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This presentation is dedicated to all healthcare workers fighting
against COVID-19.
Punnatorn Punkitnirundorn
#ตองการmRNAvaccine#ฉดPfizerใหบคลากรทางการแพทย
Test Blueprint
Interesting points from AMSci Elimination Round by P’Neung MDCU75
Human Other organisms
Cell● Cell Biology● Biochemistry/ Metabolism/ Nutrition● Genetics/ Molecular Genetics
Tissue ● Microscopic anatomy
Organ & System
● Musculoskeletal system● Respiratory system● Cardiovascular system● Alimentary system● Urinary system● Reproductive system● Endocrine system● Nervous system● Immune system● and their development
● Microbiology & Parasitology
Test Blueprint
Interesting points from AMSci Elimination Round by P’Neung MDCU75
Human Other organisms
Cell● Cell Biology● Biochemistry/ Metabolism/ Nutrition● Genetics/ Molecular Genetics
Tissue ● Microscopic anatomy
Organ & System
● Microbiology & Parasitology
● Musculoskeletal system● Respiratory system● Cardiovascular system● Alimentary system● Urinary system● Reproductive system● Endocrine system● Nervous system● Immune system● and their development
Interesting points from AMSci Elimination Round by P’Neung MDCU75
1 Biochemistry/ Metabolism/ Nutrition
นากรดอะมโน Aspartate ทถกตดฉลากดวย C-14 บนโครงคารบอน ใสเขาไปในเซลลสารในขอใดมโอกาสพบ C-14 นอยทสด?A. Urea B. Malate C. Fumarate D. Glutamate E. α-ketoglutarate
Interesting points from AMSci Elimination Round by P’Neung MDCU75
1 Biochemistry/ Metabolism/ Nutrition
นากรดอะมโน Aspartate ทถกตดฉลากดวย C-14 บนโครงคารบอน ใสเขาไปในเซลลสารในขอใดมโอกาสพบ C-14 นอยทสด?A. Urea B. Malate C. Fumarate D. Glutamate E. α-ketoglutarate
Interesting points from AMSci Elimination Round by P’Neung MDCU75
1 Biochemistry/ Metabolism/ NutritionCatabolism of Amino Acid
Carbon skeleton (โครงคารบอน)= chain of carbon atoms forming “backbone”
Intermediate metabolites in carbohydrate metabolism
Transform into new amino acids/ other biomolecules.
Enter TCA cycle and degrade into CO2 + H2O + High energy compound.
Interesting points from AMSci Elimination Round by P’Neung MDCU75
1 Biochemistry/ Metabolism/ NutritionTransaminationAspartate transfers its amino group to alpha-ketoglutarate and then transforms into oxaloacetate.
How to remember Krebs cycle?Citrate is Krebs’ starting substrate for making oxaloacetate.
Choice B
Choice C
Choice E
Interesting points from AMSci Elimination Round by P’Neung MDCU75
1 Biochemistry/ Metabolism/ Nutrition
How to remember Krebs cycle?Citrate is Krebs’ starting substrate for making oxaloacetate.
Choice B
Choice C
Choice E
Interesting points from AMSci Elimination Round by P’Neung MDCU75
1 Biochemistry/ Metabolism/ Nutrition
Choice B
Choice C
Choice E
Alpha-ketoglutarate can also be converted back to glutamate by receiving 1 amino group.
Choice D
Interesting points from AMSci Elimination Round by P’Neung MDCU75
1 Biochemistry/ Metabolism/ NutritionConverting NH3 to urea by liver Carbon skeleton
Enter metabolic pathway of carbohydrate.
● Free NH3 is toxic to cells and can lead to encephalopathy.
● Therefore, NH3 is included in another least toxic amino acid (mainly glutamate or alanine).
● NH3 is transported to liver (facilitated by Glu or Ala) and changed to urea by UREA CYCLE
At liver
Urea cycle
Interesting points from AMSci Elimination Round by P’Neung MDCU75
1 Biochemistry/ Metabolism/ NutritionUrea cycle
At liver
Notice that● NH2- in urea are from Glu/ Ala
(blue rectangle) and also arginine (green oval).
● Carbon in urea is from CO2 (in HCO3
- form)How to remember urea cycle?Ordinarily, Careless Crappers Are Also Frivolous About Urination.
Interesting points from AMSci Elimination Round by P’Neung MDCU75
2 Molecular Geneticsจากภาพ แสดง plasmid pB123 และ pB321 พรอมทงยนและตาแหนงตดของ restriction enzymes การทดลองเพอโคลนยน X โดยใช plasmid เปน vector ผานการสราง DNA ลกผสมแลวใสในเซลลโฮสต นกวทยาศาสตรควรใชพลาสมดใดและ restriction enzyme ชนดใดจงจะเหมาะสมทสด ?
A. ตองใชพลาสมด pB123 เทานน โดยใช restriction enzyme SalIB. ตองใชพลาสมด pB321 เทานน โดยใช restriction enzyme SalIC. ตองใชพลาสมด pB123 เทานน โดยใชไดทง restriction enzyme SalI หรอ PstI D. ตองใชพลาสมด pB321 เทานน โดยใชไดทง restriction enzyme SalI หรอ PstI E. สามารถใชพลาสมดไดทง pB123 และ pB321 โดยใช restriction enzyme SalI
ampR : Ampicillin resistance tetR : Tetracycline resistance lacZ : Lactose breakdown ori : Origin of replication
Interesting points from AMSci Elimination Round by P’Neung MDCU75
2 Molecular Geneticsจากภาพ แสดง plasmid pB123 และ pB321 พรอมทงยนและตาแหนงตดของ restriction enzymes การทดลองเพอโคลนยน X โดยใช plasmid เปน vector ผานการสราง DNA ลกผสมแลวใสในเซลลโฮสต นกวทยาศาสตรควรใชพลาสมดใดและ restriction enzyme ชนดใดจงจะเหมาะสมทสด ?
A. ตองใชพลาสมด pB123 เทานน โดยใช restriction enzyme SalIB. ตองใชพลาสมด pB321 เทานน โดยใช restriction enzyme SalIC. ตองใชพลาสมด pB123 เทานน โดยใชไดทง restriction enzyme SalI หรอ PstI D. ตองใชพลาสมด pB321 เทานน โดยใชไดทง restriction enzyme SalI หรอ PstI E. สามารถใชพลาสมดไดทง pB123 และ pB321 โดยใช restriction enzyme SalI
ampR : Ampicillin resistance tetR : Tetracycline resistance lacZ : Lactose breakdown ori : Origin of replication
Interesting points from AMSci Elimination Round by P’Neung MDCU75
2 Molecular GeneticsDNA cloning
Using genetic engineering/recombinant DNA technology
Polymerase chain reaction (PCR)
Recombinant DNA (DNA ลกผสม) = Composite DNA molecules comprising covalently linked segments from two or more sources
Interesting points from AMSci Elimination Round by P’Neung MDCU75
2 Molecular GeneticsMain Steps in Genetic Engineering
1. Cutting target DNA at precise locations.Restriction site
(ตาแหนงตดจาเพาะ)/Recognition sequence
By restriction enzyme(เอนไซมตดจาเพาะ)
● = restriction endonucleases (typically type II)
● Break down phosphodiester bond generating a set of smaller DNA fragments.
● Found in a wide range of bacterial species. Their function is to recognize and cleave foreign DNA.
● usually 4 to 6 bp long and palindromic.
Restriction enzyme
Recognition sequence
Source
SalI Streptomyces albus G
PstI Escherichia coli ED8654
2. Selecting a cloning vector & cutting it with the same restriction endonuclease.
Interesting points from AMSci Elimination Round by P’Neung MDCU75
2 Molecular GeneticsMain Steps in Genetic Engineering
= a small carrier molecule of DNA capable of self-replication
● = extrachromosomal, circular DNA molecule that replicates separately from the host chromosome.
● Provides genes that confer resistance to antibiotics or that perform new functions for the cell.
● We can use these special genes as selectable or screenable markers.
Bacterial plasmidBacterial artificial
chromosomes (BACs)Yeast artificial
chromosomes (YACs)
For the cloning of very long segments of DNA or for the studying in many other problems in eukaryotic molecular biology(YACs).
