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Vitamin D deficiency

Vitamin D deficiency symptoms

Severe vitamin d deficiency can cause osteomalacia in adults and rickets in children. Lesser degrees of deficiency in diet may lead to a burning sensation in the mouth and throat, weight loss, loss of appetite, visual problems, diarrhea and insomnia.

People at higher risk

* those with intake below recommended levels.

* those who have limited sunlight exposure.

* those whose kidney cannot change the vitamin to the active form. ” kidney disorder”

* those with inadequate absorption of the vitamin from their digestive tract. ” GIT disorder”

Symptoms of rickets:

* Bowed legs and bowed arms. The bowed appearance is due to the softening of bones, and their bending if the bones are weight-bearing.

* Particular bony bumps on the ribs called rachitic rosary (beadlike prominences at the junction of the ribs with their cartilages)

* Knock-knees.

* Seizures may also occasionally occur in a child with rickets, because of reduced levels of dissolved calcium in the bloodstream.

Symptoms of osteomalacia:

* Easy fatigue.

* Pain in the back, ribs, and hips. Some of the pain in osteomalacia is caused by slight cracks in the bone (the medical term is ‘partial fractures’), which are visible on x-rays.

* Bone softness.

* Muscle weakness.

* Difficult getting up from a chair or climbing steps.

* Abnormal walk.

* Bone fractures.

Secondary Hypertension

2ry hypertension represents for approximately 5-10% of all cases of hypertension, with the remaining being primary hypertension.

Secondary hypertension has an identifiable cause and treated by controlling or removing the underlying disease or pathology, although they may still require antihypertensive drugs. whereas primary hypertension has no known cause (i.e., idiopathic).

Some causes for secondary hypertension are listed below:

1-Renal artery stenosis (renovascular disease)

Renal artery disease can cause of narrowing of the vessel lumen (stenosis). The reduced lumen diameter decreases the pressure at the afferent arteriole in the kidney and reduces renal perfusion. This stimulates renin release by the kidney, which increases circulating angiotensin II (AII) and aldosterone. These hormones increase blood volume by enhancing renal reabsorption of sodium and water. Increased AII also causes systemic vasoconstriction and enhances sympathetic activity. Chronic elevation of AII promotes cardiac and vascular hypertrophy. The net effect of these renal mechanisms is an increase in blood volume that augments cardiac output by the Frank-Starling mechanism. Therefore, hypertension caused by renal artery stenosis results from both an increase in systemic vascular resistance and an increase in cardiac output.

2-Chronic renal disease

Any number of pathologic processes (e.g., diabetic nephropathy, glomerulonephritis) can damage nephrons in the kidney. When this occurs, the kidney cannot excrete normal amounts of sodium which leads to sodium and water retention, increased blood volume, and increased cardiac output by the Frank-Starling mechanism. Renal disease may also result in increased release of renin leading to a renin-dependent form of hypertension. The elevation in arterial pressure secondary to renal disease can be viewed as an attempt by the kidney to increase renal perfusion and restore glomerular filtration.

3-Primary hyperaldosteronism

Increased secretion of aldosterone generally results from adrenal adenoma or adrenal hyperplasia. Increased circulating aldosterone causes renal retention of sodium and water (see figure), so blood volume and arterial pressure increase. Plasma renin levels are generally decreased as the body attempts to suppress the renin-angiotensin system; there is also hypokalemia associated with the high levels of aldosterone.


Emotional stress leads to activation of the sympathetic nervous system, which causes increased release of norepinephrine from sympathetic nerves in the heart and blood vessels, leading to increased cardiac output and increased systemic vascular resistance. Furthermore, the adrenal medulla secretes more catecholamines (epinephrine and norepinephrine). Activation of the sympathetic nervous system increases circulating angiotensin II, aldosterone, and vasopressin, which can increase systemic vascular resistance. Prolonged elevation of angiotensin II and catecholamines can lead to cardiac and vascular hypertrophy, both of which can contribute to a sustained increase in blood pressure.

