brevis.
 Adduction is intact as adductor pollicis supplied by ulnar nerve.
 Opposition is lost in median nerve injury.
A patient is unable to extend MCP joints, adduct/extend thumb but
sensations are intact. Nerve damaged=Radial nerve
Cutaneous sensations lost over dorsum of thumb=Radial nerve
Finger drop with no wrist drop=Posterior interosseous nerve (Deep branch of
radial nerve)
Not seen in lower radial nerve palsy=Weakness of brachioradialis

▌Blood vessels & Lymphatics:

Axillary artery relation=Posterior to Pec minor
It is central structure of axilla, extends from outer border Rib1 to inferior
border of Teres major, posterior to Pec minor.
Pec major blood supply=Thoracoacromial artery
Dorsal scapular artery=Direct branch of subclavian artery
Subscapular artery=Direct branch of axillary artery
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Ulnar artery=Superficial palmar arterial arch

Radial artery=Deep palmar arterial arch
Superficial palmar arterial arch=immediately below palmar aponeurosis
Cephalic vein=in the roof of cubital fossa
Regarding cephalic vein=lies between deltoid and pec major muscles
Subclavian vein joins brachiocephalic vein to form SVC=Behind sternal head of
clavicle

▌Female Breast:
Breast=Mammary gland+Fibrous fatty tissue+nerves,vessels&lymphatics
Mammary gland=modified sweat gland, located in superficial fatty fascia
between skin and deep layer of superficial fascia; 15-20lobes
Breast lobes are separated by=Interlobular stroma [Prefer Fibrous septa]
Breast lobes open via a lactiferous duct onto=Tip of nipple
A woman who nursed her baby for 1Y. Now has quit BF. Type of change occur
in her breast tissue=Lobular hyperplasia
Lateral quadrant including nipple=Anterior axillary (pectoral) LNs
Medial quadrant=Internal thoracic/parasternal LNs
Nipple=Anterior axillary LNs
Tail of spence=Posterior axillary LNs
MC site for ca. breast=Upper outer quadrant
Regarding lymph drainage of breast except=Inferior phrenic LNs

▌Regions:
Axillary sheath derived from=Prevertebral layer of deep cervical fascia
Axillary fascia=Floor of axilla
Cubital fossa contents=Lateral to medial— Radial nerve and its deep branch,
Biceps tendon, Brachial artery and bifurcation into radial and ulnar arteries,
Median nerve (“Ronnie Beats Bad Men”)
Man cuts his wrists, structure damaged passing superficially=Ulnar nerve &
artery
Anatomic snuffbox: triangular skin depression bounded medially by tendon of
extensor pollicis longus muscle and laterally by tendons of extensor pollicis
brevis & abductor pollicis longus muscles.
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LOWER LIMB

▌Bones & Joints:

Structure passing through greater sciatic foramen except=OI tendon
Stab wound in gluteal region, structure damaged above piriformis=Superior
gluteal nerve
Iliac crest highest point lies at=L4
Weight bearing line in pelvis passes through=Ischial tuberosity
Regarding sciatic nerve=Present between greater trochanter and ischial
tuberosity.
#Pelvis, pt. is in shock=Blood loss
1˚ ossification center in long bone epiphysis at the time of birth=lower end
femur
Lesser trochanter gives insertion to=Iliopsoas tendon
MC # bone in >60Y=Femoral neck
Complication of trochanteric#=Pulmonary embolism
Head of femur supplied by=Retinacular arteries [if not in options, then mark:
medial femoral circumflex artery]
Main arterial supply of femoral head in adults=Medial femoral circumflex
artery
 Femoral head in adults=Femoral artery→Deep femoral artery→Medial
femoral circumflex artery→Retinacular artries (3-4 in no.)
 Femoral head in children=Obturator artery→Artery of ligamentum
capitis femoris/Foveolar artery
 Femoral neck in both children & adults=Medial femoral circumflex
arteries
#Fibular neck=Foot drop
Fibular neck# results in damage to: common peroneal nerve, anterior
tibial artery
Head of talus articulates with=Navicular
Bone with no muscular attachment=Talus
Lateral longitudinal arch formed by=Cuboid
Sacro-iliac joint=Plane synovial joint
Hip joint has=OE tendon inferiorly
MC hip dislocation=Posterior dislocation (90%)
Posterior hip dislocation damages=Sciatic nerve
A pt. present w/h/o RTA & dislocation of hip, which of the following muscle
groups are involved=Gluteus maximus, medius & minimus
Largest and most complicated joint of body=Knee joint
Prevent posterior displacement of femur on tibia/forward sliding of tibia on
femur=ACL
Ligament that prevents anterior displacement of femur on tibia=PCL
Unlocking of knee joint=Popliteus muscle
Locking of knee joint=Medial rotation of femur
Inversion/eversion at=Intertarsal joint (Talocalcaneal, Transverse tarsal joint)
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Overinversion of ankle=Rupture of Anterior TaloFibular ligament [“Always

Tear First”—MC ankle sprain overall]
Structure damaged d/t excessive eversion of foot=Rupture of deltoid ligament

▌Regions:
Femoral artery in relation to femoral vein below inguinal ligament=lateral
[NAVeL: lateral to medial—femoral Nerve, femoral Artery, femoral Vein,
Lymphatics in canal]
A needle when inserted 2cm below and lateral to pubic tubercle will closely
related to=Obturator nerve
Most lateral structure in femoral triangle=Femoral nerve
Most lateral structure in femoral sheath=Artery
Femoral sheath surrounds femoral vessels and lymphatics. [NOT NERVE]
Adductor canal lateral wall formed by=Vastus medialis
Popliteal nerve in relation to vessels in popliteal fossa=Posterior
True regarding flexor hallucis longus=Tendon can be felt immediately
posterior to medial malleolus.

▌Muscles & Innervation:

Flexor of both hip and knee=Sartorius
Hip Joint Knee Joint Muscle
Flexion Flexion Sartorius
Flexion Extension Rectus femoris
Extension Flexion Semitendinosus
Extension Weak flexion Biceps femoris
Adductor muscle & hamstring muscles nerve supply=Tibial nerve
Gracilis nerve supply=Obturator nerve
Adductor brevis nerve supply=Anterior br. of Obturator nerve
Inversion of foot=Tibialis posterior
Eversion of foot=Peroneus longus
Loss of inversion but eversion intact=Tibialis anterior and posterior
Insertion of flexor hallucis longus=base of distal phalanx of big toe
Adductor magnus hamstring portion nevre supply=Tibial nerve
A k/c ca. rectum develops pain in posterior aspect of thigh. Which nerve
supplies posterior aspect of thigh that can be involved in malignancy of
rectum=Sacral nerve
Nerve supply of Sartorius=Femoral nerve
Pendular knee jerk, cause=UMNL (cerebellum)
Nerve supply to plantar surface of foot=Tibial nerve
Ventral surface of foot supplied by=Medial plantar nerve
Femoral nerve root value=L2, L3, L4
Knee jerk=L4
Tapping patellar tendon causes=Contraction of QF
S1 nerve root lesion=Loss of ankle jerk
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Sciatic nerve is damaged and dorsal surface of foot sensations intact, nerve
supply=Saphenous nerve [answer by excluding other 3 options viz sural
nerve, tibial nerve and common peroneal nerve]
Lateral foot dermatome=S1
Medial foot dermatome=L4
Foot drop=Common peroneal nerve
Dorsiflexion affected=Common peroneal nerve
Tibial nerve is severed muscle that still flex knee jont=Short head BF

▌Blood Vessels & Lymphatics:

Femoral pulsation=Midinguinal point
Anterior tibial syndrome, artery involved=Anterior tibial artery
Claudication leg=popliteal artery
In some children, dorsalis pedis artery is missing congenitally, then dorsum of
foot will be supplied by=Peroneal artery
Saphenous nerve=Terminal br. of femoral nerve
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THORAX

▌Thoracic Wall, Blood Vessels, Nerves, Lymphatics

Sternum ossification=21Y
Scalene tubercle is feature of=Rib01
Subclavian artery groove=Rib01
Scalene anterior insertion=Inner border Rib01
Phrenic nerve=Anterior to scalene anterior**
Common site of rib#=Angle
1st costochondral joint=Synchondrosis (All costochondral joints are
synchondroses)
Cervical rib attached to transverse process of cervical vertebra will
compress=T1
True about cervical rib=Compress brachial plexus and Subclavian vessels
Transverse diameter of thorax is increased by=External IC muscle during
inspiration
External IC muscle and anterior interchondral fibers of internal IC
muscle=Elevation of ribs; Nutshell:External IC muscle>>Internal IC muscle
Needle inserted at 5th ICS on left side of sternum pierces=Intercostal muscle
Penetrating injury in left 4th ICS just lateral to sternum will damage which of
the following structure first=Intercostal membrane
Penetrating injury just lateral to sternum will damage which of the following
structure first? 4th ICS=Intercostal membrane; 5th ICS=Intercostal muscle
Descending thoracic aorta=Supplies pericardium, esophagus and bronchus
Both sides of 5th posterior ICS supplied by=Thoracic aorta
Most posterior intercostal arteries are br. of=Thoracic aorta
Veins of thorax drains into=Azygous vein [Azygous vein is first tributary of
SVC.]
Costocervical trunk=2nd part of Subclavian artery
Deep cervical artery br. of=Costocervical trunk
True about thoracic duct=Drains at confluence of left Subclavian and left
jugular veins
Thoracic duct=has valves
Thoracic duct does not receive lymph from=Right ½ of body
Neurovascular bundle present=Lower border of ribs
Neurovascular bundle in chest wall=Between internal and innermost ICM
Intercostobrachial nerve=2nd intercostal sensory

▌Thoracic cavity, Mediastinum, Esophagus

Structure entering thoracic inlet=Aorta
Pretracheal infection spreads to=Anterior mediastinum
Thymus=Superior mediastinum
Thymus extend=Thyroid to T4
No lymph nodules=Thymus
Present in posterior mediastinum=Descending thoracic aorta
Mass in anterior mediastinum=Thymoma
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Mass in posterior mediastinum=Neurogenic tumor

Esophagus narrowest at=Cricopharyngeus
Esophageal constriction=When crosses aortic arch
Esophageal aneurysm=LA
Compression of esophagus by which organ enlargement=LA
Compression effect on esophagus by enlargement of=LA
Esophagus passes through=Left crus of diaphragm with sling of fibers from
right crus [RJ Last]
Left vagus=anterior to esophagus
Right vagus=posterior to esophagus
Middle 1/3 esophagus supplied by=Descending thoracic aorta
Arterial Supply:
Upper 1/3=Inferior thyroid artery (ITA)
Middle 1/3=Descending thoracic aorta
Lower 1/3=Left gastric and left inferior phrenic arteries
Lymphatic drainage:
Upper 1/3=Deep cervical LNs
Middle 1/3=Superior & posterior mediastinal LNs
Lower 1/3=Left gastric & celiac LNs

▌Heart and Great Vessels:

Apex of heart=9cm from median plane
Apex beat=Left 5th ICS 8cm from midline
Anterior/costosternal surface of heart formed by=RV
Right border of heart is formed by=RA
Right border of heart on CXR=SVC
Conducting system of heart=Subendocardium
Coronary arteries=Subepicardial connective tissue
Regarding SA node=automatically generates impulses
Situation of SA node=Upper portion of sulcus terminalis
Auscultation of tricuspid valve best head at=Right lower end of body of
sternum
Regarding heart sounds=Audible on area of heart valves more precisely
Coronary arteries=always run in respective AV septal depressions
RCA obstruction after giving marginal artery affects=AV node
Infarction of posterior 1/3 IV septum, artery involved=RCA [Anterior 2/3
supplied by LAD, br. of LCA]
Inferior wall MI, artery involved=Right marginal artery
ST elevation in V4, artery involved=LAD
Anterior wall MI=LAD
If LCX is blocked, which area will be affected=Posterior surface of LV
LCX lesion, area affected=LA+LV
LCA occlusion=Infarction of LA & LV
Vessel lying close to LAD, prone to injury during surgery=Great cardiac vein
Great cardiac vein begins at apex of heart and ascend along with IV
branch of LCA.
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Middle cardiac vein begins at apex of heart and ascend posterior IV

groove accompanying PDA of RCA.
Small cardiac vein runs along right margin of heart in company with
marginal artery.
Coronary sinus continuation of=Great cardiac vein
Pain pathway in angina pectoris with pain in left shoulder radiating to
sternum and pit of stomach=Middle and inferior cervical cardiac nerves
Chest pain not related to respiration and fever=Myocardium
Sharp chest pain ↑ with respiration, relieved with sitting up and leaning
forward=Pericarditis
Female with fever for >10Ds, chest pain that aggravates on lying down. Pain is
originated at=Pericardium
A woman presents w/c/o chest pain, O/E she is found to have pericarditis
with pericardial effusion. Pain is mediated b y=Phrenic nerve
Visceral serous pericardium=Epicardium
Epicardium supplied by=Pericardiophrenic artery
Parietal layer of pericardium=Phrenic nerve
Fibrous pericardium and mediastinal pleura supplied by=Phrenic nerve
Fibrous pericardium=Phrenic nerve
Visceral pericardium=Vagus nerve
NB: Left vagus nerve takes part in formation of cardiac plexus.
Cardiac plexus contains=Both SANS & PANS fibers
Dilatation of aortic arch will compress=Left main bronchus
Nerve loops around aortic arch=left RLN
Aortic arch aneurysm=Injury to Left RLN
Aortic aneurysm, which structure is not compressed=Phrenic nerve
No valves=SVC

▌Trachea, Bronchi, Lungs:

Regarding trachea=begins at lower end of cricoid cartilage (C6)
Length of trachea in adults=11.25cm
Length of right main bronchus=2.5cm
Length of left main bronchus=5cm
Length of trachea in neonate=4cm
Narrowest part in pediatric airway=Cricoid
During tracheostomy, most probable cause of bleeding=Inferior thyroid vein
During tracheostomy, increased bleeding is d/t=Anterior jugular vein
On right side of trachea what is present?=Right vagus nerve
Right main bronchus=runs under arch of azygous vein
Left main bronchus=runs inferior to arch of aorta, anterior to esophagus
Left main bronchus crossed superiorly by aortic arch over its proximal part
and by left pulmonary artery over its distal part.
No of divisions of lower airway=21
Pancoast tumor=Superior pulmonary sulcus tumor
Oblique fissure of lung is at level=
Left lung—tip of spinous process of T3, projects anteriorly to 5th ICS, ends
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medially deep to 6th costal cartilage.

Right lung—posterior origin is lower eg T4, rest course is same
Horizontal fissure=follows curvature of Rib4, ending medially at 4th costal
cartilage
Upper most structure in hilum of left lung=Pulmonary artery
Which lobe of lung is supplied by eparterial bronchus=Right superior lobe
Correct about bronchopulmonary segments=Aerated by tertiary bronchi
FB inhaled, in which of the following lobes it will lodge=Right inferior lobar
bronchus
Because right main bronchus is wider and more direct continuation of
trachea, FB tends to enter right instead of left bronchus. From there, they
usually pass into middle/lower loba bronchi.
In standing position FB loadges in=Posterobasal segment Right lower lobe
MC site for aspiration=Superior segment, Right lower lobe
Aspiration sites:
Supine position Superior segment, Right lower lobe
Standing/Sitting upright Posterobasal segment, Right lower lobe
Right sided position 1.Posterior segment, Right upper lobe
2.Right middle lobe
Resonance of lungs can be auscultated from the back till=Rib8
Hyperresonance mostly heard at=Right MCL T2-T4 [At this region, there is
only lung tissue, below this is liver and to the left is heart.]
Pneumothorax=lung collapses inward and chest wall outward
Epithelium of preterminal bronchiole=Pseudostratified ciliated columnar
epithelium with goblet cells in larger bronchioles
Mucus not secreted=Terminal bronchiole
Goblet cells absent=Terminal bronchiole
Goblet cells replaced by Clara cells=Terminal bronchiole
About veins of thorax=Pulmonary vein lies anterior to pulmonary artery
Pulmonary artery supply to=Alveoli
Bronchial arteries supply=bronchi, non-respiratory connective tissue, visceral
pleura
Right bronchial artery is branch of=3rd posterior IC artery
Phrenic nerve runs on left side with=Pericardiophrenic artery
Bronchopulmonary segments:
-10 on each side
-Have own arterial supply
-Vein is shared between two adjacent segments
-Functional unit
Hemoptysis, embolization of right lung=Posterolateral aspect of aorta
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ABDOMEN, PERINEUM, PELVIS

▌Abdominal wall & Pelvic wall:

Transpyloric plane located at=Lower border L1 [If not mentioned, click upper
border L2]
Inguinal canal roof formed by=Internal oblique & transverse abdominis
Inguinal canal roof=Conjoint tendon
Does not form layer of inguinal canal=Rectus abdominis
Deep inguinal ring is result of deficiency of=Transversalis fascia
Approximation of falx inguinalis and conjoint tendon to inguinal
ligament=Posterior wall is strengthened
External oblique digitations with=Serratus anterior
Arcuate line=Free lower border of posterior wall of rectus sheath
Between umbilicus and pubis, posteriorly lower limit of rectus sheath
is=Arcuate line
Regarding tendinous intersections of rectus sheath=Upper most located near
xiphoid process [one at the level of xiphoid process, one at the level of
umbilicus and one halfway between these two.]
Direct inguinal hernia=Medial to inferior epigastric artery in Hasselbach
triangle
Abdominal content push through processus vaginalis=Indirect inguinal hernia
A 1Y has scrotal swelling, it is d/t=Peritoneal fluid accumulation via persistent
processus vaginalis
50Y lady w/h/o TAH 6M back now presents with incisional hernia. Structure
in lump likely to push=Transversalis fascia
Incisional hernia, first structure from within outward=Fascia transversalis
H/O appendectomy, now she develops irregular mass at the site of
incision=Incisional hernia
Suprapubic incision, artery injured in suprapubic fat is=Inferior epigastric
artery
Artery damaged at McBurney’s point during appendectomy=Deep circumflex
iliac artery
Grid iron incision:
Artery likely to be damaged=Deep circumflex iliac artery
Structure likely to be damaged=Iliohypogastric nerve
Lateral attachment of urogenital diaphragm=Ischial tuberosity, pubic rami
Urogenital diaphragm laterally attaches=Ischiopubic rami
Inferior layer of urogenital diaphragm=Perineal membrane

