JINNAH SINDH MEDICAL UNIVERSITY

GIT & HEPATOBILIARY-I MODULE STUDY GUIDE - MBBS YEAR-2, 2023

Spiral I
MODULE TITLE GIT & Hepatobiliary-I
INTRODUCTION This module provides the basis for understanding the
structure and gross and molecular functions of GIT &
Hepatobiliary system. This module is designed to be
linked with GIT & Hepatobiliary system II scheduled in
the 3rd year MBBS where the students will learn about
this system’s pathologic structure and functions. .
RATIONALE Gastrointestinal related disorders are extremely common in
Pakistan and are a cause of great morbidity and mortality.
Diseases like hepatitis and diarrhea are rampant. This module
will help students learn not only the structure and functions but
will introduce them to the clinical aspects of related disorders so
that they can link the basics with the applied aspects
TARGET 2nd year MBBS, 2023
STUDENTS
DURATION 4 weeks
MODULE By the end of the module, students of 2nd year MBBS will be able
OUTCOMES
to correlate the GIT related structures with functions and
biochemical processes
DEPARTMENTS i. Anatomy

ii. Biochemistry

iii. Physiology
OBJECTIVES By the end of the module, the students should be able to:

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 JINNAH SINDH MEDICAL UNIVERSITY
GIT & HEPATOBILIARY-I MODULE STUDY GUIDE - MBBS YEAR-2, 2023

LECTURES / DEMONSTRATIONS
ANATOMY

1) Introduction & divisions of GIT + abdominal quadrants{GROSS ANATOMY}

• Describe the divisions and parts of digestive tract
• List the abdominal quadrants & regions of GIT

2) Anterior Abdominal wall {GROSS ANATOMY}

 Enumerate the structures forming anterior abdominal wall

 Identify the boundaries of anterior abdominal wall
 Describe the muscles and fasciae of anterior abdominal wall
 Discuss the clinical conditions associated with the anterior abdominal wall

3) Inguinal Canal / Inguinal region{GROSS ANATOMY}

• Describe the extent, boundaries and content of the inguinal canal
• Describe the formation of superficial and deep inguinal rings
• Describe indirect and direct inguinal hernias
• List the different types of hernias

4) Esophagus (Abdominal Part), Stomach {GROSS ANATOMY}

• Explain gross features of abdominal part of esophagus & stomach
• List their peritoneal & visceral relations
• Explain their blood supply, lymphatic drainage & nerve supply

5) General Plan of G.I.T + Esophagus (HISTOLOGY )

• List the divisions of digestive tract
• Describe the general histological features of GIT
• Describe the histological features of esophagus.

6) Development of GIT -I (derivatives of fore-gut) {EMBRYOLOGY}

• Describe the divisions of primitive gut
• Enumerate the derivatives of foregut

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 JINNAH SINDH MEDICAL UNIVERSITY
GIT & HEPATOBILIARY-I MODULE STUDY GUIDE - MBBS YEAR-2, 2023
• Describe the development of foregut
• Describe the clinical aspect of derivatives of foregut
• Enumerate the congenital anomalies of foregut
• Discuss the features of the following congenital anomalies of foregut:
i. Hernias
ii. Esophageal atresia, esophageal stenosis, congenital hypertrophic pyloric
stenosis, duodenal stenosis & atresia, anomalies of liver, extra hepatic biliary
atresia, annular pancreas, accessory pancreatic tissue, & accessory spleen

7) Stomach {HISTOLOGY}
• Describe the histological features of stomach
• Explain how they can be differentiated from esophagus
• Describe, the microscopic features of gastric glands their constituent cells and
secretory product.
• Differentiate cardiac, fundic and pyloric glands

8) Peritoneum {GROSS ANATOMY}

• Describe the extent of peritoneum horizontally & vertically
• Define peritoneal layers, cavity, folds/mesenteries, omentum & ligaments
• Explain the attachment and reflection of peritoneum
• Explain the attachment of peritoneum on liver
• Describe the boundaries of lesser sac

9) Small Intestine & large intestine {GROSS ANATOMY}

• Explain different parts of small and large intestine
• Describe the relations, blood supply and nerve supply and lymphatic drainage of
intestine
• Describe the attachment and contents of mesentery
• List the structural differences between small and large intestine
• Discuss the relevant clinical conditions like volvulus & intussusceptions etc.