2. Selecting a cloning vector & cutting it with the same restriction endonuclease.
Interesting points from AMSci Elimination Round by P’Neung MDCU75
2 Molecular GeneticsMain Steps in Genetic Engineering
= a sequence where replication is initiated by cellular enzymes
Origin of replication (Ori)
5 R sites & 3 I sites serve as binding sites for protein DnaA.
DnaA starts replication by denature DUE (DNA unwinding element).
2. Selecting a cloning vector & cutting it with the same restriction endonuclease.
Interesting points from AMSci Elimination Round by P’Neung MDCU75
2 Molecular GeneticsMain Steps in Genetic Engineering
= a sequence where replication is initiated by cellular enzymes
Origin of replication (Ori)
5 R sites & 3 I sites serve as binding sites for protein DnaA.
DnaA starts replication by denature DUE (DNA unwinding element).
2. Selecting a cloning vector & cutting it with the same restriction endonuclease.
Interesting points from AMSci Elimination Round by P’Neung MDCU75
2 Molecular GeneticsMain Steps in Genetic Engineering
Selectable Markers
AmpR : ampicillin resistance
TetR : tetracycline resistance
Positive selection = permit the growth of a cell
Negative selection = kill cell
2. Selecting a cloning vector & cutting it with the same restriction endonuclease.
Interesting points from AMSci Elimination Round by P’Neung MDCU75
2 Molecular GeneticsMain Steps in Genetic Engineering
AmpR TetR
Bacterial genome
Selective media
+Amp +Tet +Amp +Tet
-AmpR -TetR - - -
+AmpR -TetR + - -
-AmpR +TetR - + -
+AmpR +TetR + + +
2. Selecting a cloning vector & cutting it with the same restriction endonuclease.
Interesting points from AMSci Elimination Round by P’Neung MDCU75
2 Molecular GeneticsMain Steps in Genetic Engineering
Screenable MarkerLacZ
enzyme beta-galactosidase
5-bromo-4-chloro-3-indolyl-beta-D-galactopyranoside (X-gal)
Colorless
Blue product
2. Selecting a cloning vector & cutting it with the same restriction endonuclease.
Interesting points from AMSci Elimination Round by P’Neung MDCU75
2 Molecular GeneticsMain Steps in Genetic Engineering
LacZ Bacterial genome
Differential media
+X-gal
-LacZ White colony
+LacZ Blue colony
“Blue-WhiteScreening”
3. Joining two DNA fragments covalently.
Interesting points from AMSci Elimination Round by P’Neung MDCU75
2 Molecular GeneticsMain Steps in Genetic Engineering
By DNA ligase4. Moving recombinant DNA from the test tube to a host cell (usually E. coli)
Plasmid vector
Eukaryotic genome with target gene
Restriction enzyme
Target and other DNA fragments
Purified by gel electrophoresis/ HPLC (high-performance liquid chromatography)/ “DNA library”
Recombinantvector
DNAligase
Host cell
Transformation
Calcium chloride–heat shock technique/ electroporation technique
5. Selecting or identifying host cells that contain recombinant DNA.
Interesting points from AMSci Elimination Round by P’Neung MDCU75
2 Molecular GeneticsMain Steps in Genetic Engineering
A. ตองใชพลาสมด pB123 เทานน โดยใช restriction enzyme SalIB. ตองใชพลาสมด pB321 เทานน โดยใช restriction enzyme SalIC. ตองใชพลาสมด pB123 เทานน โดยใชไดทง restriction enzyme SalI หรอ PstI D. ตองใชพลาสมด pB321 เทานน โดยใชไดทง restriction enzyme SalI หรอ PstI E. สามารถใชพลาสมดไดทง pB123 และ pB321 โดยใช restriction enzyme SalI
Cannot use pB321 vector with SalI enzyme because it can interfere plasmid replication by destroying a origin of replication.
5. Selecting or identifying host cells that contain recombinant DNA.
Interesting points from AMSci Elimination Round by P’Neung MDCU75
2 Molecular GeneticsMain Steps in Genetic Engineering
A. ตองใชพลาสมด pB123 เทานน โดยใช restriction enzyme SalIC. ตองใชพลาสมด pB123 เทานน โดยใชไดทง restriction enzyme SalI หรอ PstI
pB123PstI
AmpR
TetR3 populations of bacteria
5. Selecting or identifying host cells that contain recombinant DNA.
Interesting points from AMSci Elimination Round by P’Neung MDCU75
2 Molecular GeneticsMain Steps in Genetic Engineering
A. ตองใชพลาสมด pB123 เทานน โดยใช restriction enzyme SalIC. ตองใชพลาสมด pB123 เทานน โดยใชไดทง restriction enzyme SalI หรอ PstI
Population Genome Media
+Amp +Tet +Amp +Tet
No plasmid -AmpR -TetR - - -
+ original plasmid
+AmpR +TetR + + +
+ recombinant plasmid
-AmpR +TetR - + -
Colony transfer
Interesting points from AMSci Elimination Round by P’Neung MDCU75
3 Microscopic Anatomy
ขอใดตอไปน กลาวถกตองเกยวกบเนอเยอเกยวพน (connective tissue)?A. เนอเยอไขมนจดเปน loose connective tissueB. เนอเยอเกยวพนจะพบ basal lamina เปนฐานเสมอC. เนอเยอกระดกพฒนามาจากเนอเยอกระดกออนกอนเสมอD. Extracellular matrix ของเนอเยอเกยวพนทกชนดประกอบดวยคอลลาเจน type IVE. เนอเยอแบบ loose connective tissue และ dense connective tissue ประกอบดวยเซลล fibrocyte ระหวาง Extracellular matrix
Interesting points from AMSci Elimination Round by P’Neung MDCU75
3 Microscopic Anatomy
ขอใดตอไปน กลาวถกตองเกยวกบเนอเยอเกยวพน (connective tissue)?A. เนอเยอไขมนจดเปน loose connective tissueB. เนอเยอเกยวพนจะพบ basal lamina เปนฐานเสมอC. เนอเยอกระดกพฒนามาจากเนอเยอกระดกออนกอนเสมอD. Extracellular matrix ของเนอเยอเกยวพนทกชนดประกอบดวยคอลลาเจน type IVE. เนอเยอแบบ loose connective tissue และ dense connective tissue ประกอบดวยเซลล fibrocyte ระหวาง Extracellular matrix
Beware of these extreme words!
Interesting points from AMSci Elimination Round by P’Neung MDCU75
3 Microscopic Anatomy4 Types of Human Tissue
Epithelium Connective tissue
Muscle Tissue Nervous tissue
● = a tightly cohesive sheet of cells that covers or lines body surfaces
● For protection, absorption, transport of material at the surface, secretion, excretion, gas exchange, and gliding between surfaces
● = a group of connective tissue cells widely separated by ECM components
● Provides the supportive and connecting framework (or stroma) for all the other tissues.
= a group of elongated cells, called muscle cells, specialized for contraction
= a group of neurons & glia (in CNS), and other supporting cells (in PNS)
Interesting points from AMSci Elimination Round by P’Neung MDCU75
3 Microscopic AnatomyEpithelium
Common structures
Epithelial cell“Polarized”
Apical Domainwith apical differentiations
+ CAMs
Basolateral Domainwith cell adhesion molecules (CAMs)
& cell junctions
● Cilia● Microvilli● Stereocilia
1. Tight junctions/ Occluding junctions2.1 Zonula adherens/Belt desmosome2.2 Macula adherens/Spot desmosome3. Gap junctions
2.3 Hemidesmosome
3 types of cell junction
1. Tight junctions
2. Anchoring junctions
3. Communicating junctions
4 main types of CAM are :cadherins, selectins,
Ig superfamily, integrins.Basement Membrane
Integrins
Interesting points from AMSci Elimination Round by P’Neung MDCU75
3 Microscopic AnatomyEpithelium
Basement membrane
Epithelial cell
Fibroblast
Basal lamina
Reticular lamina
HemidesmosomeIntegrins
Fibronectin & Laminin
Components : laminin, fibronectin, type IV collagen, proteoglycans (heparan sulfate), and nidogen (or entactin)
Component : type III collagen (reticular fibers)
Basement Membrane
Produce
ProduceConnective Tissue Choice B : Basal lamina is a
basement of connective tissue
Interesting points from AMSci Elimination Round by P’Neung MDCU75
3 Microscopic AnatomyEpithelium
Bullous Pemphigoid
Skin Epithelium(Epidermis)
Hemidesmosome
Basement Membrane
Pathophysiology :Patient breaks self tolerance & develops autoantibody to BPAG1/ BPAG2 leading to subepidermal detachment.
