Case 4

Front 1

List the 3 criteria that define intellectual disability

Back 1

IQ under 70
Onset before age 18
Deficit in adaptive behaviour

Front 2

List barriers to taking history of, examining, and testing intellectually disabled patients

Back 2

History by proxy (e.g. guardian) - lower accuracy

Longer appointments

Initial non-cooperation with exams and tests

Doctor's attitudes

Patient's insecurity of own knowledge level

Front 3

What's the basic premise in treating intellectually disabled patients?

What may this require?

Back 3

That they receive the same quality of care as the general population

May require some adaptations to suit needs of patient

Front 4

Intellectual disability & consent: Children

Describe consent rights

Back 4

Children: Don’t possess decision-making capacity
(decision by parents/guardians)

Front 5

Intellectual disability & consent: "Mature minors"

Describe consent rights

Back 5

<18 but judged competent
(Can consent treatment)
(Limitations on refusals in serious situations)

Front 6

Intellectual disability & consent: adults

Describe consent rights

Back 6

18+ with decision-making capacity
(entitled to consent)
(can refuse treatment)

Front 7

Intellectual disability & consent: adults without competence

Describe consent rights

Back 7

(decision by substitute decision-maker)

Front 8

List the 3 criteria for judging decision-making capacity

How many have to missing to deem person incompetent?

Back 8

o Understands nature and effect of decision
o Free and voluntary in making decision
o Can communicate decision

(any 1 missing = incompetent)

Front 9

Liver lobes:
4 anatomical and 2 functional

Which functional lobe does caudate and quadrate belong to?

Back 9

Left functional lobe.

Front 10

Name the ligaments and stuff

Back 10

Top left, clockwise:
Left triangular ligament
Falciform lig (same at bottom)
Inferior vena cava
Bare area
Anterior coronary lig
Posterior coronary lig
Right triangular lig

Gallbladder:
-Head
-Neck
-Fundus

Porta hepatis

Front 11

Name the liver impressions

Back 11

(Left to right)

Top 3: Gastric, duodenal, and renal

Bottom 3: All colic

Front 12

Name the 2 liver blood supplies

Back 12

Hepatic artery proper

Hepatic portal vein

Front 13

Name liver innervation, and its inputs (sympathetic and parasym)

Back 13

Coeliac plexus

Inputs from vagus (para) and coeliac ganglion (sym)

Front 14

Name liver lymphatic drainage

Back 14

Coeliac drainage (via hepatic nodes)

Front 15

Name the veins of the hepatic portal system

Back 15

Left, clockwise:
Portal vein
Short gastric v
Right gastro-omental v
Left gastro-omental v
Splenic v
Inferior mesenteric v

Front 16

Name the ducts of the biliary tree

Back 16

Bottom, clockwise

Main pancreatic duct
Common bile d
Cystic d
Right hepatic d
Left hepatic d
Common hepatic d

Front 17

What do the common bile duct and common hepatic duct unite to form?

Back 17

Hepatopancreatic ampulla
or
Ampulla of Vater

*Ampulla = dilated portion of a canal or duct

Front 18

What does the Hepatopancreatic Ampulla (of Vater) open into the duodenum via?

What's this eminence guarded by?

Back 18

The Major Duodenal Papilla.

Guarded by Sphinter of Oddi.

Front 19

List the 6 functions of the liver

Back 19

Metabolism
(fats, proteins, carbs)

Storage
(glycogen, iron, fat-soluble vitamins [e.g. vit A], copper)

Production
(plasma proteins [e.g. clotting factors], plasma lipoproteins, bile)

Detox
(drugs, blood-bourne toxins, metabolic waste products)

RBC turnover & recycling component parts
(similar to spleen)

Haematopoisis
(in fetus only, relinquished to bone marrow)

Front 20

Abdominal surface anatomy:
Which plane is at T9?

Back 20

Xiphisternal plane

Front 21

Abdominal surface anatomy:
Which plane is at L1?

Back 21

Transpyloric plane

Front 22

Abdominal surface anatomy:
Which plane is at L2-3?

Back 22

Subcostal plane

Front 23

Abdominal surface anatomy:
Which plane is at L4?

Back 23

Supracristal plane

Front 24

Abdominal surface anatomy:
Which plane is at L5?