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 JINNAH SINDH MEDICAL UNIVERSITY
GIT & HEPATOBILIARY-I MODULE STUDY GUIDE - MBBS YEAR-2, 2023
10) Development of GIT- II (derivatives of mid and hind gut ) {EMBRYOLOGY}
• List the development derivatives of primitive gut tube (pharynx. esophagus stomach,
intestine)
• List the special features associated with common anomalies related to gut including
Congenital omphalocele, umbilical hernia, gastroschisis, anomalies of midgut,
internal hernia, stenosis, atresia of intestine, Mal-rotation of gut, Ileal diverticulum,
duplication of intestine, anomalies of hindgut, Hirschsprung disease, imperforate
anus, anal stenosis, rectal atresia.

• Describe the derivatives of midgut and hindgut

• Describe the formation of greater, lesser omentum and omental bursae
• Describe rotation of gut
• Describe the congenital anomalies of gut
11) Small intestine {HISTOLOGY}
• Explain the different layers of small intestine
• Describe the different glands present in the small intestine
• Discuss the cells present in intestinal glands.
• Explain Payers patches
• Differentiate among the parts of small intestine histologically

12) Large intestine {HISTOLOGY}

• Describe the histological features of different parts of large intestine
• Enumerate the different layers of large intestine
• Describe the glands and their cells in different parts of large intestine.
• Explain the difference between small and large intestine

13) Liver and Gall bladder {GROSS ANATOMY}

• Describe liver with its anatomical positions

• Explain lobes and surfaces of liver and visceral relations and impression.
• Describe the segments of liver
• Describe ligaments attached to the liver
• Discuss the different components of biliary tract
• Explain the parts ,relations and functions of the gallbladder
• Discuss the clinical related to liver and gall bladder

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 JINNAH SINDH MEDICAL UNIVERSITY
GIT & HEPATOBILIARY-I MODULE STUDY GUIDE - MBBS YEAR-2, 2023
14) Hepatic Portal System
• Identify the veins of GI tract and of hepatic portal system
• Describe the venous drainage of the organs of GI tract and the veins of hepatic portal
system
• Describe the clinical importance of the hepatic portal system and its connections

15) Development of liver, Gall bladder and Pancreas {EMBRYOLOGY}

• Describe the development of liver
• Discuss the sources of development of hepatocytes and sinusoids.
• Discuss the molecular regulation of liver induction
• Explain the formation of gallbladder & cystic duct
• Enumerate the anomalies of Liver & gallbladder
• Discuss the formation of pancreatic bud and Islet of Langerhans
• Discuss molecular regulation of pancreatic development
• Describe pancreatic anomalies.

16) Liver and gall bladder {HISTOLOGY}

• Explain histology of liver
• Discuss intrahepatic hepatic and portal circulation.
• Describe the general concepts underlying classical hepatic lobule, portal lobule and
hepatic acinus.
• Describe the microscopic structure of gall bladder.

17) Pancreas and Spleen {GROSS ANATOMY}

• Discuss the gross features of different parts of pancreas
• Describe the location &relations, of Pancreas
• List the relations of spleen
• Describe the ligaments attached to spleen
• Describe the arterial supply, venous drainage and nerve supply of pancreas and
spleen
• Discuss the clinical relevance of pancreas and spleen

18) Pancreas {HISTOLOGY}

• Discuss the histological features of Pancreas

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 JINNAH SINDH MEDICAL UNIVERSITY
GIT & HEPATOBILIARY-I MODULE STUDY GUIDE - MBBS YEAR-2, 2023
• Explain the arrangement of Pancreatic parenchyma & stroma.