5-Sleep Apnea

Sleep apnea is a disorder in which people repeatedly stop breathing for short periods of time (10-30 seconds) during their sleep. This condition is often associated with obesity, although it can have other causes such as airway obstruction or disorders of the central nervous system. These individuals have a higher incidence of hypertension. The mechanism of hypertension may be related to sympathetic activation and hormonal changes associated with repeated periods of apnea-induced hypoxia and hypercapnea, and from stress associated with the loss of sleep.

6-Hyper- or hypothyroidism

Excessive thyroid hormone induces systemic vasoconstriction, an increase in blood volume, and increased cardiac activity, all of which can lead to hypertension. It is less clear why some patients with hypothyroidism develop hypertension, but it may be related to decreased tissue metabolism reducing the release of vasodilator metabolites, thereby producing vasoconstriction and increased systemic vascular resistance.


Catecholamine secreting tumors in the adrenal medulla can lead to very high levels of circulating catecholamines (both epinephrine and norepinephrine). This leads to alpha-adrenoceptor mediated systemic vasoconstriction and beta-adrenoceptor mediated cardiac stimulation, both of which contribute to significant elevations in arterial pressure.. Despite the elevation in arterial pressure, tachycardia occurs because of the direct effects of the catecholamines on the heart and vasculature. Excessive beta-adrenoceptor stimulation in the heart often leads to arrhythmias. The pheochromocytoma is diagnosed by measuring plasma or urine catecholamine levels and their metabolites (vanillylmandelic acid and metanephrine).


This is a condition that sometimes develops during the third trimester of pregnancy that causes hypertension due to increased blood volume and tachycardia. The former increases cardiac output by the Frank-Starling mechanism.

9-Aortic coarctation

Coarctation, or narrowing of the aorta (typically just distal to the left subclavian artery), is a congenital defect that obstructs aortic outflow leading to elevated pressures proximal to the coarctation (i.e., elevated arterial pressures in the head and arms). Distal pressures, however, are not necessarily reduced as would be expected from the hemodynamics associated with a stenosis. The reason for this is that reduced systemic blood flow, and in particular reduced renal blood flow, leads to an increase in the release of renin and an activation of the renin-angiotensin-aldosterone system. This in turn elevates blood volume and arterial pressure. Although the aortic arch and carotid sinus baroreceptors are exposed to higher than normal pressures, the baroreceptor reflex in blunted due to structural changes in the walls of vessels where the baroreceptors are located. Also, baroreceptors become desensitized to chronic elevation in pressure and become "reset" to the higher pressure.

A Case of Constipation as a Chief Complaint

A 61-year-old African American Obese female was admitted to the hospital with a chief complaint of bilateral knee pain for 2 weeks. She was diagnosed with severe osteoarthritis and opioid pain medications were started.

The patient's last bowel movement (BM) was one week prior to admission and she did not have any BM after that despite multiple laxatives. She also admitted to feeling depressed.

With past history of Hypertension (HTN), gout, COPD, hypothyroidism following a radioactive iodine treatment for hyperthyoridism in the remote past.

Medications: Telmisartan/hydrochlorothiazide (Micardis), furosemide (Lasix), levothyroxine (Synthroid) 100 mcg p.o. q.d, indomethacin, lorazepam.

Family history of Gout, stroke.

Physical examination:

VS:Temp.=36.9 R.R.=16 H.R=53 BL.P.=170/95.

Chest: CTA (B).

CVS: Clear S1S2.

Abdomen: Soft, NT , absent BS.

Extremities: the knee examination showed bilateral knee swelling, left greater than right. No joint fluid. Joint tenderness was present. No pitting edema or cyanosis.


The right knee X-rays showed severe degenerative joint disease and several loose bodies in the joint. An orthopedics consultation was called and the patient agreed to a total knee replacement at a later date.

Laboratory results:

TSH and T4 levels.

What happened next?

