Operator position

Operator position

For the right-handed operator, the 8 and 10 o’clock position and for left-handed operators, the corresponding 2 and 4 o’clock position almost always allows for optimal visualization of the injection field.

Heart sounds

Heart sounds

Heart sounds are a result of beating heart and resultant blood flow . that could be detected by a stethoscope during auscultation . Auscultation is a part of physical examination that doctors have to practice them perfectly.
Before discussion the origin and nature of the heart sounds we have to distinguish between the heart sounds and hurt murmurs. Heart murmurs are pathological noises that results from abnormal blood flow in the heart or blood vessels.
Physiologically , blood flow has a laminar pattern , which means that blood flows in form of layers , where the central layer is the most rapid . Laminar blood flow could be turned into turbulent one .

Turbulent blood flow is a result of stenotic ( narrowed ) valves or blood vessels , insufficient valves , roughened vessels` wall or endocardium ,  and many diseases . The turbulent blood flow causes noisy murmurs inside or outside the heart.

Heart sounds ( especially first and second sounds ) are mainly a result of closure of the valves of the heart . While the third sound is a result of vibration of ventricular wall and the leaflets of the opened AV valves after rapid inflow of blood from the atria to ventricles . 

Third heart sound is physiologic in children but pathological in adults.

The four heart sound is a result of the atrial systole and vibration of the AV valves , due to blood rush during atrial systole . It is inaudible neither in adults nor in children . It is just detectable by the phonocardiogram .

Characteristic of heart sounds :

1. First heart sound  (S1 , lub ) : a soft and low pitch sound, caused by closure of AV valves.Usually has two components ( M1( mitral ) and T1 ( tricuspid ). Normally M1 preceads T1.

2. Second heart sound ( S2 , dub) : sharp and high pitch sound . caused by closure of semilunar valves. It also has two components A2 ( aortic) and P2 ( pulmonary) . A2 preceads P2.

3. Third heart sound (S3) : low pitched sound.

4. Fourth heart sound ( S4) very low pitched sound.

As we notice : the first three sounds are related to ventricular activity , while the fourth heart sound is related to atrial activity.
Closure of valves is not the direct cause for heart sounds , but sharp blocking of blood of backward returning of blood by the closing valve is the direct cause.



The macrolides are a group of  drugs (typically antibiotics) whose activity stems from the presence of a macrolide ring, a large  lactone ring to which one or more deoxy sugars, usually cladinose and desosamine, are attached. The lactone ring can be either 14, 15 or 16-membered. Macrolides belong to the polyketide class of natural products.

The most commonly-prescribed macrolide antibiotics are:  

Erythromycin,  Clarithromycin, Azithromycin, roxithromycin,

Others are: spiramycin (used for treating  toxoplasmosis), ansamycin, oleandomycin, carbomycin and tylocine.

There is also a new class of antibiotics called ketolides that is structurally related to the macrolides. Ketolides such as telithromycin are used to fight respiratory tract infections caused by macrolide-resistant bacteria.

Non-antibiotic macrolides :The drug Tacrolimus, which is used as an

immunosuppressant, is also a macrolide. It has similar activity to  cyclosporine.

Uses : respiratory tract infections and soft tissue infections.

Beta-hemolytic  streptococci,  pneumococci, staphylococci and enterococci are usually susceptible to macrolides. Unlike penicillin, macrolides have shown effective against mycoplasma, mycobacteria, some rickettsia and chlamydia.

Mechanism of action: Inhibition of bacterial protein synthesis by binding reversibly to the subunit 50S of the bacterial ribosome, thereby inhibiting translocation of peptidyl-tRNA. This action is mainly bacteriostatic, but can also be bactericidal in high concentrations

Resistance : Bacterial resistance to macrolides occurs by alteration of the structure of the bacterial ribosome.

Pleural effusion

Pleural effusion is a medical condition where fluid accumulates in the pleural cavity which surrounds the lungs, making it hard to breathe.

Four main types of fluids can accumulate in the pleural space:

Serous fluid (hydrothorax)

Blood (hemothorax)

Lipid (chylothorax)

Pus (pyothorax or empyema)


Pleural effusion can result from reasons such as:

  • Cancer, including lung cancer or breast cancer
  • Infection such as pneumonia or tuberculosis
  • Autoimmune disease such as lupus erythematosus
  • Heart failure
  • Bleeding, often due to chest trauma (hemothorax)
  • Low oncotic pressure of the blood plasma
  • lymphatic obstruction
  • Accidental infusion of fluids

Congestive heart failure, bacterial pneumonia and lung cancer constitute the vast majority of causes in the developed countries, although tuberculosis is a common cause in the developing world.


  1. Gram stain and culture - identifies bacterial infections
  2. Cell count and differential - differentiates exudative from transudative effusions
  3. Cytology - identifies cancer cells, may also identify some infective organisms
  4. Chemical composition including protein, lactate dehydrogenase, amylase, pH and glucose - differentiates exudative from transudative effusions
  5. Other tests as suggested by the clinical situation - lipids, fungal culture, viral culture, specific immunoglobulins

Glycogen Metabolism

Glycogen Metabolism

The formation of glycogen from glucose is called Glycogenesis


Glycogen is a polymer of glucose residues linked mainly by a(1→ 4)  glycosidic linkages. There are a(1→6) linkages at branch points. The chains and branches are longer than shown. Glucose is stored as glycogen predominantly in liver and muscle cells

Glycogen Synthesis

Uridine diphosphate glucose (UDP-glucose) is the immediate precursor for glycogen synthesis. As glucose residues are added to glycogen, UDP-glucose is the substrate and UDP is released as a reaction product. Nucleotide diphosphate sugars are precursors also for synthesis of other complex carbohydrates, including oligosaccharide chains of glycoproteins, etc.