▌Perineum:
Perineal body=Superficial perineal pouch
Not a content of deep perineal pouch=Root of penis
Bulbourethral gland of Cowper in males=Deep perineal pouch
Greater vestibular gland of Bartholin in females=Superficial perineal pouch
Infection in superficial perineal pouch=Greater vestibular gland
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Muscles cut in mediolateral episiotomy=Bulbospongiosus and superficial

transverse perineal muscle
Muscle damaged in difficult delivery=Levator ani muscle
A man with gonorrhea, c/o pain which structure of superficial perineal pouch
involved=Superficial perineal muscles
Medial boundary of ischiorectal fossa=EAS (External anal sphincter)
An ischiorectal abscess may involve the opposite fossa by the spread of
infection across midline behind anal canal.
Lymphatic drainage of perineal skin=Medial group of superficial inguinal
nodes

▌Diaphragm:
Pain from lower inferior segment of diaphragm=Subcostal nerve
All true about IVC except=Pierce central tendon of diaphragm at T10
Esophagus passes through=Right crus of diaphragm [RJ Last→Left crus;
Snell→Right crus; if both present, prefer Left crus.]
Structure passes through esophageal hiatus=Vagas trunk
Aneurysm of aorta at diaphragmatic haitus compresses=Azygous vein &
thoracic duct
Morgagni hernia seen in=Right anterior (aka anterior diaphragmatic hernia)
Diaphragmatic hernia occurs=absent pleuroperitoneal membrane
Diaphragmatic hernia can occur through all except=Caval hiatus

▌Bones & Joints:

AP diameter of female pelvis nearest to=115mm
Pelvic inlet, AP diameter is smaller than Transverse diameter=Gynecoid
Which of the following are boundaries of pelvic inlet=Pubic crest
Which of the following is most likely to be correct regarding lesser pelvis in
females=Outlet is bounded by ischiopubic rami and sacrotuberous ligament
Structure passing through pelvic inlet=Ureter
Lumbar vertebrae don’t give attachment to=Transversus abdominis
Sacral hiatus formation=Failure of fusion of laminae of S4&S5
Symphysis pubis=secondary cartilaginous joint

▌Blood vessels, Lymphatics and Nerves:

Superficial epigastric artery is branch of=Femoral artery
Superior epigastric artery branch of=Internal thoracic artery
Superficial external pudendal artery branch of=Femoral artery
First branch of AA=Inferior phrenic artery
Correct about AA=Renal arteries at L2
True about IVC=Starts at L5
Pregnant lady suddenly faints. She will be positioned in left lateral decubitus
not right lateral to avoid compression of=IVC
Following RTA, man c/o loss of sensation over distal scrotum, nerve unlikely
to have been damaged=Iliohypogastric nerve
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Pt. with multiple pelvic# having loss of sensation in perineal region, nerve
spared=Iliohypogastric nerve
Pudendal nerve supplies=motor part of EAS
Perineal area innervation=S2-4
Perineum and pelvis nerve supply=Pudendal nerve
Pudendal nerve does not supply=Posterior vaginal fornix
Nerve loss in urogenital triangle, nerve involved=Pudendal nerve
True about pudendal nerve=innervates muscles of perineum
Regarding levator ani muscle=supplied by pudendal nerve
Levator ani muscle=Pudendal nerve and branches from anterior rami of S3-S4
Nerve supply of urogenital triangle=Ilioinguinal nerve
Landmark for pudendal nerve block=Ischial spine
Block Stage of Labor Landmark/Site
Paracervical block 1 stage
st Base of broad ligament
Pudendal nerve 2 stage
nd Transvaginal
block (for episiotomy or procedure=Ischial spine
forceps deliver) Perineal procedure=Ischial
tuberosity

▌Peritoneum & Peritoneal Cavity:

Greater omentum=4 layers
Lesser omentum=2 layers
Lesser omentum=connects with duodenum
During surgery surgeon nicks hepatoduodenal ligament, structure likely to be
damaged=Bile duct
Structure on right side of gastroduodenal ligament=CBD
Regarding pancreas=Tail in splenorenal ligament
Structure lies within peritoneal cavity=NONE
Male peritoneal cavity=completely closed
Female peritoneal cavity=opening through uterine tubes
Most dependent part of peritoneal cavity:
Supine=Right subhepatic space
Standing=Rectovesical pouch in males, Pouch of Douglas in females
Fluid accumulations:
Acute pancreatitis, Posterior duodenal perforation=Lesser sac
Anterior duodenal perforation=Right paracolic gutter (also right posterior
subhepatic space)
Ruptured ectopic=Pouch of Douglas
Appendicitis=Subphrenic space

▌GIT & Accessory Organs:

Parietal cells=copious eosinophillic cytoplasm and central nucleus
Pt. after gastrectomy is on vitB12, cells lost in gastrectomy=Parietal cells
Fundus & LES removed=Loss of receptive relaxation
Pylorus removed=Increased gastric emptying of solids
Truncal vagotomy=decreased acid secretion & pepsin
17

Congenital pyloric stenosis=in a relative of affected infant

Site of abscess formation d/t posterior perforating ulcer of pyloric
antrum=Omental bursa (Lesser sac)
Gastric ulcer on anterior stomach wall=escape of gastric contents into greater
sac leading to peritonitis; may adhere to liver/penetrate liver substance
Gastric ulcer on posterior stomach wall=perforation into lesser sac; erosion of
pancreas/splenic artery
Anterior duodenal ulcer=Perforation
Posterior duodenal ulcer=Bleeding; Gastroduodenal artery
Anterior duodenal ulcer perforation=Right paracolic gutter [if not given then
Right posterior subphrenic space]

True about small gut=6-8m long

Intermittent pain of small intestine felt at=Umbilical region
Feathery appearance in left abdomen on Ba meal XR=Jejunum
Lymphoid tissue in submucosa=Ileum
Strongest layer of bowel=Submucosa
Meckel’s diverticulum contains=Gastric mucosa
Child with Meckel’s diverticulum presents with PR bleeing. It is d/t=Ectopic
gastric mucosa

Fat tags attached to wall of large gut=Appendices epiploceae

Reflux of cecum prevented=Ileocecal valve
MC position of appendix=Retrocecal
A pt. with pain on flexion of thigh=Pelvic appendix
A pt. presented with RIF pain, diagnosed as Acute Appendicitis. On flexing of
his right thigh inward and medially, he cries with pain. Type of
appendix=Pelvis
Newly married female presented with pain RIF, fever, vomiting. LMP 3 weeks
ago. TLC 12000. Dx=Acute Appendicitis
Young female presented with RIF pain with h/o amenorrhea for 6 weeks and
UPT (+) =Ectopic pregnancy
False about anal canal=superficial and deep parts of EAS make anal canal
Anal canal extent=Levator ani to anal orifice
Fecal incontinence after trauma, structure damaged=EAS
Following structure can be palpated on DRE in females except=UB
Ligament that holds uterus in anteverted position & can be palpated on
DRE=Uterosacral ligament

Weight of liver=1.5kg
Capsule of liver is known as=Glissons capsule
Liver bare area and surrounding ligament=Coronary ligaments
Quadrate lobe of liver receives blood from=Left hepatic artery
True about quadrate lobe of liver=drained by Left hepatic duct
Surgeon injects dye during surgery of liver=Ligamentum teres hepatis
18

Hepatic pedicle is formed by=hepatic duct, portal vein & hepatic artery
(DVA) in free margin of lesser omentum
GB mucosa=thrown into numerous circular folds
Terminal part of CBD in relation to pancreas=embedded in pancreas
Cholecystectomy drain placement=Right subhepatic space
Important surgical landmark in Calot’s triangle=Cystic artery

Pancreas related anteriorly=Lesser sac

Fluid accumulation in acute pancreatitis=Lesser sac
Uncinate process of pancreas is posterior to=SMA
If celiac trunk is compressed=Pancreas is spared form ischemia [also supplied
by SMA]

Splenectomy, vessels present in which ligament=Splenorenal ligament

A pt. brought to ER following RTA. O/E he was pale with low BP and #left
10th rib. Organ most likely to be injured=Spleen

Blood supply of foregut=Celiac trunk

Esophagectomy done, stomach mobilized to upper portion of thorax to
anastomose with pharynx. Which artery supplies stomach now=Right
gastroepiploic artery [if not in options then click—Right gastric artery]
Ulcer of 1st part of duodenum, which artery you will ligate=Gastroduodenal
artery
Gastroduodenal artery is branch of=Right hepatic artery
Left gastroepiploic artery branch of=Splenic artery
Ischemia of SMA=duodenojejunal junction to 2/3 of transverse colon
Abdominal angina=SMA
Middle colic artery is branch of=SMA
Regarding appendicular artery=End artery
Watershed area of colon between SMA & IMA=Splenic flexure
In portal HTN, increased pressure in=IMV
Which of the following involved in portal HTN=Esophageal vein
Middle rectal artery branch of=Internal iliac artery
Inferior rectal artery branch of=Internal pudendal artery
Anal canal supplied by=Superior and inferior rectal arteries
Proximal part of CBD supplied by=Cystic artery
GB arterial supply=Cystic artery
Gastric ulcer pain=Greater splanchnic nerve
Pain in epigastrium d/t ulcer transmitted via=Greater splanchnic nerve
Sympathetic innervation of midgut=T5-T12
PANS stimulation=Opening of intestinal sphincter
Propulsive movement of intestine affected d/t lesion of=Auerbach plexus
Myenteric system is potentiated by=ACh
Appendicitis pain radiates to umbilicus=Sympathetic T10
Nerve supply to sigmoid colon=S2,3,4
Pain of anal fissure is mediated by=Inferior rectal nerve
19

Which of the following drain into superior mesenteric nodes=Jejunum

Appendix drain into=Superior mesenteric nodes
Mucous membrane lower ½ of anal canal=Medial group of superficial inguinal
nodes

▌Urinary System:
Capsule of kidney prevent spread of infection to=other kidney
During laparotomy surgeon identifies left kidney=Anterior relations
Left kidney grossly identified from right kidney by=Arrangement of structures
in hilum
Right kidney not related to=Descending colon
Structures present anterior to left kidney=Posterior portion of lesser sac
On posterior exposure of kidneys, which of the following nerve is not liable to
injury=Lateral cutaneous nerve of thigh
LRV in relation to aorta=LRV is anterior
LRV lies posterior to=SMA
True about relation of structures in kidneys=LRV is anterior to aorta and LRA
Regarding renal column, it contains=Interlobar artery
Arteries surrounding U shaped portion of nephron of medulla=Vasa recta
Urothelium does not line=Collecting duct
Not correct regarding blood supply of kidney=Portal circulation
EPO secreted by=Mesangial cells [CPSP key]
Sources of EPO: interstitial fibroblasts in peritubular capillary bed of PCT
& perisinusoidal cells in liver

In B/L ADX surgeon did not allow resident to do surgery on right side=close
relation to IVC
Left suprarenal gland drained by=LRV
True regarding suprarenal gland=fetal gland is 1/3 of size of kidney

True about ureter=cross bifurcation of common iliac artery

Ureter not constricted in region=where it lies on psoas muscle
Narrowest point of ureter is at the level of=Ischial spine [Ureterovesicular
junction]
Common relation of ureters=Anterior to common iliac artery and posterior to
gonadal vessel**
Posterior relation of ureter=Common iliac vessels>>Genitofemoral nerve
A surgeon is operating on pt. for removal of calculus in a left ureter at the
point where it crosses pelvic brim. Which area is most appropriate for
exposure of ureter=Apex of sigmoid colon
Ureter I supplied by all except=IMA
No true about pelvic part of ureter=supplied by middle rectal artery

Vessels of base of UB present in=Dorsolateral ligament of UB

Anterior surface of UB=not covered with peritoneum
20

Suprapubic aspiration done when UB is distended because=Anterior surface

of UB not covered with peritoneum
True about UB=separated from rectum by Denonvillier fascia
Base of UB formed by=Posterior surface
In females neck UB is located=Rests on upper surface of urogenital diaphragm
In males neck UB lies on upper surface of prostate
True regarding UB=supplied by anterior division of internal iliac artery
Superior vesical artery supplie=Vas deferens
Venous drainage of UB=Internal iliac vein
Sympathetic nerves L1-L2 travel to UB via=Inferior hypogastric plexus
Neck UB and proximal urethra supplied by=Sympathetic L1-L2 via inferior
hypogastric plexus
L1-2 terminate at=Inferior hypogastric plexus
Highest no of α-receptors present=Proximal urethra [followed by prostatic
urethra]
Micturition=self-generative
Micturition controlled by=mechanoreceptors in bladder wall
Lesion above sacral segments of SC [UMNL]=
Spinal shock phase=Atonic bladder and/or awareness of bladder fullness
After spinal shock=Spastic/Automatic bladder
Lesion of sacral segments [LMNL]=Atonic bladder
If clear-cut scenario not given=Neurogenic bladder

Widest and most dilatable=Prostatic urethra

Narrow and fixed=Membranous urethra
Shortest=Membranous urethra
Narrowest part=External urethral meatus
Most dependent part=Bulbar urethra
Extravasation of urine following rupture of urethra:
Membranous Urethra=Deep perineal pouch [MUD]
Bulbar Urethra=Superficial perineal pouch [BUS]
Penile Urethra=Superficial perineal pouch [PUS]

▌Male Reproductive System:

Prostate=Pseudostratified Columnar Epithelium (Glandular epithelium)
Largest lobe=lateral lobe
Largest zone=peripheral zone
Middle lobe≈Central zone & Transitional zone=BPH (TZ)
Posterior lobe≈Peripheral zone=Ca. prostate (contains glandular tissue)
Spread of ca. prostate:
via vertebral venous plexus>>bony mets
via prostatic venous plexus>>heart & lungs mets
NB: Prostatic and vertebral venous plexuses are valveless.
Ca. prostate spread to skull bones via=Vertebral venous plexus
Not true regarding vas deferens=separated from base of UB by peritoneum
Sperm stored in=Epididymis [not in seminal vesicles.]
21

Right testicular vein enters=IVC

Epispadias, meatal opening=Dorsal surface of penile shaft
Hypospadias=Ventral surface
During tapping of hydrocele, not pierced by needle=Tunica albuginea
Ejaculatory ducts open in=Prostatic urethra
Lymphatic drainage of testes=Paraortic LNs [at the level of L1]
Dorsal vein of penis drains into=Greater splanchnic vein
Ductus deferens ends in=Ejaculatory ducts
Epididymis drains into=Ductus deferens
Intratesticular temp. less than rectal temp.=1-2˚C
Epididymis supplied by=Testicular artery

▌Female Reproductive System:

LN that does not receive lymphatic drainage of Cx?=Deep inguinal LNs
Labia majora LN=Medial group Superficial Inguinal LNs
Ca. Cx, LN involved=Internal Iliac LN (Prefer—both external&internal iliac
LNs)
Ovarian pain radiating to medial side of thigh d/t nearby presence
of=Obturator nerve
Pain of ovarian tumor referred to thigh=Obturator nerve
Obturator nerve=skin of medial side of thigh
Also pelvic appendix>>appendicitis>>via obturator nerve to medial side of
Right thigh
During C-section a structure is damaged, now patient c/o cramps in lumbar
region=Ureter
Water (ureter) runs under the bridge (uterine artery).
In females uterine artery runs above and anterior to ureter in the base of
broad ligament.
Vulva nerve supply=Ilioinguinal nerve
Anterior portion=1.Ilioinguinal nerve 2.Genital br. of genitofemoral nerve
Posterior portion=1.Pudendal nerve 2.Posterior femoral curtaneous nerve
Regarding hymen=stratified squamous epithelium
Complication of obstructed labor at station 2=VVF
Paracervical block=Base of broad ligament
Paracervical block=1st stage of labor
Pudendal nerve block=2nd stage of labor
Basal vacuolation=Early secretory phase (D16)
Tubular glands=Follicular phase
Coiled glands=Secretory phase
Saw tooth appearance=late secretory phase
Ovary Simple Cuboidal
Fallopian tube Ciliated Columnar
Uterus Simple Columnar with glands
Endo-Cx Simple Columnar
Ecto-Cx Nonkeratinized Stratified Squamous
Whiplike movements=Fallopian tube
22