TSH was 41.40 mU/L, and her Synthroid dose was increased to 150 mcg po qd. A selective serotonin reuptake inhibitor (SSRI) was started for depression.

The patient constipation persisted despite multiple medications prescribed for the problem.

A list of medications given for the constipation without success.

Her constipation gradually resolved with T4 replacement and lactulose. She will need a recheck of her TSH in 6-8 weeks.

Final diagnosis : Hypothyroidism.

What did we learn from this case?

  1. Constipation is a classic presenting symptom of uncontrolled hypothyroidism.
  2. Uncontrolled HTN and bradycardia are also common presenting symptoms of hypothyroidism.
  3. Opiods, prescribed to this patient for knee pain, made the constipation worse. Most inpatients on opioid therapy will require a stimulant laxative such as senna 2 tabs PO QHS for regular BM.

Neurological Exam

Part 1

Part 2

Abdominal Exam

Abdominal examination. Inspection, palpation, percussion and auscultation of Abdomen.

PART 1/2

PART 2/2

Answer this Case !!

What is the most likely diagnosis in the patient shown below?

a. Sprue

b. Scleroderma

c. Crohn's disease

d. Carcinoma of the colon

e. Duodenal hematoma

The Correct Answer: in 28April 10
Crohn's disease


There is a long segment of terminal ileum which is narrowed with irregular margins. There are several ulcers or sacculations present. The location and appearance of this narrowed segment is characteristic of Crohn's Disease. This long narrowed segment would qualify as the "string-sign" of peristent spasm seen with that disease. Crohn's most often affects the terminal ileum and has a bimodal age distribution. Surgery is usually avoided because of the propensity for recurrence at the site of the neo-terminal ileum.

Knee arthroscopy

The Knee Joint

Anatomy Video "Knee Joint" demonstrates the structure of the knee joint. In addition to the bones involved in the knee joint, the functions of the ligaments are described in detail. Injuries such as cruciate ligament rupture are clearly explained.


This algorithm video clip discusses all the most common causes of vaginal discharge, how to distinguish between them, how to work it up, and how to manage these patient.

Tonsillectomy Operation

video to show how tonsillectomy is performed


Answer this case

This patient came in complaining of severe abdominal pain. Why is this an emergency? The patient has:

a. A ruptured gastric ulcer.
b. A ruptured abdominal aortic aneurysm.
c. Acute appendicitis.
d. Acute renal failure.
e. An abscess in the psoas muscle.

Ranson's criteria and CT scoring system in Pancreatitis

photo of ClarkRansonR

Present on Admission - GA LAW

Blood Glucose greater than 200 mg/dl
Age greater than 55 years
Serum LDH greater than 350 I.U./L
SGOT (AST) greater than 250 I.U./L
WBC greater than 16,000/ul

NB - Amylase is NOT one of Ranson's criteria!
# Serum amylase has low sensitivity and specificity
# 20% cases of pancreatitis have normal serum amylase (particularly alcoholic aetiology)

Developing During the First 48 Hours: - C HOBBS

Serum Calcium less than 8 mg/dl
Hematocrit fall greater than 10%
Arterial Oxygen saturation less than 60 mm Hg
BUN increase greater than 8 mg/dl
Base deficit greater than 4 meq/L
Estimated fluid Sequestration greater than 600 ml

*Ranson score of 0-2, minimal mortality
*Ranson score of 3-5, 10%-20% mortality
*Ranson score of >5 has more than 50% mortality and is associated with more systemic complications.

Contrast-enhanced CT scoring system
Grade........................................... Criteria
A ................................ .......... ............. Normal
B ................................. Focal or diffuse glandular enlargement
Small intra-pancreatic fluid collection
C ....................................................... Any of the above
Peripancreatic inflammatory changes
Less than 25% gland necrosis
D ............................ .................................Any of the above
Single extrapancreatic fluid collection
25-50% gland necrosis
E ....................... .......................................... Any of the above
Extensive extrapancreatic fluid collection
Pancreatic abscess
More than 50% gland necrosis

Circulatory System and the Heart

Introduction to the circulatory system and the heart

What is the most likely diagnosis of this case?