19) Posterior abdominal wall (boundaries, lumbar vertebrae, muscles, fascia)

• Identify the level of vertebrae with respect to the three major orifices in the
diaphragm.
• Discuss the location of these orifices with respect to vertebral level and mention the
structures passing through it
• Enumerate the structures forming the posterior abdominal wall
• Identify the boundaries of posterior abdominal wall
• Discuss the general characteristics of lumbar vertebrae
• Describe the muscles and fasciae of posterior abdominal wall
• Discuss the clinical conditions associated with the posterior abdominal wall
including hernias

20) Anal Canal

• Explain the gross anatomical features of rectum and anal canal
• Describe the Ano-rectal junction
• Describe the Nerve supply and blood supply of anal canal
• Describe Ano-rectal fistula, Polyps and diverticulum
NOTE: Anal sphincters (External and internal) will be discussed with pelvis &
perineum

21) Abdominal Aorta + blood supply of abdomen

• Describe the course of abdominal aorta
• Enumerate the paired and unpaired branches of abdominal aorta
• Discuss the arteries which supply the abdominal walls

22) Inferior vena cava + venous drainage of abdomen

• Describe the formation of inferior vena cava
• List the tributaries of inferior vena cava
• Explain the relations of inferior vena cava
• Discuss the clinical conditions associated with inferior vena cava

23) Lymphatic drainage and innervation of abdomen

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 JINNAH SINDH MEDICAL UNIVERSITY
GIT & HEPATOBILIARY-I MODULE STUDY GUIDE - MBBS YEAR-2, 2023
• Explain the groups of lymph nodes draining the abdomen
• Describe the lymphatic trunks, cistern chili and the thoracic duct.
• Summarize nerve supply of abdominal viscera(GIT)
• Discuss the sympathetic trunk, splanchnic nerves, prevertebral plexus & ganglia
supplying the abdomen

24) Surface anatomy of Abdomen

• Identify the bony landmarks of the abdomen
• Discuss the abdominal regions and quadrants
• Locate the abdominal organs in each quadrant
• Discuss the surface anatomy of stomach and spleen
• Identify the surface anatomy of liver & Gall bladder
• Discuss the variable positions of diaphragm

25) Radiological Anatomy

• Identify various parts of normal GIT on a plain X ray.

BIOCHEMISTRY

TOPIC: DIGESTION & ABSORPTION

1) Digestion & Absorption of Carbohydrates
• List the main digestive enzymes and describe their action on carbohydrate
 Classify dietary carbohydrates with examples
• Explain the significance of the glycemic index
• Describe the importance of dietary fiber
• Discuss the abnormalities due to digestive enzyme deficiency
• Explain the absorption of monosaccharaides by the intestinal mucosal cells
• Discuss the clinical significance of abnormalities of digestion and absorption (e.g.
lactose intolerance)

2) Digestion & Absorption of Proteins

• List the various sources of dietary protein
• Discuss the digestion of protein

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 JINNAH SINDH MEDICAL UNIVERSITY
GIT & HEPATOBILIARY-I MODULE STUDY GUIDE - MBBS YEAR-2, 2023
• Explain the functions of the proteolytic enzymes
• Explain the mechanism of absorption of amino acids
• Discuss the significance of amino acid pool
• Explain the significance of nitrogen balance.
• Discuss the clinical significance of protein allergy, celiac sprue and cystinuria

3) Digestion & Absorption of Lipids

 Define Steatorrhoea
 List causes of Steatorrhoea
 List the constituents of dietary lipids
 Discuss the digestion of lipids
 Explain the role of lipases in lipid digestion
 Discuss the digestion of dietary cholesterol and phospholipids
 Explain the hormonal regulation of lipid digestion
 Discuss the absorption of lipids by the intestinal mucosal cells
 Describe the process of re-synthesis and secretion of lipids by the enterocytes
 Discuss the secretion of chylomicrons by the enterocytes
 Discuss the abnormalities of lipid digestion and absorption with especial reference
to cystic fibrosis

TOPIC: METABOLIC PATHWAYS OF CARBOHYDRATES

4) Glycolytic pathway of Carbohydrates Metabolism

• List the reactions of the two stages of glycolysis viz energy investment and energy
generation
• Differentiate between aerobic and anaerobic glycolysis
• Explain the role of insulin in transport of glucose inside the cells
• Explain the hormonal regulation of glycolysis
• Discuss the fate of pyruvate
• Explain the process of glycolysis in RBC’s
• Discuss the abnormalities of glycolysis

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 JINNAH SINDH MEDICAL UNIVERSITY
GIT & HEPATOBILIARY-I MODULE STUDY GUIDE - MBBS YEAR-2, 2023
5) TCA cycle of Carbohydrate metabolism
• Discuss the significance of TCA cycle as an amphibolic pathway
• Discuss the reactions of the TCA cycle and its regulatory steps
• Describe the energy produced from TCA cycle
• Explain the disorders of TCA cycle

