2022 Practical Revision for 1st Year Pharma D Students PDF

12/1/2022 Practical revision for 1st Year Pharma D students By Prof. Eman Sayed Hassan Revised by Prof. Nashwa Ali Abdelmotteleb 1 Practical examination (25 marks) will be Dynamic (10 marks) and Sheet (15 marks) Muscle and nerve CVS...

12/1/2022 Practical revision for 1st Year Pharma D students By Prof. Eman Sayed Hassan Revised by Prof. Nashwa Ali Abdelmotteleb 1 Practical examination (25 marks) will be Dynamic (10 marks) and Sheet (15 marks) Muscle and nerve CVS Arterial blood pressure Blood HB estimation Blood grouping Rh factor Hemostatic function tests (coagulation time, bleeding time) Dynamic Body Temperature 2 1  12/1/2022 Muscle and nerve 1. SMT 2. effect of temperature on SMT 3. Effect of fatigue on SMT 4. Effect of two successive stimuli 5. effect of multiple successive stimuli CVS Pacemaker Extrasystole Sheet Arterial blood pressure Blood Osmotic fragility test Hematocrite value Determination of erythrocytic sedimentation rate 3 Hemoglobin Estimation /Sahli's Hemoglobinometer Procedure: 1‐ Place 0.1N HCl till 10% mark on the scale. 2‐ Sterilize your finger. 3‐ Puncture your finger & collect a large drop of blood. 4‐ Suck the collected drop into Sahli's pipettee pipette up to the mark 20 mm3 (0.02mL). Don’t allow air to enter the pipette column. Clean the outside of the pipette from any blood. 5‐ Blow out the blood beneath the surface of the HCI in the Sahli tube‐ mix well 6‐ Let the tube to stand for 10 min. 7‐ Place the tube in the comparator block and hold it up to a strong light. Add distilled water drop by drop to the acid hematin solution (mix well after each addition) until its color matches the color of the standard color on the comparator. 8‐ Read the scale on the sahli tube to obtain the percentage of Hb and grams of Hb per 100ml of blood. N.B. 100ml blood=%=dL=deciliter 4 2  12/1/2022 Hemoglobin Estimation /Sahli's Hemoglobinometer Common questions 1. What is the brown colored solution and why it is formed?? Acid Haematin, HCL destroyed the RBCs membrane. Thus, Haemoglobin is free and binds with HCl forming acid haematin. 2. What is the unit used for haemoglobin concentration? g/dl (g%) 3. Haemoglobin concentration in different age groups: Newborns: 18‐22 g/dl Adult males: 16 + 2 g/dl Adult females: 14+ 2 g/dl N.B. dl=%=100 ml blood 4. If Haemoglobin concentration is below the normal range e.g 10 g%, what is your diagnosis? Anaemia 5. If Haemoglobin concentration is above the normal range e.g 20 g%, what is your diagnosis? polycythemia 5 Osmotic fragility test What is the principle of the test? To measure erythrocyte resistance to hemolysis while being exposed to serial concentration of hypotonic solution. When osmotic fragility is normal, red cells begin to hemolyze in 0.45% saline (partial hemolysis). Hemolysis is completed at 0.3% saline (complete hemolysis). When RBCs put in a hypotonic solution, the RBCs swell & rupture (hemolysis). When RBCs put in a hypertonic solution, the RBCs Shrink. Clinical significance: In hereditary spherocytosis, RBCs begin partial hemolysis in 0.7% saline and hemolysis is completed at 0.5%. 6 3  12/1/2022 Determination of erythrocyte sedimentation rate (ESR) ESR is define as …(it is the distance sediments by RBCs in a vertical blood column at the end of one or two hours Causes that results in an increase in ESR: Physiological: in female during menstruation. Pathological: A: tissue destruction e.g. inflammation. B: introduction of foreign body e.g. vaccination. Clinical significance: it is not specific i.e. it indicates the presence of a disease but not a specific disease in particular. Its value is: The effectiveness of the treatment, progress of the disease The severity of the disease The activity of the disease. The name of the tube is Westergren's tube that is divided from Zero (at the top) to 200mm (at the bottom). 