A 90 years old man with a history of Coronary artery disease, Hypertension, and a 30-pack year smoking history presents to the outpatient clinic for his annual checkup.

He denies recent complaints ,although reports that he has not been as "active" lately.He has a history of good adherence to health maintenance recommendations,and results of recent colonoscopy and prostate axamination are negative.
He takes aspirine,metoprolol,and an occasional multivitamins.He admits to having problems with smoking cessation.

Vital signs:
Temprature : 37.0°C (98.6°F)
Blood pressure:120/80 mm Hg
Pulse rate:60/min
Respiratory rate:10/min
Physical exam.shows a thin, elderly man withmotteled skin.His Heent , neck,chest and cardiac examination is unremarkable.
His abdomin is not tender and nondistended, but apulsating mass is palpated approximately 2 cm superior to his umbilicus, 1 cm left of midline.

The correct answer: in 25 April 01
Abdominal Aortic Aneurysm
Approximitaely 30% of AAAs are discovered during routine physical examination,although they are more difficult to detect in obese patients or when the aneurysm is small.
It occurs almost exclusively in people >60 years old(4-6%>60 have an AAA).it is associated with atherosclerosis,smoking,hypertension and a family history of AAAs.

Central & Nephrogenic Diabetes Insipidus

Causes of central diabetes insipidus:
1-Head trauma

2-Post-surgical (hypophysectomy)


* craniopharyngioma
* pinealoma
* meningioma
* germinoma
* leukemia/lymphoma
* metastatic tumors


* tuberculosis
* syphilis
* mycosis
* toxoplasmosis
* encepahlitis
* basilar meningitis

5-Granulomatous disesases

* sarcoidosis
* histiocytosis
* Wegeners' granulomatosis

6-Cerebrovascular diseases

* aneurysms
* cavernous sinus thrombosis
* Sheehan's syndrome (pospartum pituatry infarction)


Causes of nephrogenic diabetes insipidus:


* lithium
* demecyclocine
* amphotericin B
* methoxyflurane
* colchicine
* vinblastine
* aminoglycosides
* cisplatin

3-Obstructive uropathy - during relief of obstruction

4-Chronic tubulo-interstitial kidney diseases

* analgesic nephropathy
* sickle cell nephropathy
* multiple myeloma
* amyloidosis
* sarcoidosis
* Sjogrens disease
* autoimmune/lupus
* polycystic kidney disease
* medullary cystic disease

5-Electrolyte disorders

* hypercalcemia
* potassium depletion

what`s your diagnosis? Why?

The patient shown below most likely has:

a. A large right pleural effusion

b. A large left pneumothorax

c. Atelectasis of the right lung

d. Pneumonia in the right lung

e. Unilateral pulmonary edem

Correct Answer:in 23 April 10
A large right pleural effusion

There is opacification of the right hemithorax. There is a shift of the heart and mediastinal structures (i.e. the trachea) away from the side of opacification. This eliminates atelectasis, pneumonia and pulmonary edema as possibilities. There is never a shift of the heart or mediastinal structures toward the side of a pneumothorax. In addition, there should be no lung markings visible in the hemithorax which contains the pneumothorax. This is a large effusion which produces a mass-like effect and pushes the mediastinal structures away from the opacified side.

Answer this cases about Esophagus.