6) Metabolism of Glycogen with its disorders

• Explain the structure and functions of glycogen
• Describe the mechanism of glycogen synthesis and its regulation
• Describe the mechanism of glycognenolysis and its regulation
• Discuss the maintenance of blood glucose level
• Explain the various form of glycogen storage diseases

7) Metabolic pathway of Gluconeogenesis

• Describe the mechanism of gluconeogenesis
• List the reactions which are unique to gluconeogenesis
• Describe the regulation of gluconeogenesis
• Explain the Cori cycle

8) Metabolic pathway of HMP Shunt

• Describe the significance of hexose monophosphate shunt
• Describe the oxidative and non-oxidative stages of HMP shunt
• Discuss the enzymes of the HMP shunt and its regulation.
• Explain the abnormalities of the HMP shunt especially G6PD.
• Discuss the significance of reactive oxygen species
• Discuss the functions of NADPH and glutathione

9) Metabolic pathways of Fructose, Galactose & Uronic Acid

• List the sources of fructose
• Discuss the alternative mechanism of monosaccharide metabolism
• Discuss the important enzymes of fructose metabolism
• Explain the metabolic pathway of fructose
• Explain the disorders of fructose metabolism due to enzyme deficiencies

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 JINNAH SINDH MEDICAL UNIVERSITY
GIT & HEPATOBILIARY-I MODULE STUDY GUIDE - MBBS YEAR-2, 2023
• Discuss the important enzymes of Galactose metabolism
• Explain the metabolic pathway of Galactose metabolism
• Explain the disorders of Galactose metabolism due to enzyme deficiencies
• Explain the uronic acid pathway and its biochemical significance.
• Describe the importance of uronic acid pathway in liver detoxification

TOPIC: BIOLOGICAL OXIDATION

10) Bioenergetics & Biological Oxidation

• List high energy and low energy phosphates
• List the oxido-reductase enzymes
• Define bioenergetics and explain the general laws of thermodynamics
• Define free energy and equilibrium constant
• Describe the coupling of endergonic & exergonic reactions by high energy
intermediates (e.g. ATP)
• Describe the role of ATP as an energy carrier
• Describe biologic oxidation and redox potential

11) Oxidative Phosphorylation & Electron Transport Chain

 List the ion transporters in the inner mitochondrial membrane
 List the genetic defects of oxidative phosphorylation
 Describe the organization of the electron transport chain
 Discuss the functions of each complex of ETC
 Explain the energy currency of the body
 Explain the site and mechanism of synthesis of ATP
 Describe how proton are pumped from the matrix to the intermembrane space
 Discuss the significance of co-enzyme Q and the Q-cycle
 Discuss the inhibitors and uncouplers of ETC and their mechanism of action
 Discuss how electron transport chain releases free energy
 Discuss the generation of proton gradient
 Explain the significance of P.O. Ratio
 Explain Mitchell’s chemiosmosis theory of electrochemical gradient

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 JINNAH SINDH MEDICAL UNIVERSITY
GIT & HEPATOBILIARY-I MODULE STUDY GUIDE - MBBS YEAR-2, 2023
 Explain the glycerophosphate and malate shuttle
 Explain the clinical conditions which inhibit the electron transport chain

TOPIC: BIOCHEMICAL FUNCTIONS OF LIVER

12) Metabolic role of Liver & its detoxification

• Discuss the metabolic, synthetic, excretory, detoxification and storage functions of
liver
• List the liver function tests based on the five main functions of the liver
• Explain the normal level of serum bilirubin (total, conjugated and unconjugated),
urinary urobilinogen, urinary bilirubin, fecal stercobilinogen in different types of
Jaundice
• Discuss the importance of serum enzymes in the differential diagnosis of Jaundice
(ALT, AST, ALP, LDH, GGT, and 5’-Nucleotidase)
• Discuss the importance of albumin, total protein and prothrombin time in diagnosing
liver disease

13) Degradation of Hemoglobin and Bilirubin Metabolism

• List the steps of heme degradation to bilirubin
• Discuss the role of liver in bilirubin uptake and conjugation
• Discuss the secretion of bilirubin in bile
• Explain the fate of bilirubin in the intestine and its excretion in urine and stool

14) Jaundice and its biochemical investigations

• Describe the disorders of bilirubin metabolism
• Explain the types of bilirubin in the blood
• Classify jaundice
• Explain the causes with examples and diagnostic investigations of pre-hepatic,
hepatocellular & post-hepatic and obstructive jaundice

PHYSIOLOGY

1) Introduction to the digestive system and associated Hormones.