1ry lesion : bullous2ry lesion : erosion
Interesting points from AMSci Elimination Round by P’Neung MDCU75
3 Microscopic AnatomyConnective Tissue (เนอเยอเกยวพน) = CNT
Embryonic CNT/
Mesenchyme
Adult CNT Special CNT
Loose/ Areolar CNT : cell > fiber
Dense CNT : fiber > cellDense regular CNT Dense irregular CNT
Adipose tissue Bone
Cartilage Blood & Hematopoietic
Tissue
Choice A : Adipose tissue is a loose CNT?
Interesting points from AMSci Elimination Round by P’Neung MDCU75
3 Microscopic AnatomyConnective Tissue
Adult CNT
Loose/ Areolar CNT : cell > fiber
Dense CNT : fiber > cellDense regular CNT Dense irregular CNT
Components● Cell : fibroblast /macrophage/ mast cell/
plasma cell
● Non-cell/ Extracellular Components○ Fiber : collagen/ elastic/ reticular
fiber○ Extracellular Matrix (ECM)
Produce
Choice C : fibrocyte
Interesting points from AMSci Elimination Round by P’Neung MDCU75
3 Microscopic AnatomyConnective Tissue
Types of Collagen Fiber
Collagen Fiber Sites
Type I bone/ tendon/ dentin/ skin
Type II hyaline & elastic cartilage
Type III reticular lamina basement membrane
Type IV basal lamina
Type V amnion/ chorion
Choice D : Extracellular matrix of all types of CNT is composed of collagen type IV
Interesting points from AMSci Elimination Round by P’Neung MDCU75
3 Microscopic AnatomySpecial Connective Tissue : Cartilage
Cartilage development
Undifferentiated mesenchymal stem cell
Chondroblasts surrounded by perichondrium (undifferentiated cell)
Maturing chondroblasts produce ECM/ pericellular matrix enclose the space called lacunae
Isogenous group
Territorial matrixInterterritorial matrix
Chondroblast differentiate to mature chondrocyte
1 2
3
4 Cartilage growth
1. appositional growth
2. interstitial growth
Perichondrium
Interesting points from AMSci Elimination Round by P’Neung MDCU75
3 Microscopic AnatomySpecial Connective Tissue : Cartilage
3 Types of Cartilage
Hyaline cartilage Elastic cartilage Fibrocartilage
Cell Chondrocyte Chondrocyte Chondrocyte (+fibroblast)
Pericellular matrix type II collagen type II collagen type I collagen
Sites Articular cartilage/ cartilage in respiratory tract
External ear/ epiglottis/ auditory tube
Intervertebral disk/ sternoclavicular joint/ pubic symphysis
Interesting points from AMSci Elimination Round by P’Neung MDCU75
3 Microscopic AnatomySpecial Connective Tissue : Bone
Bone Formation/ Osteogenesis
1. Intramembranous ossification
● Mesenchymal cell origin/ mesenchymal template
● Mesenchymal cells differentiate to osteoblasts and osteocytes.
● Osteocytes produce osteoid (type I collagen & other proteins) as an extracellular matrix.
● By a mineralization process, calcified osteoid occurs.
Examples : Flat bones of skull/ mandible/ clavicleChoice E : All bones develop from preform cartilages.
Interesting points from AMSci Elimination Round by P’Neung MDCU75
3 Microscopic AnatomySpecial Connective Tissue : Bone
Bone Formation/ Osteogenesis
2. Endochondral ossification
● Hyaline cartilage templates● Chondrocytes become hypertrophic and secrete
type X collagen & vascular endothelial cell growth factor (VEGF)
● Blood vessel invade and matrix become calcified.● Hypertrophic chondrocytes undergo apoptosis.● Preosteoblasts and hematopoietic cells arrive.
Examples : long bones, vertebral column, and pelvis
Interesting points from AMSci Elimination Round by P’Neung MDCU75
4 Cardiovascular System
ผปวยรายหนง เมอแพทยทาการฟงเสยง Heart sound ตรวจพบวาม pansystolic murmur ทบรเวณ Apex ของหวใจ จากขอมลดงกลาวพยาธสภาพของผปวยนาจะอยทใด?A. Mitral valve B. Aortic valve C. Tricuspid valve D. Thebesian valve E. Pulmonary valve
Interesting points from AMSci Elimination Round by P’Neung MDCU75
4 Cardiovascular System
ผปวยรายหนง เมอแพทยทาการฟงเสยง Heart sound ตรวจพบวาม pansystolic murmur ทบรเวณ Apex ของหวใจ จากขอมลดงกลาวพยาธสภาพของผปวยนาจะอยทใด?A. Mitral valve B. Aortic valve C. Tricuspid valve D. Thebesian valve E. Pulmonary valve
Interesting points from AMSci Elimination Round by P’Neung MDCU75
4 Cardiovascular SystemIntroduction to Heart Sound
Ventricular Diastole
11 Atrial systole
Left atrium pumps blood ,through mitral valve, into left ventricle.
S4 “Atrial kick”
Interesting points from AMSci Elimination Round by P’Neung MDCU75
4 Cardiovascular SystemIntroduction to Heart Sound
Ventricular Systole2
2 Isovolumetric contraction● Ventricular contraction &
increased ventricular pressure● Mitral & tricuspid valve
immediately close at early of this phase due to ventricular > atrial pressure.
S1 = Mitral & tricuspid valve closure“LUB”
Interesting points from AMSci Elimination Round by P’Neung MDCU75
4 Cardiovascular SystemIntroduction to Heart Sound
Ventricular Systole3
3 Rapid ejection● Ventricular pressure increase until
it’s more than pulmonary/ aortic pressure
● Aortic & pulmonary semilunar valve open allowing blood to flow out from the heart.
Interesting points from AMSci Elimination Round by P’Neung MDCU75
4 Cardiovascular SystemIntroduction to Heart Sound
Ventricular Systole4
4 Reduced ejection● Less blood left in the ventricle so
ventricular pressure starts to reduce.
Interesting points from AMSci Elimination Round by P’Neung MDCU75
4 Cardiovascular SystemIntroduction to Heart Sound
Ventricular Diastole5
5 Isovolumetric relaxation● Ventricles start to relax making
ventricular pressure to reduce.● When ventricular < pulmonary/
aortic pressure, pulmonary/ aortic semilunar valve close.
S2 = Pulmonary & aortic semilunar valve closure“DUB”“Physiologic splitting of S2”= The aortic valve slightly close before the pulmonic one.
Interesting points from AMSci Elimination Round by P’Neung MDCU75
4 Cardiovascular SystemIntroduction to Heart Sound
Ventricular Diastole6
6 Rapid ventricular filling● Ventricular pressure reduce until
it’s less than atrial pressure.● Tricuspid & mitral valve open a
and then blood from atriums fill in ventricles.
S3
Interesting points from AMSci Elimination Round by P’Neung MDCU75
4 Cardiovascular SystemIntroduction to Heart Sound
Ventricular Diastole7
7 Reduced ventricular filling● Less blood fills in ventricles due to
less pressure gradient between atriums and ventricles.
Interesting points from AMSci Elimination Round by P’Neung MDCU75
4 Cardiovascular SystemApproach to Abnormal Heart Sound/ Murmur : Character
S1 S2 S1 S2
Ventricular Systole
VentricularDiastole
Mitral & tricuspid valve closure
“LUB”
Pulmonary & aortic semilunar valve closure
“DUB”
Mitral & Tricuspid valve close
Aortic & pulmonary semilunar valve open
Mitral & Tricuspid valve open
Aortic & pulmonary semilunar valve close
Mitral & Tricuspidregurgitation
Mitral & Tricuspid stenosis
Aortic & pulmonaryregurgitation
Aortic & pulmonary stenosis
Mitral & Tricuspid valve close
Aortic & pulmonary semilunar valve open
Mitral & Tricuspid valve open
Aortic & pulmonary semilunar valve close
Mitral & Tricuspidregurgitation
Mitral & Tricuspid stenosis
Aortic & pulmonaryregurgitation
Aortic & pulmonary stenosis
Interesting points from AMSci Elimination Round by P’Neung MDCU75
4 Cardiovascular SystemApproach to Abnormal Heart Sound/ Murmur : Character
Ventricular Systole Ventricular Diastole
Pansystolic murmur
Systolic ejection murmur
Diastolic rumbling murmur
Diastolic blowing murmur
The aortic valve slightly close before the pulmonic one.