1-What is the most likely diagnosis in the patient shown below?

a. Esophageal varices
b. Esophageal carcinoma
c. Reflux esophagitis
d. Lye stricture
e. Fibrovascular polyp

2-What is the most likely diagnosis in the patient shown below?

a. Esophageal varices

b. Esophageal carcinoma
c. Reflux esophagitis
d. Lye stricture
e. Fibrovascular polyp

3-What is the most likely diagnosis in the patient shown below?

a. Esophageal varices
b. Esophageal carcinoma
c. Reflux esophagitis
d. Lye stricture
e. Fibrovascular polyp

THE RIGHT ANSEWR : in 22April 10
There is a rapid change in the caliber of the lumen of the esophagus in the mid-esophagus. There is a segment with irregular margins and apparent destruction of the normal smooth mucosal pattern. The findings are most suggestive of a carcinoma of the esophagus. Most carcinomas of the esophagus are of the squamous cell variety. They frequently spread longitudinally along the esophageal wall in part because of the lack of a serosal lining to the esophagus.

There are long, serpiginous filling defects seen longitudinally in the esophagus. While their full extent can not be determined in this image, they started at the EG junction and continues to the level of the carina. These findings are characteristic of esophageal varices of the so-called "uphill" variety. These are almost always caused by portal hypertension and they characteristically at the level of the carina, where the esophageal plexus of veins drains into the azygous system.

There is very long segment of smoothly narrowed esophagus from just below the level of the clavicles to the EG junction. This appearance is characteristic of a stricture caused by the ingestion of a caustic material such as lye. Lye, which became component of some drain cleaners in the late ?60s, is so highly toxic that only a few drops can cause this full-thickness liquefaction necrosis of the esophagus. The acute ulcerative phase is invariably followed in several weeks by this fibrotic stage. There is a significantly higher incidence of carcinoma of the esophagus in patients with lye strictures than in the normal population.

Answer this case

A 28-year-old woman from Bosnia presents to the hospital with a 2-day prodrome of a cough with scant brown sputum, malaise, mild headache, and chills for which she is given erythromycin. Last night, pain developed in the middle and right lower quadrant of her abdomen. She has a medical history of infertility and no surgical history.
Her vital signs are as follows: temperature, 100.1°F (37.9°C); heart rate, 80 beats per minute; blood pressure, 110 mm Hg systolic, 70 mm Hg diastolic; respiratory rate, 28 breaths per minute.
The patient is alert and shows no signs of toxicity; her sclerae are anicteric. Her lungs are clear. The patient's abdomen is soft and flat but mildly tender in the middle and right lower quadrant. She has no signs of rebound pain or guarding. No mass is present, and her bowel sounds are normal.
Her pelvic examination reveals a normal cervix, no discharge via os, no cervical motion tenderness (CMT), and mild right adnexal tenderness but no mass. Her rectal tone is normal, no mass is present, and the rectum is nontender. Abdominal CT with oral and intravenous contrast enhancement was performed.
Among her laboratory findings, the white blood cell (WBC) count is 2100 per microliter; the result of a beta human chorionic gonadotropin test is negative; urinalysis findings are normal; and levels of sodium, potassium, chloride, carbon dioxide/bicarbonate, BUN, creatinine, and glucose (chem 7) are normal.

Pelvic retention of contrast material from recent hysterosalpingography: The benign clinical appearance of the patient and the absence of the expected peritoneal signs at abdominal examination conflicted with the abdominal CT scan that shows free contrast agent in the pelvis. Presumed perforated appendicitis was ruled out by means of careful history taking, which revealed the recent hysterosalpingographic examination. The patient was discharged home with the diagnosis of viral syndrome, and follow-up with her primary care physician was arranged. Whether the abdominal pain was due to erythromycin use or associated with the viral syndrome is unclear.

CT of Acute Pyelonephritis

* Inflammation of the renal parenchyma and renal pelvis due to an infectious source

* Most often secondary to an ascending lower urinary tract infection from gram-negative bacteria
- E. coli
- Klebsiella
- Proteus
- Pseudomonas.

* Exception is S. aureus, which is spread hematogenously

Pathologic Causes:
o Vesicoureteral reflux
o Obstruction in the collecting system usually due to a calculus

Signs and symptoms:
- Fever
- Chills
- Flank pain
- Dysuria
- Increased frequency of urination.
- On exam, costovertebral angle tenderness may be present.

