1st year mbbs curriculum (revised 2017) · 2019-08-05 · 4 guidelines: 1st year mbbs curriculum...

1

1st Year

MBBS

Curriculum

(Revised 2017)

National University of Medical Sciences

Pakistan

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Contents

Module No Section No Subject Page No

Module-I

Section-I Anatomy 09

Section-II Physiology 18

Section-III Biochemistry 28

Module-II




Module-III




Table of Specifications

Anatomy 115

Physiology 117

Biochemistry 119

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MBBS PROGRAMME AT NUMS Vision: We strive to inspire nationally and internationally by pursuing excellence in medical

education, research and patient care to meet the evolving healthcare needs of the

nation and the region through Professionalism, Excellence and Teamwork.

Mission: Our mission is to:

Create and nurture a diverse community of the best people as key members of

the medical community, whether in clinical practice, medical education,

research or as leaders of the health-care system, serving both the uniformed

and the nation at large.

Produce socially accountable competent doctors who will make a significant

contribution to the health of the community through evidence-based healthcare.

Attract best faculty who can contribute to the quality of medical education and

research.

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Guidelines: 1st Year MBBS Curriculum

Preamble.

This curriculum meets the standards of Pakistan Medical and Dental Council, Higher Education

Commission of Pakistan, and World Federation of Medical Education, so that our students, on

completion of program have required competencies as defined worldwide in a graduate doctor.

The curriculum for 1st year MBBS has been reviewed by faculty of constituent/affiliated colleges

in collaboration with Academic Directorate of NUMS.

Model.

NUMS curriculum, revised 2017, is based on SPICES model of educational strategies. It is

student centered, problem based, integrated, community oriented and systematic. Our

curriculum is evolved taking into consideration traditional, experiential, behavioral, and

constructivist perspectives of curricula.

Organization.

The curriculum of 1styear MBBS is modular. It is organized and the content taught is integrated

concurrently in themed modules. The themes form the building blocks of this curriculum. There

can be vertical thread of content across more than one module for the content that does not fit

into central theme of a module. In each module the sequencing of the content is subject based.

Modules.

The key detail is as follows

1. There shall be three modules in an academic year.

2. Each module shall have a title. The name shall represent the content taught and learned

the majority of time in that module.

3. The duration of three modules shall be 8 – 10 weeks each.

4. The syllabus shall be integrated horizontally around systems of the body.

5. Additional chunks of content may be added in a module that exactly does not fit in the

central theme of the module.

6. There can be vertical thread of a content across more than one module for the content

that does not fit into central theme of a module

7. There shall by vertical integration to the extent decided by the medical college.

8. Total Contact Hours of each subject as per PM&DC is under: -

5

Subject Contact Hours

Anatomy 250

Physiology 250

Biochemistry 160

Pathology 15

Community Medicine 15

Medicine & Allied 15

Surgery & Allied 15

Radiology 05

Behavioural Sciences 10

*Subject is not assessed in FIRST Professional examination

Educational strategies:

The educational strategies overarching the curriculum shall be:

Student centered

Integration

Problem based

Structured

With component of community based and electives

Teaching and Learning methods (MIT)

Multiple learning strategies are used. Interactive lectures are used to provide students entrance

to topic needing much effort by the student to understand subject matter. We have used

Problem based learning to integrate basic and clinical sciences, and give a learning experience

that is contextual, realistic, and relevant. Small group discussions encourage students to social

learning bring their concepts and learning to be discussed and schemas corrected and refined.

Working in labs provides experiential, hand on learning.

Time table / Structured Training Program

The colleges shall make their own structured training program, taking care of recommended

teaching hours in a subject as described by PM&DC.

Internal Assessment.

During the module the students shall be continually formatively assessed. The weightage of

internal assessment shall be 10 % in 1st professional MBBS Examination. There shall be three

modular and one pre -annual examination. The scores of tests at the end of each modular

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assessment and pre-annual examination shall be used for calculation of the internal

assessment.

Module and Pre-Annual Examination

There will be three module examinations, one at the end of each module.

There will be only one Pre-annual examination.

The structure of the paper of all the module examinations and pre-annual will be same as that

for annual examination though syllabus will be different.

The syllabus for modular examination will be announced by the department at least 02 weeks

prior to examination.

Pre-annual examination will be from whole syllabus.

The date sheet for Module and pre-annual examinations will be published by Examination

branch of college while the examinations will be conducted by respective department.

The result will be submitted to NUMS examination branch for incorporation in internal

assessment before annual examination

Annual Professional Examination.

The University shall take the 1st professional Examination as per PM&DC guidelines at the end

of the academic year. Each subject section has table of specification of Module, Pre-annual

and Annual examination. Annual Theory & Practical Examination shall be of 200 marks each

in; Anatomy, Physiology and Biochemistry. The pass score shall be 50% in theory and practical

separately. The detail marked distribution of 1styear is as under

S/N Subject MCQs PBQs/ SAQs/SEQS

Int Assess

Sub Total

Oral & Practical

Int Assess

Sub Total

Grand Total

1 Anatomy 25 65 10 100 90 10 100 200

2. Physiology 25 65 10 100 90 10 100 200

3. Biochemistry 25 65 10 100 90 10 100 200

600

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STRUCTURED SUMMARY OF MODULES-1st YEAR

MODULES BLOCKS

THEMES ANATOMY PHYSIOLOGY BIOCHEMISTRY

Y1M1

1. Introduction 2.Cells and genetics 3. Blood 4. Loco motor (Upper limb)

Gross anatomy Upper limb General Anatomy General anatomical terms Bone Joints Muscular system Nervous system-I (Introduction) Embryology Mitosis and meiosis, Gametogenesis Ovulation &Implantation 1st week of development 2nd week of development 3rd week of development Histology Cell (Introduction, staining, cytoskeleton, cell junctions) Surface and glandular epithelium Connective tissue(General) Bone Cartilage Muscle

Cell, transport and general physiology + Genetics Nerve and membrane potential Muscle physiology Blood Immunity

Chemistry of Protein Nucleotides and Nucleic Acid Porphyrins & Hemoglobin Biochemistry of Cell & Biological membrane

Y1M2 1.Thorax 2.Cardiovascular system

Gross anatomy Thorax Embryology Embryonic period, Fetal period Placenta and fetal membranes Twining CVS Histology Circulatory System Immune system General Anatomy Lymphatic system Circulatory system

Cardiovascular Physiology

Chemistry of carbohydrates Chemistry of Lipids Enzymes Body Fluids Minerals & Trace Elements

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Y1M3 Lower Limb Respiratory System

Gross anatomy Lower Limb General Anatomy Skin Fascia Vertebral column Nervous system-II Embryology Birth defects Body cavities Respiratory system Muscular System Skeletal system except head and neck Development of limbs Histology Respiratory system

Physiology of respiration Deep sea physiology Aviation/space physiology High altitude physiology Exercise physiology

Nutrition Water soluble vitamins Fat Soluble vitamins

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1st Year MBBS Curriculum MODULE-I

Section-I Anatomy

10

Summary:

Code Y1M1

Name Anatomy

Duration 10 weeks

Broad Themes of Module (Theme: a subject that is being integrated a majority of time of module)

Introduction 2. Cells and genetics 3. Blood 4. Loco motor (Upper limb)

Subject Themes

Gross anatomy Upper limb General Anatomy General anatomical terns Bone Joints Muscular system Nervous system-I (Introduction) Embryology Mitosis and meiosis, Gametogenesis Ovulation &Implantation 1st week of development 2nd week of development 3rd week of development Histology Cell(Introduction, staining, cytoskeleton, cell junctions) Surface and glandular epithelium Connective tissue(General) Bone Cartilage Muscle

Prerequisite Module None

Mode of Information Transfer:

MIT

Lectures

Dissection

Demonstration

CBL

Practical

Dissection movies

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Anatomy learning outcomes:

GROSS ANATOMY

Topic Learning Objectives Students should be able to:

MIT (Mode of information transfer)

GROSS ANATOMY UPPER LIMB Bones of upper limb

Identify important bony land marks of Scapula

Describe the attachment of muscles& ligaments of Scapula

Identify important bony land marks of Clavicle

Describe the attachments of muscles and ligaments of clavicle.

Identify important bony land marks of Humerus.

Identify the different types of fractures of humerus and nerve injuries

Describe the attachment of muscles & ligaments of Humerus

Identify important bony land marks of radius &Ulna.

Describe the attachments of muscles & ligaments of radius and Ulna

Identify the common sites of fractures of radius &Ulna.

LGIS/ Demo

Breast Knowledge

Discuss the structure and divisions of breast tissue

Discuss importance of fibrous septa

Discuss its blood supply and venous drainage

Discuss lymphatic drainage of each quadrant of breast

Discuss the importance of sentinel lymph node

Describe supernumerary and retracted nipples

Describe breast abscess and CA breast

LGIS/ Demo

Scapular region Knowledge

Describe muscles connecting the upper limb to thoracic wall

Describe muscles connecting the scapula to humerus

Discuss origin insertion, nerve and blood supply of these muscles

Identify the boundaries of quadrangular and triangular spaces

Identify structures present in these spaces

Discuss arteries and nerves present in this region Skill

Study prosected specimen and identify the muscles of this region

LGIS/ Demo

Acromioclavicular and sternoclavicular joint

Knowledge

Describe formation, ligaments and articulation of these joints

Discuss scapulohumeral mechanism

Discuss blood supply and nerve supply of these joints

Discuss injury and dislocation of these joints

LGIS/ Demo

Shoulder joint Knowledge

Describe movements, ligaments, nerve supply & blood supply of Shoulder joint

Describe arterial anastomosis around shoulder joint

Describe the Dislocation of shoulder joint

LGIS/ Demo

12

Explain Rotator Cuff & enumerate the injuries to it.

Discuss rotator cuff tendinitis

Describe rupture of supraspinatus tendon

Discuss dislocation of shoulder joint

Discuss shoulder pain Skill

Perform movements of shoulder joint

Study the model of shoulder joint and mark its ligaments and rotator cuff muscles around it

Axilla Knowledge

Describe the boundaries & contents of Axilla

Describe the relation of cords of brachial plexus

Describe injury to the Axillary Vein and artery

Describe axillary lymph nodes, their location, division and area of drainage

Discuss lymphangitis and lymphadenitis

Describe the importance of axillary lymph nodes in CA breast

Skill

Study prosected specimen and models of axilla

LGIS/ Demo

Arm

Knowledge

Discuss anterior and posterior compartment of arm and structures present in it

Discuss origin, insertion of muscles of anterior and posterior compartment of arm

Discuss blood supply and nerve supply of these compartments

Skill

Study the models and prosected specimen of arm and identify the structures present in this region.

LGIS/ Demo

Elbow joint Proximal and distal radioulnar joints

Knowledge

Describe the type, capsule and ligaments of these joints

Discuss the movements of these joints

Discuss muscles performing these movements

Discuss blood supply and nerve supply of these joints

Describe the anatomical significance of carrying angle

Discuss dislocation and clinical correlation of these joints

Discuss structures getting damaged in elbow joint dislocation

Skill

Perform movements at elbow joint and discuss the muscles involved in these movements

Study the models of elbow joint and recognize the bones and ligaments forming the joint

LGIS/ Demo

Cubital fossa

Describe the boundaries of cubital fossa

Enlist the contents of cubital fossa and their arrangement

Discuss the importance of structures present in cubital fossa

Skill

Mark the boundaries and contents of cubital fossa on a model

LGIS/ Demo

13

Forearm Knowledge

Discuss contents of anterior lateral and posterior fascial compartments of forearm

Discuss muscles of these compartments and their blood supply

Discuss the course of nerves and arteries present in this region

Discuss boundaries of anatomical snuff box and its importance

Describe flexor and extensor retinaculum

Discuss clinical correlations of this compartment including tennis elbow

Skill

Study prosected specimen of forearm and identify muscles, blood vessels and nerves present in this region

Study the models of forearm and discuss origin and insertion of muscles

Mark the extensor and flexor retinacula on the model

LGIS/ Demo

The region of wrist and palm of hand

Knowledge

Discuss bones of Hand

Describe functions of muscles in Thenar, Hypothenar & Central compartments

Describe the fibrous sheaths of the digits of the hand

Discuss the anatomical structures involved in Tenosynovitis

Describe Palmar aponeurosis

Enumerate fascial spaces of Palm

Describe boundaries & contents of spaces of palm

Discuss clinical importance of spaces of palm

Discuss wrist joint

Explain the movements at wrist joint

Discuss ligaments of wrist joint and its relations

Discuss the anatomical structures involved in Wrist fractures

Explain the formation of Carpal tunnel and its contents

Explain the Carpal tunnel syndrome

Describe the course & branches of nerves in Hand

Discuss metacarpophalangeal and interphalangeal joints of hand

Skill

Perform movements of wrist joint and recognize the muscles involved in these movements

Study the model of hand to visualize muscles of hand and insertion of long tendons

Study prosected specimen of hand to identify muscles and blood vessels of hand.

LGIS/ Demo

Nerves of upper limb & brachial plexus

Knowledge

Describe formation of Brachial Plexus with emphasis on Cords, Roots & trunk

Discuss injuries of the brachial plexus: Klumpke paralysis & Erb-Duchenne palsy

Describe formation, distribution & important relations of following nerves:

LGIS/ Demo

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Axillary nerve Musculocutaneous nerve Median nerve Radial nerve Ulnar nerve Describe the innervation of each compartment and the specific deficits that occur with lesions of individual nerves at different parts along the course of following nerves: Musculocutaneous nerve Median nerve Radial nerve Ulnar nerve discuss the anatomical sites of lesion of nerve correlating them to sensory and motor loss within area of distribution

Cutaneous nerves of upper limb

Knowledge

Describe the cutaneous innervation of the arm, forearm and hand.

Compare and contrast dermatomes with the cutaneous innervation of specific nerves in Arm & forearm

Skill

Draw & label cutaneous innervation of lower limb

Draw & label the dermatomes of lower limb

LGIS/ Demo

Blood supply of upper limb

Knowledge

Discuss the course, extent & branches of Axillary, Brachial, Ulnar and Radial arteries

Describe the anatomical sites of lesion of artery correlating them to ischemia within area of distribution

Describe the formation of Superficial and Deep Palmar Arches in hand

Describe the structures involved in Laceration of Palmar Arches

Describe the formation & drainage of following Veins:

Axillary vein

Basilic vein

Cephalic vein

Median cubital vein

Discuss the importance of Median Cubital Vein in venipuncture

LGIS/ Demo

Lymphatic drainage of upper limb

Discuss the lymphatic drainage of upper limb in detail LGIS/ Demo

DISSECTION Perform dissection to identify main muscles of scapular region along with their nerve supply Perform dissection to identify main muscles of arm along with their nerve supply Perform dissection to identify main muscles of forearm along with their nerve supply. Perform dissection to identify main muscles of hand along with their nerve supply Perform dissection to identify muscles forming boundaries of cubital fossa

Dissection

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Perform dissection to identify contents of cubital fossa

IMAGING Identify the common sites of fracture on radiographs correlating its predisposition to fracture in the following bones: Scapula Clavicle Humerus Radius Ulna Identify the bones and bony articulations of upper limb on AP and Lateral view of Radiographs

Demo

EMBROLOGY

MITOSIS & MEIOSIS Define Meiosis Differentiate first and second meiotic divisions. State the phases of meiotic divisions. Justify the importance and result of meiosis in both sexes Differentiate between mitosis and meiosis. Describe the structure abnormalities in chromosomes like Euploid, Aneuploid, Trisomy, Non-disjunction, Translation Correlate the structure abnormalities with clinical conditions like: Down’s syndrome Klinefelter and Tuner syndromes

LGIS

GAMETOGENESIS-I Describe the events of spermatogenesis. Describe the morphological changes during maturation of the gametes Enlist the differences between spermiogenesis and spermatogenesis

GAMETOGENESIS-II Define the ovarian cycle Describe the stages of follicular maturation primary preantral, secondary, preovulatory, Explain the hormonal control (FSH, LH) of ovarian cycle Discuss the transport of ovum from the surface of ovary to ampulla of fallopian tube

LGIS

OVULATION & IMPLANTATION

Define fertilization State normal site of fertilization Describe the results of fertilization Mentions the factors affecting fertilization Enumerate the changes that occur in spermatozoa before fertilization Explain the factors affecting penetration of sperm through the zona pellucida for formation of Pro nuclei Discuss the formation of zygote Correlate the transport of zygote from ampulla of fallopian tube to the uterine cavity and cleavage Explain the formation of blastocyst

LGIS

1ST WEEK OF DEVELOPMENT

Explain the formation of outer and inner cell masses Discuss the further development of outer cell mass (trophoblast), Differentiate syncytiotrophoblast and cytotrophoblast with its microscopic appearance Describe the process of implantation (day wise change)

LGIS

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2ND WEEK OF DEVELOPMENT

State the differentiation of embryonic pole and development of bilaminar germ disc with formation of Epiblast and hypoblast, their cavities (amniotic cavity and primary yolk sac) Discuss the development of the chorionic sac and formation of primary chorionic villi and growth of syncytiotrophablast Explain the establishment of utero placental circulation Explain why the second week is known “ as week of two’s”

LGIS

3RD WEEK OF DEVELOPMENT

Define gastrulation (formation of three germ layers) Discuss the development of primitive streak and related congenital anomalies (Sacrococcygeal teratoma) Describe the development of notochordal process, notochord canal, prechordal plate and cloacal membrane Define Neurulation List the steps of development of Neural Tube Enumerate the derivatives of Neural Crest Cells State the congenital anomalies resulting from abnormal neurulation Describe the formation of three germ layers and enlist their derivatives Differentiate three components of Mesoderm (Paraxial, Intermediate and Lateral Plate Mesoderm) Define Somites

LGIS

HISTOLOGY

CELL (INTRODUCTION, STAINING, CYTOSKELETON, CELL JUNCTIONS)

KNOWLEDGE Identify parts of Light Microscope Discuss the working & magnification of Light Microscope Identify different types of Microscopes and their functions Define resolution Describe the steps involved in tissue processing Define cell, identify various types of cells and shapes Define Cytoskeleton. Enumerate the cell junctions and describe their histological structure SKILL Identify and draw the different parts of microscope and illustrate their usage. Focus the prepared slide at different magnifications. Identify the different shapes of cells and their examples Draw a labelled diagram of different types of shapes of cells

LGIS Lab

SURFACE & GLANDULAR EPITHELIUM

Classify the body tissue into categories Define Epithelium Classify various types of Epithelium Discuss general features of Epithelial cells (basal, apical and lateral surfaces) Explain the different types of epithelium with examples Describe glandular epithelium Differentiate the structure of serous and mucus secreting cells SKILL Identify the different types of Epithelia and their examples Draw a labelled diagram of different types of simple and stratified epithelia

LGIS Lab

17

Identify mucous and serous acini with haematoxylin and eosin Draw a labelled diagram of mucous and serous acini with haematoxylin and eosin

CONNECTIVE TISSUE (GENERAL)

KNOWLEDGE Explain the components of connective tissue Describe different types of cells in connective tissue Describe different types of fibers in connective tissue Discuss various constituents of ground substance Classify various types of connective tissues Describe the histology of different types of adipose tissue SKILL Identify the microscopic structure of loose connective tissue, dense regular and irregular connective tissue Draw a labeled diagram showing the microscopic structure of loose connective tissue, dense regular and irregular connective tissue with haematoxylin and eosin Draw a labeled diagram of the connective tissue with haematoxylin and eosin

LGIS Lab

BONE KNOWLEDGE Describe microscopic features of bones and types of ossification Enlist the location of different types of bones

SKILL Identify different types of bone microscopically Draw a labelled diagram showing the histological structure of different types of bone with hematoxylin and eosin

LGIS Lab

CARTILAGE KNOWLEDGE Describe microscopic features of various types of cartilage SKILL Identify different types of cartilage microscopically Draw a labeled diagram showing the histologic structure of different types of cartilage with hematoxylin and eosin

LGIS Lab

MUSCLE KNOWLEDGE Describe the microscopic features of skeletal, smooth and cardiac muscle SKILL Identify the different types of muscle microscopically Draw a labeled histological diagram of different types of muscles with hematoxylin and eosin

LGIS Lab

List of Histology Practical’s- 1st Year MBBS Class first module

Topic

Histology and Its Methods of Study

Epithelial Tissue

Connective Tissue

Muscle tissue

Bone

Cartilage

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MODULE-I

Section-II

Physiology

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Summary:

Code Y1M1

Name Physiology

Duration 10 weeks

Broad Themes of Module

(Theme: a subject that is being

integrated a majority of time of

module)

Introduction

2. Cells and genetics

3. Blood

4. Loco motor (Upper limb)

Subject Themes

Cell, transport and general physiology +

Genetics

Nerve and membrane potential

Muscle physiology

Blood

Immunity



MIT

Lectures

Tutorials (PTT)

CBL

Practicals

Class tests

Physiology learning outcomes:

GENERAL

PHYSIOLOGY

Know the functional organization of human body.