UDP-glucose is formed from glucose-1-phosphate and uridine triphosphate (UTP)

glucose-1-phosphate + UTP → UDP-glucose + 2 Pi

Cleavage of PPi is the only energy cost for glycogen synthesis (1P bond per glucose residue)

Glycogenin initiates glycogen synthesis. Glycogenin is an enzyme that catalyzes glycosylation of one of its own tyrosine residues.

Physiological regulation of glycogen metabolism

Both synthesis and breakdown of glycogen are spontaneous. If glycogen synthesis and phosphorolysis were active simultaneously in a cell, there would be a futile cycle with cleavage of 1 P bond per cycle

To prevent such a futile cycle, Glycogen Synthase and Glycogen Phosphorylase are reciprocally regulated, both by allosteric effectors and by covalent modification (phosphorylation)

Glycogen catabolism (breakdown)

Glycogen Phosphorylase catalyzes phosphorolytic cleavage of the →(14) glycosidic linkages of glycogen, releasing glucose-1-phosphate as the reaction product.

Glycogen (n residues) + Pi → glycogen (n-1 residues) + glucose-1-phosphate


The Major product of glycogen breakdown is glucose -1-phosphate

Fate of glucose-1-phosphate in relation to other pathways:

Phosphoglucomutase catalyzes the reversible reaction:

Glucose-1-phosphate → Glucose-6-phosphate

The stomach

The Stomach :

The wall of the stomach is lined with millions of gastric glands, which together secrete 400–800 ml of gastric juice at each meal. Three kinds of cells are found in the gastric glands

  • parietal cells
  • chief cells
  • mucus-secreting cells

Parietal cells : secrete

Hydrochloric acid : Parietal cells contain a H+ ATPase. This transmembrane protein secretes H+ ions (protons) by active transport, using the energy of ATP.

Intrinsic factor: Intrinsic factor is a protein that binds ingested vitamin B12 and enables it to be absorbed by the intestine. A deficiency of intrinsic factor  as a result of an autoimmune attack against parietal cells  causes pernicious anemia.

Chief Cells : The chief cells synthesize and secrete pepsinogen, the precursor to the proteolytic enzyme pepsin.

Secretion by the gastric glands is stimulated by the hormone gastrin. Gastrin is released by endocrine cells in the stomach in response to the arrival of food.

Adult Respiratory Distress Syndrome

Adult Respiratory Distress Syndrome 
A constellation of pathologic and clinical findings initiated by diffuse injury to alveolar capillaries. This syndrome is associated with a multitude of clinical conditions which primarily damage the lung or secondarily as part of a systemic disorder. 

There are many types of injuries which lead to the ultimate, common pathway, i.e., damage to the alveolar capillary unit. The initial injury most frequently affects the endothelium, less frequently the alveolar epithelium. Injury produces increased vascular permeability, edema, fibrin-exudation (hyaline membranes). Leukocytes (primarily neutrophils) plays a key role in endothelial damage. 

Heavy, red lungs showing congestion and edema. The alveoli contain fluid and are lined by hyaline membranes. 

Severe respiratory insufficiency with dyspnea, cyanosis and hypoxemia refractory to oxygen therapy.

SALIVARY GLANDS Embryonic development

Embryonic development

The parotid derives from ectoderm
The sublingual-submandibular glands thought to derive from endoderm
Differentiation of the ectomesenchyme
Development of fibrous capsule
Formation of septa that divide the gland into lobes and lobules
The parotid develops around 4-6 weeks of embryonic lofe
The submandibular gland develops around the 6th week
The sublingual and the minor glands develop around the 8-12 week

Secretions into the duodenum and their actions

Bile - produced in the liver and stored in the gallbladder, released in response to CCK . Bile salts (salts of cholic acid) act to emulsify fats, i.e. to split them so that they can mix with water and be acted on by lipase.

Pancreatic juice: Lipase - splits fats into glycerol and fatty acids. Trypsin, and chymotrypsin - protease enzymes which break polypeptides into dipeptides. Carboxypeptidase - splits dipeptide into amino acids. Bicarbonate - neutralizes acid. Amylase - splits polysaccharides into shorter chains and disaccharides.

Intestinal enzymes (brush border enzymes): Aminopeptidase and carboxypeptidase - split dipeptides into amino acids. Sucrase, lactase, maltase - break disaccharides into monosaccharides. Enterokinase - activates trypsinogen to produce trypsin. Trypsin then activates the precursors of chymotrypsin and carboxypeptidase. Other carbohydrases: dextrinase and glucoamylase. These are of minor importance.

The Lips

The Lips

  • These are mobile muscular folds that surround the mouth, the entrance of the oral cavity.
  • The lips (L. labia) are covered externally by skin and internally by mucous membrane.
  • In between these are layers of muscles, especially the orbicularis oris muscle.
  • The upper and lower lips are attached to the gingivae in the median plane by raised folds of mucous membrane, called the labial frenula.

Sensory Nerves of the Lips

  • The sensory nerves of the upper and lower lips are from the infraorbital and mental nerves, which are branches of the maxillary (CN V2) and mandibular (CN V3) nerves.