Bony landmark in child birth=Ischial spine

Approach to Pouch of Douglas=Posterior vaginal fornix
Types of Pelvis:
Female Male
Inlet Transversely oval Heart shaped
(TD>APD)
Outlet Larger Smaller (contracted)
Pelvic cavity Wider, shallower Narrower, deeper
(funnel shaped)
Pubic arch Larger Smaller
Subpubic angle Greater Lesser
Type Gynecoid Android
Types of Pelvis in women:
Type White Females Black Females
Gynecoid
41% 41%
*Typical female pelvis*
Android 33% 16%
Anthropoid 24% 41%
Platypelloid 2% 2%
100% 100%
AP dia<TD=Gynecoid pelvis
AP dia>TD=Anthropoid pelvis
Inverted ischial spine=Anthropoid pelvis
AP dia<TD=Platypelloid pelvis
Pampiniform plexus in females=Mesovarium (aka suspensory ligament of
ovary)
Pampiniform plexus in males=Spermatic cord
[Pampiniform plexus is reduced to single testicular vein at the level of deep
inguinal ring.]
Varicocele=veins of pampiniform plexus elongated/dilated
Common on left side (left testicular vein joins LRV in which venous
pressure is higher as compared to IVC)
Rapidly developing left-sided varcicele=suspected malignant disease of left
kidney
During 2nd stage of labor=Abdominal contractions are helpful
Obstetric nerve block is performed successfully and results in urinary
incontinence. The anesthetized muscle is located in=Urogenital diaphragm
[This is pudendal block & paralyzed muscle is sphincter urethrae
externus.]
During sexual act, vaginal secretions=PANS
Most fixed part of uterus=Cervix
Position of uterus maintained by=Uterosacral lig.
Principle dynamic support of uterus holding it in position=Pelvic diaphragm
23

Supports of Uterus:
PRIMARY SUPPORTS
A.Muscular/Active=Uterus
Tone of levator ani [Pelvic diaphragm=Levator ani; 3 parts of levator ani
muscle include pubococcygeus, iliococcygeus & ischiococcygeus.]
B.Fibromuscular/Mechanical=Position of Cervix
Pelvic fascia condensation>>3 ligaments:
 Transveres cervical/cardinal ligament
 Pubocervical ligament
 Uterosacral ligament
SECONDARY SUPPORTS: A.Broad ligament B.Round ligament of uterus
►Round ligament=Anterior pull=Anteflexion
►Uterosacral ligament=Posterior pull=Anteversion
Supports of Vagina:
Upper 1/3=Levator ani muscle & 3 ligaments
Middle 1/3=Urogenital diaphragm
Lower 1/3=Perineal body
Least common site for ectopic pregnancy=Ovary
Ovarian ca. first drains into=Paraaortic LNs
After 15Ds of C-section d/t obstructive labor, pt. developed urinary
incontinence. Most likely cause is=VVF
During late pregnancy, ripening of cervix is caused by=Hydration of collagen
Female with ca. cervix that spreads to labia majora via=Round ligament of
uterus [Round lig.=from superolateral part of uterus to SC tissue of labium
majus]
During hysterectomy ureter can be damaged while ligating which
artery?=Uterine artery
MC injured artery during difficult C/section=Uterine artery
Surgery for ovary damages=Internal iliac artery
A patient presented on D18 of menstrual cycle, her normal cycle is such that
she ovulates on D14. Which phase she is in=Secretory phase
Ca. vagina below hymen (vaginal orifice) likely to spread via lymphatics
into=Medial group horizontal superficial inguinal LNs
Layers of uterus shed during menstruation=Stratum functionalis [compact &
spongy layers of uterus; also shed during parturition.]
Sensory supply of uterus passes through which ligament=Broad ligament
A pelvic abscess in the rectouterine pouch can be drained through incision
made in=Posterior vaginal fornix
Late secretory phase of menstrual cycle not characterized by=Endometrial
glands with subnuclear vacuolations
Intravaginal administration of PGs initiate cervical ripening=Hydration of
collagen
Human placenta separated from uterine wall d/t=Rupture of uterine vessels
24

Testes Para-aortic LNs

Seminal vesicles, Prostate, Internal Iliac LNs
Corpus cavernosum
Scrotum Superficial inguinal LNs
Glans penis Deep inguinal LNs

Ovaries Para-aortic LNs

Fallopian tubes Para-aortic LNs, Internal Iliac LNs
Fundus Para-aortic LNs
Body External Iliac LNs
Cervix External & Internal Iliac LNs
Body/Cervix Some lymphatics follow round
ligament>>Superficial inguinal LNs
Distal Vagina & Vulva Superficial inguinal LNs
Superior part of UB External Iliac LNs
25

HEAD & NECK

▌Embryology:
Midline cleft lips=Failure of fusion between medial nasal processes
Stylopharyngeus muscle=3rd Arch
Thymus=Endoderm of 3rd Arch
A pt. w/ opening on anterior wall of SCM muscle w/ pus coming out.
Abnormality is d/t=2nd pharyngeal cleft

▌Bones, Joints, Triangles, Muscles:

Base of posterior triangle of neck=Middle 1/3 of clavicle
Infrahyoid muscle=depresses larynx
Nodding movement of head=Atlanto-occipital joint
Rt/Lt movement of head=Atlanto-axial joint
Hyoid gives attachment=middle pharyngeal constrictor muscles
Closely related to last molar tooth of lower jaw=Lingual nerve
Carotid tubercle of C6 is so called because it is related to=CCA
Parietal bone is not=Pneumatic bone
C1 vertebrae=absent vertebral body
Suboccipital nerve=Rectus capitis posterior
Inion is a landmark of=Ext. occipital prominence
C7=Longest spine
Ligament that holds odontoid process of axis on atlas=Transverse ligament
Cruciate ligament
Transverse part: attached on each side to lateral mass of atlas and binds
odontoid process to anterior arch of atlas
Vertical part: connects body of axis to anterior margin of foramen
magnum
Intraarticular disc of TMJ is involved, muscle paralysed=Lateral pterygoid
Regarding skull of children=Vault is bigger than face
Fibrous dysplasia common in=Maxilla
Floor of middle cranial fossa=Greater wing of sphenoid
True about posterior triangle of neck=contains subclavian & 3 trunks of
brachial plexus

▌Blood Vessels & Nerves:

I&D done of abscess middle of posterior triangle of neck. 5 days post-I&D pt.
cannot extend his arm above head to brush hair=Spinal accessory nerve
SCM nerve supply=Spinal accessory nerve
Regarding chorda tympani all are true except=contains postganglionic
parasympathetic fibers [chorda tympani (CN7) joins lingual nerve (CNV3)]
Chorda tympani passes through=Petrotympanic fissure
Sensory fibers from taste buds in hard&soft palate travel along=Facial nerve
In head injury, CN7 palsy is d/t=Transverse # of petrous bone [Snell/678]
Nerve approach to inferior alveolar nerve block=Lateral to pterygomandibular
raphe, between superior constrictor and buccinators muscles. [PCB]
26

B/L RLN is cut, muscle spared=Cricothyroid

RLN hooks around=Ligamentum arteriosum
TGN anesthetic block=pterygopalatine fossa [P2=Middle cranial fossa when
pterygopalatine fossa not in options.]
Damage to middle cranial fossa, no lacrimation=Greater petrosal nerve
Pain between eye and angle of mouth=CN V2
Gustatory sweating caused by=Superficial parotidectomy
Freys syndrome: flushing and sweating instead of salivation in response
to taste of food after injury of auriculotemporal nerve which carries
parasympathetic secretomotor fibers to parotid gland and sympathetic
fibers to sweat gland. When nerve is severed fibers regenerate but
innervate wrong gland. It can occur after parotid surgery. Rx=Cutting
tympanic plexus in middle ear.

Anterior ethmoidal artery is br. of=Ophthalmic artery

All are branches of cavernous part of ICA except=Ophthalmic artery
Medial br. of ECA=Ascending pharyngeal artery
Artery arise in substance of parotid gland and lies at posterior border of
digastric muscle=Ascending pharyngeal artery
Superior thyroid artery br. of=ECA
Vertical artery that runs upward in SMG=Facial artery
Branches of ECA=08
Anterior: Superior thyroid, Lingual & Facial arteries
Medial: Ascending pharyngeal artery (smallest branch)
Posterior: Occipital & posterior auricular artery
Terminal: Maxillary & superficial temporal arteries
Middle meningeal artery is br. of=Maxillary artery
Middle meningeal artery=Foramen spinosum
ACA & MCA branches of=ICA
ICA=No branch in neck
PICA is br. of=Vertebral artery
Temporal artery related to=Auriculotemporal nerve
At beginning ICA in relation to ECA=Lateral
Rolandic artery br. of=MCA
Not a blood supply of scalp=Maxillary artery
ICA bleeding stopped by compressing=C6

Not a tributary of cavernous sinus=Deep middle cerebral vein

Protrusions of arachnoid villi takes place=Superior sagittal sinus
Superior sagittal sinus pressure in standing position=−10mmHg
Regarding pituitary gland venous drainage=directly drains in dural venous
sinuses
Great cerebral vein receives vein from=Cistern of Ambiens
Vein of Galen located at=Superior cistern/Quadrigeminal cistern
Vein not draining into Great cerebral vein=Occipital vein
27

Great cerebral vein is formed by union of 2 intercerebral veins and is

associated with straight sinus.
Vein not draining into Great cerebral vein=Occipital
Cavernous sinus thrombosis=Angular vein via superior ophthalmic vein and
deep facial vein
Cavernous sinus connected to pterygoid plexus via=Emissary vein
Inferior ophthalmic vein=cavernous sinus infection
Blood vessels of scalp located in=Dense SC layer
Jugular vein related to=ICA

▌Face, Muscles of Mastication:

Masseter=Elevation of mandible
Not a muscle of mastication=Buccinator
Muscle of fright and sadness=Platysma
Closure of lips=Orbicularis oris

▌Nose:
Floor of nasal cavity formed by=Palatine bone & Maxilla
All bones contribute to formation of nasal septum except=Lacrimal bone
Maxillary sinus opens into=Middle meatus

▌Orbit:
Levator aponeurosis analogous to=capsule of palpebral fascia of lower lid

▌Ear:
Tegmen tympnani, a thin plate of bone that separates=Cranial cavity from
middle ear
Rotation of head to Rt=(+)Hair cells in crista of Rt. horizontal semicircular
canal & (−)Lt. horizontal semicircular canal

▌Trachea & Larynx:

Tracheostomy, danger of bleeding=Inferior thyroid vein
Profuse bleeding during tracheostomy=Anterior jugular vein
Ideal site for tracheostomy= Tracheal rings 2,3 (Adults); Tracheal rings3,4
(Children)

▌Mouth & Pharynx:

SMG=Facial nerve
Posteromedial to parotid gland=carotid sheath
Nodule on anterior 2/3 of tongue, lymphatic drainage=Superior group, Deep
Cx LNs
Loss of sensation posterior 1/3 tongue=CN9
Pharynx doesn’t lie deep to=Parotid gland

▌Thyroid & Parathyroid Glands:

Isthmus of thyroid lies in front of=Tracheal ring2,3,4
28

Superior and middle thyroid veins=Internal jugular vein

Inferior thyroid vein=Left brachiocephalic vein
Thyroid venous drainage=Internal jugular vein and brachiocephalic trunk
Thyroid lymphatic drainage=Deep Cx LN
Thyroid moves with deglutition because it is enclosed in=Pretracheal fascia
Superior parathyroid gland=4th Arch
Internal laryngeal nerve passes through=Thyroid and hyoid
29

2. PHYSIOLOGY
30

CELL PHYSIOLOGY

Glycocalyx contains=CHO moiety

▌Transport across Cell Membrane:

Water enters into cell through=Pores/water channels
Water enters interstitium through=Filtration
Clathrin=Receptor-mediated endocytosis/pinocytosis
Transport across cell membrane involving clathrin, actin and
myosin=Pinocytosis
Clathrin-mediated endocytosis=MC mechanism of cholesterol uptake
Osmolarity=increases with increase in no. of solute particles
Osmotic pressure depends upon=No of particles
Albumin contributes maximum to oncotic pressure because=LMW and high
concentration

▌Organelles:
Plasma membrane thickness=7.5-10nm
Contain oxidases=Peroxisome
Peroxisomes=Long chain FAs
Abnromal protein degaradation=Proteasome
Unique feature of mitochondria=DNA
Mitochondria=Maternal inheritance
↑No of mitochondria in apical part of cell=Ciliated cell
Regression of uterus and breast after pregnancy=Lysosome
On H&E stain hollow structure around nucleus=Lysosome
True about cell=cell is in euchromatic phase if it is transcriptionally active
HeteroChromatin=Highly Condensed>>transcriptionally inactive
Euchromatin=Expressed>>transcriptionally active
Main adhesion of cell=Cell-to-cell cadherins
Cytoskeleton to ECM=Integrin
Cytoskeletal structure that connects ECM to intracellular=Intermediate
filament

▌Membrane Potential, NMJ, Synapse:

RMP achieved by=Diffusion of K+ outside the cell [High resting conductance
to K+]
RMP maintained by=Outward K+ current
Depolarization is maintained by=Na+ influx
During activation of nerve cell membrane=Membrane potential reversed
RMP -65mV, on stimulation d/t Na+ influx polarity changes to +40mV
Neuron, peak of AP=Electric gradient tend to send K+ out of cell
Muscle end plate contains=AChE
Isotonic and isometric contraction difference is that isometric
contraction=consumes more phosphate bonds
Isotonic contraction: tension develops, muscle shortens and work is done eg
31

walking
Isometric contraction: No muscle shortening and no external work done eg
hand grip
Hypokalemia=Hyperpolarization
Hypocalcemia=↓Release of NT from presynaptic vesicles
Hypocalcemia=Nerve hypoexcitability
Hypocalcemia cause all except=Depressed DTRs
Sudden decrease in Sr. Ca2+=↑Excitability of muscle and nerves
Hypermagnesemia=↓ACh release (paralysis)
32

HEMATOLOGY

▌Red Blood Cells:

Hb synthesis begins=Basophil erythroblast
Hb first detected=Polychromatophil erythroblast
Max Hb production=Orthochromatic erythroblast
Normal Hb=HbA
Max Hb concentration=Reticulocyte
Blood cells able to regenerate=Growth factors
RBCs able to regenerate=EPO
Hematopoietic growth factors=(+)PHSCs
EPO=↑EPO sensitive committed stem cells in BM
Human blood=Fe mainly in Hb
Iron stored in the form of=Ferritin
Insoluble storage form of iron in iron overload=Hemosiderin
Hemorsiderosis=accumulation of hemosiderin in macrophages w/o tissue
damage
Hemochromatosis=accumulation of hemosiderin in parenchymal cells leading
to tissue damage
Organ utilizes glucose=Brain
Cell utilizes glucose=RBC
Blood group with no agglutinins=AB+
Anemia with blast cells in peripheral blood=Erythroblastosis fetalis
NB with EF; BG is B(+); Best for Mx=B(-)
Lady w/h/o cholecystectomy presents with microcytic anemia=Blood loss
Heme binds with=Haptoglobin
Pregnant lady at 3M presented with Hb:12.5gm%, later on at 9M presented
with Hb:10gm%, PBF reveals normocytic normochromic anemia.
Cause=Normal physiological change
If CF IX not available=FFP
Best substitute for CF IX=FFP
Immediate antidote to warfarin=FFP
Platelets cannot be given=Splenomegaly
Platelets contraindicated=ITP
A pt. with hypercoaguable state have=CF V Leiden
Soldier came with heavy bleeding, ideal fluid replacement will be=Whole
blood for 3Ds
Male pt. w/h/o severe hemorrhage presented in unconscious state, transfused
with 2W old blood. Blood mainly contains=RBCs
Characteristic of stored blood=↑Hemolysis
↓ESR with ↑ in=Albumin
Osmotic fragility test:
Reagent: NaCl, anticoagulant
0.9%NaCl=No hemolysis
0.5%NaCl=hemolysis starts
33

0.45%NaCl=50% hemolysis
0.3%NaCl=100% hemolysis

▌White Blood Cells:

Cells that contain sense granules and have IgE Ab on cell membrane=Basophil
MPO present in=Neutrophil
Monocyte converted into=Multinucleated giant cell

▌Platelets:
Platelet=Cytoplasmic fragmentation of megakaryocyte (1000-3000 platelets
per megakaryocyte)
Life span of platelet=8-10Ds
Life span of transfused platelets=4Ds
Distribution of platelets=Blood stream & spleen [1/3 of total platelet pool
stored in spleen]

▌Coagulation System:
First response after vessel injury=Transient vasoconstriction
Tissue factor=Extrinsic coagulation cascade
Activation of CF XIII by collagen exposure/HMWK=Intrinsic coagulation
cascade
Conversion of fibrinogen into fibrin. What will be detected in blood=Fibrino-
peptides
Factor V deficiency=Bleeding
Factor V mutation (factor V Leiden)=Thrombosis
Factor XII deficiency=Thrombosis

▌Plasma:
Plasma proteins return to normal after=2-3Ds
Plasma proteins bind with all except=O2
34

CARDIOVASCULAR SYSTEM

▌Heart:
Long refractory period=Heart
Phase of action potential that coincides with diastole=Phase04
Na+ enters in cardiac cycle during=Depolarization
Last part of heart to be depolarized=Posterior basal portion of LV, pulmonary
conus, upper most portion of septum
Pacemaker of heart=SA node
Most prominent prepotential=SA node
Slowly depolarizing prepotential=SA node
SA node has maximum negativity because=It’s membrane is leaky to Na+ ions
Initial rise in membrane potential in SA node d/t=Transient increase in Ca2+
channels
Artificial pacemaker connected to=Right ventricle
Only conducting tissue between SA node and AV node=Bundle of His
Total delay of 0.16sec from SA node to ventricles.
Initial conduction delay from SA node to AV node=0.03sec
Delay in AV node and AV bundle system=0.13sec
Effect of ↑SANS stimulation on heart=↓AV nodal delay
Stronger than normal heart may be observed during=SANS stimulation
Vagus decrease HR d/t=K+ conductance
MCC of ↑AP duration=Mild ischemia
Infarct area relative to normal myocardium=Negative
Period where heart is susceptible to fibrillation=At the end of AP
Hyperkalemia=Flaccid and dilated heart
Hypercalcemia=Spastic heart

Coronary blood flow stops=Isovolumetric contraction

Coronary BF main metabolite=Adenosine
Coronary circulation is maintained by=Local metabolites

QRS complex slightly prior to =Ventricular systole [Electrical activity before

mechanical activity.]
MCC of current of injury=Ischemia
At J point all parts of ventricle depolarize.
U wave is d/t slow repolarization of papillary muscle
Lady with ventricular rate of 40/min, most likely=Complete heart block
3˚ block, syncope d/t=Delayed and irregular ventricular contractions
Pt. on β-blocker, ↑PR interval on ECG=Drug induced heart block

S1 is low pitch/frequency, loud sound and coincides with R wave on ECG.