Know the parameters needed for the control of the

‘internal environment’.

Understand the principles of the mechanics of

homeostasis

Able to differentiate between positive and negative

feedback as the control systems of the body

Relate positive and negative feedback system with

common examples

Differentiate between composition of intracellular and

extra cellular fluid

Know the functional organization of human body.

Know the parameters needed for the control of the

‘internal environment’.

20

Understand the principles of the mechanics of

homeostasis

Able to differentiate between positive and negative

feedback as the control systems of the body

Relate positive and negative feedback system with

common examples

Differentiate between composition of intracellular and

extra cellular fluid

GENETICS

54 CELL

PHYSIOLOGY

Comprehend organization of the physical structure of

the cell (cell Membrane, cytoplasmic organelles,

nuclear membrane, nuclear organelles)

Understand the functional systems of the cells

(ingestion, digestion, synthesis, extraction of energy

from nutrients)

Overview movements of cells (amoeboid, ciliary etc)

Know the genes in the cell nucleus

Explain the process of transcription and translation

(synthesis) in the cells

Understand the gene functions performed in the cells

Comprehend the genetic control of cells functions and

cells-reproduction

Classify various modes of transport of substances

across the cell-membrane

Compare and contrast amongst the processes of

osmosis, diffusion, facilitated diffusion, primary active

transport, secondary active transport

Relate the modes of transport with common examples

in human body

Appreciate the physiological significance of the

transport of substances through the cell membrane

55 BLOOD AND

RELATED

DISORDERS

Appreciate the composition of blood and general

functions of blood.

Know different types of plasma protein.

Comprehend composition of plasma protein and their

functions and importance for the human body.

Overview sites of hemopoiesis in the body during

different stages of life along with composition and

functions of bone marrow.

Understand different types of blood cells, their

physiological characteristics with functional differences.

Know the formation, types and functions of hemoglobin

along with its association with different kinds of anemia.

21

Classify anemia its types and causes.

Identify the factors regulating erythropoiesis and

maturation of RBC.

Comprehend basis of immune system of the body and

tissues related with immunity.

Know the types of immunity, mechanism of their

development and characteristics of different immune

mechanisms and significance of vaccination.

Describe the role and functions of white blood cells in

providing protection to the body against injury.

Appreciate the physical and functional characteristics of

different WBCs and physiological significance of

leucopenia, leukocytosis and leukemia.

Comprehend the composition and functions of reticulo-

endothelial system.

Know the principles of blood grouping and

physiological significance.

Identify the various blood groups and hazards of

matched and mismatched blood transfusion with

especial reference to Erythroblastosis fetalis.

Know various processes involved in hemostasis.

Appreciate the characteristics of platelets and their

importance in hemostasis.

Comprehend the physiology of clotting factors and

mechanism of blood clotting.

Know the effect of deficiency of platelets and clotting

factors in hemostasis with clinical significance of

hemophilia.

56 LOCOMOTION Explain different mechanisms of transportation for

maintenance of cellular homeostasis

Understand the basis of development of membrane

potential across excitable membrane.

Know Nernst potential and its importance in generation

of membrane potential.

Comprehend different mechanisms responsible for the

genesis of membrane potential (role of channels,

carrier proteins).

Understand the mechanisms by which different factors

(stimuli) produce changes in membrane potential.

Draw different phases of action potential and explain

ionic changes occurring during each phase of action

potential.

22

Comprehend the response to the application of two

successive stimuli are given during different phases of

action potential (refractory period, its types and

importance).

Classify different types of nerve fibers.

Know generation of nerve impulse and its transmission

in different types of nerve fibers (myelinated and non-

myelinated nerve fibers) with their characteristics.

Know structural and functional changes taking place in

nerve fibers in case those are damaged.

Illustrate functional and histological differences in

different types of muscles.

Draw and label neuromuscular junction, the sequence

of events taking place during neuromuscular

transmission and factors affecting thereof.

Explain the motor unit and its physiological importance.

Appreciate the mechanism of transmission of signals

from the nerve fiber to different muscles. Know the

structure and different characteristics of three types of

muscle.

Appreciate the ionic and chemical basis of muscle

contraction.

Explain the energy expenditure during muscle

contraction.

Understand different phases of muscle contraction and

effect of multiple stimuli on different phases of muscle

contraction.

Comprehend clinical importance of neuromuscular

transmission in patients of myasthenia gravis.

Appreciate the characteristics and differences between

isometric and isotonic contraction, tetanization,

contracture remainder, rigor mortis etc.

Appreciate characteristics of smooth muscle

contraction with their physiological significance.

NERVE AND

MEMBRANE

POTENTIAL

MUSCLE

PHYSIOLOGY

58 IMMUNITY

23

List of Practical:

Module 1

Compound Microscope and study of Neubauer's chamber

RBC count by Neubauer's chamber.

WBC count-TLC

Platelet count. (Demonstration only)

Determination of Haemoglobin in the blood. (Sahili's method)

Red cell indices.

Estimation of haematocrit (PCV).

Estimation of ESR.

Determination of ABO & Rh blood groups.

Estimation of bleeding & clotting time.

DLC.

Osmotic fragility of RBC

Any other practical relevant to that Module

List of Case Based Learning (CBL):

PBL 1

Mr. Zeeshan, a 43 years old mess waiter, reported in medical OPD with complaints of

difficulty in standing for long duration while serving the meals, for last six months. His

general physical examination revealed normal pulse, blood pressure and temperature.

However, the doctor observed drooping of his eye lids. His symptoms ameliorated for

several hours by administering a test dose of neostigmine. Laboratory investigations

confirmed the presence of antibodies to nicotinic acetylcholine receptors in the blood

and end plate potentials recorded on electromyography were weak. CT scan chest

was normal. The physician managed the case conservatively by anticholinesterase

drugs and patient responded to the treatment very well.

Learning objectives:

To learn the physiological basis of:

Skeletal muscle contraction especially for sustained contractions while standing.

Transmission of motor signals to skeletal muscle in nerve fibers.

Neuromuscular transmission at NMJ.

Factors/drugs that effect transmission at NMJ.

Pathophysiology and treatment options of myasthenia gravis.

Resources:

Guyton and Hall Textbook of Medical Physiology, 13th Edition by John E. Hall.

Human Physiology: From Cells to Systems, 8th Edition by Lauralee Sherwood.

Ganong's Review of Medical Physiology, 24th Edition (LANGE Basic Science) by Kim

E. Barrett, Susan M. Barman, Scott Boitano, Heddwen Brooks.

Electronic modes

PBL 2

A 6-year-old boy is brought to the family physician after his parents noticed that he

had difficulty moving his arms and legs after a soccer game. About 10 minutes after

leaving the field, the boy became so weak that he could not stand for about 30 minutes.

24

Questioning revealed that he had complained of weakness after eating bananas, had

frequent muscle spasms, and occasionally had myotonia, which was expressed as

difficulty in releasing his grip or difficulty opening his eyes after squinting into the sun.

After a thorough physical examination, the boy was diagnosed with hyperkalemic

periodic paralysis. The family was advised to feed the boy carbohydrate-rich, low-

potassium foods, give him glucose-containing drinks during attacks, and have him

avoid strenuous exercise and fasting.


To understand Frank-Starling’s law as applied to skeletal muscle mechanics.

To correlate electrolyte influences on skeletal muscle contraction.

To know details of contractile elements of skeletal muscles.

To gain insight into skeletal muscle fuel metabolism.

To understand force velocity relationship of skeletal muscles.

Resources:





Electronic modes

PBL 3

A 32-year-old woman presents to her primary care physician’s office with difficulty

chewing food. She states that when she eats certain foods that require significant

amount of chewing (e.g., meat), her jaw muscles become weak and “tired.” After a

period of rest, her jaw muscles regain their strength until she eats again. The patient

is diagnosed with myasthenia gravis and is started on neostigmine, an

acetylcholinesterase (AChE) inhibitor.


To define concepts of chronaxie and rheobase.

To differentiate between fast and slow muscle fibers characteristics.

To compare skeletal, smooth and cardiac muscle fiber properties.

To compare neuromuscular transmission of skeletal and smooth muscles.

Resources:





Electronic modes

PBL 4

25

A 21-year-old man presents to a rural emergency center with a 1-day history of

progressive stiffness of the neck and jaw, difficulty swallowing, stiff shoulders and

back, and a rigid abdomen. Upon further questioning, the patient reports that the stiff

jaw was the first symptom, followed by the stiff neck and dysphagia. On examination

he is noted to have stiffness in the neck, shoulder, and arm muscles. He has a grimace

on his face that he cannot stop voluntarily and an arched back from contracted back

muscles. The physician concludes that the patient has “tetanic” skeletal muscle

contractions. A 3-cm laceration is noted on his left foot. The patient reports sustaining

the laceration about 7 days ago while he was plowing the fields on his farm. He has

not had a tetanus booster. He is diagnosed with a tetanus infection, and an injection

of the tetanus antitoxin is given.


To understand pathophysiology of tetanic muscle contractions.

To differentiate between concepts of tetany, tetanus and tetanization.

To understand mechanisms underlying muscle fatigue.

To gain insight into latch mechanism of smooth muscle contraction.

To identify factors relating to efficient smooth muscle contraction.

To elaborate hormonal factors governing smooth muscle contraction.

Resources:





Electronic modes

PBL 5

A 14-year-old girl complained of fatigue and loss of stamina. Her appetite was

marginal, as she was very conscious of maintaining her body weight at 96 pounds.

Her monthly menstrual flow was always heavy and long, from its onset at twelve years

of age. Relevant laboratory findings included the following:

Hematocrit (Hct) 28%

Hemoglobin (Hgb) 9 g/dL

Iron 16 µg/dL

Bone marrow iron Absent

Erythrocytes Small and pale

Suggested treatment for this patient of iron deficiency anemia included ferrous sulfate

or ferrous gluconate for six months orally between meals, since food may reduce

absorption. A well-balanced diet was also suggested, as well as a gynecological

examination.

26


To identify various stages of erythropoiesis along with role of various growth and

differentiation inducers.

To develop conceptual understanding of erythropoiesis regulation.

To develop a mind map of iron metabolism in human body.

To critically reflect on working definition of anemia.

To interpret clinical manifestations of anemia.

To identify hematologic picture in various types of anemia.

To elaborate pathophysiology of various types of anemias.

To develop a working knowledge of polycythemia.

Resources:





Electronic modes

PBL 6

A 36 years lady consulted her physician with complaints of generalized weakness,

easy fatigability for the last one year and recent development of sore throat and fever

for 3 days. Her physical examination revealed pulse 98/min, temperature 101 F,

respiratory rate 18/min and blood pressure 120/80 mm Hg. Her throat was red and

congested. Her personal history revealed birth of five children in last 8 years. Her lab

investigation reveal Hb 8.2 gm/dl with hypochromic microcytic RBCs (MCV=62 fl, MCH

21 pg, MCHC 27%), TLC was 16,200/ul with 82% neutrophils, 12% lymphocytes, 4%

monocytes, 1% basophils and 1% eosinophils. She was advised oral antibiotics for

one week and antianemics for 03 months.


To learn the physiological basis of manifestations of illness and body’s immune

response.

To learn the role of various leucocytes in acute bacterial infections.

To correlate fever and increased pulse rate with body’s immune response.

To know the physiological basis of:

Inflammation

Pallor and tachycardia

Weakness & fatigability

To understand the causes of anemia, leucocytosis and deranged DLC.

To learn the mechanism of development of leucocytosis.

Resources:


27




Electronic modes

PBL 7

A 10 years old boy came to OPD with high grade fever, sore throat and dysphagia to

solids for past 04 days. History revealed that he had multiple similar episodes over

past 02 yrs.

On examination, tonsils were swollen and enlarged. Lab. investigations were as under:

Count Showed Normal Values

Neutrophils 80% (60-65%)

Eosinophils 1-5% (1-5%)

Basophils 0-1% (0-1%)

Lymphocytes 30% (20-40%)

Monocytes 1-6% (1-6%)

Lab report shows “neutrophilia”. He was diagnosed as a case of “streptococcal

tonsillitis”.


To develop answers to following queries:

1. Which type of immunity was generated in this patient?

2. Why neutrophil count is increased in this patient? What is their role in this

infection?

3. What are the classical signs of inflammation in above patient?

4. What is the role of helper T- Lymphocytes in streptococcal tonsillitis?

5. How complement system is activated in above scenario?

6. What are types based on morphology of W.B.C’s?

7. Describe briefly the functions of different types of W.B.C.s.

8. What is the role of macrophage/antigen presenting cells in immunity?

9. What are different immune deficiency diseases?

10. What are autoimmune diseases?

11. Discuss briefly Immunization?

Resources:





Electronic modes

28

MODULE-I

Section-III

Biochemistry

29

Summary:

Code Y1M1

Name Biochemistry

Duration 10 weeks




module)

1. Introduction

2. Cells and genetics

3. Blood

4. Loco motor (Upper limb)

Subject Themes

Chemistry of Protein

Nucleotides and Nucleic Acid

Porphyrins & Hemoglobin

Biochemistry of Cell & Biological

membrane



MIT

Lectures

Tutorials (PTT)

CBL

Practicals

Class tests

Biochemistry learning outcomes:

57 Biochemistry of

Cell & Biological

membrane

At the end of the learning of this set, the learners will be

able to

Illustrate and categorize different types of cytological

techniques.

Demonstrate basic techniques to study cell, separation

of materials through centrifugation, chromatography and

microscopy.

Differentiate cell organelles, their structure and

biochemical functions (Mitochondria, Ribosomes, Golgi

Apparatus, Endoplasmic Reticulum, Lysosomes,

Peroxisomes) and associated disorders.

Describe detailed chemical composition of Cell

Membrane and its biochemical significance.

Explain chemistry of receptors and signal transduction

along with the Biochemistry of membrane transport

30

mechanism, active transport, passive transport, simple

and facilitated diffusion.

Chemistry and

structure of

nucleosides and

nucleotides:

On completion of this set the learners will be able to

Appreciate the detailed Chemistry and structure of

nucleosides and nucleotides with their biochemical role,

their derivatives along with their significance.

Describe the Synthetic derivative of purine and

pyrimidines, and their role in health and diseases.

Understand types of Nucleic acids, their structure and

functions.

58 Proteins: By the time the learners finish the course they will be

able to

Explain the structure, functions and classification of

amino acids along with their buffering role in human

body in pH maintenance.

Describe Definitions, Biochemical importance and

classification of proteins based on, Physiochemical

properties, Functional, Nutritional, and structural basis.

Understand the details of Structure of proteins and their

significance.

Contrast the techniques for separation of proteins e.g.

salting out, Electrophoresis, Chromatography, and

Centrifugation.

Explain Immunoglobulins and their biochemical

significance.

Describe chemistry and functions of Plasma proteins &

their clinical significance.

59 Prophyrins and

hemoglobin:

At the end of this set, the learners will be able to

Explain Chemistry and biosynthesis of porphyrins and

their disorders (Porphyrias).

Describe Structures, functions and types of

haemoglobin, Oxygen binding capacity of haemoglobin,

factors affecting and regulating the oxygen binding

capacity of haemoglobin.

Detail the concepts of Degradation of heme, formation

of bile pigments, its types, transport and excretion,

Hyperbilirubinimea, their biochemical causes and

differentiation.

Discuss jaundice and its types, and kernictrus.

understand Haemoglobinopathies (Hb-S, thalassaemia

etc) and their biochemical causes.

31

List of Practical:

List of Case Based Learning (CBL):

Topic: Cell (Leber Hereditary Optic Neuropathy LHON):

A 27-year-old boy presented to ophthalmic OPD with rapid deterioration of vision in

both eyes. He felt blurring of central in right eye eight weeks back which gradually

increased and now developed similar symptoms in other eye. His visual acuity is 6/36

in right and 6/12 in left eye. On fundus examination optic disc showed edematous

retinal nerve fiber layer and telangectatic vessels. A CT scan brain did not reveal any

inflammatory or space occupying lesion before or after optic chiasma. These findings

led the ophthalmologist to suspect LHON.

The buccal mucosa sample was sent to human molecular biology laboratory for

identification of genetic mutation (if any) leading to the condition and confirmation of

provisional diagnosis. The scientists in the lab separated mitochondria from the cells

by disrupting the cells and centrifugation at 700g once and at 12000 g twice for 15 and

5 minutes. Sequencing of MT-ND1, MT-ND4, MT-ND4L and MT-ND6 genes was

carried out and MT-ND1 was found to have point mutation. The diagnosis of LHON

S. No Practical Topics

1. Introduction to use of Laboratory Equipment

Glassware

Spectronic 20

Microlab


Incubator

Water Bath

Hot Oven


Centrifuge Machine

Electronic Balance

pH Meter

4. Types of Solutions, their preparation and clinical significance

5. Experiments on Proteins Qualitative Analysis - I

Biuret Test

Millon’s Test

6. Experiments on Proteins Qualitative Analysis - II

Ninhydrin Test

Aldehyde Test

7. Experiments on Proteins Qualitative Analysis - III

Sulphur Test

Xanthoproteic Test

32

was confirmed. MT-ND1 is the gene spanning 3,307 to 4,262 of mtDNA and encodes

for NADH dehydrogenase of ETC.