Aortic stenosis
Pulmonic stenosis
Interesting points from AMSci Elimination Round by P’Neung MDCU75
4 Cardiovascular SystemApproach to Abnormal Heart Sound/ Murmur :Location
Right sternal border
Left sternal border
Midclavicular line
2nd intercostal space
5th intercostal space
Apex
Interesting points from AMSci Elimination Round by P’Neung MDCU75
4 Cardiovascular Systempansystolic murmur ทบรเวณ Apex ของหวใจDx : Mitral Regurgitation
2 Clinical presentations
3 Treatment
1 Causes
LA preload
Mitral regurgitation
LV preload
Cardiac output :Dyspnea on exertion
LA hypertrophy +
LV hypertrophy +
Pulmonary hypertension/ pulmonary edema/ orthopneaBack pressure
Reflex tachycardia/ palpitation
“Mitral regurgitation begets mitral regurgitation.”
Interesting points from AMSci Elimination Round by P’Neung MDCU75
4 Cardiovascular Systempansystolic murmur ทบรเวณ Apex ของหวใจDx : Mitral Regurgitation
2 Clinical presentations
3 Treatments
LA preload
Mitral regurgitation
LV preload
Cardiac output :Dyspnea on exertion
LA hypertrophy +
LV hypertrophy +
Pulmonary hypertension/ pulmonary edema/ orthopneaBack pressure
Reflex tachycardia/ palpitation
“Mitral regurgitation begets mitral regurgitation.”
Medical treatment : Diuretics, Beta blockers, CCA, ACEI, ARB, DigoxinSurgical treatment : Mitral valve repair, mitral valve replacement (MVR)
Percutaneous mitral valve repair
Interesting points from AMSci Elimination Round by P’Neung MDCU75
5 Alimentary System
โรคโลหตจาง Megaloblastic anemia เกดจากการขาด cobalamin (Vitamin B12) โดยเมดเลอดแดงจะมลกษณะใหญและตดสจางกวาปกต ตางจากโรคโลหตจางทเกดจากการขาดธาตเหลก (Iron deficiency anemia) เหตการณใดตอไปนมความเปนไปไดนอยทสดทเปนสาเหตของการเกดโรคน ?A. มการทาลาย parietal cell ในกระเพาะอาหารB. มการสราง Autoantibody ตอ intrinsic factorC. ผปวยรบประทานอาหารมงสวรตอยางเครงครดทกมอD. มการรบกวนการดดซมสารบรเวณลาไสเลกสวน jejunumE. ผปวยโรคอวนทไดทาการผาตดกระเพาะอาหารและทาบายพาส (Roux-en-Y) ตอไปยงลาไสเลกโดยตรง
Interesting points from AMSci Elimination Round by P’Neung MDCU75
5 Alimentary System
โรคโลหตจาง Megaloblastic anemia เกดจากการขาด cobalamin (Vitamin B12) โดยเมดเลอดแดงจะมลกษณะใหญและตดสจางกวาปกต ตางจากโรคโลหตจางทเกดจากการขาดธาตเหลก (Iron deficiency anemia) เหตการณใดตอไปนมความเปนไปไดนอยทสดทเปนสาเหตของการเกดโรคน ?A. มการทาลาย parietal cell ในกระเพาะอาหารB. มการสราง Autoantibody ตอ intrinsic factorC. ผปวยรบประทานอาหารมงสวรตอยางเครงครดทกมอD. มการรบกวนการดดซมสารบรเวณลาไสเลกสวน jejunumE. ผปวยโรคอวนทไดทาการผาตดกระเพาะอาหารและทาบายพาส (Roux-en-Y) ตอไปยงลาไสเลกโดยตรง
Interesting points from AMSci Elimination Round by P’Neung MDCU75
5 Alimentary SystemPathophysiology of “B12 deficiency anemia”1 Vit B12 malabsorption Cobalamins are relatively large
and lipophobic molecules that require transport proteins.
B12Dietary protein
Animal products
R protein
B12 R protein Intrinsic factor (IF)
B12 IF
B12 TCII B12 TCIII
Mouth
Stomach
Duodenum - terminal ileum
Plasma
Cell : cell division
Liver : storage/excrete
Causes
● veganism● sprue● enteritis● Diphyllobothrium latum ● achlorhydria● bacterial overgrowth● alcohol overuse● pernicious anemia (lack of IF)● gastric bypass surgery ● surgical resection of terminal
ileum● certain drugs : metformin
Interesting points from AMSci Elimination Round by P’Neung MDCU75
5 Alimentary SystemPathophysiology of “B12 deficiency anemia”2 Interference of metabolism
Anemia
Macrocytic
Demyelination : Neurologic symptom
3 Megaloblastic anemiaMCV > 100 Hb < 11-13 g/dLfL Hct < 33-39 % Hypersegmented
neutrophil
Interesting points from AMSci Elimination Round by P’Neung MDCU75
6 Urinary System
ภาวะบวมนา (Edema) เปนภาวะทมของเหลวในชองวางระหวางเซลลเพมมากขนจนทาใหเกดอาการบวม ซงสามารถเกดไดกบเนอเยอตาง ๆ ของรางกาย ขอใดตอไปนเปนสาเหตททาใหเกดภาวะบวมนา?A. ผทมภาวะทพโภชนาการB. Lymphatic obstruction C. การรบประทานอาหารรสเคมจดD. ผปวยโรคตบแขงซงมปรมาณของโปรตนในเลอดนอยลงE. ถกทกขอ
Interesting points from AMSci Elimination Round by P’Neung MDCU75
6 Urinary System
ภาวะบวมนา (Edema) เปนภาวะทมของเหลวในชองวางระหวางเซลลเพมมากขนจนทาใหเกดอาการบวม ซงสามารถเกดไดกบเนอเยอตาง ๆ ของรางกาย ขอใดตอไปนเปนสาเหตททาใหเกดภาวะบวมนา?A. ผทมภาวะทพโภชนาการB. Lymphatic obstruction C. การรบประทานอาหารรสเคมจดD. ผปวยโรคตบแขงซงมปรมาณของโปรตนในเลอดนอยลงE. ถกทกขอ
Interesting points from AMSci Elimination Round by P’Neung MDCU75
6 Urinary System
Qffiltration/
reabsorption rate
Kfendothelial
filtration coefficient
Peffeffective filtration
pressure
Kwater
permeability
Aexchange
area
delta Phydrostatic
pressure difference
delta Pioncotic
pressure difference
Pcap- Pintcapillary - interstitial hydrostatic pressure
Picap- Piintcapillary - interstitial
oncotic pressure
“นาออก” “นาเขา”
+ นาออกสทธ- นาเขาสทธ
Pathophysiology Underlying This Phenomenon
“Starling forces”
Interesting points from AMSci Elimination Round by P’Neung MDCU75
6 Urinary System
Qffiltration/
reabsorption rate
Kfendothelial
filtration coefficient
Peffeffective filtration
pressure
Kwater
permeability
Aexchange
area
delta Phydrostatic
pressure difference
delta Pioncotic
pressure difference
Pcap- Pintcapillary - interstitial hydrostatic pressure
Picap- Piintcapillary - interstitial
oncotic pressure
“นาออก” “นาเขา”
+ นาออกสทธ- นาเขาสทธ
Pathophysiology Underlying This Phenomenon
Capillary pressure● Aterial : vasodilatation● Venous : venous thrombosis/
heart failure “cardiac edema”● Mixed : high salt diet ->
volume overload(Especially in lower region)
“Transudate”
Interesting points from AMSci Elimination Round by P’Neung MDCU75
6 Urinary System
Qffiltration/
reabsorption rate
Kfendothelial
filtration coefficient
Peffeffective filtration
pressure
Kwater
permeability
Aexchange
area
delta Phydrostatic
pressure difference
delta Pioncotic
pressure difference
Pcap- Pintcapillary - interstitial hydrostatic pressure
Picap- Piintcapillary - interstitial
oncotic pressure
“นาออก” “นาเขา”
+ นาออกสทธ- นาเขาสทธ
Pathophysiology Underlying This Phenomenon
Infection (septic shock)/ inflammation/ hypersensitivity type I (anaphylaxis)
Capillary permeability to protein
Vasodilatation“Exudate”
Interesting points from AMSci Elimination Round by P’Neung MDCU75
6 Urinary System
Qffiltration/
reabsorption rate
Kfendothelial
