anatomy
anatomy
bruits
Neurotransmitters; carry impulses
across synapses
❖ Dopamine (reward-motivation)Parkinson’s
❖Serotonin (SSRIs) Depression
❖Acetylcholine (alpha adrenergic-parasympathetic)
❖Norepinephrine (blood pressure) (Beta
adrenergic)
❖Epinephrine/adrenalin(Beta adrenergic)
❖GABA-(gamma-aminobutyric acid) and Glutamine
(epilepsy and seizures)
Cranial Nerve Diagram: 12 altogether
Cursory Neurologic Exam when you go
to see you Primary Care Physician
• Sensorium and memory
• Pupils (R&R&RLA)
• Funduscopic exam
• Eyes movements
• Check Reflexes with reflex hammer
• Strength evaluation and proprioception
• Balance
Optic Chiasm
Right Brain versus Left Brain
• Right brain more adept at spatial and nonverbal
concepts and being more creative and
emotional (a scientist or musician) imagination,
holistic thinking
• Left Brain are more analytical and methodical.
They are better at things like reading, writing, and
computations. (an accountant or author) logic
No proof that one is dominant but the differences
do appear to be real between the two sides.
Autonomic Nervous System or Involuntary
nervous system
Feedback Loops
Pituitary Hormones
Anterior Pituitary
• Growth Hormone (GH)
• Thyroid stimulating hormone (TSH)
• Adrenocorticotrophic hormone (ACTH)
• Gonadotropic hormones; Luteinizing hormone (LH), ICSH,
Follicle Stimulating hormone (FSH)
• Melanocyte Stimulating Hormone (MSH)
________________________________________
Posterior Pituitary
• Anti-Diuretic hormone or vasopressin (ADH)
• Oxytocin (love and uterine contractions)
• Prolactin (lactation)
Pituitary Dysfunction
• Acromegaly, Gigantism, Dwarfism(GH)
• Hyperthyroidism (Graves Disease),
Hypothyroidism
• Cushing’s disease or Addison’s disease
• Hypogonadism
• Infertility
Thyroid and Parathyroid Glands
Feedback Regulatory Mechanisms
Thyroid and Parathyroid Glands
Parathormone has
Opposite effect
The Adrenal Glands: total weight combined
10 grams or 1/3rd of an ounce
Adrenal Gland Locations
The Effects of Prednisone
Short courses of Cortisone safe; chronic use has many
side effects
ACTH
Moon Facies
Cushionoid
Addison's and Cushing's Disease
• Adrenal Insufficiency is usually caused by autoimmune
adrenalitis (many other causes as well) and gives
symptoms related to the three hormones the adrenal
gland secretes—ADH, Cortisone and Sex Hormones.
These include weakness, fatigue, low BP, weight loss.
Treatment is hormone replacement
• Cushing’s Disease is due to an excess of steroids often
due to pituitary adenoma or long term corticosteroid
treatment. Symptoms of diabetes, HPT, moon facies,
obesity, buffalo hump
Parathyroid Disease
• Four pea sized glands in the neck behind the
thyroid gland that secrete Parathormone, a
hormone, that regulates calcium levels through
bone resorption, GI absorption and renal
excretion.
• Adenomas of the parathyroid glands and
paraneoplastic syndromes may cause
hypercalcemia and HPT. Extreme elevations of
Ca+ can be life threatening (mental and cardiac
arrhythmias)
The Pancreas
Functions of the Pancreas (Diabetes is cause by a lack
of insulin (Juvenile Diabetes) or insulin resistance
(Adult onset of Diabetes)
• Secretion of insulin, which acts to lower blood
sugar, and glucagon, which acts to raise blood
sugar.
• Digestive enzymes Lipase, Amylase, Trypsin
Diabetes Mellitus: Juvenile and Adult Onset Diabetes
(13.8 percent of Cincinnatians have the latter)
• In the Juvenile variety the B cells in the pancreas are unable to produce
insulin; possibly an autoimmune response? And no genetic factors
have been identified with 90 % with no relative with the disorder.