RELATED INVESTIGATIONS:

Test Name Result

Visual field testing Central vision deterioration

CT Scan Brain Normal study

Mitochondria are one of the most important cell organelles and work mainly as

powerhouse of the cell. Many of the enzymes of mitochondrial function are encoded

by its own DNA called mtDNA which is inherited purely from mothers. Mutations and

their transfer to next generation is found not only in nuclear DNA but also in mtDNA.

Several diseases have been found to be caused by mitochondrial dysfunction which

is due to mutations in mtDNA and examples include lactic acidosis, mitochondrial

encephalopathy, stroke-like-episodes, LHON and Leigh syndrome.

LEARNING OBJECTIVES:

1. Structure and function of different organelles of the cell.

2. Structure, function and inheritance of mitochondria

3. Techniques for isolation and study of cell components and their importance in

clinical medicine

REFERENCE BOOKS:

1. Lippincott’s textbook of Biochemistry

2. Harper’s text book of Biochemistry

3. Davidson’s Practice of Medicine

Topic: Cell (I- Cell Disease- lysosomal targeting problems)

A female infant with a normal delivery after 38 weeks and normal intrauterine life

showed the physical findings characteristic of I-cell disease. She manifested gargoyle

face, progressive psychomotor retardation, and increased serum levels of lysosomal

enzymes with decreased activities in peripheral blood lymphocytes. The diagnosis

was made by the analyses of lysosomal enzymes. The child died at the age of 2 years

and 3 months due to respiratory insufficiency. By electron microscopy, various-shaped

membrane-bound vacuoles were observed in the cytoplasm of various cells such as

hepatocytes, myocardial muscle cells, epithelial cells of the renal glomeruli, proximal

renal tubular cells, fibroblasts, and chondrocytes. By histochemical analyses we found

that these intracytoplasmic storage vacuoles contained glycosaminoglycan and

proteoglycan.

In general, peripheral blood smears are performed to obtain information with regard to

various morphological features as an aid in the diagnosis of infection or malignancy.

This report presents a patient with I cell disease (inclusion cell disease), a fatal

33

lysosomal storage disorder caused by a defect in an enzyme responsible for the

transfer of mannose-6-phosphate ligands to precursor lysosomal enzymes. As a

consequence, most lysosomal enzymes are transported outside the cell instead of

being correctly targeted into the lysosomes, resulting in the storage of

macromolecules in lysosomes. I cell disease, with its heterogeneous clinical

presentation, can be diagnosed by the presence of intracellular vacuole-like inclusions

in lymphocytes and fibroblasts, high serum lysosomal enzyme activities, and a defect

of N-acetylglucosamine-1-phosphotransferase. This report describes the

morphological aspects of peripheral lymphocytes in a blood smear of a patient, the

first clue to the final diagnosis of I cell disease. The observed vacuole-like inclusions

in lymphocytes of this patient were negative for periodic acid Schiff (PAS) and Sudan

black B staining, in contrast to earlier reports.


1. Structure and function of different organelles of the cell.

2. Structure, function and pathology of lysosomes

3. Enzyme processing and targeting to organelles

REFERENCE BOOKS:


2. Harper’s text book of Biochemistry

3. Davidson’s Practice of Medicine

34

Topic: Nucleic acids (Acute Gout):

A moderately obese 54-year-old male appeared at the emergency department

complaining of severe pain of 10 hours’ duration in his left big toe. He stated that he

was a regular consumer of meat and soda (alcohol and sea food consumption are also

risk factors). He had no other significant medical history. On examination, his left big

toe was found to be red and markedly swollen around the metacarpophalangeal joint,

and exquisitely sensitive. There was no evidence of arthritis elsewhere. Because of

the history and location of the affected joint, the attending physician suspected that

the patient was having an attack of acute gout. She ordered a number of lab tests,

including a white cell count, determination of serum uric acid, and x-ray examination

of the affected joint. The x-ray findings were non-specific; no indication of chronic

arthritis was evident. Findings of other tests are tabulated below. Under local

anesthesia, arthrocentesis was performed on the affected joint and a small amount of

synovial fluid withdrawn and sent to the laboratory for detection of cells and crystals.

Typical needle-shaped crystals of MSU showing negative birefringence were detected

in the synovial fluid.

LAB INVESTIGATIONS:

Test Name Result Normal Values

Serum Uric acid 680 µmol/L Children 120-330

µmol/L

Adult Male 210-430

µmol/L

Adult Female 150-360

µmol/L

ESR 60 mm 1 – 10 mm in 1st hour

WBC Count 11.0 x 10 9 /

L

4.0 x 11.0 x 10 9 / L

RA Factor Negative Negative

Gout is a disease caused by hyperuricemia mostly due to genetic factors while diet

and lifestyle play a minor role in its causation. Uric acid is an end product of purine

metabolism and as it is already near its saturation limit in plasma, minor increase due

to mostly under-excretion from kidney or overproduction leads to its deposition in

crystal form mostly where the solvent is stagnant like synovial fluid of relatively

immobile joints. This crystallization appears first at the most immobile and coldest fluid

body, typically big toe joint space and typically at night because temperature is further

lower at night time and due to sleep and mobility is also further decreased. Crystals in

a smooth lubricated environment play havoc and cause acute inflammatory response

leading to severe pain, redness, warmth and loss of function locally. Moreover, uric

acid deposition in other soft tissues leads to formation of tophi.

35


1. Structure and chemistry of nucleosides and nucleotides.

2. Functions of nucleotides.

3. The biochemical basis of various clinical features

REFERENCE BOOKS:

1. Harper’s text book of Biochemistry.

2. Davidson’s Practice of Medicine.


Topic: Nucleic Acids (ADA Deficiency)

A little girl aged 11 months was brought by her parents to a children's hospital. She

had had a number of attacks of pneumonia and thrush (oral infection usually due to a

fungus Candida albicans) since birth. The major findings of a thorough workup were

very low levels of circulating lymphocytes (i.e. severe lymphopenia) and low levels of

circulating immunoglobulins. The attending pediatrician suspected SCID. Analysis of

a sample of red blood Cells revealed a low activity of ADA and very high level (about

50 times normal) of dATP. This confirmed the diagnosis of SCID due to deficiency of

ADA, the enzyme that converts adenosine to inosine.

The deficiency of ADA is inherited as autosomal recessive and accounts for almost

15% cases of SCID. T lymphocytes express high activity of enzyme normally. Lack of

ADA activity leads to accumulation of adenosine and dATP which is toxic to T cells.

Secondarily B lymphocytes are also affected and lead to impaired humoral immunity.

Defective immune system allows different opportunistic infection to occur and recur.

An example of acquired immunodeficiency is AIDS. Such conditions can be treated

by, antibiotics, fortifying immune system by immunoglobulins and treating the root

cause.


Synthesis, ingestion and fate of nucleotides in human body

Role of Nucleotides in DNA synthesis and outcome of ADA deficiency

The biochemical basis of various clinical features

REFERENCE BOOKS:

Harper’s text book of Biochemistry. (Page 616)

Davidson’s Practice of Medicine.

Lippincott’s textbook of Biochemistry

Topic: Protein Chemistry (Creutzfeldt Jakob Disease)

A 70 years old man reported for the third time in last 3 weeks in medical OPD with

progressive difficulty in walking. He had muscle stiffness, twitching and involuntary

jerks in both legs. This patient was being treated by psychiatrists for depression,

agitation, mood swings, memory loss and thought problems for 2 weeks immediately

preceding the onset of current symptoms. Taking into account the rapid progression

and pattern of symptoms he was provisionally diagnosed as a case of Creutzfeldt

36

Jakob Disease. The findings of MRI, EEG and spinal tap were consistent with the

diagnosis. Patient was put on supportive symptomatic treatment and relatives were

counseled.

The protein misfolding which is contagious from abnormal to normal protein leads to

prion diseases. Prion diseases, such as Creutzfeldt-Jakob disease, occur when prion

protein, which is found throughout the body but whose normal function isn't yet known,

begins folding into an abnormal three-dimensional shape. This shape change

gradually triggers prion protein in the brain to fold into the same abnormal shape.

Through a process scientists don't yet understand, misfolded prion protein destroys

brain cells. Resulting damage leads to rapid decline in thinking and reasoning as well

as involuntary muscle movements, confusion, difficulty walking and mood changes.


Chemistry of amino acids

Levels of protein folding and how it is carried out

Abnormalities in protein structure/folding

REFERENCE BOOKS:

Lippincott’s illustrated reviews of Biochemistry

Harper’s text book of Biochemistry.


Topic: Protein Chemistry (Emphysema- α 1 antitrypsin deficiency)

A 68-year-old Caucasian man with a 25 pack-year smoking history presented with

new-onset dyspnea on exertion in the setting of workplace dust exposure. During his

evaluation, he was found to have α1-antitrypsin deficiency with evidence of

development of pulmonary emphysema. Workplace spirometric monitoring over 10

years of surveillance for an on-the-job respirator fit program demonstrated a sharp

downward slope in forced expiratory volume in one second, or FEV1, during his

periods of most significant dust exposure, which was attenuated after discontinuation

of his workplace exposure.

Blood and other body fluids contain a protein, α1-antitrypsin (α1-AT, A1AT, currently

also called α1-antiproteinase), that inhibits a number of proteolytic enzymes (also

called proteases or proteinases) that hydrolyze and destroy proteins. α1-AT comprises

more than 90% of the α1-globulin fraction of normal plasma. α1-AT has the important

physiologic role of inhibiting neutrophil elastase ––a powerful protease that is released

into the extracellular space, and degrades elastin of alveolar walls, as well as other

structural proteins in a variety of tissues. Most of the α1-AT found in plasma is

synthesized and secreted by the liver. In the normal lung, the alveoli are chronically

exposed to low levels of neutrophil elastase released from activated and degenerating

neutrophils. This proteolytic activity can destroy the elastin in alveolar walls if

unopposed by the action of α1-AT, the most important inhibitor of neutrophil elastase.

Because lung tissue cannot regenerate, emphysema results from the destruction of

37

the connective tissue of alveolar walls. Smoking causes the oxidation and subsequent

inactivation of that methionine residue, thereby rendering the inhibitor powerless to

neutralize elastase. Smokers with α1-AT deficiency, therefore, have a considerably

elevated rate of lung destruction and a poorer survival rate than nonsmokers with the

deficiency.


Fibrous proteins

Normal structure and synthesis of collagen and elastin

Abnormalities of fibrous proteins

REFERENCE BOOKS:


Harper’s text book of Biochemistry. (Page 616)


Topic: Porphyrins and Hemoglobin (Hepatitis A)

A 31 years old man presented with jaundice, nausea, anorexia, restlessness, lethargy,

fatigue and dark color urine for three days. Color of his stools was normal and there

was no itching on the skin. He was not having pyrexia and intensity of jaundice was

not of fluctuating type. There was no history of significant weight loss. There was mild

pain in the right hypochondrium. He did not have any known hemoglobinopathy. He

was non-alcoholic and there was no history of use of any drug recently.

Ultrasonography showed no fatty infiltration of liver.

Lab Investigations:

S/N Test Result Reference values

1 Serum Total bilirubin 42 µmol/L Adult 2-17µmol/L

2 Conjugated Bil (direct) 10 µmol/L 0-4 µmol/L

3 Unconjugated Bil (indirect) 32 µmol/L 0-13 µmol/L

4 Urine bilirubin Present Absent

5 Urinary urobilinogen Increased 0-4 mg/ 24 hrs

6 Serum ALT 2800 U/L Male Upto 42 U/L Female upto 32

7 ALP 54 U/L 132-365 U/L adults Levels higher in children

8 AST 40 U/L Upto 37 U/L

9 GGT 32 U/L Upto 30 U/L

10 Plasma haptoglobin normal -

11 Serum albumin 33 g/dL 35-50g/L

12 Hep B surface antigen (HBsAg) in

serum

Negative Negative

13 Anti HCV antibody (anti HCV Ab) in serum

Negative Negative

14 Anti Hep A antibody (IgM) Positive Negative

38

Hepatitis A is a viral infection and resultant inflammation of the liver caused by

Hep A virus. Unlike Hep B and C this virus does not cause chronic disease and causes

acute severe and self-limiting hepatitis making the patient immune against this virus

for rest of his life. Unlike Hep B and C which are transmitted through blood or sex, hep

A virus is transmitted through orofecal route. Senescent RBCs are broken in spleen

and heme and globin separated and globin degraded into amino acids in fixed

leukocytes of spleen. Heme is oxidized to biliverdin and bilirubin which leaves

reticuloendothelial system and travel in plasma in protein bound form. Hepatocytes

uptake and conjugate bilirubin for excretion from body in biliary route. Viral infection of

liver affects not only conjugation but also other functions of the liver like albumin

synthesis. This results in jaundice hypoalbuminemia and edema (later in chronic cases

only), though liver has got the capability to handle 300 times more bilirubin in normal

state and a capacity of hepatocyte regeneration. Chronic cellular damage, fibrosis and

regeneration leads to liver failure and a condition called cirrhosis of liver which is

leading cause of death due to hep B and C infections.


Synthesis and degradation of heme

Metabolism of bilirubin in body

Role of hepatocyte in bilirubin handling and its diseases (inherited and acquired)

REFERENCE BOOKS:


Harper’s text book of Biochemistry

Davidson’s Practice of Medicine

39

MODULE-II

Section-I

Anatomy

40

Summary:

Code Y1M2

Name Anatomy

Duration 10 weeks




module)

1.Thorax

2.Cardiovascular system

Subject Themes

Gross anatomy

Thorax

Embryology

Embryonic period, Fetal period

Placenta and fetal membranes

Twining

CVS

Histology

Circulatory System

Immune system

General Anatomy

Lymphatic system

Circulatory system

Prerequisite Module Y1M1


MIT

Lectures

Dissection

Tutorials (PTT)

CBL

Practicals

Class tests

41


Anatomy

MBBS - Y1M2

PROPOSED LEARNING OBJECTIVES AND SUGGESTED MITs (mode of

information transfer)

GENERAL ANATOMY

S.NO. TOPICS LEARNING OBJECTIVES MIT

Circulatory

System

Discuss the general structural plan of

blood vessels.

Classify blood vessels on anatomical and

functional basis

Explain each type of blood vessel and

give examples

Discuss general plan of systemic,

pulmonary and coronary circulatory

system.

Discuss general plan of portal system

with brief accounts of arterial and venous

portal systems giving examples.

Differentiate between anatomic end

arteries and functional end arteries giving

examples

Define anastomosis; describe various

types of anastomosis with examples and

their clinical significance.

Describe blood supply of arteries and

veins.

Explain the importance of collateral

circulation

LGIS

(Large

group

interactive

session)

Lymphatic

System

Discuss general plan of the lymphatic

circulatory system of the body.

Explain the mechanism of formation and

flow of lymph.

Enumerate the factors responsible for

flow of lymph.

Discuss the structural plan of lymphatic

vessels.

Describe the structural plan of lymph

nodes and their role in lymphatic system

Enumerate the capsulated lymphoid

organs

LGIS

42

Correlate the role of lymphatic system

with spread of cancer and infection.

Correlate the role of lymphatic system

with development of edema.

HISTOLOGY

Circulatory

System

KNOWLEDGE: Discuss the general histological plan of blood vessels. Describe and compare the histological structure of: Elastic artery Muscular artery Arteriole Different types of Capillaries Venule Medium sized vein Large vein Describe histological changes in intima in atherosclerosis or arteriosclerosis SKILLS: Identify elastic artery, muscular artery and large vein under light microscope and enlist at least two identification points for each. Draw labelled diagram of elastic artery, muscular artery and large vein with the help of eosin and hematoxylin pencils on the histology notebook

LGIS

Lab

Immune

System

KNOWLEDGE:

Enumerate the cells of immune system.

Describe the structure of primary and

secondary lymph nodule.

Describe the histological features of:

Lymph node

Thymus

Spleen

Tonsils

Compare the histological structure of

thymus, lymph node, spleen and tonsils.

SKILLS:

Identify slides of lymph node, thymus,

spleen and palatine tonsils under light

microscope and enlist at least two

identification points for each.

LGIS

Lab

43

Draw labelled diagram of lymph node,

thymus, spleen and palatine tonsils with

the help of eosin and hematoxylin pencils

on the histology notebook

EMBRYOLOGY

KNOWLEDGE

Embryonic

period

(3rd to 8th week)

Define neurulation

Describe process of formation of neural

plate, neural tube and neural crest cells.

Enlist derivatives of:

Surface ectoderm

Neurectoderm

Neural crest

Intraembryonic mesoderm (paraxial,

intermediate, lateral plate)

Endoderm

Describe somitogenesis and early

differentiation of somites.

Describe the development of

intraembryonic coelom

Describe the folding of the embryo in the

longitudinal plane and correlate it with its

consequences

Describe the folding of the embryo in the

horizontal plane and correlate it with its

consequences

Describe relocation of connecting stalk to

the anterior abdominal wall and its

differentiation into umbilical cord.

Describe the process of formation of

blood and blood vessels and differentiate

between angiogenesis and

vasculogenesis

Explain the embryological basis of the

neural tube defects like anencephaly and

spina bifida

Define hemangioma and explain its

embryological basis

LGIS

Fetal period

(third month to

birth)

Define fetal period

Enumerate various methods to estimate

fetal age

Describe factors affecting fetal growth

LGIS

44

Enlist the external body landmarks from

third month to birth

Define intrauterine growth retardation

Placenta and

fetal

membranes

Enlist types of chorion and give fate of

each.

Enlist types of decidua and give fate of

each.

Enumerate the fetal and maternal

components of placenta.

Differentiate between stem, anchoring

and terminal villi

Enumerate the layers forming placental

barrier

Describe placental circulation (maternal

and fetal)

Enumerate functions of the placenta

Enlist the features of maternal and fetal

surfaces of placenta.

Enumerate placental changes by the end

of pregnancy

List fetal membranes and their functions

Describe production, circulation and

significance of the amniotic fluid.

Describe the development of umbilical

cord

Define preeclampsia and correlate it with

trophoblastic differentiation

Describe the embryological basis of

amniotic bands, umbilical cord defects,

erythroblastosis fetalis and hydrops

fetalis

Define poly and oligohydramnios.

Enumerate their embryological causes

and adverse effects

LGIS

Twining

Name two basic types of twins.

Describe the mechanism behind

occurrence of dizygotic & monozygotic

twins.

Discuss the possible arrangements of

fetal membranes in case of monozygotic

twins.

Discuss fetus papyraceus, twin

transfusion syndrome and conjoined

LGIS

45

twins on basis of knowledge of

embryology

CVS-I

(Heart)

Explain the formation of heart tube.