Back 24

Transtubercular plane

Front 25

Name and abdominal divisions

A B A
C D C
E F E

Back 25

A: Hypochrondriac
B: Epigastric
C: Lateral/Lumbar
D: Umbilical
E: Iliac/Inguinal
F: Hypogastric

Front 26

Liver circulation:

Specify for Hepatic arterioles

Back 26

Interlobar arteries
Interlobular arteries
Hepatic arterioles

Front 27

Liver circulation:

Specify for Portal venules

Back 27

Interlobar veins
Conducting veins
Interlobular veins
Portal venules

Front 28

Liver circulation:

Specify for Interlobular bile ducts

Back 28

Bile canaliculi
Bile ductules (canals of Hering)
Interlobular bile ducts
R&L hepatic ducts
Common hepatic duct

Front 29

Liver circulation:

Specify for Sinusoids

Back 29

Sinusoids
Central vein
Sublobular
Collecting
Hepatic veins
Inferior Vena Cava

Front 30

Hepatic acinus = functional unit of liver parenchyma (primary tissue)

Describe its 3 zones

Back 30

Zone 1:
Exposed to blood; well perfused with O2, incoming nutrients, toxins
(Resists hypoxic damage)
(Susceptible to drugs/toxins)

Zone 2:
Middle zone

Zone 3:
Near central vein
Blood de-O2 and low nutrient
(Susceptible to hypoxic damage)
Higher conc of toxin/drug-metabolising enzymes
(Susc to metabolic intermediates)

Front 31

GIT development:

Blood vessels travel in dorsal mesentery
Fore/mid/hindgut division based on arterial supply - specify.

Back 31

Foregut: Coeliac Artery
Midgut: Superior Mesenteric Artery
Hindgut: Inferior Mesenteric Artery

Front 32

Define viral hepatitis.

Back 32

A systemic infection characterised particularly by: Inflammation and necrosis of liver.

Front 33

List the 6 modes of viral transmission, giving examples.

Back 33

Respiratory (Influenza)
Faecal-Oral (Polio)
Sexual (HIV)
Blood-borne (via insects, or direct transmission) (Hep B and C)
Direct contact (Herpes)
Zoonotic (animal disease transmitted to humans) (rabies)

Front 34

Hepatitis viral serology:

What is HBsAg?

What does it mean?

Back 34

Hep B surface antigen

Presence = active infection (person infectious)

Front 35

Hepatitis viral serology:

What is HBV-DNA?

What does it mean?

Back 35

Viral DNA

Presence = active infection (person infectious)

Front 36

Hepatitis viral serology:

What is Anti-HBs?

What does it mean?

Back 36

Antibody against HBV surface antigen

Presence = vaccination, or actual infection (person infectious)

appears late

Does NOT appear in chronic carriers

Front 37

Hepatitis viral serology:

What is Anti-HBc?

What does it mean?

Back 37

Antibody against HBV core antigen

Presence = only in actual infection

Appears at onset of acute Hep B

Persists for life

Front 38

Hepatitis viral serology:

What is Anti-HCV?

What does it mean?

Back 38

Antibody against HCV

Front 39

Hepatitis viral serology:

What is HAV-IgM?

What does it mean?

Back 39

Antibody against HAV

IgM suggests current/early, acute infection

Front 40

Interpret the serology results

Back 40

Front 41

Hepatitis viruses:

Define transmission modes

Back 41

A: Faecal-oral
B: Parenteral (blood/IV, sexual, perinatal)
C: Parenteral (mostly blood/IV, esp. needles & transfusions)
D: Parenteral (mostly blood)
E: Faecal-oral (usually water-bourne)

Front 42

Hepatitis viruses:

Define incubation period

Back 42

A: 2-6wks
B: 4-26wks
C: 2-26wks
D: 4-7wks
E: 2-wks

Front 43

Hepatitis viruses:

Define disease type + progression

Back 43

A: Acute
B: Acute; 5% become chronic
C: Acute (usu asymptomatic/mild); 55-85% -> chronic
D: Acute or chronic
E: Acute

Front 44

Hepatitis viruses:

Carrier state?

Back 44

A: N
B: Y
C: Y
D: -
E: N

Front 45

Hepatitis viruses:

Cirrhosis?

Back 45

A: N
B: Y
C: Y
D: HDV increases HBV-induced progressive liver disease
E: N

Front 46

Hepatitis viruses:

Vaccine available?