filtration coefficient
Peffeffective filtration
pressure
Kwater
permeability
Aexchange
area
delta Phydrostatic
pressure difference
delta Pioncotic
pressure difference
Pcap- Pintcapillary - interstitial hydrostatic pressure
Picap- Piintcapillary - interstitial
oncotic pressure
“นาออก”
“นาเขา”
+ นาออกสทธ- นาเขาสทธ
Pathophysiology Underlying This Phenomenon
Oncotic pressure plasma protein (esp. albumin) :● Proteinuria● Hepatic protein synthesis● Breakdown of plasma proteins
to meet energy requirements. “Hunger edema”
“Transudate”
Interesting points from AMSci Elimination Round by P’Neung MDCU75
6 Urinary SystemPathophysiology Underlying This Phenomenon
Lymph drainage :compression (tumor)/ surgery/ radiation/ obstruction
“Transudate”
Interesting points from AMSci Elimination Round by P’Neung MDCU75
7 Endocrine System
ระหวางทออกกาลงกายรางกายจะมการหลง Epinephrine (Adrenaline) จาก Adrenal medulla มากขนเพอตอบสนองตอความตองการพลงงานของรางกาย ขอใดตอไปนเปนผลของ Epinephrine ตอกระบวนการเมแทบอลซมในอวยะตาง ๆ ?A. Activated glycolysis and gluconeogenesis in liver B. Activated glycolysis and Inhibited gluconeogenesis in liver C. Inhibited glycolysis and activated gluconeogenesis in liver D. Activated glycolysis and Inhibited gluconeogenesis in cardiac muscle E. Inhibited glycolysis and activated gluconeogenesis in cardiac muscle
Interesting points from AMSci Elimination Round by P’Neung MDCU75
7 Endocrine System
ระหวางทออกกาลงกายรางกายจะมการหลง Epinephrine (Adrenaline) จาก Adrenal medulla มากขนเพอตอบสนองตอความตองการพลงงานของรางกาย ขอใดตอไปนเปนผลของ Epinephrine ตอกระบวนการเมแทบอลซมในอวยะตาง ๆ ?A. Activated glycolysis and gluconeogenesis in liver B. Activated glycolysis and Inhibited gluconeogenesis in liver C. Inhibited glycolysis and activated gluconeogenesis in liver D. Activated glycolysis and Inhibited gluconeogenesis in cardiac muscle E. Inhibited glycolysis and activated gluconeogenesis in cardiac muscle
Interesting points from AMSci Elimination Round by P’Neung MDCU75
7 Endocrine SystemEpinephrine/ adrenaline
“Stress” : fight or flight
Hypothalamus
Hypothalamospinal tract
Epinephrine
cAMP = 2ry messenger
Protein kinase A (PKA)
Phosphorylation of other proteins
+
Interesting points from AMSci Elimination Round by P’Neung MDCU75
7 Endocrine SystemGlycolysis vs Gluconeogenesisglyco = sugar
lysis = destructiongluco = sugarneo = newgenesis = production
Hexokinase
Phosphofructokinase-1(PFK-1)
Glucose 6-phosphatase
Pyruvate kinase
Fructose 1,6-bisphosphatase-1(FBPase-1)
PEP carboxykinase &Pyruvate carboxylase
Interesting points from AMSci Elimination Round by P’Neung MDCU75
7 Endocrine System
Hexokinase
Phosphofructokinase-1(PFK-1)
Glucose 6-phosphatase
Pyruvate kinase
Fructose 1,6-bisphosphatase-1(FBPase-1)
PEP carboxykinase &Pyruvate carboxylase
Glycolysis Gluconeogenesis
“Total activity”of these enzyme
determines which processes, glycolysis or gluconeogenesis,
a cell prefers.
Amount
Catalytic activity of each enzyme
molecule
Gene expression
Allosteric regulation
Extracellular signal :Hormonal/ neuronal/
growth factors/ cytokines
Interesting points from AMSci Elimination Round by P’Neung MDCU75
7 Endocrine SystemLiver cell/ Hepatocyte Glucose
Glucose 6-phosphat
e
Hexokinase IV/Glucokinase
Glucose 6-phosphatas
eLow activity
Isoenzyme/ isozyme = different proteins that catalyze the same reaction
Blood glucose Hexokinase I @ myocyte Hexokinase IV @ hepatocyte
Low level Catalyze more glucose (near Vmax).
Catalyze less glucose (conserve large activity to reach Vmax).
High level Enzymes have already been saturated.
Enzyme activity increase continuously.
Interesting points from AMSci Elimination Round by P’Neung MDCU75
7 Endocrine SystemLiver cell/ Hepatocyte
Blood glucose Hexokinase I @ myocyte Hexokinase IV @ hepatocyte
Low level Catalyze more glucose (near Vmax).
Catalyze less glucose (conserve large activity to reach Vmax).
High level Enzymes have already been saturated.
Enzyme activity increase continuously.
Interesting points from AMSci Elimination Round by P’Neung MDCU75
7 Endocrine SystemLiver cell/ Hepatocyte
PFK-1 : Phosphofructokinase-1FBPase-1 : Fructose 1,6-bisphosphatase-1
Fructose 6-phosphat
e
Fructose 1,6-bisphosph
ate
Low activity FBPase-1PFK-1
High activity
Fructose 6-phosphat
e
Fructose 2,6-bisphosph
ate
Low activityFBPase-2
PFK-2
High activityPi
cAMP-dependent protein kinase
Inhibitoryphosphate
cAMP as 2ry messenger
“phosphorylation”
ATPADP
Less amount PFK-2 : Phosphofructokinase-2FBPase-2 : Fructose 1,6-bisphosphatase-2
Isozyme B1 L-type
PFK-2 : Phosphofructokinase-2FBPase-2 : Fructose 1,6-bisphosphatase-2
Interesting points from AMSci Elimination Round by P’Neung MDCU75
7 Endocrine SystemLiver cell/ Hepatocyte
PFK-1 : Phosphofructokinase-1FBPase-1 : Fructose 1,6-bisphosphatase-1
Fructose 6-phosphat
e
Fructose 1,6-bisphosph
ate
Low activity FBPase-1PFK-1
High activity
Fructose 6-phosphat
e
Fructose 2,6-bisphosph
ate
Low activityFBPase-2
PFK-2
High activityPi
Inhibitoryphosphate
Less amount- glycolysis
+ gluconeogenesis
Interesting points from AMSci Elimination Round by P’Neung MDCU75
7 Endocrine SystemLiver cell/ Hepatocyte
Phosphoenolpyruvate
Pyruvate
Pyruvatekinase
Inactive
PEP carboxykinase &Pyruvate carboxylase
PyruvatekinaseActive
cAMP-dependent protein kinase
cAMP as 2ry messenger
“phosphorylation”ADPATP
Pi
Inhibitoryphosphate
In liver only!
Interesting points from AMSci Elimination Round by P’Neung MDCU75
7 Endocrine SystemLiver cell/ Hepatocyte
Substrates for Gluconeogenesis
Phosphorylase a
Phosphorylase b
Active
Less active
Phosphorylase B kinase
PiPi
“phosphorylation”2 ATP
2 ADP
Stimulatory phosphate
PyruvateLactate
Cori cycle
Glucose
Glycogen Glucose 1-phosphate
Glucose
Pyruvate
Gluconeogenesis@ liver
Anaerobic glycolysis@ muscle
Glucose 6-phospha
te
Interesting points from AMSci Elimination Round by P’Neung MDCU75
7 Endocrine System
Blood glucose Hexokinase I @ myocyte Hexokinase IV @ hepatocyte
Low level Catalyze more glucose (near Vmax).
Catalyze less glucose (conserve large activity to reach Vmax).
High level Enzymes have already been saturated.
Enzyme activity increase continuously.