• Adult Onset Diabetes: an epidemic with a number of risk factors; (no
identifiable gene seems to predispose to its occurrence but it does
seem to occur more frequently in some families). Insulin resistance
seems to be a factor.
Risk Factors:
• Obesity
• Age and inactivity
• African-Americans
• Smoking
• Obesity
• Hyperglycemia
• Low socioeconomic statis
• Inactivity
Organs effected by Diabetes: sugar is a
toxin
• The Kidney with albuminuria (prognosis and
diagnosismmm), decrease GFR. 50 percent of
dialysis patients with End Stage Renal Disease
have diabetes.
• Strict glucose control has greater benefit for Type
1/Juvenile as opposed to Type 2 diabetes.
• Diabetes is the primary cause of blindness in
adults ages 20 to 74.
• Associated with The Metabolic Syndrome with
arteriosclerosis disease.
Diagnosing Diabetes
• FBS--overnight fasting generally and normal value
is up to 100 mg/dl. Values of 100 to 125 mg/dL
suggest you are prediabetic, and 126 mg/dL or
higher indicates you probably have diabetes.
• Glucose Tolerance Test
• Gestational diabetes
• Hgb A1C the gold standard to diagnose and
regulate diabetes; on an annual physical if the
FBS is over 100, a Hgb A1C is performed.
Overview of Treatment
Medications to Treat Diabetes
• Metformin (Glucophage). Generally, metformin is
the first medication prescribed for type 2
diabetes. (increases sensitivity to insulin,
decreases sugar absorption and lowers sugar
production)..survival benefits?
• Sulfonylureas. Least expensive; activate B cells
• Insulin-many forms and ways to control blood
sugar levels.
Newer Medications for the Treatment
of Diabetes
• SGLT2 inhibitors: (Farxiga/Jardiance and many
more) prevents reabsorption of glucose in
proximal tubule in the kidney, osmotic
diuresis; it lowers Aic levels
• GLP-1 receptor (Trulicity) (glucagon-like
peptide agonists)associated with some weight
loss, slows emptying of stomach and by
injection.
Skeletal System
206 bones
Joints most commonly involved in
disease states
Terminology
• Tendon
• Ligament
• Vertebrae and Inter-Vertebral Discs
• Cartilage
• Synovia and synovial Fluid
• Structure of bones: cortical bone and
cancellous bone, bone marrow, periosteum
24 Vertebrae
B CELLS AND
OTHER BLOOD CELLS
Types of Joints
Various types of synovial joints:
1.Hinge joints as in knees, elbows and ankles
2.Ball and socket joints as in the hip and
shoulder (which is multiaxial)
3. Pivotal or rotational as in the spine, elbow
“Aging is the process of wearing out gradually”
• Degenerative arthritis/osteoarthritis
• Many causes like RA, psoriasis, inflammatory bowel
disease, reactive arthritis
• Falls/hip fractures
• Spinal Stenosis
The Bionic Man comes to the rescue
• Joint replacements from easiest to hardest in terms of
rehabilitation and satisfactory outcomes:
Hips< Knee< Shoulder (others ankle, elbows, finger,
vertebrae)
Conservative Treatments(surgical replacement a
final solution after all else fails)
• In the morning you have more stiffness and pain that usually decreases after you
are active.
• Neuropathic pain often chronic pain-can have regional pain syndrome
• Physical therapy: range of motion and strengthening exercises
• Pain medication: mainly NSAIDS like Advil or Celebrex
• Ultrasound
• Lidocaine patches
• Injections of joints: lidocaine, steroids, hyaluronic acid derivatives and ?stem cells
• Arthroscopic evaluation and trimming up cartilage.
If in doubt, get a second opinions when surgery
is offered is often worthwhile. But joint
replacement can be a Lifestyle issue and
replacements are very successful; how much
functionality do you want?