 Describe the characteristics of gastrointestinal wall.

 Explain functional types of movements in gastrointestinal tract: Propulsive and
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 JINNAH SINDH MEDICAL UNIVERSITY
GIT & HEPATOBILIARY-I MODULE STUDY GUIDE - MBBS YEAR-2, 2023
Mixing movements.
 Discuss the role of various hormones in GIT motility: Gastrin, Cholecystokinin,
Secretin, Gastric inhibitory peptide, Motilin.
 Describe the gastrointestinal blood flow (Splanchnic Circulation) and its regulation.

2) Functions of the smooth muscle and their electrical properties

• Explain the electrical properties of gastrointestinal smooth muscle: Slow wave and
Spike potential.
• Describe genesis of BER and its role in GI motility.
• Describe the mechanism of smooth muscle contraction.

3) Neural control of GIT.

• Describe the neural control of Gastrointestinal function: Enteric Nervous system.

• Differentiate between the functions of Myenteric and Meissner’s plexus.
• Explain the autonomic control of GIT.
• Describe the Gastrointestinal reflexes (gastro-colic, entero-gastric, colono-ileal
reflexes)

4) Secretion of saliva (composition, function and regulation)

 Mention the salivary glands and their functions.

 Describe the composition of saliva and the mechanism of secretion.
 Explain the nervous regulation of salivary secretion.

5) Mastication & Deglutition reflex

• Describe the mechanism of mastication(Chewing).

• Explain the phases of deglutition(Swallowing): Voluntary, Pharyngeal and
Esophageal.
• Explain lower esophageal tone and motility defects in esophagus.

6) Functions of stomach

• Describe the motor functions of stomach: Storage, Mixing and Emptying.

• Explain the regulation of stomach emptying.

7) Gastric secretion (composition, function and regulation)

• Explain the characteristics and secretions of gastric and pyloric glands.

• Describe the mechanism of hydrochloric acid secretion.

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 JINNAH SINDH MEDICAL UNIVERSITY
GIT & HEPATOBILIARY-I MODULE STUDY GUIDE - MBBS YEAR-2, 2023
• Describe the phases and regulation of gastric secretion.

8) Movements of small and large intestine.

• Describe the movements of small intestine: Segmentation, Peristalsis.
• Explain the movements in colon: Haustrations and Mass movement.
• Describe the effects of autonomic system in modulating intestinal motility.

9) Secretions of small and large intestine

• List secretion of different enzymes in small and large intestines

• Describe the regulation of small and large intestinal secretions
• Describe the composition, functions and control of small intestine juice (succus
entericus).

10) Pancreatic secretions (composition, function and regulation)

• Describe composition & secretions of pancreatic juice.

• Explain the mechanism of bicarbonate ions.
• Explain the phases of pancreatic secretion.
• Describe the regulation of pancreatic secretion.

11) Bile secretion (composition, function and regulation)

• Mention the composition of bile and factors for its release.

• Explain the mechanism of secretion of bile salts.
• Describe the role of bile salts in fat digestion and absorption.
• Describe enterohepatic circulation of bile salts.
• Mention the causes of gallstone formation.

12) Vomiting & Defecation reflexes

• Explain vomiting reflex & its causes.

• Explain defecation reflex & its nervous regulation.

13) Disorders of gastro-intestinal tract.

• Discuss the common disorders of GIT: Achalasia, Gastritis, Peptic ulcer,

Malabsorption, Constipation, Diarrhea, GI obstruction.

TUTORIALS

BIOCHEMISTRY

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 JINNAH SINDH MEDICAL UNIVERSITY
GIT & HEPATOBILIARY-I MODULE STUDY GUIDE - MBBS YEAR-2, 2023
TOPIC: DIGESTION & ABSORPTION
1) Abnormalities of digestion & absorption

• Discuss the clinical importance of abnormalities of digestion & absorption (e.g.