Describe the mechanism of cardiac

looping

Enlist the parts of heart tube and their

definitive derivatives

Explain the embryological basis of

dextrocardia

Describe histogenesis of heart

Describe contribution of bulbs cordis and

sinus venosus to the development of

heart

Explain different methods of septal

formation

Describe division of atrioventricular canal

Explain the embryological steps involved

in formation of interatrial septum

Correlate the internal differentiation of

right atrium with internal structure of right

atrium of definitive heart

Describe the formation of left atrium and

pulmonary veins

Explain the division of conotruncus

Describe the formation of interventricular

septum and identify sources of its

different parts

Describe the development of valves of

heart

Describe the development of conducting

system of heart

Explain the embryological basis of the

following heart defects:

Various forms of atrial septal defects

Ventricular septal defects

Fallot’s tetralogy

Transposition of great vessels

Persistent truncus arteriosus

Pulmonary stenosis

Aortic stenosis

Tricuspid atresia

Hypertrophic right and left heart

syndromes

LGIS

46

Ectopia cordis

CVS-II

(Arterial

system)

Define aortic arches

Explain the development and fate of

aortic arches

Enumerate the developmental sources of

aorta

Justify the relationship of recurrent

laryngeal nerves on the basis of your

knowledge of embryology

Enumerate the segmental branches of

dorsal aortae & give their fate

Explain the fate of vitelline & umbilical

arteries

Explain the development of arteries of the

limbs

Enumerate & explain the congenital

anomalies of arterial system which

include:

Patent Ductus Arteriosus

Coarctation of aorta

Double aortic arch

Right aortic arch

Abnormal origin of the Right Subclavian

Artery

An interrupted aortic arch

LGIS

CVS-III

(Venous

system)

Explain the fate of vitelline, umbilical and

cardinal veins

Explain the development of inferior vena

cava

Explain the development of superior vena

cava

Correlate following anomalies of venae

cavae with their development

Double Inferior Vena Cava

Absence of Inferior Vena Cava

Left Superior Vena Cava

Double Superior Vena Cava

Explain the development of lymphatic

system

LGIS

47

CVS-IV

(Fetal

circulation)

Describe fetal circulation

Describe following fetal circulatory

changes at birth:

Closure of the umbilical vein and ductus

venosus

Closure of the ductus arteriosus

Closure of the oval foramen

LGIS

SKILLS

Embryology

Identify the structures related to general

development and development of

cardiovascular system on given models

and diagrams

SGD

(Small

group

discussion)

GROSS ANATOMY

THORAX

KNOWLEDGE:

Thoracic wall

(Bones and soft

parts)

Enumerate the bones contributing in

thoracic cage

Describe the bony framework of the

thoracic cage with topographic placement

of each bone

Identify structures forming the thoracic

inlet and outlet/costal margin

Discuss sternum, with reference to its

parts and attachments

Define sternal angle and discuss its

importance in clinical practice

Classify ribs into true and false

Determine side of ribs

Discuss parts of a typical rib

Differentiate between typical and atypical

ribs

Identify typical thoracic vertebra, describe

its different parts and identification points

Compare a typical and atypical thoracic

vertebra

Describe the joints of thorax with

reference to their types and movements

Discuss and differentiate between the

pump handle and bucket handle

movements and their effect on diameters

of chest cavity

SGD and

dissection

48

Discuss the role of the accessory

respiratory muscles during inspiration

and expiration

Enlist the contents of a typical intercostal

space including muscles, nerves and

vessels

Describe the attachments, actions and

nerve supply of thoracic muscles

Discuss the arterial supply and venous

drainage of the thoracic wall.

Discuss the course and distribution of a

thoracic spinal nerve

Identify and justify the most suitable site

for an invasive procedure in an intercostal

space

Analyze the clinical scenario related to

blunt chest trauma and its complications

with anatomical reasoning

Diaphragm

Describe the parts, attachments and

nerve supply of diaphragm

Enlist the apertures in diaphragm with

their levels and structures passing

through each

Discuss the role of diaphragm and

scalene muscles in increasing the vertical

diameter of thoracic cavity

Analyze the clinical scenario related to

diaphragmatic hernia and phrenic nerve

lesions with anatomical reasoning

Correlate the tip of shoulder pain with

irritation of diaphragm

SGD and

dissection

Pleura

Enumerate and discuss various parts of

pleura and identify their locations

Describe the pleural reflections and

recesses

Describe the innervation of the visceral

and parietal layers of the pleura

Discuss the clinical significance of

reflections and recesses of pleura and

pleural cavity

Define pleural effusion, pneumothorax,

empyema and hemothorax

SGD and

dissection

49

Enlist the anatomical structures

encountered in chest tube insertion

Lungs

Identify the side of lungs

Enlist borders and surfaces of lungs

Discuss the topographic arrangement of

structures in hilum of each lung

Discuss the blood supply, nerve supply ,

lymphatic drainage and relations of

various surfaces of both lungs

Define bronchopulmonary segments.

Enlist them in each lung. Discuss their

significance.

Discuss with anatomical reasoning, the

clinical presentation of bronchogenic

carcinoma and lung trauma

SGD and

dissection

Mediastinum

(General

outline)

Define mediastinum

Describe how the mediastinum is further

divided

Enlist the structures lying at the level of

transverse thoracic plane

Outline the boundaries of each division of

mediastinum

Enumerate contents of each division of

mediastinum

SGD and

dissection

Anterior

mediastinum

Outline the boundaries of anterior

mediastinum

Enumerate the contents of anterior

mediastinum

Describe the shape, relations and blood

supply of thymus

SGD and

dissection

Superior

mediastinum

Outline the boundaries of superior

mediastinum and describe its general

topography

Enumerate the contents of superior

mediastinum

Identify carina at the site of bifurcation of

trachea into main principal bronchi

Describe immediate relations, blood and

nerve supply of thoracic part of trachea

SGD and

dissection

50

Justify the right bronchus being the most

probable site of foreign body impaction in

respiratory tract

Describe the orientation, relations and

branches of arch of aorta

Describe the formation, relations and

tributaries of superior vena cava and

brachiocephalic veins

Determine the site of ligamentum

arteriosum and its relation to left recurrent

laryngeal nerve

Describe the origin, course, relations and

distribution of both phrenic nerves

Analyze the clinical scenarios related to

compression of trachea and

damage/irritation of phrenic nerve based

upon your knowledge of Anatomy

Posterior

mediastinum

Outline the boundaries of posterior

mediastinum and describe its general

topography

Enumerate the contents of posterior

mediastinum

Describe the relations and branches of

descending aorta

Describe the course, relations and

constrictions of thoracic part of

esophagus

Discuss the reason behind esophageal

varices in case of portal hypertension

Describe the thoracic duct with reference

to its formation, course, tributaries,

termination and area of drainage

Analyze the clinical scenarios related to

chylothorax with the help of your

knowledge of Anatomy

Describe the course, relations and

distribution of both vagus nerves in thorax

Discuss the azygos system of veins with

reference to formation, course, relations,

tributaries and area of drainage of both

azygos and hemiazygos veins

Discuss the role of azygos vein in case of

caval obstruction

SGD and

dissection

51

Identify the lymph nodes in the posterior

mediastinum

Define splanchnic nerves and identify the

location of thoracic sympathetic chain

Pericardium

Enumerate various layers of pericardium

Describe the gross features of fibrous

pericardium

Describe the gross features of serous

pericardium (both parietal and visceral

layers)

Describe the reflections of parietal and

visceral pericardium resulting in formation

of transverse and oblique sinuses

Identify the locations of pericardial

sinuses

Describe the surgical significance of the

Transverse Pericardial Sinus

Discuss the innervation of various layers

of the pericardium

Define pericarditis and pericardial

effusion

Identify the best location for and enlist the

anatomical structures encountered in

pericardiocentesis

SGD and

dissection

Heart

Describe anatomical position, borders,

surfaces, apex and base of heart

Describe external features of the heart

Describe internal structure of various

chambers of heart

Compare the functional anatomy of right

and left ventricles

Describe structure of various valves of

heart

Enumerate the structures comprising the

cardiac skeleton and describe its

significance

Describe the arterial supply of heart

Explain the basis of right or left

dominance of heart

Describe the venous drainage of heart

Describe nerve supply of heart

Define angina pectoris, myocardial

infarction and cardiac tamponade

SGD and

dissection

52

Describe variations of coronary arteries in

context of myocardial infarction

Justify the chest pain, left upper limb pain,

jaw pain and epigastric discomfort as

presenting complaint of ischemic heart

disease with anatomical reasoning

SKILLS:

Gross Anatomy

of Thorax

Identify muscles, bones, ligaments,

nerves, vessels, organs and their parts

located in thorax:

on a cadaver after performing dissection

on prossected specimens

on provided models

SGD and

dissection

Surface

marking

Identify the important bony landmarks of

thorax and mark them on a subject.

Mark the borders of lungs, pleural

reflections, borders and apex of heart,

valves of heart, thoracic duct, esophagus,

trachea, main vessels and nerves of

thorax on the given subject

SGD and

Skills lab

Imaging of

head and neck

Identify the bones of thorax, aortic

knuckle, borders of heart, lungs, trachea,

hilar shadows, diaphragm and its

recesses on chest radiographs

SGD and

skills lab

List of Practical Histology (Anatomy):

Cardiac muscle

The Circulatory System-I

The Circulatory System-II

The Circulatory System-III

Problem / Case Based Learning, Scenarios:

CBL Case-1

Forty years old Azmat Ali presented in the accident and emergency department with

history of road traffic accident. He was driving the car when he hit a Pole. On

examination, pulse 100/min BP 110/70 mm of hg SPO2 95%. Chest examination

revealed marked diminished air entry on right middle and lower zone of Chest.

Resident surgeon noticed paradoxical movements of the chest-ray chest were taken

which shows that multiple ribs are broken bilaterally at multiple sites. Bilateral chest

intubation and endotracheal intubation was planned.

53


Demonstrate the morphological features of thoracic cage on skeleton.

Differentiate typical and atypical ribs and thoracic vertebrae.

Describe the framework of the thorax, including the sternum and its parts.

Identify potential causes of blunt chest trauma.

Identify complications of blunt chest trauma.

Learn the bilateral chest intubation and endotracheal intubation

Identify possible treatments and initial management for blunt chest trauma.

Learning Resources:

Clinical Anatomy by Snells

Clinically Oriented Anatomy by Keith. L. Moore

CBL Case-2

A middle aged female presented with multiple fractured ribs and right side

haemothorax after a road accident. A chest tube was put in to drain the hemothorax.

She was comfortable, no respiratory distress and maintaining the oxygen saturation

without oxygen supplementation. There is decrease air entry at base and check X-ray

revealed markedly elevated diaphragm on Rt. Side. C.T Chest-suspicion of traumatic

diaphragmatic hernia with herniation of liver in thorax. Surgeon planned lateral

thoracotomy through 7th I.C.space. Before opening he placed laparoscope through

chest tube site and confirmed the diagnosis. Liver and a part of colon were in thorax.

After opening both structures could be reduced easily. Rent in diaphragm repaired

with 1/0 Prolene suture. Post-operative – uneventful recovery.


Identify major anatomical landmarks of the diaphragm including its muscular portion,

central tendon, right and left crus, esophageal hiatus, aortic hiatus, and caval foramen.

Learning Resources:



CBL Case-3

A 10-year-old boy had a coughing fit while chewing on a pen top and subsequently

realized that the inside of the pen top was missing. He was sent home from the local

emergency department after a normal chest radiograph. Two days later he started to

wheeze and cough. A chest radiograph was again normal, but he had wheeze that

was louder on the right side of the chest and a fever. He was given intravenous

antibiotics but he did not improve and the following day was transferred to the regional

pediatric center for assessment. With rigid bronchoscopy under general anesthesia

the pen top was removed from his right main bronchus.

54


Identify the thoracic part of the trachea and bronchi describe its blood supply and

innervation.

Identify and describe the location of the lungs in the thoracic cavity.

Identify the relations of the pulmonary artery, pulmonary veins, and the bronchi at the

hilum of each lung.

Define a bronchopulmonary segment and discuss its general organization.

Name the bronchopulmonary segments and give their approximate location in

reference to the lobes of the lungs.

Learning Resources:



CBL Case-4

Consultative support to a patient was asked who had become unstable during his

postoperative phase of surgery. The patient was currently recovering from a modified

radical neck procedure for squamous cell carcinoma of the tongue. The patient

presented with tachycardia and hypotension with decreasing urinary output and poor

skin turgor. He was intermittently combative and semi-conscious. On physical exam,

surgeon noticed the neck was edematous, and a palpable mass roughly 8 cm in

diameter was felt. After connecting the bulb suction to the wall suction apparatus

approximately 600 ml of milky white fluid was immediately aspirated from the wound

with a subsequent diminution in the size of the mass. He was diagnosed a case of

chylothorax . The plan for management includes contacting the thoracic surgery team

and replacing the patient's lost fluid volume.


What is chylothorax? How would you explain the milky white fluid following this kind of

operation? Which lymphatic channel/duct would be involved?

Given the location of the surgical procedure - How would a definitive diagnosis be

made?

What is the course of the thoracic duct? What structures drain into the thoracic duct?

Define the boundaries of the posterior mediastinum, what lymph nodes can be found

in the posterior mediastinum?

Describe the major contents of the posterior mediastinum and their relationships

Learning Resources:



CBL Case-5

A previously healthy 50-year-old woman presented with a low-grade fever, a

generalized headache, and chest pain of 2 to 3 weeks’ duration. She described

intermittent sharp chest pain over the precordium that intensified when she lay down

55

and shortness of breath after minimal exertion. On physical examination, she

appeared weak and ill. Her temperature was 36.7°C (98.0°F), and her pulse was 110

beats per minute, regular, and had normal volume and character. Her blood pressure

was 115/70 mm Hg, which decreased to 90/70 mm Hg on inspiration; her respiratory

rate was 22 breaths per minute. Dullness to percussion, scattered inspiratory crackles,

and diminished air entry were evident over both lung bases. A CT scan of the chest

showed bilateral pleural effusions. An abdominal CT scan was normal. The patient

was admitted to the coronary care unit and underwent diagnostic pleural aspiration

and pericardiocentesis. The diagnostic procedure was a pericardial biopsy. The

patient had cardiac tamponade, caused by tuberculosis.


To learn the anatomy of the intercostal space and its contents.

To learn the anatomy of the pleura its reflections and pleural spaces.

To learn the anatomy of the pericardium its reflections and pericardial spaces.

For what other reasons (besides sampling pleural fluid) might a thoracocentesis be

performed? what is the procedure of pericardiocentesis and pericardial biopsy

Learning Resources:



CBL Case-6

Mr. Ahmed, a middle aged businessman after a heavy meal at a well-known

restaurant, walked briskly to join his fellows. He fell short of breath and developed

chest pain radiating to inner aspect of his left arm. The pain reduced on stopping.

He was taken to Casualty Department. On arrival, his pulse rate was 95/minute, blood

pressure was 80/50 mmHg and he had pallor on face and cold sweat. The heart

sounds were normal on auscultation. His chest X-ray (PA view) showed cardiomegaly.

He informed the doctor that he was taking medication for hypertension.

He was admitted to CCU and given supportive therapy. His Electrocardiogram showed

ST-elevation in all leads. Troponin-I (cardiac marker) was raised in blood. His coronary

angiography next morning showed narrowing of 3 coronary arteries


What are the possible causes of pain in this case? Why do you think this is cardiac

pain? Chest pain with radiation to the neck or arm is a ‘characteristic’ symptom of

acute myocardial infarction (AMI) in many patients; explain why the pain can be felt in

these distant regions.

Describe the blood supply to the heart, listing the major arteries and branches. What

arteries of the heart are most commonly occluded?

Why do occlusions rapidly lead to infarct in the heart? Which artery supplies the

papillary muscles?

What does the left anterior descending (LAD or anterior interventricular) coronary

artery supply?

56

What branches come off the LAD? What arteries of the heart are most commonly

occluded? Why do occlusions rapidly lead to infarct in the heart?

What is myocardial infarction? Which mechanisms cause an acute myocardial

infarction (AMI) considering changes in coronary artery?

What is coronary angiography ?

Learning Resources:



CBL 7

During a routine physical exam for participation in interscholastic sports, the physician

noted that Bilal, a twelve-year-old boy, had a long continuous heart murmur at the

second intercostal space near the left sternal border. A systolic thrill was also noted in

the same region. When questioned, the patient's mother recalled that Bilal had periods

of cyanosis and breathlessness as an infant, but that his previous pediatrician said

that the murmur and the symptoms were nothing to be concerned about. Bilal also

mentioned that he tires easily during physical activity. Chest films and Doppler

ultrasound were ordered. The radiographs indicated slight left ventricular hypertrophy,

and ultrasound revealed a patent ductus arteriosus. Bilal was scheduled for surgery

to ligate the ductus arteriosus. The surgery resulted in successful ligation of the ductus

arteriosus; however, Bilal experienced hoarseness when speaking following the

procedure. Laryngoscopy revealed paralysis of the left vocal fold.


What is the ductus arteriosus, and where is it located?

What is the prenatal function of the ductus arteriosus, and what usually happens to it

after birth?

What are the eventual consequences if the ductus arteriosus is not closed?

What likely caused paralysis of the left vocal fold?

Why would Doppler ultrasound be used to diagnose a patent ductus arteriosus?

Identify and trace all the branches of the arch of the aorta in the region and the

relationship of the vagus and phrenic nerves to them.

Identify the anatomy of the four chambers

Compare and contrast the anatomical characteristics right and left sides of the heart.

Learning Resources:



57

MODULE-II

Section-II

Physiology

58

Summary:

Code Y1M2

Name Physiology

Duration 10 weeks




module)

1.Thorax


Subject Themes Cardiovascular Physiology



MIT

Lectures

Tutorials (PTT)

CBL

Practicals

Class tests


Physiologic

anatomy of heart

and cardiac action

potential

Appreciate the physiological arrangement of right and left

hearts along with the parallel arrangement of systemic

circulation.

Know the physiologic anatomy of cardiac muscles, its

functional syncytium and intercalated disc and difference

between cardiac, skeletal and smooth muscles.

Know the phases of action potential in cardiac muscle and

autorrhythmic cells/ conducting system of the heart along

with comparison of action potential in different tissues of

the heart.

Associate movement of ions across the cell membrane

with different phases of action potential.

Comprehend importance and relationship between

refectory period and mechanical periods.

Know the mechanism of generation and propagation of

cardiac impulse in conductive system of heart.

Appreciate characteristics of spread of cardiac impulse

through conductive system, atrial and ventricular

myocardium and its association with the function of heart.

59

Cardiac cycle To understand various cardiac events in relation to each

other

To understand and interpret cardiac cycle diagram

Comprehend preload and afterload, its influence on stroke

volume. The Frank-Starling’s mechanism and role of

autonomic regulation of heart rate and pumping action.

Know about the myocardial bioenergetics.

ECG Comprehend genesis of ECG, the way it is recorded and

its relationship with the electrical axis of heart.

Understand significance of waves, segments and intervals

of ECG recording.

Learn the concept of a vector and principles of the

measurement of ECG vector.

Appreciate relationship between vector and lead, type and

locations of leads and principles for vector analysis.

Know general principles of analysis of ECG.

Arrhythmias Understand the basis of common cardiac arrhythmias,

process that produce them and their clinical significance.

Evolve the concept of sinus arrhythmia and its clinical

significance.

Appreciate principal changes in ECG during myocardial

ischemia and infarction.

