Index

Subject Page
Anatomy 1
Physiology 42
Histology 87
Biochemistry 116
Genetics 112
Professionalism, 156
Communication
and medical ethics.
I) Introduction to Anatomy:
1) Levels of organization of the body:

1
2) What is this position? 3) Label the anatomical planes:

2
 4. Label the terms of direction:

Skin

3
5. Label the terms of movement:
(A) (B) (C) (D)

(E) (F) (G) (H)

4
 (I) (J) (K) (L)

6) Label the terms of movement:

(A) (B) (C) (D)

(E)

5
(II) Anatomy of the Skeletal system:
1) Identify the types of bones according to position:
(A) (B)

2) Identify the bones:

(A) (B) (C)

6
3) Identify the bones of the upper Limb:

1 A

2 B

3 C

7
4) Identify the bones of the Lower Limb:

1
A

B
3

5 4 C

5) Identify the types of bones according to ossification:

(A) (B)

8
6) Identify the types of bones according to shape:

D
A

9
7) Identify the types of bones according to Structure:
B

8) Label the parts of a long bone:

A
C

B
E

A
10
(III) Anatomy of the Joints:
1) Label the different types of joints and their examples:
Type I:

Type II:

11
2) Name the type of joint according to shape and give an example in the body:
Type III:

Type: Type: Type:

Example: Example: Example:

Type: Type: Type:

Example: Example: Example:

Type:
Example:

12
3) Label the name of the joint and its type according to shape:

Name:
Type:

Name:
Type:

Name:
Type:

Name:
Type:

Name:
Type:

13
 Name:
Type:

Name:
Type:

(IV) Anatomy of the Integumentary System and Fascia:

1) Label the layers of the integumentary system:

14
2) What are these lines called?

3) Label the parts of a hair:

15
4) Label the subcutaneous glands:

16
5) Label the parts of the nail:

6) Label the parts highlighted:

17
7) Label the fascia:
A B C

G D

18
A, B, C, D, E and F are all forms of:

V) Anatomy of the Cardiovascular System:

1) Label the major chambers and vessels of the heart

19
2) Label the valves of the heart:

3) Label the arteries of the heart:

20
4) Label the chambers and veins of the heart:

21
5) Label the vessels:

VI) Anatomy of the Respiratory System:

1) Label the parts of the respiratory tract:

22
2) Label the parts of the organ:

VII) Anatomy of the Muscular System:

1) Label the different types of muscles in the body:

23
2) Label the parts of this muscle:

24
3) Label the different shapes of muscles:

25
VIII) Anatomy of the Digestive System:
1) Label the parts of the digestive system:

26
2) Label the divisions of the oral cavity:

3) Label the parts of the stomach:

27
4) Label the parts of the small intestine:

28
5) Label the parts of the large intestine:

29
6) Identify the three major salivary glands:

30
IX) Anatomy of the Endocrine System:
Label the different endocrine glands in the body

31
X) Anatomy of the Lymphatic System:
1) What lymphatic duct drains each area?

2) Identify this lymphoid organ and label the vessels attached to it:

Organ:

32
3) Label the lymphoid organs:

4) Label the lymphoid tissues:

33
XI) Anatomy of the Urinary System:
1) Label the parts of the urinary system:

2) Label the parts of the kidney:

34
3) Label the parts of the nephron:

4) Label the parts of the lower urinary tract in males:

35
XII) Anatomy of the Nervous System:
1) Identify this cell and label its parts:

Cell:

2) Identify the types of cells:

A B C D

36
3) Identify the types of connections:
A B C

37
4) Label the parts of the CNS and its protections

5) Label the different brain lobes

38
6) Label the parts of the PNS

39
XIII) Anatomy of the Reproductive System:
1) Label the parts of the male reproductive system:

40
2) Label the parts of the female reproductive system:

3) Label the parts of the uterus and the uterine tube:

41
 Calculation of the Volumes of Body Fluid Compartments and
water balance

Body fluids are solutions of water, into which many organic molecules
are dissolved (carbon-containing molecules such as carbohydrates, lipids,
proteins) and inorganic molecules as ions (atoms with a net charge).

Water content (total body water/TBW) 65% of our body.

- (40-42 L) in an adult weighing 70 kg.

- The percentage varies between 50-70% depending on gender and the

amount of adipose tissue.

- 60% of the total body weight in adult men.

- 50% of BW in adult women because their bodies contain much fat.

- More than 70% of BW in infants, so water loss leads to rapid

dehydration.

- In old age the water content is decreased

42
Compartments of body fluids:

1) Intracellular fluid (ICF): two thirds (about 28 liters) of total body fluids.