S2 high pitch/frequency, sharp sound and coincides with end of T wave.
S2 in comparison with S1=↑Frequency
Splitting of S2=Delayed closure of pulmonary valve
Isovolumetric contraction=S1
35

Isovolumetric relaxation=S2
Ventricular filling=S3
Atrial kick against hypertrophied ventricle=S4
Heart sound that indicates condition of myocardium=S3
S2=closure of aortic and pulmonary valves
Max aortic pressure=Slow ejection phase
Aortic pressure lowest=Isovolumetric contraction
During ↑HR=diastolic period decreased more than systolic
Starling law=explains ↑CO in response to ↑VR
According to Starling law CO can be increased by=EDV
Cardiac reserve=max % by which CO can be increased above normal [130-
140bpm]
Cardiac index=CO/Min/M2=3.2L
Max CO=After delivery
In athletes which of the following is increased at rest=SV [if not in options
then: CO]
Dye used in indicator dilution method=Cardio-green dye
CO measurement via thermodilution=Temperature changes downstream with
CO
Measurement of CO by thermodilution=inaccurate d/t respiratory changes in
PA temperature
Will cause bradycardia=Oculocardiac reflex
In a patient oculocardiac reflex stimulated causing bradycardia and
hypotension. Initial Mx=Removal of stimulus
Right ventricle pressure=10-25mmHg
Left HF=Pulmonary edema
Right HF=Peripheral edema

▌Circulation:
Difference between systemic and pulmonary circulation=Low resistance in
pulmonary circulation
Max BP dissipated=Arteriolo-capillary
Highest cross sectional area=Capillaries
Old age=↓Vascular compliance
Deep sleep=↓Peripheral vascular tone
Person standing, VR from legs mainly facilitated by=Contraction of skeletal
muscle
Return of blood during exercise=Calf muscle
During exercise, VR from legs=Muscle pump of calves
Turbulence of blood in anemia d/t=↓Viscosity
↑Blood viscosity=↑MAP
Venous pressure increases 8mmHg, what is effect on capillary pressure=No
change
Proteins that escape to tissue from blood vessels=Reabsorbed by lymphatic
system
8% blood loss via=Veins
36

Hemorrrhage after compensation=HR decreases

↓Effective circulation volume=↑Renin
BP drops from 100mmHg to 70mmHg=↓ in carotid sinus activity
Baroreceptors respond maximally to=rapidly decreasing BP
MAP (mmHg) Reflex Mechanism
70-100 Arterial baroreflex
50-70 Arterial chemoreflex
<50 CNS ischemic response
[most potent mechanism]
Most important response in shock as a whole=CNS ischemic response
↑ICP, systemic BP rises to maintain perfusion to brain, reflex known
as=Cushing reflex
System with maximum feedback gain in controlling BP=CNS ischemic
response
Infinite feedback gain=Renal-Body fluid mechanism
During exercise ↑blood supply to muscle via=Local metabolites
Exercise=↓TPR d/t skeletal muscle arteriolar dilatation
Local metabolites in skeletal muscle=↓TPR [Autoregulation by local
metabolites: brain, coronary arteries, skeletal muscle]
Reduction of BF to brain=Seizure
Result of ischemia on brain autoregulation=Ablation of autoregulation
Brain BF least affected=Exercise
AT2 is responsible for=Systemic vasoconstriction of arterioles [AT2 causes
vasoconstriction of both arterioles and venules, if both in option then prefer
arterioles.]
A young pt. with BP 150/95, ↑Sr. renin levels. Which one of the following is
stimulus for high renin=↑Sympathetic stimulation via renal nerves
Mean systemic filling pressure is regulated by=VR
Systolic BP directly related to which of the following=Renin
SAB given, there is sudden loss of sensation d/t=Loss of vasomotor tone
37

RESPIRATORY SYSTEM

▌Ventilation (V):
Quiet inspiration=Diaphragm
Quiet expiration=Elastic recoil of lungs and chest wall
Forceful inspiration=External IC muscle and accessory respiratory muscles
(SCM, SA, Scalene)
Forceful expiration=Rectus abdominis and Internal IC muscle
Lung capacity increase in inspiration=2/3 rd by diaphragm

Inspiration=decrease in negative intrapleural pressure

Injury resulting in pneumothorax=pleural pressure equal to atmospheric
pressure

Surfactant=DPPC+CHO+Proteins
Surfactant=prevent alveolar collapse
↑Concentration of surfactant in AF=Last trimester
Surfactant deficiency=↓Compliance

Normal quiet respiration:

Inspiration=Active
Expiration=Passive
Work of inspiration:
1.Compliance work/Elastic work: 65-70%
2.Airway resistance work: 23%
3.Tissue resistance work: 7%
Max site of airway resistance=Medium sized bronchi

Obstructive lung disease=RV, FRC & TLC are increased.

Volume of air remaining in lung after maximal expiration=RV
After maximal inspiration, maximum air expired=VC
↓VC=paralysis of inspiratory muscle
During pregnancy, healthy woman shows no change in respiratory
parameters. Which is most likely to occur during last trimester of
pregnancy=↓VC
In pregnancy cause of respiratory distress=↓TLC
Best pulmonary function test in Asthma=FEV1
Asthma=↓FEV1
Dead space=humidify and filter inspired air
Calculate alveolar ventilation where VT=500mL, RR=10bpm>>3500mL/min

▌Pulmonary Blood Flow (Q):

Pulmonary circulation=Low pressure, low resistance circuit
At normal conditions=VR and PBF are equal
Which of the following has direct relationship=PBF and VR
PBF is hindered by=Pulmonary embolism
38

Pulmonary vasoconstriction occurs d/t=↓Systemic PO2

Hypoxia causes vasoconstriction in pulmonary vessels.
Pulmonary artery pressure increases in=Hypoxia
Regulation of PBF=Hypoxic vasoconstriction
Distribution of BF:
Supine=Uniform throughout lungs
Standing=lowest at apex; highest in base and medium in between

▌V/Q Ratio:
Lung Zone V Q V/Q
Apex Lower (↓) Lowest (↓↓) Higher=3*
Base Higher (↑) Highest (↑↑) Lower=0.6**
*Wasted ventilation=Dead space
**Wasted perfusion=Shunt

▌Gaseous Exchange, O2 & CO2 Transport:

PO2 at sea level=80-100mmHg
PaO2 is lower than PAO2 because=it makes gradient and allows diffusion
across respiratory membrane
CO2 transported in lung through=Simple diffusion
Highest diffusion across respiratory membrane=CO2
Maximum diffusion capacity=CO2
Maximum affinity for Hb=CO
P50 in right shifted OBC=35mmHg
P50 in normal OBC=25mmHg
Changes in OBC:
Left-shifted OBC Right-shifted OBC
LOWER=LEFT ↑H+
↓H+ (↑pH) ↑PCO2,
↓PCO2 ↑Temp,
↓Temp ↑2,3-BPG—exercise, altitude,
↓2,3-BPG TH, GH, Androgens
Others: Fetal Hb, MetHb,
CO poisoning, Haldane
effect in lungs, stored blood
Right shifted OBC=Acidosis
Bohr Effect=Right shift
Haldane Effect=Left shift
D/t inspiration what decreases=Volume of arterial pulse
In which of the following vein, venous PO2 and PCO2 appropriate with
arterial blood=Vein of dorsum of warm hand
O2 level in blood are decreased in=Hypoxic hypoxia
CO poisoning, MetHb & anemia don’t result in hyperapnea because=PaO2
remains normal
PaO2 normal, SaO2 decreased=CO poisoning
Left shifted OBC=CO poisoning
39

CN poisoning=Inactivation of cytochrome oxidase

▌Control of Breathing:
Regarding pneumotaxic center which is true=(-) Inspiration
Inspiratory neuron=Apneustic center
Activity of central chemoreceptors is stimulated by=↑PCO2
Central chemoreceptors sensitive to=Change in pH of surrounding CSF
In hypoxemia respiratory center stimulated through=carotid body
Stimulatory effect of ↑H+ in arterial blood on the respiratory center is
through=Peripheral chemoreceptors in carotid bodies [H+ cannot cross BBB
but CO2 can cross that’s why CO2 has effect on both central and peripheral
chemoreceptors.]

▌Miscellaneous:
Brain BF regulated by=PCO2
A pt. with h/o head injury developed cerebral edema; cause of ↑RR is=↑ICP
In hypoxic vasoconstriction which of the following is decreased=PaO2
Blood leaving placenta has PO2=30%
↓PaO2, ↑PaCO2, ↑H+=Hypoventilation
↓PaO2 in blood=Hypoventilation
Pt. with PO2 of 69mmHg, pH of 7.4, PCO2 40mmHg=Living in high altitude
A person in high altitude, O2 delivery to tissues in maintained by=↑Hb conc.
Apnea=Rise in PCO2
Rise in PCO2 in awake apneic > anesthetized apneic
In awake apneic humans
First 10sec: 7mmHg (43mmHg/min)
Next 10sec: 2mmHg (13mmHg/min)
Thereafter: 6mmHg/min
Anesthetized with airway obstruction: 12mmHg in first minute then 3-
4mmHg/min
Acidosis, hyperventilation=Salicylate poisoning
Pt. exposed to hyperbaric O2=Spontaneous pneumothorax
40

GIT PHYSIOLOGY

▌Basic Principles: Structure, Neural & Hormonal Control:

Mass movement affected in colon d/t problem in=Auerbach plexus
Muscularis externa=Myenteric (Auerbach) plexus=controls Motility
Submocosal=Submocosal (Meissner’s) plexus=Secretions/blood flow
Prolong use results in persistent increase in gastrin secretion=PPI
Gastric acid stimulation by=Gastrin
Stomach antrum removed, what happen=↓Gastrin
G cells present in gastric antrum
If fundus is removed=↓Compliance as receptive relaxation is function of orad
region
Secretin=(+) Pancreatic HCO3- secretion
Gastrin secretion inhibited by=Somatostatin

▌GIT Motility:
Regarding primary peristalsis=begins when bolus enters esophagus
A very fat boy was eating burger, a large bolus stuck after eating. What will
happen next=2˚ peristalsis generated by intrinsic nervous system to remove
it
Regarding peristalsis=Contraction of smooth muscle behind food bolus
NB/infants tend to defecate immediately after they eat because of=Gastrocolic
reflex
After feeding baby. diarrhea develops=Gastrocolic reflex
Defecation occurs d/t=Mass movement
Most important component in act of defecation=Rectoanal reflex [RAIR
(RectoAnal Inhibitory Reflex)—involuntary IAS relaxation in response to
rectal distention]

▌GI Secretions:
Intrinsic factor secreted from=Fundus
High HCl=Pepsinogen converted into pepsin
Which enzyme released from small intestine=Enterokinase [Only enzyme
released by small gut.]
α2-macroglobulin inhibits=Trypsin

▌Digestion and Absorption:

Specific dynamic response is=Digestion
Fe absorption is adversely affected by all except=Ingestion with citrus fruits
Maximum absorption of water=Jejunum
Maximum absorption of water and electrolytes=Colon [Jejunum?]
Bile salts reabsorbed=Ileum

▌Miscellaneous:
Pt. with small gut removed few weeks ago shows increased gastric motility
with diarrhea; cause=Osmotic plus secretory
41

Adult with h/o jejunostomy and iliectomy, presents with diarrhea, O/E 15-
20BS/Min. The most likely cause of this decrease transit time in intestine is
d/t=Secretory plus osmotic
Diarrhea corrected after fasting, most likely type of diarrhea=Osmotic
Vitamin produced by intestinal bacteria=Vitamin K
Highest potential difference in wall of stomach is when=Aspirin ingestion
Following terminal ileal resection=Large amount of water in feces
2nd preference=↑Bile in stool
Ileal resection→unabsorbed bile salts→(+)water & electrolyte secretion in
colon→diarrhea and ↑water content of stool
Jejunostomy=Osmotic
Ileostomy produces: osmotic>Secretory diarrhea
Jejunostomy and ileostomy=Both osmotic and secretory
Colostomy=Secretory
Pt. with fluid loss, now shows metabolic acidosis with hypokalemia. Most
fluid loss will be through=Colon
Colon is reservoir of HCO3- and K+ so loss of fluid from colon→Acidosis &
Hypokalemia
Pt. with gastrectomy presents with anemia after 1.5Y. What will you
give?=VitB12
42

RENAL PHYSIOLOGY

Fluid restriction in CRF=0.5L/day

Max renal tubular transport=Lactate
Not isotonic to plasma=5% DA [initially isotonic but after utilization of
glucose it becomes hypotonic>>overall effect is hypotonic.]
5%DA given in large amount=(-)ADH
Max increase in ECF volume=Hypertonic saline infusion
Hot sunny day, sudden collapse=Excessive sweating
↓Plasma proteins=↑GFR
↓Protein content in glomerular filtrate d/t=pore size and negative charge
MCC of K+ shift from intracellular to extracellular=Strenuous exercise
[Release K+ from skeletal muscle]
↑GFR causes ↑absorption of salt & water from=PCT
Severe hypomagnesemia may result in=Hypocalcemia
Hypomagnesemia causes=Hypercalcemia
Severe hypomagnesemia causes=Hypocalcemia
Highest magnesium stores present in=Bone
Hypermagnesemia=Neuromuscular depression [Preference01=↓ACh release]
Difference in plasma and ISF osmolarity=1mOsm
Thirst decreased by=baroreceptor efferent
Diagnostic finding on Ix of metabolic alkalosis=HCO3- >24mEq/L
Dry mouth increases all except=Plasma volume
K/C of DM came to ER, insulin given; what change in blood will happen?=↑pH
As acidosis (↓pH) from ketone bodies corrected by insulin therefore→↑pH
K+ lost mostly from which segment of nephron following dietary
irregularities=DCT
ECF differ from ICF in=High conc. of Na+ & Ca2+
If only volume is mentioned in options prefer that.
↑in both RBF and GFR=Dilatation of afferent arteriole
Cause of anemia in CRF=↓EPO production
Thirst increased by=↓Plasma volume
Important buffer of blood=HCO3-
Maximum increase in ECF d/t infusion of=Hypertonic NaCl
K+ is mainly regulated by=Aldosterone
Micturition=Self-generating
Calculate clearance, urinary flow 20mL/min, conc. in urine 10mEq/L, in
plasma 10mEq/L=20mL/min
Scenario, Tmax not saturated=Urate
Infusion of 1L NS=↑Urine osmolarity
Infusion of isotonic fluid→↑Plasma volume but no change in Posm→↑Urine
volume, ↑Uosm
In juxtaglomerular nephron Na+ actively reabsorbed electrically neutral from
lumen of nephron from which segment=PCT [Thick ascending limb?]
Greatest clearance=PAH [PAH>Dietary K+>Inulin]
43

TBW=1/3ECF + 2/3ICF [TBW=60% of body weight; minimum in adult

women, maximum in NB]
Osmolarity controlled by=Feedback of osmoreceptors
Pt. on dialysis, anemia is d/t=↓EPO
Protein content less in glomerular filtrate=Pores and negative charge
A pt. brought to ER in critical condition, Acid-Base profile reveals: pH 7.08,
PCO2 66mmHg, HCO3- 18mEq/L. What is most likely biochemical
diagnosis?=Metabolic acidosis and respiratory acidosis
DCT is site for=Final composition of urine
Acidosis, hyperventilation=Salicylate poisoning
Important mechanism for tubuloglomerular feedback=↓Peritubular Na+ conc.
Most of water absorption occur with or w/o ADH=PCT
High anion gap in=Uncontrolled DM [DKA]
High anion gap acidosis because acids like ketoacids, lactic acid, acetyl
salicylic acid, ethanoic acid etc.
Non-anion gap acidosis is d/t ions like Cl-, HCO3-
Anion gap=Measured cation-Measured anion
Na+ is multiplied by 2 to account for obligate anions accompanying Na+.
Glucose reabsorption in renal tubules=2˚ Active transport
Most important indicator of muscle protein loss=Urinary nitrogen
Renal compensation in respiratory alkalosis=NaHCO3 excretion
44

ENDOCRINOLOGY

cAMP mechanism=LH, Glucagon

cGMP mechanism=ANP, NO

▌Hypothalamus:
Origin of ADH & Oxytocin=Hypothalamus
ADH inhibited by=Alcohol
ADH responds to=Osmolarity
Osmoreceptors are receptors for=ADH
In late pregnancy, uterus is most sensitive to=Oxytocin

▌Pituitary Gland:
Hormones produced by pituitary acidophils are regulated by=Releasing
hormones
Releasing hormones: release of hormone in target gland
Release-inhibiting hormones: inhibit the release of hormone in target gland
A—GP=Acidophils—GH (Somatotrophs), PRL (Mammotrophs)
B—FLAT=Basophils—FSH, LH, ACTH, TSH
GH=Polypeptide [if present in options: acts indirectly via IGF, click it]
GH=Converts chondrocytes into osteogenic cells [Preference 2=Thyroid
hormone]
Hormone increased during sleep=GH
If asked increased level during sleep than awake=Cortisol
GH maximally rises in=Exercise [Max GH secretion: NREM>Exercise>REM]
If sleep is mentioned then answer=GH
If NREM is mentioned then click it.
PRL regulated by=Dopamine (aka PIF)