The Rehab Process: no fun
Most important
question; how
much and for how
long will I have
pain?
Athletic Injuries and Cancer
• Anterior Cruciate Ligament (ACL) and PCL tears
• Torn Cartilage in knee (surgery or not?) Quadriceps exercises
• Plantar fasciitis (calf stretching)
• Tendon tears (biceps, quadriceps)
• Dislocated shoulder
Cancers:
• Osteosarcoma, Chondrosarcoma (rare)
• Multiple Myeloma and Leukemia (bone marrow biopsies)
• Metastatic Cancer (Prostate, breast, and lung most common)
Plantar Fasciitis
Rheumatoid Arthritis: A Chronic
Disorder with a variable course
• 0.24 to 1 percent incidence with 2 to1 women
• RA is an autoimmune disorder. It occurs when
your body’s immune system attacks the synovium
of the joint that produces joint fluid that
nourishes the cartilage and lubricates the joints.
• If left untreated it can invade and destroy a joint
and surrounding bony tissue.
• The exact cause of the immune system’s attacks is
unknown
Joints involved with RA
Treatment of Rheumatoid Arthritis (immune
suppressants) very effective with good outcomes
Temporalis Muscle
Masseter Muscle
Muscular Disorders
• ALS, Muscular dystrophy and Myasthenia
gravis can directly effect the muscles and
many illnesses cause secondary muscular
weakness but most muscular disorders relate
to trauma of one sort or another.
Sarcopenia
The Rotator Cuff (external rotation)
Shoulder Replacement
Reason to treat
Hepatitis C?
Why is pancreatic cancer so difficult to cure? The
location of the pancreas and the late onset of
symptoms
• 60,000 new cases each year with a 5 year survival rate
of 10 percent.
• 50 percent of patient present with metastatic disease,
30 percent with locally invasive disease.
• 10th leading cause of cancer and the 3rd leading cause
of cancer related mortality.
• Few are surgical candidates; mainly heavy duty chemo
that increases life expectancy by 2-6 months
• Risk factors; smoking, obesity, alcoholism and
pancreatitis.
• Host of genetic risk factors.
The Gall Bladder
• Stores bile that digests fats and colors the stool brown
• Gall stone; 6% of men and 9% of women (may
predispose to cholecystitis)
• Most asymptomatic; but recurrence of biliary colic
common if you have had one attack
• Cholecystitis, Pancreatitis and Common Duct stones
more serious
• Laparoscopic removal of gall bladder (minimally
invasive)
• Diagnostic tool now used Endoscopic Ultrasound (EUS)
Factors Influencing Weight
• Leptin is a hormone, made by fat cells, that
decreases your appetite.
• Ghrelin is a hormone released primarily in
the stomach that increases appetite, and also
plays a role in body weight.
• Microbiome (intestinal flora in the gut, mainly
large intestine)
• Hypothalamus in the Central Nervous System
• Of course: Diet, Mood, Good Food and Exercise play
a significant role
Bariatric Surgery for Morbid Obesity
(BMI > 40)
• When all else fails:
Disorders of the GI tract
• Celiac disease (gluten in wheat, rye, and barley)
genetic immune disorder with one percent incidence
with majority undiagnosed.
Diagnosis antibody testing and biopsy
• Irritable Bowel syndrome (IBS)
• Ulcerative Colitis-superficial and confined to colon
(relapses but 20 % go on to colectomy)
• Regional ileitis (Crohnes Disease) penetrating and can
involve entire GI tract—fistulae, abscesses, strictures,
treatment similar to UC. Follow with fecal calprotectin)
• C difficile bacteria and other ‘super bugs’
• Hemorrhoids
Colon Cancer
T-cells
B-cells
Peripheral Blood Smear
CBC and Differential Blood Cell Count
Neutrophils Relative 37.0 % bacterial infections
Lymphocytes Relative 53.0 % immune system, leukemia
Myeloid Lymphoid
NK cells are best known for killing
virally infected cells, and
detecting and controlling early
signs of cancer.