2) Extracellular fluid (ECF): The fluid outside cells. It constitutes one third
(about 14 liters) of total body fluids. It is separated from the intracellular
fluid by the cell membrane.

- Extracellular fluid (ECF) is the internal environment that supplies the

cells with substances needed for cellular function.
43
 It consists of: Plasma (3.5 liters): inside the blood vessels.

Interstitial fluid: between cells (10.5 liters).

Composition of body fluids

- The extracellular fluid contains large amounts of sodium, chloride,

and bicarbonate

- ICF contains large amounts of potassium, magnesium, and

phosphate ions.

44
Measurement of the volumes of body fluid compartments

Measurement of Volumes of Body Fluids:

Principle of measurement: Dye dilution technique

- A known amount of a dye or indicator is injected into the body.

- Enough time is allowed for uniform distribution of the dye in a fluid

compartment.

- Then the dye concentration in that compartment is measured.

- The compartment volume is calculated as follow:

Volume of fluid = Amount of dye injected / Concentration of dye.

Characters of indicator or dye used: The dye should be;

1. Not toxic.

2. Rapidly and equally distributed throughout the chosen

compartment (not distributed through any other compartment).

3. Not metabolized.

4. Not rapidly excreted. 5.Easily measured.

Measurement of total body water (TBW):

- Deuterium oxide (D2O, heavy water) is the most frequently used

indicator to measure total body water.

- Tritium oxide

- Aminopyrine

45
This indicator is distributed evenly in all body fluid compartments i.e., ICF
and ECF

Measurement of ECF volume:

- The most accurate measurement of ECF volume is that obtained by

using inulin, a polysaccharide. Inulin (more accurate)

- Mannitol

- Sucrose

They are distributed in ECF only

Measurement of intracellular fluid volume

o The intracellular fluid volume cannot be measured directly, but it

can be calculated by subtracting the ECF volume from the TBW

ICF = Total body water – ECF

Measurement of plasma volume can be measured by:

• Evans blue dye (more common)

• Radioactive iodine bound to plasma proteins

They are distributed only in vascular part of ECF

Measurement of ISF

• Can not be measured directly, but measured by:

ISF= ECF - plasma volume

46
Measurement of blood volume

Measurement of RBCs volume

Can be measured directly by:

• chromium (Cr51)

• Iron (Fe59)

• Phosphorus (P32)

RBCs volume = Blood volume – Plasma volume

Problem:

Amount of D2O injected = 4 mg

Plasma concentration = 0.01 mg/100 ml

Water Balance

Body water is kept constant by adjusting water input and water

output.

A) Water input (about 2400 ml/day) 2 sources;

a. Exogenous water: ingested in the form of water or liquid (about

2200 ml/day).

b. Endogenous water: synthesized as a result of metabolism (about

200 ml/day).

47
 B) Water output (about 2400 ml/day)

- Under normal conditions, water loss occurs through the following

routes;

a. Insensible water loss (about 700ml) from lungs (water vapor) and skin
(insensible

Perspiration)

b. Sweating: only about 100 ml are lost under normal conditions, but in
exercise sweating

Increased.

c. Feces (about 100ml) water loss in feces increases in case of diarrhea.

d. Urine (about 1500 ml)

1) Control of water input 2) Control of water output

It is controlled by thirst sensation It is controlled mainly by adjusting

which caused by stimulation of the urine volume by antidiuretic
thirst center in the Hypothalamus. hormone (ADH) secreted from
posterior pituitary gland.

48
Problem 1

• A 70 kg male is injected with 1.5 g of mannitol. During the

equilibration period, 5% of the mannitol was excreted/hour. After
two hours of equilibration, the plasma concentration of mannitol
was measured as 9 mg/100 ml.

What body fluid compartment is being measured, and what is its

volume? Is this a reasonable number?

Problem 2

• A 70 kg male is injected with 1.5 g of mannitol and 4 mg of

deuterium oxide. After two hours of equilibration, the plasma
concentration of mannitol was 9 mg/100 ml and for deuterium
oxide was 0.01 mg/dl

What is the volume of ISF?

Problem 3

In a 70 kg male, calculate the average volume of TBW, ICF, and ECF

Problem 4

• An adult female is injected with 500 mg of Evans blue dye.

• After equilibration, the plasma concentration of Evans blue was 16

49
 mg/100 ml.

• Her hematocrit was 35%

• What is the volume of the blood?