Clinical Findings:

1- CBC
- Elevated white blood cell count.

2- Urinalysis
- Bacteriuria
- Pyuria
- White blood cell casts

3- Acute pyelonephritis is clinical diagnosis,
- Radiographic imaging is used to evaluate underlying pathology
- Rule out any complications as:
-Emphysematous pyelonephritis.....Most often occurs in diabetics Can produce gas in the collecting system and renal parenchyma.

Right kidney is markedly enlarged and has a wedge-shaped area of low attenuation

Radiographic Imaging Findings:
$ Enlarged kidneys (U/S and CT)
$ Hydronephrosis (U/S and CT)
$ Wedge shaped areas of low attenuation secondary to decreased perfusion (CT)
$ Loss of the ability to distinguish the corticomedullary border (CT)
$ Perinephric stranding (CT)


o Antibiotics for non-complicated pyelonephritis.
o Radical nephrectomy for emphysematous pyelonephritis.
o Percutaneous drainage of abscesses

Answer this case

Look at the following case. Why is this an emergency? The patient has:

a. A tension pneumothorax.
b. An acute pneumonia of the right lung.
c. Had a pulmonary embolism.
d. A simple pneumothorax.
e. Been shot.


There is a large, right-sided, tension pneumothorax that is displacing the heart and mediastinal structures to the left. Tension pneumothoraces can result from penetrating injuries or can arise spontaneously. They are serious because air exchange is compromised in both the lung with the pneumothorax and the opposite lung which is being compressed. They are treated by decompressing the tension and re-expanding the lung.


Topic is Hyperthyroidism and all the different types and how to distinguish between them:
Topics Include:
-Grave's Disease
-Silent Thyroiditis
-Subacute Thyroiditis
-Euthyroid Sick Syndrome
-Pituitary Adenoma
-Exogenous Administration

Rabies : Post-exposure Prophylaxis

# cleanse the wound with a solution of soap and water + povidone iodine solution
# evaluate the need to institute rabies post-exposure prophylaxis - you can use the
algorithm prn

# scratches, abrasions, open wounds or mucous membranes exposed to saliva or other potentially infectious material constitute significant non-bite exposures
# simple contact (eg. petting) with a rabid animal, or its urine or feces, does not constitute a non-bite exposure
# bites of squirrels, hamsters, guinea pigs, gerbils, chipmunks, rats, mice and other small rodents, rabbits and hares almost never require post-exposure prophylaxis
# theoretically, human bites that penetrate skin could represent a significant exposure, but there have been no reported cases in the USA
# direct exposure to bats, even in the absence of a definite bite or scratch, may represent a significant exposure eg. child, intoxicated or mentally retarded adult, sleeping in the same room as a bat; household contacts of those exposed patients do not require post-exposure prophylaxis
# post-exposure prophylaxis consists of 1 dose of rabies immunoglobulin (20IU/kg) and 5 doses of rabies vaccine over 28 days (days 0, 3, 7, 14 and 28)

# a larger dose of rabies immunglobulin (40 - 50 IU/kg) is recommended for significant bites about the face and neck
# if anatomically feasible, the full dose of RIG should be given at the bite site or in a muscle as anatomically near the bite site as practical
# the rabies vaccine should be given in the deltoid muscle (not buttocks); or antero-lateral thigh in very small children
# side-effects of vaccination include mild erythema, pain and swelling at the site of injection; systemic effects such as headache, nausea, muscle aches and dizziness; and serum sickness-like reaction (arthalgia, arthritis, angiedema, generalised urticaria, nausea, vomiting, fever and malaise)
# rabies vaccination should not be discontinued because of mild reactions
# patients with a history of prior rabies vaccination only require 2x IM doses of rabies vaccine, one immediately and the second dose on day 3
# the same post-exposure rabies protocol should be used for immuno-compromised and pregnant patients
# children should receive HRIG based on body weight (20IU/kg), but should receive the same adult dose of rabies vaccine

Classic Triads

Beck’s ,Cushing's ,Waddell's triads:
Beck’s triad
Beck's triad was described by the thoracic surgeon Calude S. Beck in 1935. It's components are:

1. Distended neck veins
2. Distant heart sounds
3. Hypotension

i.e. rising venous pressure, falling arterial pressure, and decreased heart sounds found in the presence of pericardial tamponade.