The Immune System; Lymphoid System
B cells T cells
Cytotoxic T Cells (CD8 T Cells)
Cytotoxic T cells kill their target cells, primarily by releasing cytotoxic granules into the cell to be killed.
These cells recognizejju their specific antigen (such as fragments of viruses) when presented by MHC
(Hyman leukocyte antigens (HLA) Class I molecules that are present on the surface of all nucleated
cells.
MHC Class I molecules interact with a protein called CD8 on the cytotoxic T cells, which helps to
identify this cell type. Cytotoxic T cells require several signals from other cells to be activated, such as
from dendritic cells and T helper cells.
Their main function is to kill virally infected cells, but they also kill cells with intracellular bacteria or
tumorous cells.
T-Helper Cells (Th) (CD4 T Cells)
T helper cells have a wider range of effector functions than CD8 T cells and can differentiate into many
different subtypes, such as Th1, Th2, Th17 and regulatory T cells.
They become activated when they are presented with peptide antigens by MHC Class II molecules, which
are expressed on the surface of APCs. MHC Class II molecules interact with a protein called CD4 on the T
helper cells, which helps to identify this cell type.
The roles of a CD4 T cell may include activating other immune cells, releasing cytokines, and helping B cells
to produce antibodies. They help to shape, activate and regulate the adaptive immune response.
Memory T Cells
Following an infection, antigen-specific, long-lived memory T cells are formed. Memory
T cells are important because they can quickly expand to large numbers of effector T
cells upon re-exposure to the antigen and have a low threshold for activation.
They provide the immune system with memory against previously encountered
antigens. Memory T cells may either be CD4+ or CD8+.
Immunoglobulins
• Immunoglobulins, also known as antibodies,
are glycoprotein molecules produced mainly
by plasma cells and initiate the immune
response by specifically recognizing and
binding to particular antigens, such as bacteria
or viruses, and aiding in their destruction.
Classes of Immunoglobulins
The five major antibody classes are:
• Immunoglobulin G (IgG), 80%, is found in all body fluids and
protects against bacterial and viral infections.
• Immunoglobulin M (IgM), is the first antibody to be released by B
cells during primary response
• Immunoglobulin D (IgD, important in B cell activation
• Immunoglobulin A (IgA), which is found in high concentrations in
the mucous membranes, particularly those lining the respiratory
passages and gastrointestinal tract, and prevent attachment of
pathogens to epithelial surfaces.
• Immunoglobulin E (IgE), found on mast cells and basophils and
triggers release of histamine which is associated mainly with allergic
reactions (when the immune system overreacts to environmental
antigens such as pollen or pet dander). It is found in the lungs, skin,
and mucous membranes.
Immunizations
Adult Immunizations
Amino Acids
What is a chromosome?
• Chromosomes are the things that make
organisms what they are. They carry all of the
information used to help a cell grow, thrive,
and reproduce. Chromosomes are made up of
DNA. Segments of DNA in specific patterns are
called genes. ... You will find
the chromosomes and genetic material in the
nucleus of a cell and mitochondria.
A chromosome contains hundreds to
thousands of genes.
Genes and Chromosomes
Difference between DNA & RNA
• DNA is a long polymer with deoxyribose (a sugar) and
phosphate backbone. Having four different
nitrogenous bases: adenine, guanine, cytosine and
thymine.
• RNA is a polymer with a ribose (a sugar) and phosphate
backbone. Four different nitrogenous bases: adenine,
guanine, cytosine, and uracil.
Differences between DNA & RNA: Thymine is the pyrimidine base of
the DNA, whereas Uracil is the pyrimidine base of the RNA. The
occurrence of thymine and uracil is a crucial difference as thymine is
only found in DNA and uracil is only found in RNA. Methyl group is
absent in uracil whereas present in thymine at the C-5 position.