Comprehend changes in ECG and cardiac function during

common abnormalities in ionic composition of body fluids.

Understand the pathophysiology of ectopic focus and its

clinical significance.

Know how and when to carry out cardiac massage and its

significance.

Appreciate the events of cardiac cycle and prospective

changes in ECG, heart sounds, pressures and volumes

during different phases thereof.

Hemodynamics of

circulation

Know the organization of circulatory systems i.e. Greater

(Systemic) and Lesser (Pulmonary) circulations along with

accessory circulatory system (Lymphatic).

The physiologic anatomy of different types of blood

vessels and their importance.

To know the relationship between flow, resistance and

conductance.

Have the concept of blood flow, its types and significance

of turbulent and laminar flow, the concept of pressure

gradient, resistance to blood flow and its significance.

Understand the Physiology of vascular compliance?

Changes in compliance of blood vessels with age and

60

comparison between the compliance of arteries versus

veins.

Appreciate the origin of arterial pressure pulse and its

propagation to the peripheral arteries.

Know the factors damping the arterial pulse and

abnormalities of arterial pulse.

Know about the jugular venous pulse, its significance and

differentiation from arterial pulse.

Control of Local

Blood

To know about acute and chronic control of local blood

flow

To about theories of metabolic control of blood flow

To know about active and reactive hyperemia

To know the effects of blood flow control on total

peripheral resistance

Capillary

dynamics

Understand the principles of capillary dynamics, structure

of Interstitium, Starling’s forces for fluid exchange across

the capillary membrane and factors affecting thereof.

Ha ve

the concept of starling’s equilibrium, and how of the

interstitial space is kept dry?

Know the mechanism of formation of interstitial fluid, its

composition and factors creating starling’s disequilibrium

leading to the development of edema.

Appreciate Types of edema, its pathophysiology and

safety factors preventing edema formation.

Cardiac output Understand the determinants of cardiac output and factors

affecting cardiac output.

Appreciate the mechanics of low and high cardiac outputs

along with their effects on heart.

Comprehend the factors affecting stroke volume, heart

rate and total peripheral resistance.

Understand Fick’s principle for the measurement of

cardiac output.

Venous return Recognize the role of veins in blood flow, their functions

and factors regulating venous return and significance of

venous reservoirs.

Appreciate the equality of cardiac output and venous

return.

To understand factors affecting venous return

61

Arterial blood

pressure

Comprehend the determinants of arterial pressure, factors

affecting and mechanisms regulating blood pressure on

short and long term basis.

Understand mean arterial pressure and its significance.

Comprehend the individual and integrative role of baro

receptors, chemoreceptor, volume receptors, arterial

natriuretic factors and Renin-angiotensin – aldosterone

system in regulation of arterial pressure.

Understand the characteristics of regional circulations

(skeletal muscles, pulmonary, coronary & cerebral) and

factors regulating thereof.

Cardiac failure Define cardiac failure, its pathophysiology and clinical

manifestations

To know different types of cardiac failure

Physiology of treatment of cardiac failure

Heart sounds To know about origin of heart sounds

To know about murmurs

To know about clinical importance of various heat sounds

Circulatory shock Define shock, its types, stages of development and

differences between compensated and uncompensated

shock.

Understand the pathophysiology of compensated and

uncompensated shock.

Comprehend the short term and long term compensatory

mechanisms in circulatory shock.

Know the pathophysiology of irreversible shock.

Comprehend the general principles for the treatment of

shock.

Effect of exercise

on CVS

Know the types and severity of exercise in different sports.

Have the concept of general adaptive changes in muscles

in response to increased and decreased physical activity.

Know about the fuels available in body during rest and

exercise.

Comprehend cardiovascular and pulmonary changes

(including oxygen consumption) during different grades of

exercise.

62

List of Practicals:

Module 2

Examination of the chest related to CVS

Examination of arterial pulse.

ECG recording & interpretation.

Measurement of arterial B.P

Effect of exercise & posture on BP

Examination of the apex beat

Auscultation of normal heart sounds.

JVP / Tripple response


List of Case Based Learning Scenerios:

PBL 1

A 55 years old male was brought to cardiac emergency department with the history of

severe left sided chest pain. His ECG showed ST segment elevation and significant

Q waves in leads I, aVL and V6. These findings suggested that he sustained acute

infarction of the left side of left ventricle. QRS complex was positive in lead aVF and

predominantly negative in lead I. The treating doctor showed ECG to final year medical

students and told that there was right axis deviation in the ECG as well.

Learning objectives

To know about basics of cardiac impulse generation and propagation

To understand ECG leads and normal ECG

To understand and interpret vector analysis

To know Physiological basis of ST segment shift (current of injury)

To understand ECG changes in acute myocardial infarction

To understand physiology of treatment of acute myocardial infarction

Resources:





Electronic modes

PBL 2

A 65 years old man suddenly woke up while sleeping during night due to severe

breathlessness. On arrival to emergency, his blood pressure was 105/70 mm Hg and

pulse rate 110 per minute. Auscultation of lungs revealed fine crepitations. Further

investigations revealed a low cardiac output of 4 l/min and right atrial pressure of 10

mm Hg. After few days he developed pitting oedema of legs and sacral region. The

patient was diagnosed as a case of heart failure.


To understand pathophysiology of heart failure

63

To know about types and stages of heart failure

To understand starling forces acting on capillary

To understand pathophysiology of pulmonary and systemic oedema

To understand role of kidney in heart failure

To understand physiology of treatment of heart failure

Resources:





Electronic modes

PBL 3

A 75 years old man comes into emergency department and faints. Five minutes later,

he is alert. An electrocardiogram was recorded immediately. It showed 75 P waves of

normal morphology per minute whereas QRS complexes were recorded at the rate of

35 per minute. Close observation of ECG revealed that QRS complexes were wide

with high voltage and there was no relation between P waves and the QRS complexes.


1. To know the normal anatomy and physiology of heart.

2. To know about the generation and conduction of cardiac impulse.

3. To understand the physiological basis of normal electrocardiogram.

4. To know about vectorial analysis

5. To know about sinus arrhythmias.

6. To learn the pathophysiology of heart blocks.

7. To know the physiological basis of escape beats/rhythm.

8. To understand about ectopic beats/rhythm.

9. To learn the mechanisms of tachyarrhythmias.

10. To know about paroxysmal tachyarrhythmias

Resources:





Electronic mode

PBL 4

A 73 years old man comes to emergency department complaining of chest pain,

dyspnea on exertion and syncope. The patient has poorly managed

hypercholesterolemia and 10 years history of hypertension.

Vital signs

Temperature 37 degree C

Pulse 85/min

64

RR 18/min

BP 100/75mmHg

Physical examination

Palpation of carotid upstroke reveals a pulse that is both decreased and late, relative

to the apical impulse that is laterally displaced

A systolic murmur is present, loudest over the aorta, and peaking at mid-systole

Lungs are clear and there are no rales

Investigations

ECG: left axis deviation. No abnormalities in ST segment

Chest X-ray: Enlarged left ventricle and calcification of aortic valve

Doppler ultrasonography: A greatly increased velocity of flow during the systolic

portion of the cardiac cycle. The left atrium and left ventricular chambers are enlarged.

Left ventricular hypertrophy is present.

Cardiac enzymes: CK-MB, troponin-I and myoglobin levels are within normal ranges

Diagnosis: Aortic valve stenosis


To develop a working knowledge of:

1. Physiological anatomy of the heart

2. Cardiac cycle

3. Heart sounds and their relationship to events of cardiac cycle

4. Cardiac output & venous return

5. Concept of ventricular ejection and diastolic filling

6. Concept of pre-load and after-load

7. Cardiac work & pumping effectiveness of heart

8. Cardiomegaly and ventricular hypertrophy

9. Clinical examination of the cardiovascular system (CVS)

10. Types of murmurs

11. Pulmonary complications of cardiovascular disease

12. Differential diagnoses of dyspnea on exertion

13. Electrocardiogram (ECG)

14. Biochemical indicators of myocardial damage

Resources:





Electronic modes

65

PBL 5

A 68-year-old woman presents to the emergency center with shortness of breath, light-

headedness, and chest pain described as being like “an elephant sitting on her chest.”

She is diagnosed with a myocardial infarction. She is given oxygen and an aspirin to

chew and is not felt to be a candidate for thrombolytic therapy. Her heart rate is 40

beats per minute (bpm). Although there are P waves, they seem to be dissociated

from the QRS complexes on the electrocardiograph (ECG). The patient is diagnosed

with complete heart block, probably as a result of her myocardial infarction. The patient

is taken to the intensive care unit for stabilization, and plans are made for pacemaker

insertion.


To understand concept of circus movements.

To define current of injury and know the significance of J point.

To gain insight into concept of re-entrant signals in heart muscle.

To elaborate factors resulting in cardiac impulse delay at AV node.

To list factors responsible for cardiac conduction blocks.

To classify various types of heart blocks.

To develop detailed knowledge of various types of AV nodal blocks.

Resources:





Electronic modes

PBL 6

A 57-year-old man presents to the emergency center with complaints of chest pain

with radiation to the left arm and jaw. He reports feeling anxious, diaphoretic, and

shortness of breath. His past history is significant for type II diabetes mellitus and

hyperlipidemia. On examination, the patient appears to be in moderate distress and

anxious. His electrocardiograph (ECG) shows evidence of acute myocardial injury in

the inferior leads. The emergency room physician suspects that the left anterior

descending artery is involved.


To understand regulation of coronary circulation.

To develop an understanding of various neuronal receptors on coronary vasculature.

To gain insight into concepts of coronary steal syndrome and systolic stretch.

To identify ECG changes in myocardial infarction.

To apply concepts of vectorial analyses to abnormal ECG findings.

Resources:


66




Electronic modes

PBL 7

A 60 years old lady presented in medical OPD with complaints of bilateral swelling

lower limbs for the last about three months. She also gives history of epistaxis.

Physical examination revealed pitting oedema over the legs. Laboratory investigations

showed prolonged clotting time and decreased plasma proteins. Ultrasound abdomen

revealed cirrhosis of the liver.


To know the various causes of bilateral swelling of lower limbs.

To know the relation of decreased plasma proteins with swelling of legs.

What is the cause of epistaxis in this problem?

To know the causes of pitting edema.

To know about the causes of non-pitting edema.

To know about forces acting upon capillary membrane.

To know about Starling’s equilibrium.

To know about edema safety factors.

To know about lymphatic system.

Resources:





Electronic modes

67

PBL 8

A 55 years old man presented in medical OPD of Military Hospital with dyspoea, pallor

swelling of legs for the past one month. On physical examination, he had pitting edema

of legs and sacral region, and raised JVP. His chest radiograph showed marked

enlargement of heart while ECG revealed Q wave in leads 1, V3 and V4. Doppler

Echocardiography revealed ejection fraction of 30%. Physician diagnosed that the

patient was suffering from congestive cardiac failure due to past myocardial infarction.


To know pathophysiology of edema and its types.

To comprehend the mechanism of development of edema.

To know safety factors to prevent the development of edema.

To understand concept of preload, after load, ejection fraction and peripheral

resistance.

To know changes in ECG presenting in the old myocardial infarction.

To understand changes in cardiovascular system in response to myocardial infarction

that lead to changes in Starling’s forces and development of edema.

To learn the mechanism of development of cardiomegaly and cardiac dilatation and

changes leading to reduction in ejection fraction.

To understand pathophysiology of raised JVP in this patient.

Resources:





Electronic modes

PBL 9

A 58 years old business man with obesity, having BMI of 31, with sedentary lifestyle

and a known case of essential hypertension is on irregular treatment. He had previous

history of chest pain on/off which was relieved by taking rest and placing some tablet

under tongue. He was brought to emergency department with a history of severe,

crushing precordial chest pain, radiating to left arm for last one hour, associated with

history of profuse sweating and two episodes of vomiting. On examination he had

blood pressure of 145/80mmHg, pulse rate 62 beats/min regular, respiratory rate 28

breaths/min. ECG showed significant ST segment elevation. Serum cardiac enzymes

CPK and Trop-T were markedly raised.

On the basis of history, clinical examination and investigations, he was diagnosed as

a case of acute myocardial infarction. He was shifted to coronary care unit and

managed with thrombolytic therapy, high saturation oxygen inhalation, and opioid

analgesics. Few hours later he again developed chest pain and became unconscious,

repeat ECG was done and bizarre electrocardiogram was noted down without any

regular cardiac rhythm and diagnosis of ventricular fibrillation was made, immediate

CPR was started and electrical current applied to chest wall via AED (automatic

68

electrical defibrillator), but patient could not revive despite of all possible and timely

measures.


To be able to develop knowledge to answer following queries:

What is blood pressure?

What are the determinants of blood pressure?

What is mean arterial pressure and how will you calculate it?

What is essential hypertension? How will long term un-controlled hypertension affect

heart functioning?

Discuss the nervous regulation of blood pressure?

What is angina pectoris? Why taking rest relieved chest pain in this patient?

What is acute myocardial infarction? Discuss the pathophysiologic events leading to

myocardial infarction.

Besides ventricular fibrillation what could be the other possible causes of death in this

patient?

What is ventricular fibrillation?

Explain the causes of ventricular fibrillation?

Resources:





Electronic modes

69

MODULE-II

Section-III

Biochemistry

70

Summary:

Code Y1M2

Name Biochemistry

Duration 10 weeks




module)

1.Thorax


Subject Themes

Chemistry of carbohydrates

Chemistry of Lipids

Enzymes

Body Fluids

Minerals & Trace Elements



MIT

Lectures

Tutorials (PTT)

CBL

Practicals

Class tests


Carbohydrate

Chemistry

Upon successful completion of this course, students will

be able to:

Define and classify carbohydrates with the understanding

of biochemical nature, significance of important member

of each group.

Explain structure of carbohydrates, isomerism and

properties of monosaccharide.

Enist different dietary sources and understand common

disorders related tochemistry of CHO.

Describe important homo and hetero Polysaccharides,

their important examples and biochemical role,

Understand the biomedical importance of carbohydrates

and their derivatives in health and disease conditions

Lipid Chemistry By the time the students finish the course, they will be able

to:

71

Define and classify lipids on different basis along with

appropriate examples.

Difference between oil, fat, waxes and vegetable ghee as

well as the process of hydrogenation and iodination,

saponification, acid number polansky,s number and other

physical attributes.

Describe saturated, unsaturated, poly unsaturated,

essential, non essential, Trans and cis type of fatty acids

and their significance in health and disease.

Distinguish structure of Glycero and sphingophospholids

as well as other different complex lipids and appreciate

their biochemical significance.

Describe Eicosanoids, their functions in health and

disease and the inhibitory action of NSAIDS and steroids

on them.

Recognize the sterol structure and different important

steroids especially the cholesterol, its functions and

significance with regards to IHD.

Summarize classification of lipoproteins, chemical

composition, functions and disorders

Understand the rancidity, its types and lipid per oxidation

and its clinical implications.

Enzymes At the end of the course, students are expected to be able

to:

Define different terms e.g, Coenzymes, co-factors,

holozymes, prosthetic group, ribozymes, zymogens

isozymes etc.

Classify enzymes and describe mechanism of enzyme

actions.

Explain different properties of enzymes and factors

affecting enzymes activity.

Illustrate enzyme kinetics in relation to Michaelis-Menten

Equation and Lineweaver- Burke plot.

Describe enzyme regulations, activation, inhibition and

biomedical importance of synthetic inhibitors.

Understand role of enzymes in clinical diagnosis and

therapeutics.

72

Body Fluids By the time the students finish the course, they will be able

to:

Define pH, buffers and briefly explain their mechanism of

action.

Explain Henderson- Hasselbalch Equation and develop

problem-solving skills based on this equation.

Describe Types of particles, solutions and colligative

properties

Understand the phenomenon of osmosis and osmotic

pressure and its implications regarding clinical situations.

Explain Surface tension, viscosity & their importance

related to body fluids.

Minerals and

Trace elements

By the end of the course, the students will be able to:

Classify minerals (macro minerals e.g Na, K, Ca, Cl, PO4

and micro minerals e.g Fe, Zn, Mg, Se, I, Cu, Cr, Cd, Mn).

Describe absorption/resorption and body regulation of

minerals, nutritional sources, RDAs, toxicity and deficiency

states of minerals.

Enlist the trace elements and briefly explain their

biochemical significance.

List of Practicals:

S. No CONTENTS

EXPERIMENT- 4. EXPERIMENTS ON CARBOHYDRATES /

BENEDICT'S TEST

EXPERIMENT-5. MOLISCH TEST

EXPERIMENT -6. IODINE TEST

EXPERIMENT-7. FEHLINGS TEST

EXPERIMENT-8. SELIWANOFF'S TEST

EXPERIMENT -15. EXPERIMENT ON LIPIDS (RANCIDITY OF FATS)

EXPERIMENT -16. MICROSCOPIC STUDY OF CHOLESTEROL

CRYSTALS

EXPERIMENT- 17. COLOUR TESTS FOR CHOLESTEROL

(SALKOWSKIS TEST)

EXPERIMENT -18. LIEBERMANN BURCHARD TEST

73


Topic: CHO chemistry (Anticoagulation)

A 62-year-old female presented to clinic with pain, swelling and redness to her right

lower leg. She stated that she was experiencing right calf pain worse with

walking. She noted that she returned home from a vacation to Europe last week which

included a 15-hour flight. The patient's vital signs were stable and she was

afebrile. The patient had a past medical history including hypertension and type 2

diabetes both of which were controlled with oral medications.

On examination, physician noticed that patient’s right leg to be slightly erythematous

and her calf is tender to touch. She had trace pedal edema in the affected leg and

limps slightly when walking. Her right calf was greater in size compared to her

left. Given this patient's medical history as well as her recent sedentary activity on her

long flight, physician suspected her to have DVT and ordered a venous ultrasound of

her right leg. Ultrasound results reveal a deep venous thrombus in her popliteal vein.

Based on this patient's ultrasound results, doctor prescribed her five days of

subcutaneous injectable heparin as well as coumarin. She was instructed her to return

to the clinic in five days to recheck her INR. She was issued strict instructions to return

should she develop chest pain or shortness of breath.


1. Chemistry and functions of GAGs

2. Heparin and its role in body

3. Proteoglycans chemistry and functions

REFERENCE BOOKS:




Topic: Enzymes (Diagnosis of biliary obstruction)

A 40 years old female presented with jaundice and pain in epigastrium for three days.

She also complained of nausea, vomiting, itching on skin, anorexia, pale color stools

and dark color urine. On examination her skin and sclerae were yellow. There was no

history of fever or weight loss over last few months. Ultrasonography abdomen

showed gall stones and no mass in the bile duct was seen. Other lab investigations

are as under

LAB INVESTIGATIONS:


Serum bilirubin Total 40µmol/L 2-17 µmol/L

Conjugated 22 µmol/L 0-4 µmol/L

74

Unconjugated 18 µmol/L 0-13 µmol/L

Serum ALT 46 U/L Upto 40 U/L

AST 49 U/L Upto 40 U/L

ALP 620 U/L 132-365 U/L

GGT 130 U/L Upto 30 U/L

Enzymes are mostly intracellular species or they are secreted into specific

cavities e.g, digestive enzymes. Normal cellular turnover causes some release into

the plasma and that constitute the basis for normal levels of plasma enzymes. If a

certain enzyme in increased more than normal in plasma, it means cellular rupture in

the tissue in which this particular enzyme or its specific isoform was abundant.