Lactose Intolerance)
• Correlate the interpretation of laboratory investigations with relevant clinical
conditions

TOPIC: METABOLIC PATHWAYS OF CARBOHYDRATES

2) Disturbances in Carbohydrate Metabolism

• Discuss the clinical importance of disturbances in carbohydrate metabolism (e.g.

G6PD deficiency)
• Correlate the interpretation of laboratory investigations with relevant clinical
conditions

TOPIC: ELECTRON TRANSPORT CHAIN

3) Disturbances of Electron Transport Chain

• Discuss the clinical importance of disturbances of electron transport chain (e.g.

Carbon monoxide poisoning)
• Correlate the interpretation of laboratory investigations with relevant clinical
conditions

TOPIC: JAUNDICE

4) Jaundice and its biochemical investigations

• Classify Jaundice
• List the causes of each type
• Correlate the interpretation of laboratory investigations with relevant clinical
condition

PRACTICALS

ANATOMY

1) Esophagus + stomach

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 JINNAH SINDH MEDICAL UNIVERSITY
GIT & HEPATOBILIARY-I MODULE STUDY GUIDE - MBBS YEAR-2, 2023
• Recognize the general arrangement of layers in GIT
• Identify the slides of esophagus and stomach under microscope
• Describe the light microscopic features of each layer of esophagus
• Identify characteristic features of each layer of stomach
• Differentiate the 3 histological regions of stomach
• Differentiate the histological feature of stomach & esophagus

2) Small intestine
• Identify small intestine under light microscope
• Discuss the histological features of small intestine

3) Liver and gall bladder

• Identify liver ,its classical hepatic lobule and portal triads
• Identify the layers of gall bladder under light microscope
• Discuss the histological features of both.

4) Pancreas
• Identify the slide under light microscope
• Discuss the histological features of pancreas

5) Large Intestine
• Identify large intestine under microscope
• Describe the important histological features of large intestine.
• Identify the appendix on the basis of its distinguished features
• Identify the histological features of anorectal region
• Differentiate between basic histological features of small and large intestines.

BIOCHEMISTRY

TOPIC: DIGESTION & ABSORPTION

1) Serum Glucose Estimation

• List and explain the biochemical investigations done for Diabetes Mellitus
• Outline the method for serum glucose estimation by spectrophotometer
• Estimate the serum glucose levels and give its interpretation
• Correlate the interpretation of laboratory investigations with relevant clinical
conditions

TOPIC: JAUNDICE
2) Serum LFT’s (Liver function test) profile
• List and explain the Liver function tests
• Identify the chemical tests and bio-techniques used to perform Liver function
tests
• Interpret the serum Liver function test

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 JINNAH SINDH MEDICAL UNIVERSITY
GIT & HEPATOBILIARY-I MODULE STUDY GUIDE - MBBS YEAR-2, 2023
• Correlate the interpretation of laboratory investigations with relevant clinical
condition

3) Serum Aminotransferase (ALT)

• Identify the chemical tests and bio-techniques used to perform serum
Aminotransferase
• Estimate the serum Aminotransferase level (ALT)
• Interpret the serum Aminotransferase level (ALT)
• Correlate the interpretation of laboratory investigations with relevant clinical
condition

4) Serum Bilirubin
• Explain the method used to perform Serum Bilirubin by Spectrophotometer
• Estimate serum Bilirubin level (Total, Direct & Indirect Bilirubin)
• Interpret serum Bilirubin level
• Correlate the interpretation of laboratory investigations with relevant clinical
condition

• Internal assessment will be according to JSMU policy.

The details of internal assessment will be determined by
the respective institutions.
INTERNAL
• Internal assessment carries 20% weightage in the final,
ASSESSMENT
end-of-year examination.
• A module test will be held at the end of this module.
Marks obtained will contribute to Internal Assessment.
FINAL EXAM Final Annual exam will consist of MCQs ( One Correct &One
Best) and OSPE (observed + unobserved stations)
COURSE The module will be evaluated through a feedback form posted on
EVALUATION JSMU website

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