7 Read the value of ESR ESR Normal values of erythrocyte sedimentation rate in male is 5mm in the first hour and 8 mm in the second hour. Normal values of erythrocyte sedimentation rate in female is 10mm in the first hour and 16 mm in the second hour. 8 4  12/1/2022 Hemostatic function tests (bleeding time and coagulation time) Bleeding Time (BT) is defined as it is the time needed for bleeding to stop when a small injury of skin occurs. It depends on platelet number &function. Normal bleeding time is 2‐6 min. It is prolonged in purpura and it is normal in hemophilia. Coagulation time (CT): it is the time which elapses from the start of bleeding and the formation of a clot. Normal coagulation time is 5‐8 min. It depends on coagulation factors. Coagulation time is increased in hemophilia, but normal in purpura, 9 Determination of blood groups On the basis of agglutinogens (antigens) present in the red cells, individuals are divided into four major blood groups A. B, AB and O. As a general rule. The blood of any person does not contain an agglutinogen and its corresponding agglutinin (in the plasma). * Group A: Individuals contain agglutinogen A & agglutinin b. *Group B: Individuals contain agglutinogen B & agglutinin a. *Group AB: Individuals contain both A and B agglutinogens & neither a nor b agglutinin (thus group AB is universal recipient). *Group O: Individuals contain neither A or B agglutinogen (thus group O is universal donor) & & agglutinin a, b. Indication of ABO testing: before blood transfusion 10 5  12/1/2022 How you did the experiment?? 2 Drops of blood (contain the antigen or not) + either Anti‐A, Anti‐B sera (antibody)‐ Mix the blood and serum a toothpick using a different toothpick for each side‐ wait for 2 min. Interpretation of the results 11 Rh system How you did the test: A drop of blood (antigen) + Anti‐D serum (antibody)‐ Mix the blood and serum well wait for 2 min. Rh +ve Rh ‐ve Rh +ve people have Rh agglutinogen. Rh negative have NO Rh agglutinogen. As a general rule. The blood of any person does not contain an agglutinogen and its corresponding agglutinin (in the plasma). Both Rh +ve people & Rh negative have NO agglutinin. However, Rh –ve people could develop agglutinin if received Rh +ve blood transfusion. Rh +ve people never ever have Rh antibody/agglutinin. 12 6  12/1/2022 Importance of determination of Rh 1. Blood transfusion: injection of human blood containing Rh factor into another person who is Rh negative will produce in the recipient's plasma anti Rh agglutinin (nothing will happen in the first time). If this person received another transfusion of Rh‐positive blood, the injected cells will agglutinate and hemolyze. 2. Marriage : If an Rh negative woman married an Rh positive man, the baby may be Rh + fetus. Small amounts of fetal blood leaks into the maternal circulation at the time of delivery, this leads to development of anti Rh agglutinin in the maternal plasma (nothing will happen for the first baby Except if the mother previously received Rh +ve blood transfusion). Also, significant titer of anti Rh agglutinin develops in the maternal plasma during the postpartum period. During the next pregnancy, the mother's agglutinins cross the placenta to the fetus. When anti Rh agglutinins cross the placenta to the Rh + fetus, they cause hemolysis and various hemolytic disease of the newborn (erythroblastosis fetalis). If hemolysis is severe, the fetus may die in utero. 13 Importance of determination of Rh (marriage) Erythroblastosis fetalis Nothing will happen if the female is Rh+ve and the male Rh ‐ve 14 7  12/1/2022 Measurement of the arterial blood pressure Definition of ABP: the pressure exerted by blood stream on the lateral walls of the arteries, leading to distension. Name of the Equipment: Sphygmomanometer which consists of: 1. A rubber bag: 2. Hand (air) pump: A valve controls this inflation and deflation of the cuff. 3. Mercury manometer: vertical tube which is graduated from zero to 300 mmHg. 4. Mercury reservoir: Make sure that the screw is on position. Human blood pressure is most commonly measured in the brachial artery of the upper arm (Which artery?). Precautions: Put the sphygmomanometer at the same level of the heart. Precaution for the patients Avoid smoking (30 min before BP is taken). The patient to rest for at least 5 min. The examining room should be quiet and comfortably warm. The patient should by lying or sitting The arm should be free of clothes. Palpate the brachial artery pulsation. Position the arm so that the brachial artery, at the antecubital crease, is at the same level of the heart If the patient is seated, rest the arm on a table a little above the patient’s waist; if standing, try to support the patient’s arm at the midchest level. 