Isoforms or isozymes of one enzyme mean a single change in primary structure of

protein which does not affect the activity or stability of enzyme much but give different

bands on electrophoresis. Increase in plasma ALT means hepatocellular damage


1. Classification of enzymes

2. Factors affecting enzyme activity

3. Mechanism of enzyme action

Topic: Enzyme

A 65 years old chronic alcoholic reported to surgical OPD CMH Rwp with complains

of weight loss, anorexia & abdominal pain radiating to the back. Physical

examination showed a palpably enlarged gall bladder. Lab investigation showed:

Lab Investigation:

Computed tomogharapgy showed a mass in the head of pancreas. The patient was

diagnosed as a case of obstructive jaundice due to the pancreatic

adenocarcinoma.

Many diseases that cause tissue damage result in an increased release of

intracellular enzymes into the plasma. The level of specific enzyme activity in the

plasma frequently correlates with the extent of tissue damage. Alkaline phosphatase

Patient Value

Serum conjugated bilirubin

level

Increased

Urine bilirubin Present

Urine urobilinogen Absent

Fecal urobilinogen Absent

Serum ALP Highly Increased

Serum ALT Marginally Increased

Serum AST Marginally Increased

75

(ALP) is elevated in certain bone and liver diseases. ALP is useful for the diagnosis

of rickets, hyperparathyroidism, carcinoma of bone, and obstructive jaundice.


Mechanism of action of enzymes

Factors affecting enzyme activity

Role of enzymes in clinical diagnosi

Topic: Body Fluids

A 45-year-old male previously known to have duodenal ulcer presents with complaints

of persistent vomiting for past 36 hrs. He has no history of abdominal pain. He

complains of being dizzy when he stands up.

On examination his pulse is 95 beats/min, blood pressure is 90/50mmHg with sunken

eyes and dry oral cavity.

LAB INVESTIGATIONS:


Plasma Na+ 130mEq/L 135 – 145mEq/L

pH 8 7.35 -7.45

Urea 50mg/dl 10-40mg/dl

Cl- 80mEq/L 90-106mEq/L


1. Body fluid compartments.

2. Regulation of water balance

3. Weak acids and bases

4. Henderson Hassel Balch equation

CBL Session

A middle aged man was brought to emergency department with a history of persistent

vomiting and profuse watery diarrhea for the last 10 hours. Pt had a rapid feeble pulse,

sunken eyes and coated tongue. His blood pressure was 80/40 mm of Hg. He was

diagnosed as a case of acute gastroenteritis.

Related lab investigations:

Result Normal value

Serum Na + 130 meq/L 135-145 meq/L

“ K + 2.8 meq/L 3.5-5 meq/L

“ Urea 50 mg/dl upto 40 mg/dl

“ Creatinine 1.2 meq/L 0.6-1.2 mg/dl

“ Cl - 76 meq/L 96-106 meq/L

Learning Objectives:

Movement of materials across cell membranes

Simple diffusion

76

Carrier mediated diffusion and active transport

Osmosis and surface tension

Topic: Minerals (Copper Storage Disease, WD disease)

An 8-years boy was brought to PAEDS OPD in the hospital. He was presenting mild

cognitivedeterioration and clumsiness and common parkinsonian features.

Parents informed that the child had delayed slurred speech. It was also informed by

the parents that on opening arms child present wing-beating tremors. On details

family history parents informed that three years girls died two years earlier because of

same symptoms. Physician observed Kayser–Fleischer rings (KF rings) using slit

lamp and skin turgor&Spasticity was poor. Persistent elevatedlevels of serum

alanine aminotransferase (ALT), and aspartate aminotransferase (AST) levels were

observed. The attending pediatrician suspected Wilson Disease. Liver nodular

growths were observed in abdominal USG. To confirm diagnosis Liver FNAC was

performed which showed very high level of copper accumulation. High level of copper

was also observed in 24-hour urine exam. Furthermore, reduced Serum ceruloplasmin

levels was observed. In order to confirm the Wilson disease whole blood samples was

sent to molecular laboratory for genetic analysis in ATP7B gene.

S.No Tests Patients Refence

1 ALT 134U/L Upto 42 U/L

2. Urine Cu 65mmol/L >1mmol/l

3. Serum Cu 75mmol 11-24mmol/L

4. Serum ceruloplasmin 8 mg/L 15-20mg/L

5. USG abdomin Nodular liver Negative


Copper metabolism in Human and its absorption

Functions of Copper

Dietary sources of Copper

Copper containing Enzymes

Topic: Iron Deficiency Anemia:

A multiparous female presented in medical OPD with the complaints of generalized

weakness, occasional dizziness, easy fatigability and shortness of breath. She

belonged to a low socio-economic status. Her past medical history reveals postpartum

hemorrhage.

On examination she was pale, her pulse was 90 beats/min, blood pressure was

100/70mmHg.

https://en.wikipedia.org/wiki/Kayser%E2%80%93Fleischer_ring

77

LAB INVESTIGATIONS:


Hb 8.5g/dl 12-14g/dl

MCV 70fl 80-100fl

MCH 20pg 27- 31pg

MCHC 28g/dl 32- 36g/dl

S.Fe 34µg/dl 50- 170µg/dl

TIBC 400µg/dl 250- 370µg/dl

S. Ferritin 10µg/L 15- 150µg/L

Peripheral Blood

Smear

Hypochromia

Microcytosis


1. Classify minerals

2. Sources, Absorption and Transport of Iron

3 Disorders of iron metabolism

78

MODULE-III

Section-I

Anatomy

79

Summary:

Code Y1M3

Name Anatomy

Duration 10 weeks




module)

Lower Limb

Respiratory System

Subject Themes

Gross anatomy

Lower Limb

General Anatomy

Skin Fascia

Vertebral column

Nervous system-II

Embryology

Birth defects

Body cavities

Respiratory system

Muscular System

Skeletal system except head and neck

Development of limbs

Histology

Respiratory system

Prerequisite Module Y1M1 & Y1M2


MIT

Lectures

Dissection

Tutorials (PTT)

CBL

Practicals

Class tests

80


ANATOMY

LEARNING OUTCOMES Y1M3

S.

N

O

TOPIC DISCI-

PLINE

MIT LEARNING OUTCOMES

1 Hip bone Gross

Anatomy

SG

D

Skill:

Demonstrate the anatomical position of bone and

determine the side

Recognize important bony land marks on gross

inspection as well as on radiographs

Identify the muscles & ligamentous attachments

on bone

Knowledge:

Describe the muscles & ligamentous attachments

on bone

Discuss injuries of hip bone and identify them on

radiographs

Compare gender differences of hip bone

2 Gluteal Region Gross

Anatomy

SG

D

Skill:

Explore and identify the structural anatomy of

gluteal region of the cadaver after performing

dissection.

Knowledge:

Describe in tabulated form the origin, insertion,

nerve supply and action of gluteal muscles

Enumerate structures deep to gluteus maximus

Describe boundaries of greater sciatic and lesser

sciatic foramina and enumerate structures

passing through them

Summarize the origin, relations and main

branches of nerves and vessels of gluteal region

Analyze clinical scenarios regarding:

Injury to superior gluteal nerve

Injury to inferior gluteal nerve

Injury to sciatic nerve

Intragluteal injections

3 Femur Gross

Anatomy

SG

D

Skill:

Demonstrate the anatomical position of bone and

determine the side



Knowledge:

81

Describe the muscle & ligamentous attachments

on bone

Describe femoral fractures and identify them on

radiographs

Analyze clinical scenarios related with coxa vera

and coxa valga

Analyze clinical scenarios related with interruption

of blood supply to head & neck of femur

4 Anterior fascial

Compartment of

Thigh

Gross

Anatomy

SG

D

Skill:

Dissect the front of thigh to:

Trace continuity of fascial layers of abdominal wall

with perineum & thigh

Explore the arrangement of superficial inguinal

lymph nodes & their drainage area

Locate the superficial inguinal ring

Reveal the course of great saphenous vein

Explore the fascia lata and opening contained in it

Identify the attachments of muscles of anterior

facial compartments of thigh along with their blood

and nerve supply

Explain the boundaries and contents of femoral

canal

identify the boundaries and contents of femoral

triangle

Knowledge:

Describe the boundaries, compartments, contents

and importance of femoral sheath


blood and nerve supply and actions of muscles of

anterior facial compartments of thigh

Analyze the clinical scenarios related with:

Varicose veins

Great saphenous vein cutdown

Great saphenous vein in coronary bypass surgery

Femoral vein catheterization

Femoral hernia

Femoral nerve injury

5 Medial fascial

Compartment of

Thigh

Gross

Anatomy

SG

D

Skill:


medial compartment of thigh of the cadaver after

performing dissection.

Knowledge:

Describe the origin, insertion, nerve supply and

actions of muscles of medial facial compartments

of thigh

Analyze the clinical scenario related with obturator

nerve injury

82

6 The back of the

thigh

Gross

Anatomy

SG

D

Skill:

Explore and identify the structural anatomy of back

of thigh of the cadaver after performing dissection.

Knowledge:


actions of muscles of posterior facial

compartments of thigh

Mark the deep seated structures on the surface of

region

Analyze the clinical scenario related with sciatic

nerve injury with special reference to sciatica

7 Hip joint Gross

Anatomy

SG

D

Skill:

Demonstrate the articulation of hip joint

Knowledge:

Describe the articulation, type, capsule, ligaments,

synovial membrane, nerve supply, blood supply

and important relations of hip joint

Discuss the various movements of hip joint along

with muscles responsible for these movements

Discuss the importance of artery to the ligament of

the femoral head in Fractures of the Femoral Neck

Discuss the anatomical structures involved in

Dislocation of Hip Joint

Analyze the clinical scenarios related with hip joint

stability and trendelenburg’s sign

Discuss the anatomical basis of arthritis of hip joint 8 Bones of leg Gross

Anatomy

SG

D

Skill:

Identify the patella and its landmarks

Demonstrate the anatomical position of tibia &

fibula and determine their side



Knowledge:

Discuss patellar dislocations & patellar fractures

Describe and identify the muscle & ligamentous

attachments on tibia & fibula

Identify the common sites of fractures of tibia and

fibula and correlate them with their clinical

presentation based on the knowledge of Anatomy

Discuss clinical importance of intraosseous

infusion of tibia in infants

9 Popliteal fossa Gross

Anatomy

SG

D

Skill:


popliteal fossa of the cadaver after performing

dissection.

Knowledge:

83

Enlist the structures forming various boundaries of

popliteal fossa

Enumerate the contents of popliteal fossa and

discuss their inter-relationships

Draw and label genicular anastomosis and

discuss its clinical significance

10 Fascial

compartments of

leg

Gross

Anatomy

SG

D

Skill:


fascial compartments of leg of the cadaver after

performing dissection

Knowledge:

Enumerate the contents of anterior, lateral and

posterior compartments of leg.

Describe origin, insertion and actions of muscles

contained within anterior, lateral and posterior

compartment of leg.

Explain blood and nerve supply of anterior, lateral

and posterior compartment of leg

Discuss the following clinical conditions related

with structures in the region of leg:

Anterior compartment of leg syndrome

Tenosynovitis & dislocation of peroneus longus &

brevis tendons

Gastrocnemius & soleus muscle tears

Ruptured tendocalcaneus

Rupture of plantaris tendon

Plantaris tendon & autografts

Deep vein thrombosis & long distance air travel

Describe the retinaculae of ankle with reference to

their attachments and structures passing

underneath them

Analyze the clinical scenarios related with

common peroneal and tibial nerve injuries

84

11 Knee joint Gross

Anatomy

SG

D

Skill:

Demonstrate the articulation of knee joint

Knowledge:

Describe the articulation, type, capsule, ligaments

(extra and intra articular), synovial membrane,

nerve supply, blood supply, important relations,

and movements related to the knee joint

Explain the mechanism of locking and unlocking

of the knee joint

Name the bursae related to knee joint and point

out those which communicate with the joint cavity

Analyze the clinical scenarios related with patellar

tendon reflex and various types of bursitis

Discuss the following:

Quadriceps femoris as knee joint stabilizer

Strength of knee joint

Knee injury and synovial membrane

Ligamentous injury of knee joint

Meniscal injury of knee joint

Pneumoarthrography

Arthroscopy

12 Proximal & distal

Tibiofibular joints

Gross

Anatomy

SG

D

Knowledge:


nerve supply, blood supply, and movements

related to these joints

13 Ankle joint Gross

Anatomy

SG

D

Skill:

Demonstrate the articulation of ankle joint

Knowledge:


synovial membrane, nerve supply, blood supply,

movements and important relations of the joint

Differentiate between acute sprains of lateral

ankle and medial ankle

Describe the fracture dislocation of ankle joint

Discuss the sensory and motor loss associated

with tibial nerve entrapment in tarsal tunnel

syndrome

Analyze the clinical scenario related with achilles

tendon reflex

85

14 Articulated foot Gross

Anatomy

SG

D

Skill:

Identify the bones of foot

Demonstrate anatomical position and determine

their side of calcaneus and talus

Recognize important bony landmarks, muscular &

ligamentous attachments on calcaneus & talus

Knowledge:

Describe articulation among various bones of foot

Describe foot as a functional unit

Describe arches of foot with reference to bones of

arches, and mechanisms of arch support

Discuss mechanism of walking

Discuss the clinical problems associated with the

arches of foot 15 Intertarsal joints Gross

Anatomy

SG

D

Skill:

Identify articulation, type of joint, important

ligaments and movements at these joints on an

articulated foot 16 Sole of foot Gross

Anatomy

SG

D

Skill:

Explore and identify the structural anatomy of six

layers of sole of foot of the cadaver after

performing dissection

Knowledge:

Describe the attachments and relations of plantar

aponeurosis


nerve supply and action of muscles of sole of foot

Describe arteries and nerves of sole of foot

17 The dorsum of foot Gross

Anatomy

SG

D

Knowledge:


action of extensor digitorum brevis

Describe arteries and nerves of dorsum of foot

18 Cutaneous

innervations of

lower limb

Gross

Anatomy

SG

D

Knowledge:

Describe the cutaneous nerve supply of lower limb

Draw & label cutaneous innervation of lower limb

Draw & label the dermatomes of lower limb

86

19 Blood supply of

lower limb

Gross

Anatomy

SG

D

Knowledge:

Describe blood supply of lower limb

Discuss the following:

Arterial palpation

Collateral circulation

Traumatic injury to femoral artery

Arterial occlusive disease of the leg

Saphnous cut down

Varicose veins

20 Lymphatic drainage

of lower limb

Gross

Anatomy

SG

D

Knowledge:

Describe the lymphatic drainage of lower limb

21 Surface marking Gross

Anatomy

SG

D

Skill:

Mark the nerves and vessels of lower limb on the

surface of region with the help of important bony

landmarks HISTOLOGY

22 Respiratory system Histolog

y

IL Enlist the main divisions of respiratory passage

along with the structures constituting each?

Define respiratory and olfactory epithelium

Enumerate cells comprising respiratory & olfactory

epithelium. Describe their light microscopic

structure with the help of diagram

Describe the histological structure of the following

with the help of diagram:

Paranasal air sinuses

Nasopharynx

Larynx

Trachea

Lungs

Pleura

Differentiate various parts of bronchial tree on the

basis of lining epithelium, presence of cilia, glands,

cartilage, smooth muscles, and elastic fibers

Analyze clinical scenario regarding:

Immotile cilia syndrome

Respiratory distress syndrome EMBRYOLOGY

87

23 Birth defects Embryo IL Enumerate types of birth abnormalities & define

each of them with at least one example

Summarize principles of teratology

Classify teratogens with associated human

malformations in tabulated form

Enlist numerical & structural chromosomal

abnormalities

Discuss the following numerical chromosomal

abnormalities:

Trisomy 21

Trisomy 18

Trisomy 13

Klinefelter syndrome

Turner syndrome

Discuss the following structural chromosomal

abnormalities:

Cri-du-chat syndrome

Angelman’s syndrome

Prader-willi syndrome

Miler-dieker syndrome

Define mosaicism & discuss its embryological

basis

Discuss critical periods of prenatal human

development

Discuss invasive and noninvasive approaches for

assessing growth & development of fetus in utero

24 Development of

body cavities

Embryo IL Explain transformation of single intraembryonic

coelom into pericardial, pleural and peritoneal

cavities

Enlist development sources of diaphragm

Describe development of diaphragm

Discuss positional changes of diaphragm with

reference to age of fetus

Explain the innervation of diaphragm with

reference to its developmental sources


Ventral body wall defects

Diaphragmatic hernias

88

25 Development of

respiratory system

Embryo IL Describe the development of the following:

Larynx

Trachea

Bronchi

Lungs

Describe different stages of lung maturation

Enlist factors responsible for normal lung

maturation

Enlist the postnatal changes that occur in lungs


Various types of tracheoesophageal fistulas

Respiratory distress syndrome

Ectopic lung lobes

Congenital cysts of lungs

26 Development of

skeletal system

Embryo IL Describe histogenesis of cartilage

Describe histogenesis of bone

Explain development of joints

Describe development of vertebral column

Define spina bifida. Enlist its different types. Give

embryological basis of bifid spine alongwith

methods of prenatal assessment in this anomaly

Explain development of ribs and sternum with

congenital defects

Discuss embryological basis and associated birth

defects of:

Klippel feil syndrome

Accessory ribs

Fused ribs

Hemivertebra

Rachiscisis

Anomalies of sternum

89

27 Development of

muscular system

Embryo IL Describe development of skeletal musculature

Define lateral somitic frontier. Enlist the structures

whose borders are defined by lateral somitic

frontier.

Enumerate the muscles derived from primaxial

and abaxial domains

Summarize the innervation of axial skeletal

muscles

Enlist the developmental source of:

Head muscles

Limb muscles

Cardiac muscles

Smooth muscles

Discuss the following clinical anomalies:

Poland sequence

Prune belly syndrome

Muscular dystrophy

28 Development of

limbs

Embryo IL Describe the formation of limb buds

Define apical ectodermal ridge and discuss its role

in limb development including digits

Describe limb growth and development

Discuss rotation of limbs during development.

Describe the relationship between rotation of

limbs & cutaneous nerve supply of limbs

Differentiate between development of upper and

lower limbs

Discuss development of limb musculature

Enumerate and describe the various types of limb

defects. Discuss their embryological basis

General Anatomy

29 Skin & fascia General

Anatomy

SG

D

Enumerate the components of integumentary

system.

Enlist the functions of integumentary system

Enlist the two main parts of skin. Enumerate its

layers with their general features.

Enumerate appendages of skin. Describe their

general features.

Define cleavage lines? Describe their clinical

importance.