Cushing's triad (not to be confused with the Cushing reflex) is a sign of increased intracranial pressure. It is the triad of:

1. Hypertension (progressively increasing systolic blood pressure)

2. Bradycardia

3. Widening pulse pressure (an increase in the difference between systolic and diastolic pressure over time)

Cushing's triad suggests a cerebral hemorrhage in the setting of trauma or an space occupying lesion (e.g. brain tumor) that is growing and a possible impending fatal herniation of the brain. Cushing's triad is named after an American neurosurgeon Harvey Williams Cushing (1869-1939).

Waddell's triad
is recognized in clinical practice as associated with high-velocity accidents such as motor vehicle, auto-pedestrian, or bicycle crashes

Waddell's triad consists of

1. Femur fracture
2. Intra-abdominal or intrathoracic injury
3. Head injury,

Answer this all MCQs

Answer each statement by true or false
1-The secretion of insulin is stimulated by:

a. adrenaline

b. somatostatin

c. fatty acids

d. acetylcholine

e. amino acids

2-The following are true about the autonomic nervous system:

a. the postganglionic neurones are largely unmyelinated

b. all preganglionic neurones are cholinergic

c. the preganglionic neurones of the sympathetic nervous system are
shorter than the parasympathetic nervous system

d. the parasympathetic outflow is only found in the cranial nerves

e. the sympathetic preganglionic neurones leave the spinal cord via
the dorsal roots of spinal nerves T1-L3

3-The following topical medications are contraindicated in iritis

a. pilocarpine

b. atropine

c. latanoprost

d. b-blockers

e. acetazolamide

THE RIGHT ANSWERS: in 16 April 10
1- a.F b.F c.T d.T e.T
Insuline secretion is stimulated by +blood
glucose,acetylcholine,aminoacids,fattyacids,glucagone & sulphoylurea.
It is inhibited by somatostatin, adrenaline

2- a.T b.T c.T d.F e.F
Parasympathetic outflow is also found in the sacral outflow(s2-4).
sympathetic oreganglionic neurones leave the spinal cord via the ventral roots of spinal nerves T1-L3.

3- a.T b.F c.T d.F e.F
Both pilocarbine& latanoprost can + occular inflamation.

Computer assisted knee replacement surgery

Also known as knee arthroplasty.The process involves relieving the patient from pain and disability from degenerative arthritis. Knee replacement surgery thus consists of replacing the diseased or damaged joint surfaces of the knee with metal and plastic components to ease continued motion of the knee.

Indications and Contra-indications of Chest Tube Insertion

Indications for Chest-Tube Insertion.

In all patients on mechanical ventilation
When pneumothorax is large
In a clinically unstable patient
For tension pneumothorax after needle decompression
When pneumothorax is recurrent or persistent
When pneumothorax is secondary to chest trauma
When pneumothorax is iatrogenic, if large and clinically significant
.Esophageal rupture with gastric leak into pleural space


.Malignant pleural effusion
.Treatment with sclerosing agents or pleurodesis
.Recurrent pleural effusion
.Parapneumonic effusion or empyema
.Postoperative care (e.g., after coronary bypass, thoracotomy, or lobectomy)


* The need for emergent thoracotomy is an absolute contraindication to tube
* Relative contraindications include the following:
o Coagulopathy
o Pulmonary bullae
o Pulmonary, pleural, or thoracic adhesions
o Loculated pleural effusion or empyema
o Skin infection over the chest tube insertion site


The most important complications associated with chest-tube insertion include
bleeding and hemothorax due to intercostal artery perforation, perforation of vis-
ceral organs (lung, heart, diaphragm, or intraabdominal organs), perforation of major vascular structures such as the aorta or subclavian vessels, intercostal neuralgia due to trauma of neurovascular bundles, subcutaneous emphysema, reexpansion pulmonary edema, infection of the drainage site, pneumonia, and empyema. There may be technical problems such as intermittent tube blockage from clotted blood, pus,
lines for the insertion of a chest drain.
or debris, or incorrect positioning of the tube, which causes ineffective drainage.