Back 46

A: Y
B: Y
C: N
D: N
E: N

Front 47

Hepatitis viruses:

Preventions/Interventions

Back 47

A: Sanitation, hygiene (limit food/water contamination), human-human contact precautions
B: Avoid IV drugs, screen transfused blood, safe sex
C: Avoid IV drugs, screen transfused blood, safe sex
D: Ditto HBV
E: Sanitation, hygiene (esp. water)

Front 48

Define jaundice (icterus)

Back 48

Yellowish discolouration of tissue (e.g. sclerae of eyes, and skin).

From deposition of bilirubin/bile pigment (either un- or conjugated)

Front 49

What is hyperbilirubinaemia?

How does it occur?

Back 49

Abnormally high amounts of bile pigment (bilirubin) in the blood

From either
- increased production
or
- decreased removal

Front 50

Summarise heme metabolism

Back 50

\\Reticuloendothelial cells\\
(in spleen, liver, bone marrow)
- Break down old RBCs (main work)
Heme -> [Heme oxygenase] -> Biliverdin -> [Biliverdin reductase] ->
--->
\\Unconjugated Bilirubin\\
Water-insoluble (can't excrete via urine)
Tightly bound to serum albumin
Toxic! (Don't you know?)
--->
\\Liver\\
1. Uptake
2. Conjugation
3. Excretion (actively transported into bile)
--->
\\Conjugated Bilirubin\\
Water-soluble (can piss out)
Only loosely albumin-bound
Relatively non-toxic
--->
\\Bile\\
Bile -> Duodenum
(conjug bili passes along small intestine)
Conjug bili -> [via bacteria beta-glu.] -> unconjug bili
Unconj bili -> [via normal gut bacteria] -> Urobilinogen (colourless, soluble)
--->
//Stool//
80-90% passed here
Urobilinogen -> Stercobiligen -> Stercobilin (colours stool)
--->
//Bloodstream reabsorption//
10-20%
AKA Enterohepatic circulation
(ie. back to liver)
--->
//Urine secretion//
~5%
Via kidneys
Urobilinogen -> Urobilin (colors urine)

Front 51

Prehapatic jaundice:
Explain mechanism.

Back 51

Excess bilirubin production (e.g. due to haemolysis - RBC breakdown) OVERWHELMS liver capacity of conjugate/excrete it

i.e. Increased unconj bili in blood

Unconj and conj bili both increased.

*Nothing wrong with liver

Front 52

Prehapatic jaundice:
Explain complications.

Back 52

Urine not dark (bili not excreted via urine)

Stool not pale/clay-coloured

Urobilinogen levels INCREASED in urine and stools
(Liver can increase conj bili output, but can't keep up totally)

May be spleen enlargement (palpable)

Front 53

Hapatic jaundice:
Explain mechanism and complications.

Back 53

Impaired liver function/Hepatocellular damage
(virus, toxins, enzyme defects)

1. Defective uptake of unconj bili
= unconj bili in blood
= Urine not dark
= May have pale clay-coloured stool (if decreased stercobilin in stool)

2. Defective conj of bili
= Raised unconj bili in blood
= Urine not dark
= May have pale clay-coloured stool (if decreased stercobilin in stool)

***3. Defective excretion of conj bili
(AKA intrahepatic cholestasis)
= Raised *conj bili* in blood
= Dark urine (presence of conj bili)
= Pale clay-coloured stool (conj bili can't get to GIT properly)

Front 54

Hapatic jaundice:

Explain multiple stages by viral hepatitis

Back 54

Viral hepatitis can

Damage cells (decrease conj of bili)

Cause tissue swelling
= impair conj bili outflow
(dark urine)

Front 55

Post-hepatic Jaundice:
Explain mechanism and complications

Back 55

Blockage of bile after liver
(gall stones or pancreatic head cancer)

Increased conj bili in blood

Dark urine
(presence of conj bili)

Pale/clay-coloured stool
(conj bili can't get to GIT properly)

Pain from gall-stones
(aggrav. by fatty food consumption - needs bile for digestion)

Front 56

Cell injury and death:

Contrast Necrosis and Apoptosis

Back 56

Uncontrolled VS genetically programmed

Involves energy deprivation VS requires energy

Inflammation VS ~no inflammation

Group of cells affected VS single/few cells

Reversible -> irrev VS Irreversible once started

Cell swells/lyses due to water influx VS Cell shrinkS as cytoskeleton disassembled

Random destruction of organelles and nuclear material VS Orderly packaging of organelles/nuclear fragments