Cardiomyocyte
PFK-2 : Phosphofructokinase-2FBPase-2 : Fructose 1,6-bisphosphatase-2
Interesting points from AMSci Elimination Round by P’Neung MDCU75
7 Endocrine System
PFK-1 : Phosphofructokinase-1FBPase-1 : Fructose 1,6-bisphosphatase-1
Fructose 6-phosphat
e
Fructose 1,6-bisphosph
ate
Low activity
PFK-1 FBPase-1
High activity
Fructose 6-phosphat
e
Fructose 2,6-bisphosph
ate
Low activity
PFK-2FBPase-2
High activity
Pi
cAMP-dependent protein kinase
Inhibitoryphosphate
cAMP as 2ry messenger
ATPADP
More amount
Cardiomyocyte
“phosphorylation”
Isozyme B2 (H-type)
Interesting points from AMSci Elimination Round by P’Neung MDCU75
7 Endocrine SystemCardiomyocyte
เอารป สตก มาไดไงอะ555555แคปมามะ5555 กอปมาเดะโดนลขสทธ
is believed not to have gluconeogenesis pathway.
Effects of Epinephrine on Hepatocyte & Cardiomyocyte
Pathway Hepatocyte Cardiomyocyte
Glycolysis Inhibit Stimulate
Gluconeogenesis Stimulate -
Choice C
Interesting points from AMSci Elimination Round by P’Neung MDCU75
8 Nervous System
ผปวยรายหนง มพยาธสภาพทบรเวณสมองสวน medulla ทางดานขาง (lateral medulla) ซงบรเวณดงกลาวประกอบดวย tract (กลมของเสนใยประสาท) ทมความสาคญ เชน spinothalamic tract (เสนใยประสาทรบความรสกบางชนดจากไขสนหลง) และ sympathetic tract อกทงยงมนวเคลยส (กลมของตวเซลลประสาท) ของเสนประสาทสมองคท 5, 8, 9, 10 รวมถงพยาธสภาพทบรเวณ cerebellum บางสวน อาการในตวเลอกใดตอไปนเปนสวนหนงของอาการทพบไดในผปวย?A. รมานตาขยาย (Mydriasis)B. อาการจมกไมไดกลน (Anosmia)C. ความคดสบสน (Disorientation)D. อาการเวยนหว บานหมน (Vertigo) ทรงตวไมอย (Ataxia)E. กลามเนออมพาตแบบออนปวกเปยกดานตรงขามกบพยาธสภาพ (Contralateral flaccid paralysis)
Interesting points from AMSci Elimination Round by P’Neung MDCU75
8 Nervous System
ผปวยรายหนง มพยาธสภาพทบรเวณสมองสวน medulla ทางดานขาง (lateral medulla) ซงบรเวณดงกลาวประกอบดวย tract (กลมของเสนใยประสาท) ทมความสาคญ เชน spinothalamic tract (เสนใยประสาทรบความรสกบางชนดจากไขสนหลง) และ sympathetic tract อกทงยงมนวเคลยส (กลมของตวเซลลประสาท) ของเสนประสาทสมองคท 5, 8, 9, 10 รวมถงพยาธสภาพทบรเวณ cerebellum บางสวน อาการในตวเลอกใดตอไปนเปนสวนหนงของอาการทพบไดในผปวย?A. รมานตาขยาย (Mydriasis)B. อาการจมกไมไดกลน (Anosmia)C. ความคดสบสน (Disorientation)D. อาการเวยนหว บานหมน (Vertigo) ทรงตวไมอย (Ataxia)E. กลามเนออมพาตแบบออนปวกเปยกดานตรงขามกบพยาธสภาพ (Contralateral flaccid paralysis)
Interesting points from AMSci Elimination Round by P’Neung MDCU75
8 Nervous SystemDiagnosis (Dx) : Lateral medullary syndrome/ PICA syndrome/ Wallenberg syndromeWhat is it? : one type of vascular lesions of the medulla
Arterial Supplies of the Brain● Internal carotid artery● Vertebral artery
Left ventricle
Ascending aorta
Aortic arch
(Right) Brachiocephalic
trunk
Left common carotid artery
Left subclavian artery
Right subclavian
artery
Right common carotid artery
Right internal carotid artery
Left internal carotid artery
Right vertebral
artery
Leftvertebral
artery
Basilarartery
Interesting points from AMSci Elimination Round by P’Neung MDCU75
8 Nervous SystemArterial Supplies of the Brain● Internal carotid artery● Vertebral artery
Interesting points from AMSci Elimination Round by P’Neung MDCU75
8 Nervous SystemArterial Supplies of the Brain
Vertebral artery
Posterior inferior cerebellar artery (PICA)
Basilar artery
Anterior inferior cerebellar artery (AICA)
Superior cerebellar artery
Posterior cerebral artery
Middle cerebral artery
Anterior cerebral artery
Internal carotid artery
Supply medulla & cerebellum
Interesting points from AMSci Elimination Round by P’Neung MDCU75
8 Nervous SystemLateral Medullary Syndrome
Lateral medullary & inferior cerebellar infarction
Infarction = injury/ death of tissue resulting from inadequate blood supply.
Cranial nerve nucleus
Interesting points from AMSci Elimination Round by P’Neung MDCU75
8 Nervous SystemLateral Medullary Syndrome
A group of
soma nerve fiber (axon)
CNS Nucleus Tract
PNS Ganglion Nerve
Note :
Sensory system
Autonomic system
Cerebellum
V : trigeminal systemCranial nerve nucleus
Interesting points from AMSci Elimination Round by P’Neung MDCU75
8 Nervous SystemLateral Medullary Syndrome
Touch/ Pressure
Pain/ temperature
Trig
emin
al n
erve
(V
1/ V
2/ V
3)
Trig
emin
al
gang
lion
Spinaltrigeminal
nucleus
Spinaltrigeminal
tract
Principaltrigeminal
nucleus
Trigeminothalamic/ ventral trigeminal
tract
Thalamus
Cerebrum
Motor nucleus of CNV
Muscles of mastication
Pons
Medulla
V : trigeminal systemCranial nerve nucleus
Interesting points from AMSci Elimination Round by P’Neung MDCU75
8 Nervous SystemLateral Medullary Syndrome
Touch/ Pressure
Pain/ temperature
Trig
emin
al n
erve
(V
1/ V
2/ V
3)
Trig
emin
al
gang
lion
Spinaltrigeminal
nucleus
Spinaltrigeminal
tract
Principaltrigeminal
nucleus
Trigeminothalamic/ ventral trigeminal
tract
Thalamus
Cerebrum
Motor nucleus of CNV
Muscles of mastication
Pons
Medulla
Clinical presentation : ipsilateral loss of pain and temperature sensation from the face.
VIII : vestibular nucleusCranial nerve nucleus
Interesting points from AMSci Elimination Round by P’Neung MDCU75
8 Nervous SystemLateral Medullary Syndrome
Cochlear nucleus @ caudal pons-rostral medulla/ CNVIII level
Vestibular nucleus @ rostral medulla
VIII : vestibular nucleusCranial nerve nucleus
Interesting points from AMSci Elimination Round by P’Neung MDCU75
8 Nervous SystemLateral Medullary Syndrome
Sound wave stimulates
hair cell @ampulla/
saccule/ utricle.
Vest
ibul
ar
gang
lion
Vest
ibul
ar
nerv
eVestibular nucleus : superior/lateral
/medial/ inferiorFl
occu
lono
dula
r lo
be o
f cer
ebel
lum
Abducens nucleus
Oculomotor/ trochlear nucleus
Medial longitudinal fasciculus (MLF)
Vest
ibul
ocer
ebel
lar
tract
Medialvestibulospinal
tract
Lateralvestibulospinal
tract
Motor neuron of head & neck muscles
Motor neuron of muscles of extremities
“Vestibulo-ocular reflex” to maintain visual fixation
Thalamus
Cerebrum
Vestibulothalamic tract
VIII : vestibular nucleusCranial nerve nucleus
Interesting points from AMSci Elimination Round by P’Neung MDCU75
8 Nervous SystemLateral Medullary Syndrome
Sound wave stimulates
hair cell @ampulla/
saccule/ utricle.
Vest
ibul
ar
gang
lion
Vest
ibul
ar
nerv
eVestibular nucleus : superior/lateral
/medial/ inferiorFl
occu
lono
dula
r lo
be o
f cer
ebel
lum
Abducens nucleus
Oculomotor/ trochlear nucleus
Medial longitudinal fasciculus (MLF)
Vest
ibul
ocer
ebel
lar
tract
Medialvestibulospinal
tract
Lateralvestibulospinal
tract
Motor neuron of head & neck muscles
Motor neuron of muscles of extremities
Clinical presentation : nystagmus, nausea, vomiting, and vertigo (บานหมน).