What is the chemistry of cytosine,
adenine, thymine and guanine made
• As a nitrogenous base, cytosine is full of
nitrogen atoms (it has three). It also has one
ring of carbon, which makes it a pyrimidine. A
purine, on the other hand, has two rings of
carbon. There are two
pyrimidines, cytosine and thymine, and two
purines, adenine and guanine, in DNA.
Basic structure of DNA
What is an amino acid?
• An amino acid is an organic molecule that is
made up of a basic amino group (−NH2), an
acidic carboxyl group (−COOH), and an organic
R group (or side chain) that is unique to each
amino acid. The term amino acid is short for
α-amino [alpha-amino] carboxylic acid
Amino acids
• ESSENTIAL AMINO ACIDS
• Essential amino acids cannot be made by the
body. As a result, they must come from food.
• The 9 essential amino acids are: histidine,
isoleucine, leucine, lysine, methionine,
phenylalanine, threonine, tryptophan, and valine.
• Nonessential amino acids
include: alanine, arginine, asparagine, aspartic
acid, cysteine, glutamic
acid, glutamine, glycine, proline, serine,
and tyrosine.
General Knowledge
• In humans, each cell normally contains 23
pairs of chromosomes, for a total of 46.
Twenty-two of these pairs, called autosomes,
look the same in both males and females. The
23rd pair, the sex chromosomes, differ
between males and females.
Karyotyping
Difference between Meiosis and
Mitosis
• Sperm and ova; they fuse to form a zygote
M, E, N proteins are
envelope proteins
Hemagglutinin-
esterase destroys
receptors
Covid-19 and the Pandemic
A multisystem disease since every blood vessel in the body
has Angiotension 2 receptors. It is more lethal than the flu
with ‘long haul’ symptoms lingering in more than 30 percent
of patients with shortness of breath, chronic fatigue, renal
failure, brain fogginess to name a few. These may last
months/years and be irreversible. At this time over 700,000
Americans have died and a sizable proportion could have
been saved with high vaccination rates and government policy
that dealt with it as a medical issue and not a political one.
Misinformation and anti-vaxxer push back remains a serious
problem. Age and compromised immune systems are major
risk factors. If you recover from Covid within 2 weeks your
outlook of have any long-haul consequences decreases
dramatically.
Covid-19; therapy; still no magic bullets or
even curative remedies in the pipeline
Therapy
• Ventilation with PO2 of greater than 60% not SOB, CPAP,
Intubation and other assisted ventilation as late as possible.
• The prone position improves breathing
• Antiviral treatment Remdesivir, Baricitinib, Tocilizumab
when given early and usually with steroids may be
beneficial.
• Steroids (hydroxydexamethasone) 10% reduction in
mortality (no standardization of dose)
• Convalescent Serum is no longer recommended
• Anticoagulation with LMWH (Low Molecular Weight
Heparin) to prevent DVT and strokes due to clotting.
Pulmonary System
Pulmonary System
Lungs in Detail
The Pleural Space
Functions of the Lungs
• Exchange of CO2 (hypercapnia) and O2 (hypoxia)
Use pulse oximeter to gage blood oxygen levels
• Acid and Base Balance (Respiratory Acidosis) with
hyperventilation you can produce respiratory
alkalosis and dizziness.
• Pulmonary arteries (deoxygenated blood) come
from the right ventricle of the heart and
pulmonary veins (oxygenated blood) returned
blood to the left atrium of the heart.
• Filtering and removal of bacteria and small
particles in the air (tracheal elevator)
Pulmonary Studies
• Chest x-ray (not a screening test)
• Pulse Oximetry (will become part of the fitbit?)
• Serum CO2 and arterial blood gases (acidosis or
alkalosis) Low CO2 suggests acidosis or
ketoacidosis, a complication of diabetes; high
CO2 may indicate pulmonary alkalosis.