▌Thyroid Gland:
Tyrosine derivative doesn’t include=Prolactin
Thyroid hormone=↑FFA

▌Parathyroid Gland, Vitamin D:

Vitamin D acts on intestinal mucosa via=Gene expression

▌Endocrine Pancreas:
Insulin dependent uptake of glucose into=Skeletal muscle
via GLUT4 into skeletal muscle & adipose tissue
Usually glucose transported into cell by Na+/Glucose cotransporter
In k/c of DM, urine c/e demonstrates ketone bodies, mechanism of formation
of ketone bodies is=Insulin deficiency
Hypoglycemia increases=Secretin
Insulin increased by=GIP
All increase insulin secretion=Gastrin, CCK, GIP, Secretin, GLP-1
Most potent stimuli=GIP, GLP-1
45

Somatostatin decreases secretion of=Insulin

Glycogenolysis caused by deficiency of=Insulin
At the end of marathon race=↓Insulin, ↑Glucagon
↑ by hypoglycemia=Glucagon
Glucagon=↑Sr. FFA
Delayed action of insulin=(+)mRNA transcription of lipogenesis
CHO, Fat and protein synthesis=Insulin
Hormone that stores CHO, Fats and proteins=Insulin
Insulin=Allow glucose to pass through cell membrane
↓Insulin will cause=Ketogenesis in liver
Doesn’t rise in stress for surgery=Insulin

▌Adrenal Gland:
Stress hormone=ACTH
Stress of surgery=↑ACTH
Destruction of anterior pituitary cause ↓function of=Zona fasciculata
GFR=SEX
Zona Glomerulosa Salt steroids Angiotensin
Zona Fasciculata Energy steroids Anterior pituitary
Zona Reticularis SeX steroids -
17-ketosteroids in urine seen maximally in=Normal male
C19 steroids (adrenal androgens) are excreted in urine as 17-ketosteroids.
Steroids mechanism of action on cells=Act on genes
Steroids and thyroxine act via gene activation
Action of steroids as anti-inflammatory=(-)Phospholipase
Aldosterone secreted in response to=↑Plasma K+
Most potent stimulus for Aldosterone=↑Plasma K+
Most potent stimulus for ADH=Nausea
Most potent stimulus for renin=Sympathetic drive
2˚ Hyperaldosteronism can occur d/t=↑Renin
Most important hormone involved in gluconeogenesis=Cortisol
Hormone causing gluconeogenesis=Cortisol
For gluconeogenesis prefer cortisol over glucagon.
For glycogenolysis prefer glucagon.
For Glucagon=cAMP>>Gluconeogensis
Hormone increased during sleep as compared to day wakefulness=Cortisol
Hormone causes extra-hepatic protein catabolism and hepatic protein
anabolism=Cortisol
Corticosteroids=↓Osteoblastic activity
Fetal adrenal cortex secretes=DHEA

▌Reproductive Hormone System:

Increase at puberty=GnRH [Puberty initiated by onset of pulsatile GnRH
release from hypothalamus; FSH&LH also secreted in pulsatile fashion.]
46

Shortest T½=GnRH (2-4min)

Aldosterone=20-30min
Thyroid hormones=5-7D
Estrogen, progesterone and testosterone act via=Transcription
Male:
Hormone that increases content of skeletal muscle proteins=Testosterone
Testosterone main function=↑Muscle&bone growth
Appropriate for testosterone=Converted to DHT in target cells
Sertoli cell function=Androgen binding globulin
Pt. with normal amount of semen production but azoospermia=Defect in
sertoli cells
LH in males=Acts on Leydig cells
Female:
GnRH regulates secretion of=FSH and LH
GnRH not inhibited by=Carcinoma
Enzyme specific for female hormone production=Aromatase
Female with hot flushes=↑FSH&LH
Regarding menopause=↑Gonadotrophins (↑FSH&LH, ↓Estrogen)
Menopause=Ovarian unresponsiveness
If 28D cycle, progesterone level on D21 will be=10ng
During mid luteal phase level should be >10ng
Pt. with menstrual cycle of 32D will ovulate on=18th Day [32-14=18]
Breast stroma and duct development=Estrogen
Breast lobules and alveoli development=Progesterone
Regarding breast atrophy in young, caused by=Both estrogen and
progesterone
Adult female with breast atrophy d/t decrease in=Estrogen plus progesterone
Estrogen (+) stroma & progesterone (+) gland proliferation and atrophy
involves both glandular tissue and stroma that’s why author prefer both.
In post-menopausal women=Estrogen
Breasts during pregnancy and lactation shows=Lobular hyperplasia
Function of hCG=Maintains corpus luteum [Prevents involution of corpus
luteum]
Milk present in breast during pregnancy with normal PRL level but there is
no lactation d/t=Inhibitory effect of progesterone
Preference 1=Progesterone
Preference 2=Both estrogen and progesterone
In later stages of pregnancy, production of estrogen & progesterone=placenta
Parturition caused by/started=Fetal cortisol
Fetal cortisol ↑oxytocin receptors in uterus→↑Sensitivity of uterus
Fetal cortisol→↑Degradation of progesterone
Amenorrhea d/t lactation=PRL
Amenorrhea during lactation=(-)GnRH [if not in options click (-)FSH&LH]
During lactation amenorrhea is d/t=Inhibition of FSH&LH
Breastfeeding→(-)Pulsatile release of GnRH from hypothalamus→(-)LH
from pituitary; Plasma conc. of FSH is sufficient to induce follicle growth
47

but inadequate pulsatile LH signals results in ↓estradiol production in

follicles; PRL (-) effect of FSH and LH on ovary.
Dyspnea during pregnancy=↑PaCO2 level d/t progesterone
Normal menstrual blood flow=<80mL (35-40mL)
Following combination of hormones regulate lactation=Oxytocin, PRL, ACTH
70% Abs in=Vaginal secretions
48

3. NEUROSCIENCE
49

NEUROANATOMY

Facial colliculus located in=Pons

Brainstem stroke, vertebral artery dissection, dysphagia=Nucleus ambiguus
Pt. presented with right deviation of tongue associated with ↓sense of
vibration and touch. Artery involved=ASA
Excitation of hypothalamus=Shivering
Shivering center=Posterior hypothalamus
LMN lesion=Flaccid paralysis
Fight or fright response=↓Bronchial secretions
GVE to palate muscles=Nucleus ambiguus
Regarding grey mater foot processes=Protoplasmic astrocytes
Irregular foot processes present in inter-neuron space and around vessels in
CNS=Protoplasmic astrocyte
RTA on CAT scan hematoma compressing postcentral gyrus, what is most
likely affected=Sensations
Regarding CSF=Less protein than plasma
Corpus striatum=Caudate+Lentiform
Medial geniculate body=Midbrain
Base of cerebellum has transverse fibers of=Inferior olivary nucleus
Fine motor movements controlled by=Cerebellum [Why not cerebrum?]
Cerebellum lies below below=Tentorium cerebelli
Inappropriate regarding internal capsule=Sensory fibers through anterior limb
Left cerebral hemisphere lesion=Right upper and lower limbs
Broca’s area supply=MCA
Secondary visual area=Left angular gyrus [Lesion=loss of ability to recognize
objects/loss of ability to interpret what we see.]
Visual and auditory area combine=Wernicke’s area
Stimulation of VMN of hypothalamus=Anorexia
65Y woman is blind, o/e she denies that she has any problem with
eyesight=Cortical blindness
Anton-Babinski syndrome: denial of blindness despite clear pathological
evidence for it after bilateral occipital infarction.
Ipsilateral facial anesthesia with contralateral hemiplegia and some other
findings, lesion=Ventral pontine syndrome
Motor aphasia+Lesion of Broca’s area in dominant hemisphere
Motor aphasia=Broca’s area
Sensory/Receptive aphasia=Wernicke’s
Anomic aphasia=Angular gyrus
Global aphasia=Lesion in Broca’s area, Arcuate fasciculus, Wernicke’s area
Nonfluent aphasia Broca’s area (Inferior frontal gyrus)
Fluent aphasia Wernicke area(Superior temporal gyrus)
Anomic aphasia Angular gyrus (area 39)
Global aphasia Perisylvian region
Lesion Wenicke area=Talk rapidly but make little sense [Wernicke
aphasia=Word salad]
50

Athetosis=Globus pallidus
Chorea=Caudate nucleus
Athetosis rarely seen alone, most of times present alongwith chorea hence
choreoathetosis.
Ascending reticular formation (RF) located=Floor of aqueduct of sylvius
Corpus callosum at occipital lobe=Forcep major
Corpus callosum=Commissural fibers
Lateral ventricles separated by=Septum pellucidum
3rd ventricle laterally bounded by=2/3 of thalamus
Fine nystagmus, no ophthalmological/neurological sign=Cerebellum
Auditory area=MCA territory
Nucleus ambiguus=Supplies Larynx
PANS nucleus of vagus =Dorsal nucleus***
Olfactory area is present in=Anterior perforating substance
Olfactory cortex=Posterior inferior temporal gyrus
Only sensation that doesn’t pass through thalamus=Olfaction
A pt. presented to his dentist d/t inability to put his denture. Dentist referred
back to physician saying there is no dental problem. Site of lesion=SN
(Substantia nigra)
Deep coma, lesion=Nucleus ceroleus
Deep coma Nucleus ceroleus
Prolonged coma Periaquiductal Gray mater
Permanent coma Thalamus
Cingulate gyrus=ACA territory
About CSF=Arachnoid granulations seen by naked eyes

Olfactory nerve termination=Cribriform plate

Light reflex=CN2,3
Pt. w/c/o bitemporal hemianopia, lesion=Upper part of optic chiasm
Preference01=Optic chiasm
Preference02=If two options eg upper and lower part of optic chiasm then
choose upper part
Pituitary gland causing bitemporal hemianopia, lesion=Optic chiasm
Right optic tract lesion=Left homonymous hemianopia
Oculomotor nerve supplies=Ciliary ganglion
15Y girl with fixed dilated pupils, lesion=CN3
Trochlear nerve diplopia=On adduction
Trochlear lesion=Impaired downward gaze on adduction
12Y girl develop deafness after a sudden exposure to bomb blast. Dx=Mixed
deafness
Taste sensation from CN7,9,10=Solitary tract
Taste sensation from base on tongue=Superior salivatory nucleus
Taste sensation carried to cortex=Via thalamus
Hypoglossal nerve lesion=Deviation of tongue towards same side of lesion on
protrusion (You lick your own wound; same side)
Hypoglossal nerve=Pure motor
51

Ansa cervicalis=Hypoglossal, C1, C2

T2 corresponds to=T4 spinal segment

Cord Level Corresponding Vertebra
Upper Cervical Same as cord level
Lower Cervical +1
Upper Thoracic +2
Lower Thoracic +2 to +3
Lumbar T10-T12
Sacral T12-L1
Nucleus pulposus=Notochord
Content of vertebral canal except=vertebral arteries
Cauda equina not derivative of=NCCs
Rotation restricted in=Lumbar region
Lateral horn absent=Cervical region
Maintain flexor tone of arm=Rubrospinal tract
Rubrospinal tract→flexor tone→sitting
Vestibulospinal tract→extensor tone→standing
Nerve that doesn’t have posterior cutaneous supply=C1
Posterior rami of C1, C6, C7, C8, L4 & L5 spinal nerves supply the deep
muscle of back but do not supply the skin.
Hemisection vs total spinal section differentiated by=Spinal shock
During lumbar puncture structure pierced=Ligamentum flavum
Patient with injury on left 8th C segment of SC will not show following
sign=↓Sense of pain and temperature below lesion on same side
Pain & Temperature loss=Contralateral
Position & vibration sense loss=Ipsilateral
A child develops urinary incontinence, loss of control over bowel=Conus
medullaris syndrome
DC-ML system=Proprioception
Contralateral loss of pain and temperature at T9 and ipsilateral loss of
proprioception below T8, bilateral normal reflexes=Lesion of spinothalamic
tract at T8
Epidural space is widest at=L2 [5mm]

NEUROPYSIOLOGY

Slow writhing movements, site of lesion=Globus Pallidus (GP)

Memory center=Temporal lobe
Center for De javu phenomenon=Temporal lobe
Deep sleep=↓Vascular tone
Taste sensation final relay=Gustatory cortex
Gustatory cortex=Frontal of operculum and insula
After paralysis pt is sensitive to pain, damage/lesion=Thalamus
NT of conticostriatal fibers=Glutamate
52

Person solving arithmetic problem. EEG wave present=Beta

Beta waves=Persons awake with eyes open
Alpha waves=Person awake with eyes closed

Rods and cones excitatory potential to ganglion and bipolar cells=Glutamate

Visual impulse associated with=Dissociation of Rhodopsin to retinal and
opsin

Posterior white column doesn’t carry=Temperature

Lateral spinothalamic tract=Pain and temperature
Ventral spinothalamic tract=Crude touch and pressure
Ventral spinothalamic tract=Starts in lumbar region & ends in VPL nucleus of
thalamus
Tactile sensation carried by=DC-ML system

Nor-epi=Adenylyl cyclase activity

Not synthesized at postganglionic sympathetic fibers=Histamine
Highest no of α-receptors=UB neck, proximal urethra
α-adrenergic=Mydriasis
Regarding SANS=Epi ↑skeletal muscle blood flow

Stretch reflex mechanism=Muscle spindle

GTO=Muscle relaxation
Muscle spindle=Muscle contraction
Motor unit=Single motor nerve fibers innervating multiple muscle fibers
Patellar tendon reflex is initiated by stimulating=Muscle spindle
When tension in muscle increased to threaten rupture, relaxation is caused
by=GTO
GTO responds to=Tension
Prevents muscle tear under high pressure=GTO
During stretch in skeletal muscle which of the following change occur in
nuclear bag fibers=↑Impulse generation
Spindle fibers decrease in discharge of impulses when=Muscle contracts
Job of spindle is to contract muscle, when its done its firing is decreased.

Fast pain fibers=A delta

Pain transmitted from fingertips=A delta fibers
Sensations from tips and lips=A beta fibers
Released at pain inhibitory fibers=Enkephalin
Preganglionic ANS fibers=Type B
Postganglionic ANS fibers=Type C
Pure autonomic fibers=Type B
When body is cold=Krause bulb is stimulated
Two-point discrimination=Meissner corpuscle
Maximum 2-point discrimination=Lips, prefer tongue if given in options
Maximum distance of 2-point discrimination=Back/Scapula
53

Incorrect regarding vibration sense=It’s receptor is Meissner corpuscle

Body response in cold to regulate temperature=Hunger
Burning hot temperature on skin=45˚C
Rectal temperature at which permanent cell death occurs=106˚F
Intratesticular temperature less than abdominal cavity=2-3˚C
True about non-shivering thermogenesis=Fatty acids uncouple oxidative
phosphorylation
Stroke with pointed object, flaring on skin=Axonal reflex [Triple response]
Preference01=Axonal reflex
Preference02=Histamine
54

4. HISTOLOGY
55

▌Cell and Cell Cycle:

H2O2=Peroxisome
SER=Detoxification
SER: steroid synthesis, detoxification, produce peroxisomes, contain Ca2+
RER: protein synthesis; continuous with nuclear membrane; gives
basophilia to cells; absent in axon hillock
Regression of gravid uterus and breasts following delivery is d/t activity of
mainly=Lysosomes
Medical student was studying a microscope slide of transitional epithelium.
He noticed unduly thick and darkly stained luminal plasma membrane of
the surface cells. It is most likely d/t=Aggregation of cytoskeletal elements
Packaging and transport of CHO and proteins=Golgi bodies
During mitosis chromosome double in=Interphase
Chromosomes double/replicate=Interphase
Chromosomes arranged on equatorial plate=Metaphase
Mitosis & pairing of chromosomes=Metaphase
Chromosomes visible=Metaphase
Chromosome thickest=Metaphase
Spindle fibers attach to centromere and divide=Anaphase
Centromere split and chromatids divide=Anaphase
2 separate chromatids formed=Telophase
A female has genetic configuration as XXX. The no of barr bodies in her
cells=02 [Inactive chromosome=Barr body; Rule is only one X chromosome
remains active, rest become barr bodies.]
Barr body found in which phase of cell cycle=Interphase
Organelle with microtubules in its structure=Centriole
Organelle with double membrane=Nucleus

▌Epithelial tissue & Skin:

Intercellular junctions:
Belt=Adhering junctions
Spot weld between cells=Desmosome
Spot weld between cells and BM=Hemidesmosome
Connection between cells with movement of ions across=Gap juntions
Gap junction=↑conduction of heart
Cadherin=Cell-to-cell attachment
Cell present in dermis=Mast cell
Epidermis contains=Melanocytes
Melanocytes derived from NCCs
Location: Stratum basale of epidermis
Synthesize melanin in membrane bound melanosome
Melanin=Brown pigment
No of melanocytes same in all races, melanin degradation is more in whites
than blacks; melanosomes are present in basal layer in whites and in all
layers of epidermis in blacks
Soft keratin with no nucleus=Stratum corneum
56

▌Muscle:
Power stroke in skeletal muscle contraction=Myosin
In skeletal muscle at rest, active sites on actin filaments are physically covered
by=Tropomyosin

▌Connective tissue, Bones, Cartilage and Joints:

Collagen type in hyaline cartilage=Type2 [car-two-lage]
Joint between epiphysis and diaphysis=Synchondrosis
Example of traction epiphysis=Condyle of Tibia
Types of joint between vertebrae are of following except=1˚cartilaginous joint
Deposition of bone in fracture area d/t activity of=Periosteal cells
Strength of bone mainly provided by=Collagen fibers
Elastic cartilage=Auditory tube
[Elastic=Eustachian tube, Epiglottis, External Ear]
Ehlers-Danlos syndrome=Type3 collagen, hypermobile joints
Knee joint=2 menisci
Houseship lacunae contain=Osteoclasts
Epiphyseal line is remnant of=Epiphyseal cartilage
Reticular fibers present in=Tonsils
Microscopic feature of compact bone=Lamellae are regularly arranged
Osteon shows=Concentric lamellae containing Haversian system

▌Nervous Tissue:
Outermost covering of nerve=Epineurium
Myelin in CNS is formed by=Oligodendrocyte
Axon arise from conical shaped part of neuron cell body=Axon hillock
Tissue repair in CNS=Glial

Tissue cannot regenerate=Lens**

Ciliary body=Pigment epithelium continuous with pigment epithelium of
retina
Not a basic tissue of body=Blood
Meiosis occurs at which of the following transformation=1˚Spermatocyte to
2˚Spermatocyte
1˚spermatocyte=4 sperms
57

5. EMBRYOLOGY
58

▌General Embryology:
Gastrulation=all 3 germ layers
Compaction occurs=4th division (16-cell stage)
Fetal period=from week8 onwards
Used for screening congenital anomalies=Estriol
Gestational age estimation at 5-12Weeks=CRL
Markers for NTDs=↑AFP
Anencephaly=Folic acid deficiency
Infants with absence of limbs=Amniotic bands
Teratogenic effect on embryo is mainly in=3-8Weeks
Obliteration of uterine cavity in pregnancy=Decidua capsularis and parietalis
Space between splanchnic and somatic mesoderm=Extraembryonic chorionic
cavity
Extraembryonic coelom=Between somatic and splanchnic mesoderm
Least teratogenic=Lysergic acid
Intermediate mesoderm=Genitourinary system
AT which age head of fetus becomes exactly half the length of CRL=3rd month

▌Special Embryology:
2nd arch derivative=Stylohyoid
Liver develop from=Ventral mesentery of distal gut
Cloacal membrane=derivative of both ectoderm and endoderm
Cloaca=arise from hindgut caudal end
Promordial germ cells (PGCs) formed from=Epiblast at week2
In fetal life=Left 2nd bronchus absent
Ciliary body develops=Neuroectoderm, mesoderm
Epithelium=Neuroectoderm, Stroma=Mesoderm
►Developmental counterparts of male and female reproductive organs
Mesonephric duct functionally persists as=Ductus deferens
Nephron=Mesoderm
Bladder=Endoderm
Whole female urethra, most of male urethra=Endoderm
Distal urethra=Ectoderm
Female at GA 34 weeks having SFH of 28Weeks, cause is=Renal Agenesis
Young girl with primary amenorrhea, o/e breasts and secondary sexual
characteristics are normal, on US ovaries normal but uterus absent.
Structure responsible for this abnormality=Paramesonephric duct
Child with h/o bed wetting though toilet trained, on investigation at one side
duplication of ureter found and one of them was opening in vagina.
Cause=Early division of ureteric bud
Pt. with bicornuate uterus present with which congenital anomaly=Urinary
system
Failed fusion of mullerian duct=Bicornuate uterus; 30% cases will have co-
existing urinary tract anomaly.
Stomach rotation=Week05
Limb buds=Week04
59

6. BIOCHEMISTRY
60

▌Metabolism:
Correct sequence of protein synthesis=mRNA>Cytoplasm>Ribosome>tRNA
Substance that yield high calories per gram=Fat
Order of energy utilization=CHO>Fats>Proteins
After 48H of starvation, source of energy for body is=Muscle protein
[Lippincott]
Conversion of glucose-1-PO4 to glucose-6-PO4=Phosphoglucomutase
Fructose-6-PO4 to fructose-1,6-bisphosphate=Common in gluconeogenesis
and glycolysis
Neimann-Pick disease=Defective sphingomyelinase
Tay-Sach’s disease=Deficient hexosaminidase

▌Nutrition:
Essential AA=Phenylalanine
Apathy, pallor, edema, enlarged liver & low Sr. albumin=Kwashiorkor
More in mother milk than cow milk=Lactose
Lactose:Protein ratio: ►Human milk=7:1 ►Cow milk=4:1
Maximum CHO content=Wheat
Preference01: Rice, CHO content=81gm
Preference02: Wheat, CHO content=71gm
Minerals not found/low bioavailability=Tubers
↑Consumption of CHOs will ↑demand for=Thiamine
↑CHO consumption=Thiamine
High output HF, thiamine deficiency=Wet Beriberi
If person is taking protein in his diet, what will be necessary=Riboflavin
CHO in diet Thiamine
Protein in diet Riboflavin
Fats in diet Biotin
Richest source of VitaminD=Cod liver oil
A pregnant lady during ANC visit informs that she is strict vegetarian. You
suspect she will be deficient in=Vitamin B12
Vitamin K=Clotting factor synthesis
14Y boy with chronic diarrhea. BT=14sec, CT=50min, no family history of such
disorder. Dx=Vitamin K deficiency
Ascorbic acid=Collagen synthesis
61

7. MICROBIOLOGY
62

▌Bacteriology:
Life threatening clinical condition caused by Clostridium perferingens=Diffuse
clostridial myonecrosis (Gas gangrene)
MC secondary infection in influenza in elderly=Pneumocci
Definitive Dx of PTB=Sputum for AFB
Chlamydial infection causing chlamydial psittacosis=Obligate intracellular
Infective cause of global blindness=Chlamydia trachomatis
Pertussis spread=Nasopharyngeal and bronchial secretions
Preterm delivery caused by=Bacterial vaginosis
Golden yellow colonies=Staph. aureus
Peitonitis=E. coli
Ascitic tap=E. coli
Pyogenic peritonitis=Bacteroids
Puerperal sepsis=Bacteroids
Post-op abdominal and gynecologic infections=Bacteroids
Abscess=Staph. aureus
Acute osteomyelitis=Staph. aureus
Acute osteomyelitis in SCD=Salmonella
TSS=Staph. aureus
Wound infection=Staph. aureus>Pseudomonas
Hospital acquired pneumonia=Staph. aureus
Pyogenic lung abscess+meningitis=Staph. aureus
Septic meningitis=Streptococcus
Initiation of dental caries=Streptococcus
Cellulitis=Strep. pyogenes
Subacute bacterial endocarditis=Strep. viridans
Prosthetic valve endocarditis=Strep. epidermidis
Tubo-ovarian cyst=Gonococcus
Fatal diarrhea=V. cholerae
Gas gangrene=Clostridium perferingens/Clostridium welchii (old name)
Pseudomembranous colitis=C. difficile
Chlamydia=PID, trachoma, LGV
Granuloma with yellow pigment=Actinomyces
Multiple draining sinuses=Actinomyces
IUCD infection=Actinomycosis
Vulva itching+pink purulent discharge=T. vaginalis
Vulval pruritis with pinkish frothy vaginal discharge=T. vaginalis
↑Lymphocytes=TB
Tetnospasmin=Blocks synaptic inhibition
UTI, culture yields greenish growth with fruity smell, organism is oxidase (+)
and non-lactose fermenter. Rx=Ciprofloxacin
Prevention of infection in ICU=Hand washing
Widal test=1:160 of H & O is diagnostic
63

Menstruating woman uses tampons, she develops high-grade fever, vomiting,

diarrhea, hypotention. Causative organism=Staph. aureus
Neuropenic, hypotensive pt. admitted in oncology ward with h/o dysuria &
fever. Growth of pseudomonas=Release of TNF and IL-1 in blood

▌Virology:
Virus acts by=Altering protein synthesis
Viruses in human cause cancer=Oncogenes
Radiation act via proto-oncogenes
14Y boy w/h/o fever for 4Ds, generalized lymphadenopathy and pupuric
rash=Infectious mononucleosis (IM)
Boy with testicular swelling and fever=Mumps virus
Pain in chin, not relieved by Tab. Tegral 200mg, eruption noted at that
area=Herpes zoster
Infection in post-liver transplant patient=CMV
MC infection after BT=CMV [BT is also a transplantation.]
Chorioretinitis in AIDS=CMV
Bronchogenic ca.=CMV
Burkitt lymphoma=EBV
Lymphoma in AIDS=EBV
Non-Hodgkin lymphoma=EBV
Hairy tongue=EBV
Nasopharyngeal ca=EBV
Infectious mononucleosis=EBV
Kaposi sarcoma=HHV-8
Ca. cervix=HPV-16
Vulval papules=HSV
Meningoencephalitis=Echovirus
Herpangia=Coxsackie virus
Hand-foot-mouth disease=Coxsackie virus type A
Young girl with rash behind ear, spread to face, neck, arms and chest=Measles
Hepatitis A IgG indicates=Recovery from infection
Pregnant lady with jaundice=Hepatitis E
Best screening test available for HIV=ELISA
[Sensitivity=>98.5%, Specificity=>99%]
Confirmatory test=Western blot
If baby born to HIV mother and age <18M=PCR
HIV in female, which cancer can occur=Ca. cervix

▌Parasitology:
Cysticercosis cause=Eggs of T. solium
Cysticersosis=T. solium
Cysts in liver=T. echinococcus
Child with diarrhea, e/o rectal prolapse, on stool RE, a worm with small
anterior end seen=Trichuris trichuria
Blackwater fever=P. falciparum
64

SCC UB=Schistosomiasis
Cholangiocarcinoma=Clonorchis sinensis
Migratory lesion of foot=Cutaneous larva migrans
Ascaris lumbricoides=Appendicitis
About hydatid cyst all true except=Larvae enter humans by penetrating skin

▌Mycology:
Meningitis in AIDS=Cryptococcus neoformans
Fungi causing meningitis=Cryptococcus
Donut shaped cysts=Crptosporoidosis
MC nonbacterial opportunistic infection in burn wound=Candida
Rhinosinusitis with medial necrosis and granuloma=Aspergillosis
65

8. PHARMACOLOGY
66

k/c of RHD came for tooth extraction. He is allergic to penicillin. Antibiotic

for endocarditis prophylaxis=Clindamycin
Vasodilator with no effect on HR given in angina=Metaprolol
Not an effect of nitroglycerin=↓Afterload
Toxicity of Li with thiazide=Pharmacokinetic interaction [↑plasma conc. of Li
by 25-40%]
Reversal of action of morphine by naloxone=Pharmacodynamic
In PD, levodopa given along with carbidopa=↓Peripheral activation
OCD=Clomipramine [DOC=Fluoxetine]
Familial tremor Rx=Propranolol>Procyclidine
Aminophylline metabolism inhibited when used with=Cimetidine
Blood level monitoring after antibiotic administration=Vancomycin
Penicillin given=To prevent RF and IE
↑Metabolism of drug by=↑Liver enzymes
Warfarin toxicity Rx=Vitamin K>FFP
Endometriosis=Danazole
↓Gentamycin clearance in old age=↓Renal function
Young girl, severe rhonchi, breathlessness, PEFR <50%. Mx=IV steroids &
bronchodilator
More LA conc. in blood by=Intercostal block
Basic drugs bind=α-glycoprotein
Acidic drugs bind=Albumin
Acetaminophen poisoning, N-acetylcysteine cause=Convert to acetylated
metabolites
Selective COX-2 inhibitor=Celecoxib
Potent COX-2 inhibitor=Meloxicam
True regarding tramadol=Weak Meu agonist
Ketorolac analgesia most preferable=Non-diabetic female undergoing
cholecystectomy
MOA of steroids in inflammation=(-)Phospholipase
Allergic reactuion with hypotension, Rx=IM adrenaline [Vastus lateralis]
Mifepristone=Progesterone antagonist
(+)Uterine contractility
(-)Prostaglandin dehydrogenase→↑PGs
Drug (-) ca. breast mets to liver=Tamoxifen
Systemic fungal infection=Amphotericin B
Rupivacaine preferred over bupivacaine=Less toxic
Onset and duration of LA depends on=Tissue pH
Cytochrome P450 reaction=Hydroxylation
Cimetidine=(-)Hepatic enzymes
MC s/e of IUCD=Menorrhagia
β-blocker given cautiously in=Thyrotoxicosis
Common s/e of cholinergic drugs=Salivation
Bradycardia is s/e of=Halothane
True about bupivacaine=0.5 in 50mL means 50mg dose
67

Traveler’s diarrhea not responding to antidiarrheal drugs. Which drug should

be given=Norfloxacin
Angina worsens by=Theophylline
Tachyphylaxis=↓Drug effect with repeat dose
Captopril block=Enzyme that catalyzes conversion of AT1 to AT2
Serotonin syndrome=TCA with fluoxetine
Urinary incontinence, drug given=Oxybutynin
Protamine s/e=Hypotension
Compared to propranolol, atenolol is=More likely to produce CNS s/e
To facilitate action of atropine=TCA block cholinergic
Atropine block=Salivary gland
L-dopa effect starts decreasing d/t=↓SN fibers (substantia nigra)
Curare cause block at=NMJ
Agent that causes impairment of nerve function by blocking Na
channels=Tetradotoxin
Lady treated with AEDs for long period, now presents with thickening of
gums, broadening of her lips and nose, mild hirsutism. Most likely
agent=Phenytoin
Tocolytic agent that cause ↑blood sugar=Terbutaline
Contraindication of propofol=Hypersensitivity
Emergence delirium=Ketamine
Distribution of drug enhanced=Lipid solubility
Atorvastatin prevents=Progression of atheroma
Digoxin toxicity worsened by=Hypokalemia
Partial pressure of halothane=243
Low estrogen OCP=Liver adenoma
High estrogen OCP=DVT/Thromboembolism
Anticholinergic used in=COPD
DOC for DM in pregnancy=Insulin
Rx herpes labialis=Acyclovir
Rx eye infection HSV=Trifluridine
Drug addict with c/o pain=IM ketorolac
40Y teacher writing on board, suffering from shaking of hands=Ropinirole
Maximum safe dose of bupivacaine=150mg
Bupivacaine=Blockade of voltage-gated Na channel
Succinyl choline toxicity=Deficiency of PChE
DOC for Afib=Digoxin
DOC for hyperthyroidism-induced Afib=β-blocker
↑Digoxin toxicity=Hypokalemia, Hypercalcemia, Hypomagnesemia
Phenobarbitone=P450 inducer
α-Adrenergic receptor antagonist=Doxazosin
Pt. taking propranolol develops prolonged PR interval. Cause=Drug-induced 1˚
heart block
Erythmatous swelling on back of hand=Cloxacillin
Ofloxacin=Gonorrhea, Chlamydia
Anticoagulants contraindicated=Thrombocytopenia
68

9. PATHOLOGY
69

GENERAL PATHOLOGY

▌Cellular Injury:
Hypertrophy results in=↑DNA content
Permanent cells cannot divide but in an attempt to divide they duplicate
their DNA content (from 2n to 4n) but cell doesn’t actually divide. So nuclei
of hypertrophied cells may have higher DNA content because cells fail to
undergo mitosis.
Hypertrophy=Results in ↑DNA content
A person has nodule on vocal cord, most likely mechanism=Hyperplasia
Tissue damage by ionizing radiation d/t=Free radicals (FRs)
Nuclear pyknosis=Irreversible cell injury
Most important feature of reversible cell injury=Cellular swelling
Diagnostic of dead cell=Karyolysis
Myelin figure=Reversible injury
Councilman bodies=Apoptosis
Stroke death, brain necrosis=Liquefactive necrosis
Type of necrosis in brain infarction=liquefactive necrosis
Pt. with cervical lymphadenopathy, sputum AFB (+), sign to look for TB on
microscopy=Caseous necrosis
Microscopic feature of PAN=Fibrinoid necrosis
Microscopic feature of any vasculitis=Fibrinoid necrosis
Necrosis of any immune mediated disease=Fibrinoid necrosis
Pt. w/c/o abdominal pain, Sr. amylase↑, he was diagnosed with pancreatitis,
his omentum will show=Fatty necrosis
About metaplasia=One epithelium changes to another normal epithelium
Most sensitive cell to hypoxia=Neuron
An obese man w/h/o atherosclerosis, underwent laparotomy d/t bleeding in
abdomen. Peroperative findings: small gut purple, SMV is okay. Dx=Wet
gangrene
Sites of metastatic calcification=Kidney
Interstitial tissues of kidney, lung and gastric mucosa (these tissues lose
acid quickly; ↑pH favors Ca2+ deposition); Nephrocalcinosis of CDs may
lead to nephrogenic DI and RF.
MCC of metastatic calcification of kidney=Hyperparathyroidism
Hypoparathyroidism also results in metastatic calcification; ↑PO3- in
blood→↑precipitation of Ca2+ in tissues; therefore if hyperparathyroidism
is not mentioned in options click Hypoparathyroidism.
Insoluble excess Fe stored in parenchyma of organ=Hemosiderin

▌Inflammation & Repair:

Acute inflammation=Neutrophils
Chronic inflammation=Macrophages, epithelioid cells, giant cells
ICAM, VCAM=Adhesion molecules
Most likely chemical mediator responsible for pain in inflammation=PGs
Yellow color effusion, neutrophils: 98%, lymphocytes: 2%=Purulent exudate
70

Edema of acute infection, feature=Protein >3gm

CPSP: always prefer protein >3gm for exudate.
3 POD following TAH with BSO, serosanguinous discharge from wound,
rd

cause=Wound dehiscence
Main difference between 1˚ & 2˚ intention wound healing=Wound contraction
Open wound healing=Contraction of myofibroblasts

▌Neoplasia:
Sarcoma differs from carcinoma=Structural difference
Difference between benign and malignant=Metastatses
Most sensitive to radiotherapy=Craniopharyngioma
Order of sensitivity= Seminoma>>Glial glioma>>Craniopharyngioma
Cholangiocarcinoma=Clonorchis sinesis
Factor least in doubling of carcinoma=Exfoliation
Not associated with hormone secretion=Chondrosarcoma
Mass of mature disorganized tissue indigenous to certain organ=Hemartoma
Presence of pancreatic tissue in gastric mucosa=Choristoma
Brain tissue in nasal cavity.
Indole acetic acid seen=Carcinoid syndrome
Hydroxy indole acetic acid in urine=Carcinoid syndrome
Tumor that is not APUDoma=Ca. pancreas
APUD cell tumor; Amine Precursor Uptake & Decarboxylation
Pap smear=2˚ prevention
Statement false about carcinogenesis=Papilloma viruses produce tumors in
animals but not in humans.