Physiological solutions
Mole: molecular weight of the substance in grams
Molarity: the amount of moles of a compound dissolved in 1 liter of
water.
Example:
If the molecular weight of sodium is 23 gm and chloride is 35 gm and
glucose 180 gm so:
1 molarity Na+= 23 gm/L
1 molarity NaCl = 58 gm/L
1 molarity Glucose = 180 gm/L
osmole:The molecular weight of a solute, in grams, divided by the numb
er of ions or particles into which it dissociates in solution.
Osmoles = No. of particles of dissociation. × no. of moles
• For non-ionizing molecules as glucose, urea and inulin: 1mole =
1osmol/L
• For a substance that dissolve into 2 particles as Nacl : 1mole = 2
osmol/L
• For a substance that dissolve into 3 particles as CaCl2: 1mole
=3osmol/L
Osmolarity
The number of osmoles per liter of solution.
The osmolarity of ECF and ICF averages 280 to 300 mosm/L.

50
Osmolality
The number of osmoles per kilogram of solvent.
Tonicity
the osmolality of a solution relative to plasma

Physiological solutions in experiments

The artificially prepared solutions that are used to keep animal tissues
alive outside the body.

51
How?
By providing a homeostatic environment outside the body under
controlled conditions while performing a pharmacological experiment on
isolated tissues.
Role of these solutions
1. To keep the isolated tissues alive
2. To provide nutrients to the tissues
3. Act as a buffer
4. Mimic the body tissue fluid (in ionic composition)
Why not use Pure Water?
• Perfusion of tissues with pure water destroys the cells.
• It draws important crystalloids from the cells
• It also leads to rupture of the cell membrane due to accumulation
of water inside the cells.
Physiological Solutions (IV fluids) in Medical Practice
Physiological solutions are given intravenously for patients as fluid
replacement therapy in cases of:
1. Dehydration
2. Diarrhea
3. Blood or plasma loss

MOST IMPORTANT CRITERIA is isotonicity

The prepared solution should be isotonic to tissue fluid. Alterations in this
principle may lead to loss of function due to shrinkage or swelling

52
53
1. Physiological saline
0.6% sodium chloride solution for frog’s tissues.
0.9% for mammalian tissues.
0.9% NaCl is an Isotonic IV fluid
2. Ringer’s solution
• Ringer's solution typically contains
• NaCl
• KCl
• CaCl2
• NaHCO3
• Sometimes with other minerals such as MgCl2
• The precise proportions of these vary from species to species
• Ringer’s solution is an isotonic IV fluid.
3- Glucose 5% solution
• Isotonic IV fluid
• administered to supply water and to correct an increase in serum
osmolality.
4-Tyrode’s solution
It resembles lactated Ringer's solution, but contains
• magnesium
• sugar (usually glucose) as an energy source
• bicarbonate and phosphate as a buffer instead of lactate.
It must be gassed with oxygen and carbon dioxide when used for cell
culture applications and physiology.

54
55
56
Transport through the cell membrane

Osmosis:
It is the passive flow of water across a semi-permeable
(selectively permeable) membrane down a concentration
gradient of water i.e. from high concentration of water to
low concentration of water or low concentration of solute
to high concentration of solute.

Types of physiological solutions

 Isotonic solution has the same osmolarity as plasma and

causes no change in cell volume e.g. NaCl solution 0.9 %.
 Hypotonic solution has osmolarity less than the plasma which
causes drawing water into the cell resulting in cell swelling.
 Hypertonic solution has osmolarity higher than the plasma
which causes drawing water out of the cell resulting in cell
shrinkage.
- Hyperosmolarity can cause coma called hyperosmolar coma.
- Hypoosmolality can cause convulsions due to swelling of the
neurons.

57
58
Calculation of change in cell volume:
Any change in the cell volume due to change in ECF osmolarity can be calculated from
the following equation.
π i x Vi = π f x V f
Where:
• π i& Vi are the initial osmolarity and volume
• π f & Vf are the final osmolarity and volume
Example
When an RBC with an initial volume of 100 u and a normal osmolarity of 285 mosm/L
is placed in hypertonic solution of 325 mosm/L;
Its final volume will be:
285 x l00 = 325 x Vf
Final volume = (285×100)/325 = 88 u means that the RBC is shrunken.

Osmotic fragility test of red blood cells (RBCs)

Materials:
Distilled water, NaCl solution of a concentration 1gm%, Test tubes and test
tube rack, Pipettes 1 ml and 5 ml.
Procedures:
1. Prepare NaCl solutions (0.9% - 0.1%) in test tubes.
2. Clean your finger with alcohol and dry it.
3. Prick your finger by a sterile needle.
4. Squeeze your finger when a drop of blood appears, put your finger on
the top of the tube. Invert the tube, shake its contents, and allow to
stand for 15 minutes,
5. Repeat this again with each tube.