• Spiral CT with Calcium index
• Sputum Culture
• Lung Biopsy
Electrolytes
Normal Blood Ph. is 7.4: below is acidosis, above
alkalosis
Treatment of OSA:
Lose weight
Sleep on your side
CPAP
Dental Prosthesis
Surgery (controversial
The mechanics of Intubation and being
on the ventilator
Pulmonary Function Tests; spirometry
Normal Pulmonary Function
• The normal one second value for the (Forced
Expiratory Volume) FEV1/FVC (Forced Volume
Capacity) ratio is 70% (and 65% in persons
older than age 65).
Pneumonia
• Bacterial (community acquired and hospital
acquired) Just like MRSA
• Viral
• Aspiration
• Pneumocystis Pneumonia and unusual bacterial
in Immune compromised patients of any sort. HIV
especially
• Procalcitonin responds to tissue injury: New lab
test to differentiate between bacterial and viral
pneumonia and meningitis.
Idiopathic Pulmonary Fibrosis.
• Most have no known cause; 3-5 year course. Newer
treatments with nintedanib and pirfenidone, ground
glass appearance on x-ray, pulmonary hypertension.
• 40,000 deaths per year and often goes undiagnosed
because of non-specific symptoms.
• Life expectancy after diagnosis 8-12 years.
• Anything that damages the lung like irradiation, certain
drugs, pneumonia, pneumoconiosis,
• Rare diseases like connective tissue disease, Systemic
lupus erythematosus, Rheumatoid arthritis,
Sarcoidosis, Scleroderma
Medical Conditions
• Tuberculosis (declining incidence in US)
• Histoplasmosis (high incidence in Ohio valley,
but rarely causes serious disease)
• Pulmonary embolus
• CHF
• Atelectasis
COPD/ Emphysema( 3rd leading cause
of death)
1% with COPD have genetic Alpha-1-antitrypsin deficiency ,
• Cigarette smoking (1/3RD nonsmokers), asthma, chronic bronchitis, fumes
and industrial irritants.
Acute-or-chronic respiratory failure that predispose to pulmonary infection,
pulmonary embolism, cardiac arrhythmia and lung cancer
Treatment:
1. Stop smoking and avoid air pollutants
2. Rx active infections/ sputum liquefiers
3. LAMA (long acting muscarinic antagonists/anti-parasympathetic drugs
like atropine
4. LABA (long acting beta2 agonists) like adrenalin
5. Long acting steroids—effective if eosinophil count elevate
6. O2 if needed based on pulse oximeter (<88-90%)
7. Some new anti-inflammatory drugs (Monoclonal antibodies-Triple Rx.)
More on COPD/ slowly progressive; no
predictive tests
• FEV peaks at age 20.
• Asthmatics have better prognosis
• CT diagnostic insight (multistage loss of tissue
leads to increase cancer risk
• O2 bronchitis phenotype leads to metabolic
syndrome
• 6 minute walk--<350 meters
• Stress test
Leading causes of death in US
• Heart disease: 647,457.
• Cancer: 599,108.
• Accidents (unintentional injuries): 169,936.
• Chronic lower respiratory diseases: 160,201.
• Stroke (cerebrovascular diseases): 146,383.
• Alzheimer's disease: 121,404. (5.5 million people
are affected)
• Diabetes: 83,564.
• Influenza and pneumonia: 55,672
• Where will Covid 19 Fit?
The Pleural Spaces
• Asbestosis and Mesothelioma (of the pleura)
• Pleural Effusions; Transudate or Exudate
• Congestive Heart Failure most common cause
but many others such as Cirrhosis, Cancer,
Pneumonia, Nephrotic syndrome, Drugs
• Empyema
• Hemothorax mainly due to trauma
• Chest Tubes
Occupational Exposures
• Silicosis
• Black lung disease
• Asbestosis
• Talcosis
• Hyperimmune pulmonitis
• All of these conditions you can multiply by 10
in heavy smokers.
Lung Cancer: Number one Killer (116,000
cases with 72,000 deaths in 2019
Americans). Five year survival rate 20.5%