▌Hemodynamic Disorders:
MC factor in pathogenesis of thrombus=Endothelial injury
Platelet aggregation d/t=Damaged endothelium
Group of young men bathing in beech, next day develop blisters on back,
shoulders and limbs, cause=Mast cell destruction
DIC related to all except=Bacteremia
Shock, progressive stage=Metabolic acidosis
MCC septic shock=Gram (+)
Fluid replacement in heavy bleeding=Whole blood for 3Ds
Female presents with DVT, she was taking some drugs=OCP
Adult pt. with severe burn injuries presents with high grade fever, on blood
culture gram (-) organisms seen; pt. finally developed bleeding. Cause=DIC
Axonal flare response is from=Vasodilation
DIC d/t=Thromboplastin
Thrombus formation=Damaged valve, ↓BF, ↑blood viscosity
20Y woman bleeding PV, high grade fever, ↑PT, ↑APTT=DIC
Systemic arterial emboli=LV mural thrombus
Endotoxin activates=Complement system
BP 70/40mmHg, Sr. lactate 30mg, CVP 2cm H2O, cause=Hypovolemic shock
A pregnant lady suddenly died in automobile accident=AF embolism
71

Line of Zahn=Coralline thrombus

Man in shop suddenly collapsed, HR 120bmp, BP 90/60mmHg, first had
excruciating chest pain, Dx=Pulmonary embolism
Following will cause massive infarction and destruction leading to
death=Thromboembolsim
22Y female with 13W of pregnancy had crush injury and fracture long bone in
RTA, died 3Ds later. Most likely cause=Fat embolism
Shock w/o having vasodilation=Burn
Organ with least chance of infarction=Liver
Pale infarction=Dense tissue
Hemorrhagic infarction=Loose tissue
Immediate effect of severe hypotension=Oliguria
Extent to which a tissue get disturbed by occlusion of its blood supply
depends on=Rate of development of thrombosis

▌Immunopathology:
Success in kidney transplant and tissue compatible transplantation from
relative=90%
Following transplantation within 1Y, highest increase in incidence=B cell
lymphoma
Following transplant MC malignancy=Skin>>Lymphoproliferative
Side effects of nonspecific immunosuppression (Post-transplantation
Immunosuppressive Rx)
A.Infections:
Transplant recipients are at high risk of opportunistic infections especially
by viruses
Risk of infections greatest during first 6Months
Risk of bacterial infections highest during first month
Fungal infections usually occur in first 3Months; MC fungal infection=P.
jiroveci; others are Candia and Aspergillus
The risk of viral infections is highest during first 6Months; MC
infection=CMV; others are HSV, BK virus after renal transplant, HZV
B.Malignancy:
1.NMSC (Non-Melanotic Skin Cancer)=MC; 50% of transplant recipients
will develop skin malignancy within 20Y of transplantation
2.PTLD (Post-Transplant Lymphoproliferative Disorder)=Abnormal
proliferation of B cells usually in response to EBV infection; incidence is
highest during first year post-transplant especially children are at risk.
3.KS (Kaposi Sarcoma)=Transplant recipients have 300-fold increased risk
of developing KS although this malignancy is still very uncommon
Mild transplant rejection=Lymphocytes
Most acceptable evidence that supports genetic predisposition of
SLE=↑Incidence in monozygotic twins
Butterfly rash=SLE
Drug induced SLE=Phenytoin
Others: Procainamide, Hydralazine, Isoniazid, Quinidine
72

Malar rash, generalized lymphadenopathy, pallor, protein 8, albumin 3.5, ANA

(+); further test=Anticentromere Ab
SCID=Absent B and T cells
TB Abs=Cell-bound
HIV=↓Helper T cells
Not a natural immunity=Plasminogen
TCR complex binds with=MHC
MC immunodeficiency=Selective IgA deficiency
Prozone phenomenon=False (-) result d/t high Ab titer
Ab that doesn’t cross placenta=IgM
Test for dry mouth and eye=Anti-SS A, Anti-SS B
HLA DR4=RA
Ankylosing spondylitis=HLA B27
Organ transplanted, failed within 10Min, cause=Preformed Abs
SLE is d/t=B & T cell dysfunction
45Y woman has had increasing malaise for the past year, o/e BP 265/150
mmHg; lab studies show plasma renin activity 9 ng/mL/H. She then suffers a
stroke with right basal ganglia hemorrhage and dies. Autopsy shows B/L
small kidneys with granular surfaces, microscopically shows hyperplastic
arteriosclerosis with fibrinoid necrosis, petechial hemorrhages, micro-
infarcts in cortices=Systemic Sclerosis
Diphtheria vaccine reaction=T3HSR
Any serum cause serum sickness (T3HSR)
6Y old with rhinitis, edema, utricaria=T1HSR

▌Genetics & Diseases of Infancy and Childhood:

Polydactyly, microcephaly=Patau syndrome, Trisomy 13
Achondroplasia=ADD
MC genetic disorder=Multifactorial
Fragile X syndrome=Trinucleotide disorder
Turner syndrome=Short stature
Pseudohermaphroditism with 46XY=Androgen insensitivity
Normal looking girl presents with 1˚amenorrhea, o/e normal breasts, axillary
and pubic hair scanty, normal vulva with short blind vagina. Her
karyotype=46XY
Androgen insensitivity/Testicular feminization—Normal male hormones
but absent receptors; MCC male pseudohermaphroditism
40Y k/c of Down syndrome. Risk of=Alzheimer disease [Early onset Alzheimer
disease]
Down syndrome=↑Incidence with increasing maternal age
Incidence of Down syndrome in 40Y old lady=1 in 100
For maternal age >45Y=1 in 25 live birth
Maximum FiO2 which doesn’t cause retrolental fibroplasia in fetus=>0.5
Extra point: PaCO2 >55mmHg in respiratory failure
Chest pain, lens dislocation=Marfan syndrome
73

MCC of genetic intellectual disability=Down syndrome

2nd MCC=Fragile X syndrome
Cause of mental retardation=Fragile X syndrome
Autosomal Dominant Disorders (ADD)=Structural
Very Powerful DOMINANT 6Humans
V= vWD, VHL (von-Hippel-Lindau) syndrome
P= Peudohypoparathyroididm (PHP)
D= myotonic Dystrophy
O= Osteogensis imperfect, Others: Familial adenomatous polyposis (FAP),
Li-fraumani syndrome
M= Marfan syndrome, MEN
I= Intermittent porphyria
N= NF T1, NF T2
A= Achondroplasia, Adult PCKD
N= Noonan’s syndrome
T= Tuberous sclerosis
6H= Hereditary spherocytosis, familial Hyperholesterolemia, Huntington
disease, Hereditary hemorrhagic telangiectasia, Hereditary nonpoliposis coli
(HNPC), Hypertrophic obstructive cardiomyopathy (HOCM)
Autosomal Recessive Disorders (ARD)=Functional/metabolic
ABCDEFGH
A= Albinism, A1AT deficiency, Ataxia telangiectasia, Alkaptonuria,
ARPCKD
B= Blood disorders—Thalassemia, SCD
C= CF, CGD (Chronic granulomatous disease), CAH (Congenital adrenal
hyperplasia), Cystinuria
D= Dubin Johnson syndrome, Pendred syndrome (Deafness)
E= Enzyme deficiencies—Glycogen storage diseases, Lysosomal storage
diseases
F= Friedrech’s ataxia, Fanconi syndrome, Fructose intolerance
G= Galactosemia, Gaucher’s disease, Glanzmann’s thrombosthenia
H= Hereditary hemochromatosis, Homocystinuria
Others:
Kartagener syndrome
Wilson disease
Phenylketonuria
Mucopolysaccharidoses EXCEPT Hunter syndrome
Sphingolipidoses EXCEPT Fabry's disease
Xeroderma pigmentosa (XP)
X-linked Recessive Disorders (XR)
Bob’s Father Had GOLD Watch.
B= Bruton’s agammaglobulinemia
F= Fabry disease
H= Hunter syndrome, Hemophilia A & B
G= G6PD deficiency
O= Ocular albinism, Ornithine transcarbamylase deficiency
74

L= Lesch-Nyhan syndrome
D= Duchenne/Becker’s muscular dystrophy
W= Wiskott-Aldrich syndrome
Others: Vitamin D resistant rickets, Alport syndrome
Ocular anomalies, corneal defects, lens prolapse, tall stature and hypermobile
joints=Marfan syndrome
Proband
Ankylosing spondylitis=ARD
Epicanthal fold, protruded tongue, umbilical hernia=Trisomy 21
Allele=Nonidentical gene on same locus
Robertsonian translocation=Down syndrome
Short stature, small hands and feet, hypogonadism=Prader Willi syndrome
45XO, short stature, prominent crease line=Gonadal dysgenesis with follicular
aplasia
Pt. came with 1˚ amenorrhea, webbed neck, short stature, Dx: Turner
syndrome, her karyotype=45XO
Turner Syndrome:
MC sex chromosomal abnormality in females
1/3000 female births
Mosaicism karyotype 45X/46XX=75% of all viable cases, because 45XO
conceptuses are non-viable
Short stature in >95% cases [CPSP]
Webbed neck=Dilated lymphatic channels/cystic hygroma
Streak gonads=Devoid of oocytes, menopause before menarche=MC genetic
cause of 1˚ amenorrhea=Risk of dysgerminoma
Preductal coarctation of aorta, Bicuspid aortic valve
Absent barr body in buccal mucosa in 45XO
Scanty/no barr body=Turner syndrome
Single barr body=Klinefelter syndrome
Barr body diagnostic for=Turner syndrome
Amniocenetsis vs transcervical CVS before 14Ws=10% ↑risk of fetal talipes

▌Environmental Pathology & Nutrition:

Estrogen doesn’t increases risk of=Ca. GB
Least teratogenic=Lysergic acid
XR in pregnant woman=5Rad
Exposure to >20Rad leads to birth defects
Ionizing radiation=Leukemia
MC site of malignancy in person suffering from nuclear
outbreak=Hematopoietic
Head&Neck irradiation=Papillary thyroid carcinoma***

In vitamin K deficiency, first and foremost factor depleted=Protein C

Vitamin K deficiency, fist factor depleted is=Protein C
In vitamin K dependent factors, shortest T ½=Protein C
In vitamin K dependent coagulation factors, shortest T ½=CF-VII
75

Neurological dysfunction=Vitamin E deficiency (Vitamin B12 vs Vitamin E)

Vitamin B1 deficiency=Beriberi
A primi taking Fe tablets, lots of vegetables and juices. She is at risk of
developing=Vitamin B12 deficiency
Pallagra=Deficiency of nicotinic acid
Vitamin K not absorbed, CF decreased=PT
Not a feature of malnutrition in adults=Thrombocytopenia
76

SPECIAL PATHOLOGY

▌Cardiovascular System:
Acute MI pt. found collapsed after 48H, o/e pulseless, on ECG irregular waves
seen; pathophysiology=Re-entry current
Afib=Pulsus deficit
35Y man with B/L creps, on CXR heart fills completely, mass in RV; what is
main cause=Myxoma
Post-MI peripheral cyanosis=↓CO
MC involved heart valve=Mitral valve
Premature baby born, MC finding=PDA
Fever for 10Ds, chest pain unrelated to respiration=Myocardium
Child was examined by Pediatric surgeon for patent foramen ovale, the most
likely cause for this anomaly=Incomplete anatomic fusion of septum primum
and septum secundum
LVF=Aortic valve lesion
Male with transmural infarction died suddenly in washroom after
8Ds=Cardiac tamponade
Left to right shift before reversal=Eisenmenger syndrome
Cause of HCMP=Myocyte disarray
First observable sign of irreversible cell injury in cardiac cell=Contraction
bands in cytoplasm
Pleural tap, specific gravity 1.006, most likely cause=CCF
Diagnostic for IE=Blood culture
MDM, irregularly regular seen in=↑Pressure gradient across mitral valve e.g.
MS

Important sign in hypertensive retinopathy=AV nipping

Ulcer d/t HTN=Martorell ulcer [Hypertensive ischemic leg ulcer]
50Y k/c of HTN with severe chest pain radiating to back, died. Autopsy
finding=Medial necrosis of aorta
BP: 170/110 mmHg, not taking Rx=Hyperplastic arteriosclerosis
Regarding HTN in old age=Diastolic HTN
Prominent PA and right border of heart, ↑translucency of lungs=Athersclerosis

▌Hematology:
Auer rods are only present in=AML [Sudan Black B+]
Normal size spleen=G6PD deficiency
Also hallmark of ITP.
Massive splenomegaly=Myelofibrosis
Massive splenomegaly=Wt. >1000gm; myelofibrosis, CML, HCL
Moderate splenomegaly=Wt. 500-1000gm; thalassemia major, hereditary
spherocytosis, amyloidosis, Neimann-Pick disease
Mild splenomegaly=Wt. <500gm; infectious mononucleosis
12Y boy, k/c of hemophilia A has had episodes of pain about his knee for past
6Ys. Overtime, there has been an increase in size of his knee joint with
77

deformity. Lab studies show ↓CF-VIII activity. Which of the following

materials is most likely to be seen within joint space following episodes of
pain? Preference01=Hemosiderin; Preference02=Cholesterol crystals
Hemophilia A CF-VIII XR
Hemophilia B CF-IX XR
Hemophilia C CF-XI AR
Hemophilia A=Classic hemophilia
Factor VIII complex components:
1.Small component=VIII:c=Procoagulant protein/Anti-hemophilic factor
2.Large component=VIIIR (CF-VIII related protein)=vWF
Hemophilia gene located on=X chromosome
H/o gum bleeding and wound bleeding, prolonged BT & PT=CF-VIII
deficiency
Prolonged BT and APTT=vWD*** [2 important conditions with prolonged
BT and APTT: 1.vWD 2.Afibrinogenemia]
NTK:
BT=Platelet plug formation
PT=Extrinsic coagulation cascade [Play Tennis Outside]
APTT=Intrinsic coagulation cascade [Play Table Tennis Inside]
CML=Philadelphia chromosome t9;22
CML=Chromosome 9 and 22
Hodgkin disease=Reedsternberg cell
Nematodes=↑↑Eosinophilia
Pt. with ↑IgE levels=Parasitic infections
Bence Jones protein=MM
Russel bodies=MM [Mott cell: plasma cells with Russel bodies; Russel
body=Eosinophilic Ig-containing inclusion body]
Ferruginous body Asbestosis
Lipschutz body HSV
Ciratte body Lichen planus
Lewy body Parkinson disease
Negri body Rabies
Severe hemolytic disease=Fetus Rh(+), Mother Rh(-)
Megaloblastic anemia=Folic acid deficiency
↑Platelet count after=Splenectomy
Folate deficiency, megaloblastic anemia=Gluten enteropathy
Megaloblastic anemia, investigation=IF autoantibodies
IDA in pregnancy=↑TIBC
MCC of macrocytosis in Asia=Alcohol
MCC macrocytosis in Pakistan=Liver disease
64Y with posterior cervical lymphadenopathy; o/e firm, mobile,
hepatosplenomegaly absent; o/I Hb13%, Hct40%, WBC 7230, PC 250,000;
histopathology shows numerous small monomorphic lymphocytes. Dx=HD,
lymphocyte predominance [MC site of HD=Cervical LNs]
A girl w/h/o gum bleeding, PC 85000, giant platelets=Bernard Soulier
syndrome
78