15 What are the methods for determining ABP? Two methods are used for determining blood pressure: Palpatory and auscultatory.. A) Palpatory Method Disadvantage: The palpatory method measures only the systolic pressure, which is usually around 5 mm Hg lower than that obtained using the auscultatory method (less accurate than the auscultatory method). Advantage: it is important to avoid silent gap in some hypertensive patients. The silent gap (the auscultatory gap): It is found in patients with hypertension, its cause is unknown. During auscultation, For example, the sounds may first appear at 210 mm Hg (systolic pressure), disappear from 180 to 160 mm Hg (silent gap), then reappear and finally disappear at 120 mm Hg (diastolic pressure). It leads to marked error if the palpatory method for blood pressure measurement is not taken prior to auscultation. Steps: VIP Apply the cuff (not tight not loose,), to the upper arm, with the lower border 1‐2 cm from the antecubital crease. Secure the cuff snuggly Position the patient’s arm so that it is slightly flexed at the elbow. The manometer is placed so as to be at the same level as the cuff on the patient’s arm and the observer’s eye should be vertical. Feel the radial artery with the fingers of one hand, rapidly inflate the cuff until the radial pulse disappears and this is the systolic pressure by palpatory method. Deflate the cuff promptly and completely and wait 15 to 30 sec. 16 8  12/1/2022 II‐ Auscultatory Method: This method is based on sounds produced at the lower end of the partially compressed artery due to turbulence. If the pressure in the cuff exceeds the systolic pressure, the artery is closed and there will be no sound. If the pressure in the cuff is below the diastolic pressure also there will be no sound because the artery is fully opened and there is laminar blood flow. When the cuff pressure is between systolic and diastolic pressures, there will be intermittent flow of blood through the artery. The intermittent flow produces turbulence at the end of the cuff, which produces a sound (Korotkoff sounds). The pressure where the sound first appears is the systolic pressure. (when the systolic pressure is recorded? This muffled sound continues for another drop in pressure of 5 mm Hg after which all sounds disappear. Diastolic pressure is the pressure at which the sounds suddenly drop (Not the stop of sound). When the diastolic pressure is recorded?? B.P. is expressed as systolic pressure/diastolic pressure (120/80). 17 What is the normal range of ABP?? It is 100‐139/60‐89 mmHg. Average is 120/80 in adult male Steps: Place the diaphragm of the stethoscope lightly over the brachial artery in the antecubital fossa. Inflate the cuff rapidly again to the level just determined (30 mm Hg over that previously taken for systolic blood pressure reading by palpatory method, and then deflate it slowly at a rate of about 2 to 3 mm Hg per second. Note the level at which you hear the sounds of at least two consecutive beats. This is the systolic pressure. Continue to lower the pressure slowly until the sounds become muffled and then disappear (5th Korotkoff’s sound). This is the diastolic pressure Deflate the cuff rapidly to zero. 18 9  12/1/2022 Pacemaker of the heart Definition: A part of the heart that initiates rhythmic excitatory impulses and spreads it to the whole heart. Pacemaker of the human is sinoatrial node (SA node) Pacemaker of the frog is sinus venosus. Warm saline resulted in 19 This curve shows the effect of temperature on pacemaker. A shows the effect of cold saline on cardiac pacemaker, which decreases the heart rate. This effect is due to 1) decreased membrane permeability to ions. B shows the effect of warm saline on cardiac pacemaker, which increases the heart rate This effect is due to 1) increased membrane permeability to ions. C is the normal C 20 10  12/1/2022 Extrasystole (Premature Beats) Definition: Beat comes before the normal expected beat and transient interrupt the rhythm. Extrasystoles are produced only during diastole because the cardiac muscle during systole is in absolute refractory period. This beat is followed by an unusual long interval of rest called the compensatory pause. Causes: Produced by impulses discharged from an ectopic focus during cardiac diastole due to I) Physiological causes (it can occur in Normal person): Excessive tea & coffee drinking. Excessive cigarette smoking. Lack of sleep. Severe anxiety. II) Pathological causes: ‐ Local area of cardiac ischemia. Calcified plaque Mechanical irritation during cardiac catheterization 21 Extrasystole (Premature Beats) The arrow (A) is pointed to premature beats, this due to a stimulus applied during diastole. A is followed a pause (B) called compensatory pause. If the stimulus is applied in the cardiac systole, there will be no response because the heart is in the absolute refractory period (name of the period of excitability). 