30 Vertebral column General

Anatomy

SG

D

Describe the anatomy of vertebral column with

reference to:

Number of vertebra in different regions

Curvatures of vertebral column

Describe defects in the curvature of vertebral

column

90

31 Nervous system-II General

Anatomy

SG

D

Describe division of nervous system on gross

anatomical basis

Enumerate components of central and peripheral

nervous system. Describe their general features

Define autonomic nervous system (ANS). Enlist

the differences between autonomic and somatic

nervous system

Enlist the main divisions of ANS? Describe

differences of its two main divisions in tabulated

form.

Enumerate cranial parasympathetic ganglia.

Describe their general features

Define enteric nervous system. Describe its

general features.

List of Practical work:

Histology of Bronchial Tree

Histology of Lung -I

Histology of Lung -II

Case Base Learning Scenarios:

CBL Case-1

A middle aged female presented with multiple fractured ribs and right side

haemothorax after a road accident. A chest tube was put in to drain the hemothorax.

She was comfortable, no respiratory distress and maintaining the oxygen saturation

without oxygen supplementation. There is decrease air entry at base and check X-ray

revealed markedly elevated diaphragm on Rt. Side. C.T.Chest-suspicion of traumatic

diaphragmatic hernia with herniation of liver in thorax. Surgeon planned lateral

thoracotomy through 7th I.C.space. Before opening he placed laparoscope through

chest tube site and confirmed the diagnosis. Liver and a part of colon were in thorax.

After opening both structures could be reduced easily. Rent in diaphragm repaired

with 1/0 Prolene suture. Post-operative – uneventful recovery.


Identify major anatomical landmarks of the diaphragm including its muscular portion,

central tendon, right and left crus, esophageal hiatus, aortic hiatus, and caval foramen.

Learning Resources:



91

CBL Case-2

A 10 years old boy had a coughing fit while chewing on a pen top and subsequently

realized that the inside of the pen top was missing. He was sent home from the local

emergency department after a normal chest radiograph. Two days later he started to

wheeze and cough. A chest radiograph was again normal, but he had wheeze that

was louder on the right side of the chest and a fever. He was given intravenous

antibiotics but he did not improve and the following day was transferred to the regional

pediatric center for assessment. With rigid bronchoscopy under general anesthesia

the pen top was removed from his right main bronchus.


Identify the thoracic part of the trachea and bronchi describe its blood supply and

innervation.

Identify and describe the location of the lungs in the thoracic cavity.

Identify the relations of the pulmonary artery, pulmonary veins, and the bronchi at the

hilum of each lung.

Define a bronchopulmonary segment and discuss its general organization.

Name the bronchopulmonary segments and give their approximate location in

reference to the lobes of the lungs.

Learning Resources:



LOWER LIMB:

CBL –3

A 55‐year‐old man presented to his local hospital in November 2001 with weakness

and pain in his left foot. Eighteen months previously, he noted his inability to curl the

toes of his left foot. This was associated with numbness of the sole of the same foot.

He was unable to stand on the toes of his left foot, and the numbness had spread to

the whole left sole and the back of the leg. He had developed severe pain in the back

of his left thigh, radiating down to the ankle, very similar to the sciatica he had

experienced 10 years previously on the right side. He was well systemically. On

examination, the neurological abnormalities were confined to his left leg. No wasting

was evident, but there was severe weakness in the muscle groups innervated by the

tibial nerve and numbness in the S1 dermatome. All deep tendon reflexes were intact

and the plantar responses flexor. General examination was unremarkable other than

a pigmented lesion on his back.

Blood tests, including full blood count and erythrocyte sedimentation rate, were

normal.

92

Nerve conduction studies showed an absent left posterior tibial motor response from

abductor hallucis, with a normal left common peroneal motor amplitude from extensor

digitorum brevis (4.2 mV at ankle). The left sural sensory action potential was 16 μV

initially, but fell to 6 μV in a month. Electromyography showed denervation changes in

the gastrocnemius and abductor hallucis, but not tibialis anterior, consistent with a

tibial or sciatic nerve lesion.

Magnetic resonance imaging (MRI) of the lumbosacral spine was normal, but MRI of

the thighs showed diffuse swelling and edema of the sciatic nerve from below the

buttock to the level of the popliteal fossa on the left. The extent of swelling was thought

to be unusual for a neurogenic tumor


Describe the anatomy of the lateral femoral (hip) region, including the gluteal muscles,

their nerve supply, and their actions in locomotion.

Identify the sacral plexus, its general plan, and its major branches in the hip and

posterior thigh regions

Identify the sciatic nerve its root value and area of supply

Define the greater and lesser sciatic foramina and the structures traversing each.

Define the term sciatica and its causes

CBL 4

Tahir’s mother a 70 years old lady was brought to the emergency of Railway hospital

due to slipping in the bathroom. She was complaining of severe pain in the left hip

along with inability to put pressure on left leg during an effort to walk. On enquiry she

gave a history of generalized bone pains and chronic backache since menopause.

She also told the doctor that her intake of dairy products was low and she was taking

pain killer for the relief. Besides taking pain killer she has not seek the advice of any

doctor for her condition. On examination her left leg was shorter than right side and

was lying externally rotated. Movements of hip were painful but there was no external

wound. Doctor on duty in ER administered drugs for relief of pain and sent the patient

to Radiology department for x-rays. Her urine and blood were taken for routine

investigation in the laboratory.

X-ray

Showed fracture neck of femur on left side

Bone mineral Density was low in all the bones

X-ray spine also revealed biconcave vertebrae, with wedging of L2 vertebra

93

LABS

Hb = 9.9 g /dl TLC 8,900/cmm BSR 146mg/dl

Urea = 34 Creatinine 1.00

Serum Calcium 8 mg/dl

Serum Phosphorus 4.2 mg/dl

Alkaline Phosphatase 196 units

Serum Parathyroid Levels were normal

Urine R/E showed no abnormality

She was shifted to orthopedics ward for further management.


Describe the bony structure of the hip joint including bones and ligaments contributing

to its strength and flexibility

Define the Trendelenburg gait and Trendelenburg's sign

Describe the role of vitamin D, Parathormone and calcitonin in regulating the calcium

metabolism. Defineosteomalacia and osteoporosis and describe their main clinical

features. Discuss the role of Bisphosphonates in the treatment of osteoporosis.

CBL CASE NO 5

An 88-year-old man presented with a 2-day history of a painful mass in his right groin.

Abdominal examination disclosed mild tenderness in the right lower quadrant. A 6-cm

right inguinal mass was palpated that was non-reducible and exquisitely tender to

palpation. The leukocyte count was 13.4 х 109/L. The preoperative diagnosis was

strangulated inguinal hernia. At laparotomy, a large, edematous, inflamed femoral

mass, medial to the femoral vein, was identified. The anterior surface was opened,

and purulent fluid was drained. The hernial sac was found to contain a perforated

appendix. After appendectomy, the sac was closed at its base, and the redundant

portion was amputated. The femoral hernia was repaired by suturing the iliopubic tract

to Cooper's ligament. Pathological examination of the excised specimen

demonstrated acute and chronic appendicitis with perforation of the appendix and

periappendicitis in the hernial sac. Postoperatively, the patient was given a 4-day

course of antibiotics intravenously.


Given what you know about the anatomy of the inguinal region and the anteromedial

thigh.

Why would the femoral vein be used for catheterization instead of vessels closer to

the heart, like the external jugular, for instance?

Define the femoral triangle and adductor canal, their contents and the spatial

relationships of the structures passing through them.

Identify the femoral and obturator arteries and veins and their branches. Give their

areas of distribution.

CBL CASE 6

94

An eighteen-year-old girl, a case of post-polio residual paralysis, came to our

institution ambulating on all four limbs. She incidentally had a huge swelling arising

from her left knee. The swelling had started insidiously when she was ten years old

and gradually increased over the years to attain the present size. The mechanical

impediment with occasional pain and ulceration on its under surface had restricted her

ambulation even on her all four limbs for the previous two years. On examination, she

had a flail right lower limb with a fixed flexion deformity of 60° at right knee. Her left

lower limb had grade 4 muscle power at hip, grade 3 extensor power at knee and

equinovalgus deformity of left ankle and foot, apart from the massive swelling at the

knee. The swelling was single, oval in shape and present

Over the anterior aspect of the left knee centering over the patella and measuring

about 15x14 cm. The surface was predominantly smooth with some areas of

lobulations and the skin was free from swelling. There were scars of old pressure sores

on its under surface. It was non-tender on palpation, firm in consistency with some

cystic areas in between (Fig.1). Radiological examination revealed a soft tissue mass

with noevidence of calcification and not involving the knee joint. As a first stage

procedure, she underwent excision of the swelling in to after identifying the well-

defined cleavage between the swelling and the patella. The histopathological

examination report confirmed our preoperative diagnosis of bursal cyst. Confirmed our

preoperative diagnosis of bursal cyst. After 3 months, she underwent posterior soft

tissue release for correction of the fixed flexion deformity of


Describe the synovial bursa and tendon sheaths

Enlist the bursae with relations around the knee joint

Describe the boundaries and contents of popliteal fossa

Identify the arterial anastomosis around the knee joint

CBL Case-7

A first year medical student enjoyed running for exercise and relief of tension. Near

the end of a particularly long and strenuous run, she suddenly developed a severe

pain on the bottom of her foot. She immediately stopped running and sat down to rest;

the pain subsided somewhat, but persisted. Although she rested from running for

several days, the pain did not go away and was particularly apparent if she stood for

long periods in the gross anatomy lab. Upon arrival at the hospital her injured foot was

swollen, deformed and held rigid. There was tenderness on the bottom of her foot from

heel to the heads of the metatarsals, especially just anterior to the calcaneal

tuberosity. AP, lateral and oblique x-rays were done, and an undisplaced fracture of

the talarneck was shown. Neurological tests revealed no nerve involvement other than

the pain, which appeared to be related entirely to the soft tissues on the bottom of her

foot. The orthopedic surgeon ordered a split plaster of Paris that should be reapplied

when swelling settles.

95


What soft tissue structures are located on the bottom of the foot between the calcaneal

tuberosity and the heads of the metatarsals? What single fibrous structure spans the

same bones? What is the function of the plantar aponeurosis, long

plantar, spring and short plantar ligaments?

How would the talus get fractured as a result of a fall on the heel? What other

bones may fracture from such trauma? What complication may arise from such a

fracture?

Discuss the anatomy of bones and arches of foot

Describe the anatomy of ankle joint and subtalar joints

http://www.med.umich.edu/lrc/coursepages/m1/anatomy2010/html/musculoskeletal_system/leg_tables.html#tuberosity of the calcaneus

http://www.med.umich.edu/lrc/coursepages/m1/anatomy2010/html/musculoskeletal_system/leg_tables.html#tuberosity of the calcaneus

http://www.med.umich.edu/lrc/coursepages/m1/anatomy2010/html/musculoskeletal_system/leg_tables.html#heads of metatarsals

http://www.med.umich.edu/lrc/coursepages/m1/anatomy2010/html/musculoskeletal_system/joints_lower_tables.html#long plantar

http://www.med.umich.edu/lrc/coursepages/m1/anatomy2010/html/musculoskeletal_system/joints_lower_tables.html#long plantar

http://www.med.umich.edu/lrc/coursepages/m1/anatomy2010/html/musculoskeletal_system/joints_lower_tables.html#plantar calcaneonavicular (spring) ligaments

http://www.med.umich.edu/lrc/coursepages/m1/anatomy2010/html/musculoskeletal_system/joints_lower_tables.html#plantar calcaneocuboid (short plantar) ligament

96

MODULE-III

Section-II

Physiology

97

Summary:

Code Y1M3

Name Physiology

Duration 10 weeks




module)

Lower Limb

Respiratory System

Subject Themes

Physiology of respiration

Deep sea physiology

Aviation/space physiology

High altitude physiology

Exercise physiology

Prerequisite Module Y1M1&Y1M2


MIT

Lectures

Tutorials (PTT)

CBL

Practicals

Class tests


Introduction to

Respiratory System

To know the functional anatomy of respiratory tract

To understand the functions of various parts of

respiratory system

To highlight the non-respiratory functions of

respiratory tract

Pulmonary Mechanics

To know the functions of respiratory muscles

To understand various pressures acting on lungs and

chest wall

To understand the change in pressures during each

phase of respiration

To know the normal lung volumes/capacities

To understand the concept of static v/s dynamic lung

volumes/capacities

Pulmonary Compliance

To understand the concept of lung and chest wall

compliance

98

To know the composition & role of surfactant in

alveolar surface tension

To understand the concept of work of breathing

Respiratory Membrane

& Diffusion of Gases

To study the layers of respiratory membrane

To know the concept of diffusing capacity through

respiratory membrane

To study the factors affecting gas diffusion through

respiratory membrane

Diffusion of gases &

Oxygen transport

To know the mechanics of oxygen diffusion from

alveoli to blood

To understand the mechanism of oxygen transport in

the arterial blood

To know the mechanics of oxygen diffusion from

blood to tissue fluid

To study the mechanics of oxygen diffusion from

tissue fluid in to cell

Oxygen transport &

Dissociative curve

To study the role of Hb in oxygen transport

To study the normal oxygen-hemoglobin dissociation

curve

To study the factors that shift oxygen-hemoglobin

dissociation curve

Carbon dioxide

transport

To know the various chemical form in which CO2 is

transported in blood

To study the normal CO2 dissociation curve

To understand the concept of haldane effect

Nervous regulation of

respiration

To study different group of neurons composing

respiratory center

To study the control of inspiration and respiratory

rhythm

To understand the role of pneumotaxic center in

respiration

To understand the regulatory mechanism of hering-

breuer inflation reflex

Chemical regulation of

respiration

To study the central chemosensitive area & its

stimulation by CO2 and H+

To know the role of peripheral chemoreceptors for

control of respiration

To study the composite effects of PCO2, pH, & PO2

on alveolar ventilation

Pulmonary circulation

Va/Q

To understand pressure differences b/w pulmonary &

systemic circulation

To study the pulmonary blood flow and effect of

hydrostatic pressure on it

99

To understand the concept ventilation perfusion ratio

Hypoxia

To study various causes of hypoxia

To know the effects of hypoxia on the body

To study the role of oxygen therapy in different types

of hypoxia

Cyanosis/Asphyxia/

Hypercapnia

To study the causes of cyanosis and asphyxia

To study the hypercapnia & its association with

various forms of hypoxia

To study the effects of very high blood CO2 levels on

respiratory center

Hazards at High

Altitude

To study the change in composition of air at high

altitude

To study the effects of low oxygen pressure on the

body

To study the change of alveolar PO2 at different

elevations

Acclimatization at High

altitude

To study the mechanism of acclimatization of the

body to low O2

To understand the cause of natural acclimatization in

natives of H.A

To study the principals of acclimatization

Respiratory adjustment

during exercise

To study oxygen consumption and pulmonary

ventilation during exercise

To study the respiratory changes during exercise

To study body’s regulation of respiration during

exercise

AMS/HAPE/HACE

To study the causes & clinical features of

AMS/HAPE/HACE

To understand the pathophysiological mechanism of

development of AMS

To study the various treatment modalities for

AMS/HAPE/HACE

Aviation/space

physiology

100

List of Practical:

Module 3

Examination of the chest related to respiratory system (respiratory rate)

Auscultation of breath sounds

Spirometry: Lung volumes and opacities

Spirometry: FEV1 and FVC

Stethography.

PEFR Peak Expiratory Flow Rate

CPR



PBL 1

A 10-year-old boy is brought to the emergency department because of difficulty in

breathing that developed while playing football. The boy has a history of allergies,

including a pollen allergy, but never previously showed this level of respiratory

difficulty. He now complains of tightness in the chest. There is no family history of

allergies or asthma. Both parents smoke cigarettes.

PHYSICAL EXAMINATION

Vital Signs: Temp 37°C, Pulse 120/min, Resp rate 30/min and shallow, BP 110/95 mm

Hg

Physical Examination: Patient is wheezing, anxious, and short of breath. The

wheezing is more prominent on exhalation, and there is an extended forced expiratory

phase. The chest antero-posterior diameter appears large for age and size. The nasal

mucosa is edematous, and the pharynx is coated with a clear postnasal discharge.

A beta2-adrenergic agent was administered by an inhaler, and the symptoms quickly

subsided. The patient’s anxiety was relieved, and heart rate and breathing rate

returned to normal. The patient was scheduled for pulmonary function tests.

LABORATORY STUDIES

Spirometry: Normal values. When challenged with methacholine, however, a

hyperreactivebroncho constriction occurred with decreased FEV1, decreased forced

vital capacity, and increased residual volume. Forced spirometry flow/volume loop:

Scooping, diminished peak flow.

DIAGNOSIS : Asthma


After discussion you should be able to:

List the passages through which air passes from the exterior to the alveoli, and

describe the cells that line each of them.

List the major muscles involved in respiration, and state the role of each.

Define the basic measures of lung volume and give approximate values for each in a

normal adult.

Define lung compliance and airway resistance.

101

Compare the pulmonary and systemic circulations, and list some major differences

between them.

Describe basic lung defense and metabolic functions.

Define partial pressure and calculate the partial pressure of each of the important

gases in the atmosphere at sea level.

Define hypoxia and describe differences in subtypes of hypoxia.

Resources:





Electronic modes

PBL 2

Mr. Ahmed, 25-years- old, young man of average built was enjoying good health. One

day he decided to do some exercise and went for jogging in exercise. After about a

round of one km, he felt severe palpitation and breathlessness. Becoming concerned,

he went to hospital. His pulse was 100/min, BP – 145/85 mmHg and respiratory rate

was 28/min. The doctor advised him spirometry at rest and as well as after exercise.

Following were the findings:

At Rest After Exercise

VT 500 ml VT 1000 ml

IRV 3000 ml IRV 4000 ml

ERV 1100 ml ERV 1500 ml

IC 34500 ml IC 50000 ml

VC 4600 ml VC 6500 ml

Doctor reassured Mr. Ahmed and sent him to his home.


To know the respiratory muscles involved at rest and in exercise.

To co-relate the changes in thoracic cage, muscle movement and compliance of lung

at rest and in exercise.

To understand the changes in pleural pressure, alveolar pressure and trans-

pulmonary pressure at rest and in exercise.

To comprehend the concept of spirometry.

To know the values of lung volume and capacities at rest and in exercise.

To appreciate the limitation in spirometry.

To understand the compliances of lung and factors effecting it.

To comprehend the concept of work of breathing and factors effecting it.

Resources:


102




Electronic modes

PBL 3

Ahmed returned to his apartment in the cold winter night. He turned on his old heater

and shut all the windows and door. After having a sleep of 2 hours, he woke up and

noticed that his vision became progressively blurred. When he got up he became

much disoriented and fell down. One of his friends incidentally stopped by and found

Ahmed unconscious and hyperventilating with a reddish complexion. He immediately

took him out of the house and called for an ambulance. The duty doctor made a

diagnosis of “CO poisoning” based upon history and examination. Ahmed was treated

with hyper baric oxygen therapy.


To develop working knowledge of:

Causes of CO poisoning

Relate the symptoms to Carbon monoxide poisoning.

Physiological basis of CO poisoning in this patient.