“Vestibulo-ocular reflex” to maintain visual fixation
Thalamus
Cerebrum
Vestibulothalamic tract
IX & X : nucleus ambiguusCranial nerve nucleus
Interesting points from AMSci Elimination Round by P’Neung MDCU75
8 Nervous SystemLateral Medullary Syndrome
Muscles innervated bynucleus ambiguus
Glossopharyngeal nerve Vagus nerve
stylopharyngeus muscle
Intrinsic muscles of the soft palate, larynx, pharynx, parasympathetic to heart
Spinal trigeminal nucleus/ nucleus solitarius/
inferior salivatory nucleus
Dorsal motor nucleus/ nucleus solitarius /
spinal trigeminal nucleus
Sensory : epiglottis, external auditory meatus, visceral organs, baroreceptorMotor : parasympathetic to heart & GI tractSecretomotor : mucous gland @ GI/ RS
Sensory : pharynx, middle & external ear, posterior ⅓ of tongue (somatic & taste), baroreceptorSecretomotor : parotid gland
IX & X : nucleus ambiguusCranial nerve nucleus
Interesting points from AMSci Elimination Round by P’Neung MDCU75
8 Nervous SystemLateral Medullary Syndrome
Muscles innervated bynucleus ambiguus
stylopharyngeus muscle
Intrinsic muscles of the soft palate, larynx, pharynx
initiate the mechanism of swallowing and phonation
ipsilateral laryngeal, pharyngeal, and palatal paralysis
Clinical presentations :dysarthria, dysphagia, and dysphonia [hoarseness]
Uvular deviation :palatal palsy
Loss of gag reflex
Spinothalamic tractSensory system
Interesting points from AMSci Elimination Round by P’Neung MDCU75
8 Nervous SystemLateral Medullary Syndrome
Pain/ temperature
Vert
ebra
l ne
rve
Dors
al ro
ot
gang
lion
dorsal horn (lamina I&V)
Lateral spinothalamic
tract
Fasciculus gracilis/
cuneatus
Thalamus
Cerebrum
Touch/ pressure/ vibration/
proprioception
Gracile/ cuneate nucleus
Medial lemniscus
Spinothalamic tractSensory system
Interesting points from AMSci Elimination Round by P’Neung MDCU75
8 Nervous SystemLateral Medullary Syndrome
Pain/ temperature
Vert
ebra
l ne
rve
Dors
al ro
ot
gang
lion
dorsal horn (lamina I&V)
Lateral spinothalamic
tract
Fasciculus gracilis/
cuneatus
Thalamus
Cerebrum
Touch/ pressure/ vibration/
proprioception
Gracile/ cuneate nucleus
Medial lemniscus
“Sensory homunculus” @ postcentral gyrus
Spinothalamic tractSensory system
Interesting points from AMSci Elimination Round by P’Neung MDCU75
8 Nervous SystemLateral Medullary Syndrome
Pain/ temperature
Vert
ebra
l ne
rve
Dors
al ro
ot
gang
lion
dorsal horn (lamina I&V)
Lateral spinothalamic
tract
Fasciculus gracilis/
cuneatus
Thalamus
Cerebrum
Touch/ pressure/ vibration/
proprioception
Gracile/ cuneate nucleus
Medial lemniscus
Clinical presentation : contralateral loss of pain and temperature sensation from the trunk and extremities
Descending sympathetic tractAutonomic system
Interesting points from AMSci Elimination Round by P’Neung MDCU75
8 Nervous SystemLateral Medullary Syndrome
Hypothalamus
Hypothalamospinal tract
Ciliospinal center @ Lateral horn/ intermediolateral cell
column (T1-T2) levelSuperior cervical ganglion
Target organ Normal sympathetic function
Pathology
Iris dilator muscle
Dilate pupil (Mydriasis).
Miosis เลก
Superior tarsal muscle
Elevate tarsus. Ptosis ตก
Sweat gland Produce sweat. Anhidrosis แหง
(Pseudo)enophthalmos ไมงอก
smc of blood vessel
Contract blood vessel.
Flushing
Horner Syndrome
Inferior cerebellar peduncleCerebellum
Interesting points from AMSci Elimination Round by P’Neung MDCU75
8 Nervous SystemLateral Medullary Syndrome
Functions :● Flocculonodular lobe
(vestibulocerebellum) : equilibrium● Vermis (spinocerebellum) : equilibrium● Cerebellar hemisphere
(cerebrocerebellum) : muscle tone & movement
Inferior cerebellar peduncleCerebellum
Interesting points from AMSci Elimination Round by P’Neung MDCU75
8 Nervous SystemLateral Medullary Syndrome
Clinical presentations : ipsilateral cerebellar signs
Dystaxia
Dysmetria
Dysdiadochokinesia
Finger-to-nose test
Interesting points from AMSci Elimination Round by P’Neung MDCU75
8 Nervous SystemLateral Medullary Syndrome : Clinical presentations
Vestibular nuclei nystagmus, nausea, vomiting, and vertigo
Inferior cerebellar peduncle
ipsilateral cerebellar signs (dystaxia, dysmetria, and dysdiadochokinesia)
Nucleus ambiguus of CNs IX and X
ipsilateral laryngeal, pharyngeal, and palatal paralysis (loss of the gag reflex, dysarthria, dysphagia, and dysphonia [hoarseness])
Spinothalamic tracts
contralateral loss of pain and temperature sensation from the trunk and extremities
Spinal trigeminal nucleus and tract
ipsilateral loss of pain and temperature sensation from the face
Descending sympathetic tract
ipsilateral Horner syndrome (ptosis, miosis, hemianhidrosis, vasodilation, and apparent enophthalmos).
“Don’t pick a (PICA) horse (hoarseness) that can’t eat (dysphagia).”
Interesting points from AMSci Elimination Round by P’Neung MDCU75
9 Immune Systemเดกหญง และพชาย ไดรบการวนจฉยวาเปนโรคอสกอใส แตทงสองคนมอาการทแตกตางกนโดยเดกหญงมอาการนอยกวาพชาย ซงมารดาไดใหขอมลวาเดกหญงเคยไดรบวคซนอสกอใสชนด live attenuated vaccine มากอน แตพชายไมเคยไดรบ จากขอมลดงกลาวเพราะเหตใดเดกหญงจงมอาการนอยกวาพชาย?A. การตดเชอของเดกหญงเปน primary immune response จงสามารถตอบสนองไดรวดเรวและรนแรงกวาB. การตดเชอของเดกหญงเปน secondary immune response จงสามารถตอบสนองไดรวดเรวและรนแรงกวาC. การให live attenuated vaccine เปนการให antibody แกเดกหญง เมอเกดการตดเชอจงสามารถตอบสนองไดรวดเรวและรนแรงกวาD. การให live attenuated vaccine จดเปน natural passive immunization ทาใหเดกหญงสราง antibody ตอเชอไดมาก เมอเกดการตดเชอจงสามารถตอบสนองไดรวดเรวและรนแรงกวาE. การให live attenuated vaccine จดเปน natural active immunization ทาใหเดกหญงสราง antibody ตอเชอไดมาก เมอเกดการตดเชอจงสามารถตอบสนองไดรวดเรวและรนแรงกวา
Interesting points from AMSci Elimination Round by P’Neung MDCU75
9 Immune Systemเดกหญง และพชาย ไดรบการวนจฉยวาเปนโรคอสกอใส แตทงสองคนมอาการทแตกตางกนโดยเดกหญงมอาการนอยกวาพชาย ซงมารดาไดใหขอมลวาเดกหญงเคยไดรบวคซนอสกอใสชนด live attenuated vaccine มากอน แตพชายไมเคยไดรบ จากขอมลดงกลาวเพราะเหตใดเดกหญงจงมอาการนอยกวาพชาย?A. การตดเชอของเดกหญงเปน primary immune response จงสามารถตอบสนองไดรวดเรวและรนแรงกวาB. การตดเชอของเดกหญงเปน secondary immune response จงสามารถตอบสนองไดรวดเรวและรนแรงกวาC. การให live attenuated vaccine เปนการให antibody แกเดกหญง เมอเกดการตดเชอจงสามารถตอบสนองไดรวดเรวและรนแรงกวาD. การให live attenuated vaccine จดเปน natural passive immunization ทาใหเดกหญงสราง antibody ตอเชอไดมาก เมอเกดการตดเชอจงสามารถตอบสนองไดรวดเรวและรนแรงกวาE. การให live attenuated vaccine จดเปน natural active immunization ทาใหเดกหญงสราง antibody ตอเชอไดมาก เมอเกดการตดเชอจงสามารถตอบสนองไดรวดเรวและรนแรงกวา
Interesting points from AMSci Elimination Round by P’Neung MDCU75
9 Immune SystemThe Theme of Immunology
Innate immunity Adaptive immunity
Specific to groups of molecule with shared structure (PAMPs, DAMPs, etc.)