Pt. developed hemolysis d/t G6PD deficiency, what will happen next=Self-
limiting
Thalassemia carrier %age in Pakistan=5%
Plasma cell disorder and amyloidosis=Amyloid light chain
G6PD deficiency=Bite cells
Definitive diagnosis of folate deficiency=RBC folate level
Thalassemia & SCA=HB electrophoresis
IDA=↓Ferritin levels
Lead poisoning=Lead in blood and urine
Pernicious anemia=Autoantibodies to IF
Aplastic anemia=BMB
Wilson disease=Sr. Ceruloplamsin
Coumarin (Warfarin)=↑CT
MM Dx=Immune electrophoresis
IDA best diagnosed=Sr. ferritin
Anemia of hypothyroidism=Normocytic normochromic (?) [Macrocytosis
occur in hypothyroidism d/t to hypercholesterolemia]
Pt. with blood group A, serum not cross matched with donor=IgM
Sr. not matched means agglutination d/t Ag-Ab reaction
IgG=smaller and coats cell
IgM=Larger with 10 antigenic sites and agglutinate cells
Burkitt lymphoma=EBV
EBV=Interfere with DNA repair→Burkitt lymphoma
BT:20, CT:18, PC:180,000=Platelet function disorder
Uremic nephropathy=Normocytic, normochromic anemia
MCC of ↑BT=Aspirin
Aplasia=Failure of cell production
IDA=MCC of anemia in pregnancy
Swelling of knee, PT 12sec, APTT 6sec, CF-VIII 85%, CF-IX 7%=Christmas
disease
k/c of MM, now develop hypercalcemia, polyuria and confusion, urine Osm
310, reason of polyuria=ADH can’t act on tubules
Chronic intravascular hemolysis=↓Haptoglobin
A man living in high altitude, c/o headache & bluish discoloration of finger
tips, o/e BP 160/90mmHg, PCV 62%, Dx=2˚ Polycythemia
Young pt. with Hb 6g/dL, TLC 3500, PC 100,000, Dx=Aplastic anemia
MC diagnostic feature of IDA=Microcytic hypochromic picture on PBS
Pt. having hyperplastic BM, anemia, ↑PC, probably suffering from=Leukemia
Upto 14Y=ALL
40-60Y=AML, CML
>60Y=CML, CLL
Stimulus for EPO secretion=Hypoxia
EPO is always raised in 2˚ polycythemia
Polycythemia vera is only type of polycythemia with ↓EPO
Type of defect in hereditary spherocytosis=Structural defect
Pt. with anemia, jaundice and ↑Retic count=Hemolytic anemia
79

Pregnant lady with anemia, best Ix=CBC

IDA in pregnancy=Sr. ferritin [Because TIBC gives false value.]
65Y old pt. diagnosed with severe aplastic anemia, HLA compatible sibling
available, the best option of Rx is=Anti-Thymocyte Globulin (ATG)
followed by cyclosporine
Consider age as top factor in such scenarios
ATG, cyclosporine=1st line for non-severe AA or severe AA but age >40Y or
severe AA but HLA identical donor NA
HSCT (transplant)=1st line for severe AA with HLA matched donor available
Man with weakness and dysphagia, blood picture with target cells=IDA
If CF-IX not available=FFP
Cryoprecipitate for CF-VIII
Washed RBCs used for prevention of=HSR
Transfusion reaction occurs if A+ transfused with=AB (-)

▌Respiratory System:
Carbon laden macrophages=Anthracosis
Chronic bronchitis=Persistent cough + sputum production
Pink puffer=Emphysema
Blue bloater=Chronic bronchitis
MC histology in lung tumors=Adenocarcinoma
ILD with non-caseating granulomas + hilar LNs=Sarcoidosis
Septicemia on ventilator support, CXR shows opacity=Diffuse alveolar
hemorrhage
Caplan’s syndrome usually affect=Coal workers
Coal→pneumoconiosis→Caplan’s syndrome
Pt. with cough and cyanosis=↑Conc. of deoxygenated Hb
Mesothelioma=Asbestosis

▌Gastrointestinal System and Accessory Organs:

Betel nut chewing=Submucosal fibrosis***
Gastric lymphoma associated with=H. pylori gastritic
In erythema migrans=Filiform papillae absent [aka Geographic tongue/Oral
erythema migrans/Benign migratory glossitis
Corrugated plaques lateral surface of tongue=Hairy leukoplakia
Regarding IBD=Cobblestone appearance>Perianal lesion
MCC of premalignant change in mouth in adults=Lichen planus
Prefrence02=Chronic ulcer

Severe liver disease with bleeding disorder, Mx=FFP

Dx liver abscess=CT scan
Amoebic liver abscess=Serology
MCC of fatty liver=Obesity, PEM
ALP (obstructive jaundice) d/t=Stone
Pregnant lady with jaundice, she went to remote village to see her parents;
cause=Hepatitis E
80

Commonest hepatitis=Hepatitis A
Epidemic/Remote area/Pregnancy=HEV
Cause of edema in cirrhosis=Portal HTN
Raised AFP=HCC
A person with some changes in eyes, HBsAg and Anti-HCV are (-), Ix=Sr.
ceruloplasmin
Enzyme may fall in liver injury=Pseudo-AChE
MCC of HCC in developing countries=Both HBV and HCV
If both not present in same option then prefer HBV
HBV=Carcinoma
HCV=Chronicity
HCV cause HCC after causing cirrhosis but HBV can cause HCC both
directly and indirectly after cirrhosis.
Pregnant lady with CBD obstruction, diagnostic Ix=GGT
For nonpregnant/male=ALP

Pt. with abdominal pain, US shows fluid filled spaces in pancreas=Sr. lipase
MC exocrine pancreas tumor=Ductal adenocarcinoma

▌Urinary System:
ARF, which part of nephron affected=PCT
Autopsy findings of CRF pt.=Hypertrophied parathyroid glands
Proteinuria in AGN=BM defect
Dialysis done when GFR decreases to=5%
Spread of renal tumor=Renal vein
Carcinoma spreads to large vessels=Clear cell carcinoma of kidney
Can even reach to heart via IVC
CRF, most unlikely=Hypophosphatemia
Mesangialization of capillary BM is most closely associated with=MPGN
Mesangialization=Thickening of glomerulus mesangium d/t deposits
MPGN/Mesangiocapillary glomerulonephritis=Both thickening of
mesangium and GBM
Membranous glemrulonephritis=Only GBM thickening
3 types of MPGN:
1.Mesangiocapillary GN; Immune-complex mediated
2.Dense Deposit disease; dysregulated AP of complement
3.Type 3 MPGN
Recurrent infection in elderly=Urinary tract obstruction
Infantile PCKD d/t=Nonunion of mesonephros and ureteric bud
Acute nephritis=PSGN
EM granular appearance=Membranous GN
Cause of edema:
Nephrotic syndrome=Hypoalbuminemia
Nephritic syndrome=Salt retention
HF=↑capillary pressure 2˚ to ↑venous pressure
Carcinoma UB=S. hematobium
81

Hyperoxaluria=↓Blood Ca2+ to form Ca.oxalate

Child with h/o sore throat, after 3 weeks develop edema and hematuria,
cause=PSGN
Least chances of renal stones associated with=Hyperlipidemia

▌Reproductive System:
Epidemiological studies to determine potential risk factors for development of
penile SIN. It is observed that persons who develop this disease are elderly
men. Their medical Hx reviewed. Which of the following diseases most
likely to be found to precede development of penile neoplasia in these
men=Phimosis
Circumcision is well established and effective prophylactic measure against
penile cancer.
Ca. prostate with bony mets=Sr. Acid phosphatase
↑AFP=Embryonal carcinoma
A tall man with normal external genitalia, married but had no kids. He had
normal ejaculation period, semen analysis showed azoospermia, possible
cause=Sertoli cells
Married man with no kids was diagnosed as sterile with azoospermia, IOC=Sr.
FSH & LH
Pt. with testicular mass, diagnosed as yolk sac tumor. FU marker=AFP

Pre-eclampsia triggering factor=Endothelial alteration

Full term pregnancy, fever with chills, watery discharge=Chorioamnionitis
Indirect cause of maternal mortality=Heart diseases (Review MMR & causes)
MC obstetric death in our country=Hemmorrhage
Cause of death of females apart from obstetric causes in our country=Domestic
violence
Amniocentesis done at term with baby’s head at station -2, needle will
pierce=Posterior fontanelle
Common cause of subfertility=Anovulation
Intraepithelial lesion of vulva=Paget disease
18Y daughter of mother who received DES (diethyl stilbestrol) in her first
trimester, presents with foul smelling PV discharge, o/e growth arising from
upper 1/3 of anterior vaginal wall. The most likely lesion=Clear cell
carcinoma
DES is known RF for=Clear cell carcinoma vagina
The most striking lesion in glomerular vessels in pregnancy induced
HTN=Fibrin deposits
Woman with abdominal distention, SOB; o/e abdominal mass, ascites, right
sided PE. Dx=Meig syndrome
Recurrent abortion, not corrected after FFP=APS
Least likely cause of abortion in 17-20W=Fetal cytogenetic abnormality
Karyopyknotic index (aka Maturation index) in females is for=Cervical
dysplasia
82

MC tumor of ovary producing estrogen=Granulosa cell tumor

FSH acts in granulosa cells→↑activity of aromatase enzyme→conversion of
testosterone to estrogen via short pathways
Premalignant lesion localized to vulva is most likely=Paget disease
Atypical endometrial hyperplasia=Precancerous lesion, presents with
irregular bleeding and confirmed by histopathology
Leiomyoma=Typical whorled appearance of smooth muscle bundles, it
undergoes red degeneration during pregnancy, present with severe pain
Solid tumor with fibrous tissue, transitional epithelium and theca cells,
histopathology uterus shows endometrial hyperplasia. Most likely
tumor=Brenner [Urothelium within ovarian tumor]
Characteristic lesion in eclampsia=Generalized microthrombi in arterioles and
capillaries
Young lady evacuated uterus for missed abortion few weeks back, since then
she developed irregular spotting with foul smelling PV discharge, o/e small
growth in vagina seen, o/Ix βHCG is 5X more than expected at weeks of
gestation. Most likely Dx=Choriocarcinoma
Common carcinogen in Ca. cervix=HPV
Dx tumor marker ca. ovary=Ca-125
Tumor with all germ layers=Teratoma
Ovarian counterpart of testicular seminoma=Dysgerminoma

▌Breast & Endocrine Glands:

Breast, peau de orange appearance=Lymphedema
Ductal cell carcinoma=Poor prognosis Her2neu

Acromegaly=↑GH in adults
Gigantism=↑GH in children before epiphyseal closure
Female w/h/o profuse PPH failed to breast feed her baby. Most likely
Dx=Shehaan syndrome
SIADH=Hypo-osmlar overhydration

Which of the following thyroid disease has highest incidence of

malignancy=Nonfunctioning thyroid nodule
40Y old k/c of hypothyroid with mass, on FNAC ↑lymphocytes=Thyroid
lymphoma
k/c thyrotoxicosis presents with ↓VA and visual field defects=Optic nerve
compression
Hashimoto’s disease=Autoimmune, Hypothyroidism
B/L exophthalmos, anti-thyroid antibodies=Grave’s disease
A female with hoarseness of voice, mild dysphagia, neck mass; tumor
marker=Calcitonin [Tumor marker of Medullary thyroid carcinoma]
No bony mets=Medullary thyroid carcinoma
Medullary thyroid carcinoma=Calcitonin

1˚Hyperparathyroidism=Adenoma
83

Pseudohyperparathyroidism=Defective end organ responsiveness to PTH

Addison’s disease=↑Melanin pigmentation

Albinism, vitiligo=↓Melanin pigmentation
VMA in urine=Phaeochromocytoma
30Y male newly diagnosed with HTN, ECG shows ventricular hypertrophy,
Sr. cholesterol 200mg/dL, FBS 88mg/dL, urinary sugar +4, RFTs normal, K
2.5 mmol/L, Na 140 mmol/L, cause of HTN=1˚ hyperaldosteronism

▌Head & Neck, Eyes, Otorhinolaryngology:

MC salivary gland tumor=Parotid gland
Painless superficial parotid tumor; on histopathology no capsule, pseudopod
growth=Pleomorphic adenoma
Superficial parotid gland tumor, painless, on histopathology no capsule,
pseudopod growth=Mucoepidermoid
Preference02=Pleomorphic adenoma—it also doesn’t have true capsule but
surrounded by pseudofibrous capsule; mark it when mucoepdermoid not
given in options
Which tumor invades neural sheath of peripheral nerves=Ex-pleomorphic
adenoma

Better hearing in noisy environment=Osteosclerosis

▌Skin:
A person with malignant melanoma, risk factor is=Prolonged sunlight
exposure
SCC=Keratin pearls, prickle cells
Behcet’s disease=Skin blisters, chronic mouth ulcers
EM (erythema multiforme)=Target lesions (Bull’s eye)
Painful papules in labia=HSV2
TB ulcer=Undermined edges
Premalignant lesion=Compound naevus
BCC, most likely=Locally malignant
Locally malignant tumor=BCC & Carcinoid
Carcinoma doesn’t show distant mets=BCC
Senile/solar/actinic keratosis=SCC
%age of malignant transformation in Lichen planus=1-10%
Highest occurrence of malignant changes in nevus=Congenital giant nevus
Person with malignant melanoma, risk factor=XP

▌Musculoskeletal System:
Ewing sarcoma=Small blue cells
Blue sclera and brittle bones=Osteogenesis imperfect
OI pts. can not BITE= Brittle Bones, I(Eye)=Blue sclera, Teeth=Dental
imperfections, Ear=Hearing loss
Albert bone disease=Brittle bones
84

Osteomalacia=Vitamin D deficiency
Rickets=Failure of osteoid tissue to calcify
Acute gouty arthritis=Uric acid deposits
Pt. with bone pain, Ca2+ (N), ↑ALP=Paget’s disease
Ca2+ PO4 PTH ALP
Osteoporosis
↔ ↔ ↔ ↔
*All normal*
Osteomalacia
↓ ↓ ↑ ↑
[↓Vit.D→↓Ca2+,PO4→↑PTH,ALP]
Osteopetrosis
↓ ↔ ↔ ↔
*Only ↓Ca2+*
Paget disease
↔ ↔ ↔ ↑↑
*Only ↑ALP*
Limb growth affected if #=Epiphyseal plate
2Y child with fever, arthralgia, blindness=Juvenile arthritis
Cell defective in osteoporosis=Osteoclast
Feature of rickets and osteomalacia=↓Bone density
Old woman with swelling on external ear, she is k/c of gout with (-)
birefringent crystals=MSU

▌Neuropathology:
Neurofibromatosis=Café O Laite spots
Acoustic neuroma=Vestibular component CN8
Meningioma=MC radiation induced tumor
Progressive decline in recent memory, neurofibrillary tangles=Alzheimer
disease
Unilateral painless bulging of eye, normal blood profile, radiological
studies=Glioma of optic nerve
MC site of obstruction for hydrocephalus=Aqueduct of Sylvius
85

10. BIOSTATISTICS
& ETHICS
86

In order to prevent complication of procedure/intervention what must be

done=Doctor should not cross his competency level
A pharma representative comes to you and offers 3Ds trip to Thailand. he tells
you that there will be an academic panel discussion in your hospital about a
newly launched drug and ask you to take part in it, what will you do?=Ask
you hospital administration what to do
A student wanted to study relationship between increased temperature and
duration of surgery, to evaluate results which statistical test he should
apply=Regression analysis
Frequency distribution=Tells distribution of value appearing in data
Information care session is for=Clears myths and misconceptions of patient
and relatives about disease
A normal healthy individual is=Who eats, sleeps and exercise regularly and
lead a disciplined life
Vomiting present or absent=Nominal (Yes/No or Present/Absent means
nominal.)
A doctor divided some peoples on age basis and then randomly
allocated=Stratified random sampling
In doctor-patient relationship, first and foremost is=Mutual trust
Chi-square is used to measure=Statistical analysis
Data on smaller study on one group of people is combined with data from
larger study. What type of data is this=Meta-analysis
You did a study, it rejected null hypothesis, it means=There is difference
Hypothesis for anti-hypertensive drug, your research has rejected null
hypothesis=Your hypothesis accepted
In a study about DM between 2 groups it was found women with mean of
200±50, men with mean of 205±10=Women with low mean and high SD
Maternal mortality in Pakistan compared to developed countries=100X more
Referral system means=Sending to a better higher facility
Definition of reliability of test=Ability of test to produce repeatable results
Extent to which test measures what it was originally designed to
measure=Validity
Most important test for judging prognosis of disease=Positive predictive value
Test to rule out disease=Sensitive [a test with higher sensitivity when negative
rules out disease.]
Sensitivity and specificity is for=Diagnosis and exclusion of disease
Psychological stress is d/t=Economic viability
Main pillars of medical ethics=Autonomy, beneficence, maleficence, justice
Factor having positive impact on positive prediction value of test=True
positive
A team of cardiologists investigating the relationship between MI and activity
level during 24H preceding the attack in 1200 mean aged 50-75Y. Activity
level was classified as heavy, moderate & mild exertion. Results show heavy
exertion in 50%, moderate exertion in 35% and mild exertion in 15% cases.
Which graph is appropriate to display this data=Pie diagram
87

►Clue: when sum of all values given is 100 and none of them is zero then
answer is pie chart.
20% receiving HRT, 40% not. Best way to present data=Pie diagram [When
categories are given and their sum is 100 then=Bar chart]
Risk measurement between exposed vs non-exposed=Cohort study
How to study rare diseases=Case control studies
Doctor randomly selects 200 pts. of hemorrhoids. 100 had surgery, 100 had
high fiber diet. After a period of 1Y, doctor observed that pts. who had
surgery respond well with having P <0.01. Type of study=Prospective cohort
study
Typical case control studies scenario=Disease present and disease not present
Confidentiality can be breached=When pt. authorizes
Medical ethics=Moral code of conduct for professional doctors
SD taken with mean, check=Variability
Curve of normal distribution=Gaussian curve
SD shows=Variability among individual observations
Sick role=Exemption from normal duties and obligations
How can doctor provide better management to patients=By better
communication
Breaking a bad new:
Present information in a crispy and acceptable way (preferred)
Should be told to pt. in a formal session exclusively
For efficient doctor-patient relationship best way to start conversation
by=Asking name, age, address
Study in which every person of population has equal chance of being
selected=Random sampling
Counselling in patients is=To help themselves
A young girl who is going to die, asks you “Am I going to die?”, doctor’s
response should be=What your parents have told you?
How good is a test at correctly diagnosing peoples with a condition, this
features qualifies=Sensitivity
Screening is done=To detect disease at its early stage
Confidence interval=Mean with standard error of mean
Positive predictive value affected by=Prevalence of disease