Dynamics of Oxygen transport by the blood.

Understanding of oxygen-Hb dissociation curve and effect of CO on this curve.

Forms of transport of respiratory gases in blood including O2, CO2, CO & Nitrogen.

Assessment of how CO caused a reduction in the oxygen-carrying capacity of the

blood.

Learning the physiological basis of treatment with hyper baric oxygen.

Compare the skin color of the patient in cyanosis, CO poisoning and

methemoglobinemia.

Resources:





Electronic modes

PBL 4

A 17-year-old student suspected of asthma has experienced reversible, periodic

attacks of chest tightness with coughing, wheezing, and hyperpnea. She states that

expiration is more difficult than inspiration. She is most comfortable sitting forward with

arms leaning on some support. X-rays revealed mild over inflation of the chest. Results

from laboratory and pulmonary function tests are as follows:

103

Frequency 20 breaths/min

Vital capacity (VC) 2.9 L

FEV1.0 1.4 L

FEV1.0/FVC 56%

Functional residual capacity (FRC) 3.89 L

Total lung capacity (TLC) 6.82 L

PaO2 70 mm Hg

PaCO2 26 mm Hg

Pulse 108 b/min

BP 120/76 mm Hg

Intermittent use of a bronchial smooth muscle dilator (1:1000 epinephrines by

nebulizer) for several days caused marked improvement, resulting in the following

laboratory and pulmonary function tests:

VC 4.15 L

FEV1.0 3.1 L

FEV1.0/FVC >75%

FRC 3.7 L

TLC 5.96L

PaO2 89 mm Hg

PaCO2 38 mm Hg

Pulse 129 b/min

BP 122/78 mm Hg


To understand mechanics of pulmonary ventilation underpinning various lung

pressures and volumes.

To acquire working knowledge of lung volumes and capacities.

To apply concept of ventilation perfusion ratio to physiological as well as pathological

clinical constructs.

To critically reflect on obstructive vs. restrictive pathophysiology of lung diseases.

To discuss pathogenesis, presentation and treatment of asthma.

Resources:





104

Electronic modes

PBL 5

A 24-year-old pregnant woman presented to the hospital in preterm labor and

subsequently delivered a premature infant at only 27 weeks gestation (normal term

pregnancy is 37-42 weeks). After the delivery, the infant cried, but it subsequently

began to grunt and showed signs of hypoxia despite oxygen supplementation. The

baby immediately was intubated by endotracheal tube and given surfactant down the

endotracheal tube. The baby’s hypoxia resolved, and he was transferred to the

neonatal intensive care unit for further stabilization.


To know composition of pulmonary surfactant.

To understand concept of surface tension and its role in pulmonary ventilation.

To list changes in various pulmonary pressures at birth.

To understand pathophysiology of respiratory distress in infants.

To gain insight into treatment options for respiratory distress syndrome in infants.

To identify pathophysiological basis of retrolental fibroplasia.

Resources:





Electronic modes

PBL 6

A 55-year-old man with a history of a chronic lung disease presents to his primary care

physician with worsening shortness of breath. He was diagnosed about 1 year ago.

He gives a history of smoking cigarettes (one pack a day for 30 years) but has no other

medical problems. His general appearance is that of a thin male who appears to be in

mild distress. His cardiac examination is normal, but he is noted to have an expanded

anterior-posterior diameter of the chest with expiratory wheezes and breathing through

pursed lips. A chest x-ray reveals hyper inflated lung fields bilaterally and no infiltrates.

The patient’s physician recommends spirometry to differentiate emphysema, which is

an obstructive pulmonary disorder, from restrictive lung disease.


To understand pathophysiology of COPD.

To develop detailed knowledge of obstructive vs. restrictive lung disease.

To develop concept of FEV1/FVC ratio as a diagnostic tool for lung pathology.

To gain insight into treatment options for COPD.

Resources:

105





Electronic modes

PBL 7

A 36-year-old woman presents to her primary care physician with complaints of

shortness of breath, arthritic pain, and multiple skin lesions. The patient is short of

breath on examination with a slightly low pulse oximetry reading, consistent with mild

hypoxemia. She has multiple skin lesions, and a biopsy reveals noncaseating

granulomas consistent with sarcoidosis. Chest x-ray findings revealing

hilaradenopathy are also suggestive of sarcoidosis. The physician explains to the

patient that he likely has a restrictive disease process, and recommends formal

pulmonary function testing.


To list various obstructive vs. restrictive lung disease processes.

To understand concept of ventilation perfusion matching.

To develop knowledge of physiological and pathological pulmonary circulation shunts.

To list components of respiratory membrane.

To elaborate factors influencing diffusion of gases across respiratory membrane.

Resources:





Electronic modes

PBL 8

A patient presented in medical OPD with complaints of pain in joints, dizziness, vertigo,

visual abnormalities and confusion. After taking his history it was found out that the

patient was a diver and was exposed to rapid decompression (high rate of ascent)

above 18,000 ft. So based on his symptoms the physician suspected him as a case of

decompression sickness.


To understand the physiology of decompression.

Explain effects of high partial pressures of gases on body.

To know the effects of high partial pressures.

To know the effects of hypoxia.

To know the treatment of decompression.

Resources:

106





Electronic modes

107

MODULE-III

Section-III

Biochemistry

108

Summary:

Code Y1M3

Name Biochemistry

Duration 10 weeks




module)

Lower Limb

Respiratory System

Subject Themes

Nutrition

Water soluble vitamins

Fat Soluble vitamins

Prerequisite Module Y1M1&Y1M2


MIT

Lectures

Tutorials (PTT)

CBL

Practicals

Class tests


Nutrition At the end of this set students will be able to

Describe the concept of food, nutrition, Diet and Balanced

Diet.

Define different parameters regarding food and nutrition

like RDA, etc.

Concepts of BMR, Caloric requirements of the body,

Energy Balance.

Appreciate carbohydrates, fats and proteins as major food

source and their nutritional requirements.

Understand the nutritional quality of a protein, essential

amino acids their nutritional importance and nitrogen

balance.

Elaborate the sources of carbohydrates, their glycemic

index.

Recall the nutritional importance of fats and fatty acids,

essential fatty acids, saturated, unsaturated and poly

unsaturated fatty acids.

109

Understand and estimate caloric requirements of the

body.

Describe the concept of Balanced Diet.

Explain nutritional requirements in: - Pregnancy -

Lactation - New born and in nutritional disorders.

Explain Protein Energy Malnutrition.

Differentiate between Marasmus and Kwashiorkor.

Water soluble vitamins

After completion of this unit students will be able to

Classify water soluble vitamins.

Describe the chemistry of water soluble vitamins.

Explain the Biochemical Functions of water soluble

vitamins.

Differentiate the deficiency manifestations of water

soluble vitamins, Hypervitaminosis and its clinical fall outs

Enlist the daily allowances and sources of water soluble

vitamins.

Describe the hypervitaminosis of water soluble vitamins.

Fat Soluble vitamins

After completion of this unit students will be able to

Explain general features of fat soluble vitamins.

Explain the chemistry of fat soluble vitamins.

Describe the biochemical Functions of fat soluble

vitamins.

Explain the deficiency manifestations of fat soluble

vitamins.

Enlist the daily allowances and sources of fat soluble

vitamins.

Describe causes and manifestations of Hypervitaminosis

and toxicity.

List of Practicals:

EXPERIMENT -19. TESTS FOR URINE ABNORMALITIES-I

EXPERIMENT -20. TESTS FOR URINE ABNORMALITIES-II

EXPERIMENT -21. PREPARATION OF URINE REPORT BY ANALYZING

GIVEN SAMPLE OF URINE 73

At the end of the year the learner will be able to

Operate the centrifuge machine

Identify the presence of specific amino acids (aromatic amino acids, sulpher

containing amino acids)

Differentiate fibrous and globular proteins

110

Detect proteins in urine

Perform

Molisch’s test for general detection of Carbohydrate.

Iodine test for polysaccharides (starch &glycogen).

Benedict’s test for reducing carbohydrates.

Barfoed’s test to differentiate reducing mono and disaccharides.

Selivenoff’s test for detection of keto sugars.

Test on rancidity of fats.

Examination of cholesterol crystals.

Salkowski’s tes for presence of cholesterol.

Liebermann Burchard test for the determination of cholesterol in blood


Topic: Vitamin A Deficiency:

A 54-year-old male reported to medical OPD with a complaint of slow onset,

progressive difficulty in seeing the objects at night. The problem had increased over

the past six months. He had stopped driving because he could not see the road,

properly. All forms of artificial light seemed dim; however, daytime vision was normal.

He never had any other past ocular problems. There was no difficulty in distinguishing

colors.

Investigations:

Name of test Patient Value Reference

Range

vitamin A level 0.12 mg/L

0.30-1.20 mg/L

The patient was diagnosed as a case of Nyctalopia (night blindness) due to vitamin A

deficiency. He was started on oral vitamin A 10,000 international units (IU), twice a

day. After one month of treatment, the patient reported improvement in his vision.

Vitamin A is a fat soluble vitamin, necessary for a variety of functions such as vision,

proper growth and differentiation reproduction and maintenance of epithelial

cell. Night blindness (nyctalopia) is one of the earliest symptoms of vitamin A

deficiency. Vitamin A deficiency can occur as a result of malnutrition, malabsorption,

or poor vitamin metabolism due to liver disease.


Sources & biochemical function of Vitamin A.

Wald's visual cycle

Deficiency of vitamin A

Hypervitaminosis A

111

References Books:

1 Harper’s Text book of Biochemistry

2 Lippincott’s text book of Biochemistry


Internet and other reference sites

Topics: Folic Acid and Pregnancy

A 37 Years female, with 21st week of gestation, belonging to a rural area, reported in

obstetric OPD for a routine examination. She looked pale and malnourished.

On abdominal examination her fundal height was not in accordance to her LMP.

She was advised for anomaly scan and other base lines.

Investigations:

PARAMETERS PATEINT NORMAL REFERENCE

RANGES

Hb 9g/dl 12- 15g/dl

MCV 103fl 80-100fl

MCH 32pg 27-31pg

S.Folic acid 0.5ng/ml 2-20 ng/ml

Anomaly Scan Anencephalic fetus

On the basis of clinical history, examination and investigations she was

diagnosed as case of NTD (neural tube defect).


Sources of folic acid

Absorption and metabolism of folic acid

Deficiency effects of vitamin B9

Reference Books:

Lippincott’s Biochemistry (Latest Edition)

Harper’s Textbook of Biochemistry

Davidson’s principles of Medicine

Internet & other related journals

112

Topic: Scurvy

A 9 Year child presented on family OPD, with complaints of spongy bleeding gums

with loose teeth. Her mother gives the H/O his delayed healing in wounds. She tells

that he has sometimes red dots on legs and bleed from the nose.

On investigation, X-Ray shows bone thinning; CBP shows low level of Hb, raised TLC.

RBCs show howell jolly bodies. He was diagnosed as scorbutic.

Learning Objects:

What is the differential diagnosis?

What is etiology

Give the biochemical basis if this.

Enlist the functions of the missing biomolecule

Cause diagnosis & management of scurvy.

Reference Books:

Lippincott’s Biochemistry (Latest Edition)

Harper’s Textbook of Biochemistry

Davidson’s principles of Medicine

Internet & other related journals

Topic: Bleeding disorder due to vit. K deficiency

A postpartum woman from a rural Baluchistan community gave birth to a baby girl with

the aid of a midwife at home. She brought the baby to the hospital because of

continued bleeding and oozing from the umbilical stump. It is likely that this bleeding

diathesis is secondary to a deficiency of vitamin K.

Lab Investigations:

Test Name Level Normal Values

Prothrombin Time

Prothrombin Time 16 Sec 13Sec

P.T.T.K

Patient 38 Sec 34Sec

Bleeding Time

Bleeding Time 09 Min 2-8 min

Coagulation Time

Coagulation Time 12 Min 6-11.5 min

Fibrin – D – Dimer

Result 260 ng /ml < 250 ng / ml

Plasma Fibrinogen

Plasma Fibrinogen 450 mg / dl 200 – 400 mg / dl

113


1. Classification of Vitamin

2. Fat soluble vitamins

3. Vitamin K sources, function

4. Vitamin K deficiency

References Books:

Harper’s Text book of Biochemistry

Lippincott’s text book of Biochemistry


Internet and other reference site

Topic: Vitamin B12 (Pernicious Anemia)

A 35 years old female presented to the physician with the complaints of severe

weakness, weight loss, loss of appetite, depression and memory loss. She had an

excision of a gastric ulcer 4 years ago. On examination, she has tingling and

numbness in hands and feet, pale yellow skin, red and thick, decreased positional and

vibrational sense. On advice of physician, following lab investigations were carried out

Lab Investigations:

Parameters Normal Value Patient value

Haemoglobin 12-14g/dl 8.9g/dl

RBC count 4-5.5X1012/L 3.0x1012 /L

MCV 76-96fL >100fL

Serum Vit B12 150-600pmol/L <70mg/dl

Urinary methymalonic

acid

Upto 0.5umol/L Raised

Schilling’s Test Normal Low

Vitamin B12 deficiency is more common in patients who fail to absorb the vitamin from

the intestine. A severe malabsorption of vitamin B12 leads to pernicious anemia. It is

an autoimmune disorder results in destruction of the gastric parietal cells that are

responsible for the synthesis of a glycoprotein called intrinsic factor. Vitamin B12

obtained from the diet binds to intrinsic factor in the intestine and subsequently

transported into the general circulation. Lack of intrinsic factor prevents the absorption

of vitamin B12, resulting in pernicious anemia. Patients with cobalamin deficiency are

usually anemic, but later on neuropsychiatric symptoms can be developed. Vitamin

B12 deficiency can cause weakened bones and may lead to hip fractures. An enlarged

liver is another symptom.

114


Definition and classification of water soluble vitamins

Source, synthesis, absorption of Hematopoietic vitamins

Functions of Hematopoietic vitamins

Diseases and treatment of Hematopoietic vitamins

REFERENCE BOOKS:




At the end of the year the learner will be able to discuss the following topics with

detailed

understanding of biochemistry along with their clinical correlations:

Cell organelles

Nucleotides

Plasma proteins

Jaundice

Thalaesemisias

Kernictrus

Pernicious anemia

Scurvy

Ricketts

Osteoporosis

Vitamin K deficiency

Kawashiorker and merasmus

Enzymes and clinical diagnosis

Therapeutic use of enzymes

Lactose intolerance

115

First Professional MBBS Examination ANATOMY

Table of Specifications for Annual First Professional Examination:

Theory

Time Allowed =03 hrs (Including MCQs)

Marks of theory paper =90

Internal Assessment =10

Total marks =100

Pass Marks =50

25 x MCQs (on separate sheet) (25 Marks) Time =30 min

Q. No. 1,2,3,4,5,6,7,8,9

(7x SAQs/SEQs (C1 & C2) = 07 marks each

2 x SAQs/SEQs(C3) = 08 marks each) (65 Marks) Time = 2 hours

30 minutes

S. No

Topic

NUMBER OF MCQs (25)

(C1=10, C2=10, C3=5) 1 mark each

NUMBER OF SAQs/SEQs (09)

7x SAQs/SEQs (C1 & C2) = 07 marks each

2 x SAQs/SEQs(C3) = 08 marks each

1. Embryology 04 01

2 Histology 04 01

3 General Anatomy 03 01

4 Upper limb 05 02

5 Lower limb 05 02

6. Thorax 04 02

Total 25 (25 Marks) 09 (65 Marks)

116

Theory: Internal Assessment (IA) Calculation

A B C F

Roll No.

Name

All Modules/ Pre annual Exams or any other exam

Total Marks of internal assessment Out 0f 10

Total Marks Sum of Marks obtained x10/ sum of total marks in all exams

Table of Specifications for Annual Professional Exam: Practical

VIVA 50 marks

Practical 40 marks

Total

Non Observed OSPE Observed

station OSPE

Manual

Internal Examiner

External Examiner

Gross embryology, & X – rays

Histology 1. Long Slides 04 marks.

2. Surface marking

3. 02 marks.

25 Marks

25 Marks 20 Marks 10 Marks

07 Marks 03 marks

90 marks

Practical: Internal Assessment Calculation

A B C F

Roll No.

Name

OSPE /Practical Class tests throughout the year /Pre annual Practical Exams or any other exam



117

First Professional MBBS Examination

PHYSIOLOGY

Table of Specifications for Annual First Professional Examination:

Theory



Internal assessment =10

Total marks =100

Pass Marks =50


Q. No. 1,2,3,4,5,6,7,8,9


2 x SAQs/SEQs(C3) = 08 marks each) (65 Marks) Time = 2

hours 30 minutes

S No

Topic NUMBER OF MCQs (25)

(C1=10, C2=10, C3=5)

1 mark each



2 x SAQs/SEQs (C3) = 08 marks

each

1 Cell, Nerve muscle

06 01

Whole Course 2 Blood 08 01

3 CVS 06 03

4 Respiration + Environmental + Sports

05 02

Total 25 07 02

Grand Total 25 (25 Marks) 09 (65 Marks)

118


A B C D

Roll No.

Name





Viva (Theory) 50 marks

Practical 40 marks

Total

Internal Examiner

External Examiner

OSPE (20) Experimental Physiology + Table Viva

Practical Procedure

Practical Journal Observe

d Unobserved

25 25 10 10 12 5 3 90


A B C D

Roll No.

Name

OSPE /PTT/ Class tests throughout the year /Pre annual Exams or any other exam



119

First Professional MBBS Examination

BIOCHEMISTRY

Table of Specifications for Annual First Professional Examination: Theory



Internal assessment =10

Total marks =100

Pass Marks =50


Q. No. 1,2,3,4,5,6,7,8,9


2 x SAQs/SEQs (C3) = 08 marks each) (65 Marks) Time = 2 hours 30

minutes

Topic

NUMBER OF MCQs (25)

(C1=10 marks, C2=10 marks, C3=5

marks) 1 mark each



2 x SAQs/SEQs (C3) = 08 marks

each

Chemistry of Protein & Amino Acids

03 01

Any 2 from whole courses

Enzymes 03 01

Vitamins 03 01

Porphyrins & Hemoglobin 03 01

Chemistry of CHO, Nutrition 04 01

Chemistry of lipids + Minerals and Trace elements

04 01

Nucleotides and Nucleic Acid, Biochemistry of cell & Body Fluids + Biological membrane

05

01

Total 25 (25 Marks) 09 (65 Marks)

120


A B C D

Roll No.

Name



Total Marks Sum of Marks obtained x10/ sum of total marks in all

exams


Viva (Theory) 50 marks Practical

40 marks Total

Internal Examiner

External Examiner

OSPE (20) Viva + Performance

Journal

Observed (2 Station)

Unobserved (10 Station)

25 25 10 10 15 5 90


A B C D

Roll No.

Name

OSPE /PTT/ Class tests throughout the year /Pre annual Exams or any other exam


Total Marks Sum of Marks obtained x10/ sum of total marks in all

exams

1st year mbbs curriculum (revised 2017) · 2019-08-05 · 4 guidelines: 1st year mbbs curriculum...

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