Insertion of Chest-Tube

and THIS

Clinical Application of Acetazolamide: (Diamox)

-It is well-absorbed orally, excreted by tubular secretion -- proximal tubule
-At maximal carbonic anhydrase inhibition: 45% inhibition of bicarbonate reabsorption

*causes significant bicarbonate loss
* hyperchloremic metabolic acidosis
*limited effectiveness because:
o bicarbonate depletion increases sodium chloride reabsorption
*reduction in aqueous humor and cerebrospinal fluid production

Clinical Application:

*decreases rate of aqueous humor production -- leads to a decline in intraocular pressure.
*most common indication for use of carbonic anhydrase inhibitors
*Dorzolamide (Trusopf): carbonic anhydrase inhibitor:
no diuretic or systemic metabolic effects
reduction in intraocular pressure comparable to oral agents

Urinary Alkalinization:
*increased uric acid and cystine solubility by alkalinizing the urine (by increasing bicarbonate excretion)

*for prophylaxis of uric acid renal stones, bicarbonate administration (baking
soda) may be required

Metabolic Alkalosis:
*Results from:
-decreased total potassium with reduced vascular volume
-high mineralocorticoid levels
-These conditions are usually managed by treating the underlying causes;
however, in certain clinical settings acetazolamide may assist in
correcting alkalosis {e.g. alkalosis due to excessive diuresis in CHF

Acute Mountain Sickness:
*Symptoms: weakness, insomnia, headache, nausea, dizziness {rapid ascension of
all of 3000 meters}; symptoms -- usually mild
*In serious cases: life-threatening cerebral or pulmonary edema
*Acetazolamide reduces the rate of CSF formation and decreases cerebral spinal
fluid pH.
*Prophylaxis against acute mountain sickness may be appropriate

Other Uses:
*some role in management of epilepsy
*As weak diuretic for adjunctive treatment of: edema due to cogestive heart failure
*hypokalemia periodic paralysis
*increase urinary phosphate excretion during severe hyperphosphatemia.

Answer every statement by true or false

1-The intraocular pressure:

a. is at its peak usually at around mid-day
b. is at its lowest in the evening
c. is higher in winter than in summer
d. shows greater diurnal variation in the glaucomatous eyes than the healthy
e. is higher in patients with thicker cornea when measured with applanation

2- Which is true about the viruses:

a. they contain either RNA or DNA nuclei acids only
b. HIV virus is a DNA virus
c. cytomegalovirus is a DNA virus
d. all herpes viruses are sensitive to acyclovir
e. viral replication within the host cells is inhibited by interferons

3- The sphenoid bone transmits the following structures:

a. middle meningeal artery
b. mandibular branch of the trigeminal nerve
c. optic nerve
d. internal carotid artery
e. nasociliary artery

THE RIGHT ANSWER : in 7 April 10

1* a.T b.F c.T d.T e.T

The IOP is highest at mid day and lowest in the morning at around 3:00 am
Thicker cornea gives a higher reading when the IOP measured by applanation tonometer

2* a.T b.F c.T d.F e.T


* contain nuclei acids which are either DNA or RNA
* HIV virus is a retrovirus and contains RNA
* cytomegalovirus is a herpes virus and contains DNA, it is not sensitive to
* induce interferon production which inhibits viral replication

3* a.T b.T c.T d.F e.F

the internal carotid artery grooves the body of sphenoid bone but doesn`t enter the cranium through it.
the nasociliary artery is a branch of the ophthalmic artery within the orbit.

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