22 11  12/1/2022 Simple muscle twitch Definition: single sudden contraction followed by a relaxation due to a single stimuli. Duration: 0.1 sec Phases: 1. latent period (0.01 sec) the period between the application of the stimulus till the appearance of response. 2. Contraction phase: the muscle is shortened (0.04 sec) 3. Relaxation phase: the muscle regain its initial length (0.05 sec) Methods of anesthesia: Pithing Latent Muscle used: gastrocnemius muscle period Nerve used: sciatic nerve Stimulus: electrical stimuli Apparatus: kymograph 23 Effect of temperature on SMT ‰ This curve represents the effect of temperature on simple muscle twitch. ‰ Curve C1. is the normal SMT. ‰ The curve (C3) represent the effect of …cold.solution/cooling on SMT. This results in increased latent period, reduced the strength, and increased duration. ‰ This effect is due to…decreased membrane permeability to ions, increased viscosity of muscle protein, and reduced metabolic reaction. ‰ The curve (C2) represent the effect of …warm…………..solution/warming on SMT. This results in …reduced…….latent period, …increased…..the strength, and …reduced……duration. ‰ This effect is due to…increased permeability to ions……and …decreased viscosity of muscle protein, and increased metabolic reaction. 24 12  12/1/2022 Effect of two successive stimuli on SMT This curve represents the effect of …two successive stimuli on simple muscle twitch. Curve C1. is the normal SMT. The curve (C2) occurs when stimulus falls on the contraction ‐ phase of the first stimulus. This curve due to summation of response. if the stimulus is repeated multiple times tetanus‐ occurs. C4 The curve (C3) occurs when stimulus falls on the early relaxation phase of the first stimulus. This curve is called curve of two humps. If the stimulus is repeated multiple times ‐clonus‐ occurs. The curve (C4) occurs when stimulus falls on the late relaxation‐ phase of the first stimulus. This curve is called separate contractions. If the stimulus is repeated multiple times separate contractions/staircase contractions occurs. If the second stimulus falls on the latent period of the first stimuli,…No response.will occur. This due to that the muscle in the absolute refractory phase. 25 Effect of multiple successive stimuli * The name of the figure is effect of multiple successive stimuli on simple muscle twitch…….……. Curve C2 is called clonus. It occurs when multiple successive stimuli falls on the early relaxation phase..... C2 is defined as succession of contractions with incomplete relaxation. C2 can be converted into curve C3 by cooling and fatigue because they increased duration of contraction. C2 can be converted into curve C1 by warming.because it decreased the duration of contraction. Curve C3 is called tetanus It defined as continuous contractions without relaxation. It occurs when multiple successive stimuli falls on the contraction phase. 26 13  12/1/2022 Body Temperature Normal body temperature is 36.5‐37.2°C Materials: thermometer Methods: 1. Oral (by mouth) 2. Axillary (under the arm, it is lower than the normal oral temperature by approximately 0.5 ºC i.e. add 0.5 ºC to the value). 3. Rectal (by the rectum, it is higher than the normal oral temperature by approximately 0.5 ºC i.e. subtract 0.5 ºC from the value). Indication of axillary or rectal measurement: Infants and Children Mouth breather Tumor or infection in the mouth Comatozed patients 27 Procedure For Glass Mercury thermometer: Remove it from container, and firmly grasp the end opposite the mercury bulb, sterilize of the bulb by alcohol. Gently shake the thermometer down to 35°C or below. Oral: Insert bulb or tip under the tongue –Close lips firmly, breathe through the nose, and wait for 3 minutes , Axillary: wipe the patient’s underarm with a dry towel prior to measurement and insert the bulb in the axilla with adducted arm/ wait for 3 minutes. Rectal: The patient lies on one side with the hip flexed, lubricates the bulb and then inserts it about 3 to 4 cm into the anal canal in a direction pointing to the umbilicus (rectal)‐ wait for 2 minutes. Read the temperature by holding the thermometer opposite to the bulb and rolling it to and fro until you find the highest point where the mercury thread reached, Reinsert it for another minute and read it again. If the temperature is still rising, repeat this procedure until 2 successive readings are of similar values (record the temperature). Re ‐ sterilize thermometer by alcohol from stem to bulb, shake it, and put it in the container. 28 14