Specific to any particular antigens
Limited diversity Very large diversity
No memory cell Memory cell
Initial response Later responseInnate immunity Adaptive immunity
APC
Cytokine
Interesting points from AMSci Elimination Round by P’Neung MDCU75
9 Immune SystemThe Theme of Immunology
Innate immunity
virus
infected cell
Activated natural killer (NK) cell kills infected cell.
Stress signal
Dendritic cell/ macrophage (antigen presenting cell; APC) phagocytoses infected cell after stimulated by nonself molecules (pathogen associated molecular patterns; PAMPs).
APC circulates to draining lymph node.
NK
APC
APC
Interesting points from AMSci Elimination Round by P’Neung MDCU75
9 Immune SystemThe Theme of Immunology
Interaction Between Innate & Adaptive Immunity
APC processes viral antigens and
presents them at MHC (major
histocompatibility complex) molecules.
MHC class I
APC CD8
Costimulatory molecule/ costimulator Effector CD8+ T cells
circulate to site of infection.
CD8
Naïve CD8+ T cell
T cell receptor
(TCR)
Costimulatory receptor
Clonalexpansion
นอนนรจง
Memory CD8+ T cells
Interesting points from AMSci Elimination Round by P’Neung MDCU75
9 Immune SystemThe Theme of Immunology
MHC class II
APC CD4
Costimulatory molecule
Effector CD4+ T cell
CD4 Naïve CD4+ T cell
TCR
Costimulatory receptor Clonal
expansion
Interaction Between Innate & Adaptive Immunity
Memory CD4+ T cell
Full B cell activation requires 3 steps.
BNaïve B cell
B
B cell receptor
(BCR)
MHC class II
1
B cell (as APC) recognizes, processes, and presents viral antigen
Interesting points from AMSci Elimination Round by P’Neung MDCU75
9 Immune SystemThe Theme of Immunology
Effector CD4+ T cell
CD4 Naïve CD4+ T cell
Activation, differentiation, & proliferation
Full B cell activation requires 3 steps.
2 B cell is activated by effector CD4+ T cell via stimulatory signal.
BCRMHC
class II B
CD4Effector CD4+ T cell
TCR
Stimulatory signal
B cell undergoes proliferation, isotype switching, & somatic hypermutation.
Interesting points from AMSci Elimination Round by P’Neung MDCU75
9 Immune SystemThe Theme of Immunology
Effector CD4+ T cell
CD4 Naïve CD4+ T cell
Activation, differentiation, & proliferation
Full B cell activation requires 3 steps.
3
BCR
MHC class II B
TFHFollicular helper T cell
TCR Among this B cell population, the one whose receptor has highest affinity to antigen is selected.
Differentiation
Follicular dendritic cell
Interesting points from AMSci Elimination Round by P’Neung MDCU75
9 Immune SystemThe Theme of Immunology
Effector CD4+ T cell
CD4 Naïve CD4+ T cell
Activation, differentiation, & proliferation
Full B cell activation requires 3 steps.
3
BCR
MHC class II B
TFHFollicular helper T cell
TCR
Clonal expansion & differentiation
Differentiation
Follicular dendritic cell
Memory B cell
Plasma cells circulate to site of infection.
Interesting points from AMSci Elimination Round by P’Neung MDCU75
9 Immune SystemThe Theme of Immunology
Adaptive immunity
infected cell
Humoral immunity Cell-mediated immunity
virus
Plasma cell
Neutralizing antibody
Prevent cell from being infected with virus.
CD8
Viral antigen at MHC class I
TCR
CD8+ T cells recognize & kill infected cells.
Interesting points from AMSci Elimination Round by P’Neung MDCU75
9 Immune System1ry vs 2nd Immune Response to the Same Antigen
T cell function B cell function
Interesting points from AMSci Elimination Round by P’Neung MDCU75
9 Immune System1ry vs 2nd Immune Response to the Same Antigen
T cell function B cell function
1ry response
2ry response
T
Naïve T cell Effector T cell
Memory T cell Effector T cell
B
Naïve B cell Plasma cell
Memory B cell Plasma cell
Interesting points from AMSci Elimination Round by P’Neung MDCU75
9 Immune SystemWhat make memory cell has a higher performance than that of naïve cell?
Memory T cell Memory B cell
● Greater number of memory cell than that of naïve cell : typically 10x to 100x.
● Prolonged maintenance from cytokine stimulation : increased anti-apoptotic protein & low-level proliferation.
● Rapid response : more active gene.● Immediate action at peripheral tissue : less
dependent on costimulation.
● Prolonged survival without antigenic stimulation.
● “Fully activated” : potential isotype switching & high-affinity receptor
“The success of vaccination is attributed in large part to the ability to generate memory cells on initial antigen exposure.”
Interesting points from AMSci Elimination Round by P’Neung MDCU75
9 Immune SystemImmunization
= immunity that is induced by exposure to a foreign antigen
= immunity from transferring serum or lymphocytes from a specifically immunized individual
Interesting points from AMSci Elimination Round by P’Neung MDCU75
9 Immune SystemImmunization
Types of immunity Passive Active
Naturally acquired Maternal IgG passed through placenta, IgG in colostrum
Natural exposure to antigen
Artificially acquired Serum, antitoxin, IVIG Vaccine, toxoid
C. การให live attenuated vaccine เปนการให antibody แกเดกหญง เมอเกดการตดเชอจงสามารถตอบสนองไดรวดเรวและรนแรงกวาD. การให live attenuated vaccine จดเปน natural passive immunization ทาใหเดกหญงสราง antibody ตอเชอไดมาก เมอเกดการตดเชอจงสามารถตอบสนองไดรวดเรวและรนแรงกวาE. การให live attenuated vaccine จดเปน natural active immunization ทาใหเดกหญงสราง antibody ตอเชอไดมาก เมอเกดการตดเชอจงสามารถตอบสนองไดรวดเรวและรนแรงกวา
Interesting points from AMSci Elimination Round by P’Neung MDCU75
10 Microbiology & Parasitology
ขอใดตอไปนกลาวไมถกตองเกยวกบโรคไขมาลาเรย?A. โรคไขมาลาเรยเกดจากเชอกอโรคใน Genus PlasmodiumB. คนเปน Intermediate host หรอ Vertebrate host ของเชอกอโรคมาลาเรยC. การทผปวยมอาการหนาวสนเปนชวง ๆ เกดจากการทเชอทาใหเซลลเมดเลอดแดงแตกD. เชอกอโรคมาลาเรยมยงเปน Definitive host และมการสบพนธแบบไมอาศยเพศเทานนเกดขนภายในตวยงE. เชอกอโรคมาลาเรยอยกลม Apicomplexa ซงม Apical organ สาหรบการเขาไปในเซลลของ Host
Interesting points from AMSci Elimination Round by P’Neung MDCU75
10 Microbiology & Parasitology
ขอใดตอไปนกลาวไมถกตองเกยวกบโรคไขมาลาเรย?A. โรคไขมาลาเรยเกดจากเชอกอโรคใน Genus PlasmodiumB. คนเปน Intermediate host หรอ Vertebrate host ของเชอกอโรคมาลาเรยC. การทผปวยมอาการหนาวสนเปนชวง ๆ เกดจากการทเชอทาใหเซลลเมดเลอดแดงแตกD. เชอกอโรคมาลาเรยมยงเปน Definitive host และมการสบพนธแบบไมอาศยเพศเทานนเกดขนภายในตวยงE. เชอกอโรคมาลาเรยอยกลม Apicomplexa ซงม Apical organ สาหรบการเขาไปในเซลลของ Host
Interesting points from AMSci Elimination Round by P’Neung MDCU75
10 Microbiology & ParasitologyLife Cycle of Plasmodium spp.
“Apical organ”
“Anopheles spp.”(A. dirus, A. minimis,
A. maculatus)
ยงกนปลอง
Interesting points from AMSci Elimination Round by P’Neung MDCU75
10 Microbiology & ParasitologyLife Cycle of Plasmodium spp.
“Fever/ febrile paroxysm”
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