59
Observations:
When normal RBCs are placed in isotonic solution (0.9% NaCl solution).
water volumes in ICFs and ECFs remain the same (osmotic equilibrium) no
change in cell volume.
When RBCs are placed in a hypotonic solution. water enters cells, cells
swell until they begin to burst (at 0.45% NaCl concentration) releasing
hemoglobin.

Hereditary spherocytosis
Spherocytosis is a hereditary deficiency of a protein in the
membrane of RBCs leading to:
 RBCs become rigid.
 RBCs become more permeable to water.
 RBCs become small and spherical.
SO, for these reasons rupture of RBCs becomes easy.

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In a normal person RBCs start to burst at 0.45% NaCl
concentration, but in patients with hereditary spherocytosis the
RBCs start to burst at 0.65% NaCl.
So, we can use osmotic fragility test in diagnosis of hereditary
spherocytosis.

Sympathectomy
Definition: Interruption of sympathetic supply to an organ

Indications or applications of sympathectomy:

1. Primary hyperhydrosis
2. Raynaud's disease
3. Primary or essential hypertension
4. Chronic pain
Methods:
1. Medical by Botox injection

2. Surgical by cutting sympathetic supply

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 Primary hyperhydrosis
Definition: Excessive sweating that is not always related to
heat or exercise.
 Types:1-Palmar hyperhydrosis
2-axillary hyperhydrosis

Raynaud's disease

 Definition: Recurrent vasospam or vasoconstriction of

fingers and toes and usually occurs in response to stress
or exposure to cold.
 Manifestations:On exposure to cold or stress:

1. Fingers or toes become white.

2. Fingers or toes become blue.
3. Fingers or toes become red.

Marwa, 18 years old medical student, went to the psychologist

complaining from social withdrawal and frequent
embarrassment. During the session, it was found that her main
problem is excessive sweating of her palms that increase with
emotional stress which began with her childhood, but it
became worse in the last years. She described significant
embarrassment related to shaking or holding hands, meeting
new people and, as a result, social withdrawal. She felt anxious
about exams as she had difficulty in handling papers, and tools,
what is your diagnosis?

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 Primary hyperhidrosis

A 15 years old girl suffering from pain and color changes

provoked by cold temperatures or emotional stress in her
fingers usually begin with pallor of her fingers then bluish
coloration with Numbness and pain in the affected area, what`s
your diagnosis?

Raynaud's disease

63
 Application ON CHOLINERGIC RECEPTORS
[I] PARASYMPATHOMIMETICS (ACETYLCHOLINE AGONISTS):
- These drugs exert actions similar to parasympathetic. They include:
A- Drugs acting directly (i.e. directly stimulating cholinergic receptors)
they can directly bind the cholinergic receptors as:
* Acetylcholine, Methacholine

B- Drugs acting indirectly i.e. inhibit cholinesterase enzyme

<<Anticholinestrases>>
- These drugs inhibit true cholinesterase (acetylcholinestrase) and
pseudocholinestrase (butyryl cholinesterase) enzymes preventing
destruction of acetylcholine released from cholinergic nerve fibers
therefore acetylcholine actions become more prolonged and more
marked.
Anticholinesterases are of 2 types:
a) Reversible:
These drugs combine temporarily (short time, few minutes to few
hours) with cholinestrase enzyme e.g.
- neostigmine (prostigmine)
- eserine (physostigmine)
b) Irreversible: These drugs combine strongly and for a long time (few
- Organophosphorus.
They cause massive inhibition of cholinesterase enzyme leading to
irreversible depolarization of motor end plate  paralysis of skeletal
muscles including respiratory muscles  asphyxia  death.

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[II] PARASYMPATHETIC BLOCKERS (ACETYLCHOLINE ANTAGONISTS)
- These are drugs that antagonize action of acetylcholine .
- They include:
A) Parasympatholytics (Muscarinic blockers)
 These drugs block muscarinic actions of acetylcholine by
competitive inhibition.
 e.g. atropine, homatropine.
B) Ganglion blockers
 They block nicotinic action of acetylcholine at autonomic ganglia.
 They are often used to block sympathetic activity but rarely to block
parasympathetic activity.
 Importance: commonly used in treatment of hypertension.
 e.g. of ganglion blockers:
T.E.A. (Tetra ethyl ammonium) and large dose of nicotine and
anticholinesterases (large dose).
C) Neuromuscular blockers
a- Presynpatic block
Drugs inhibiting the release of acetylcholine from motor nerve
endings. e.g. Botulinium toxin  interfere with synthesis and release of
acetylcholine  muscular paralysis.
b- Post synaptic block
Drugs preventing the action of acetylcholine on motor end plate.
These are either: curare or succinylcholine.

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 Application on adrenergic receptors
[I] Sympathomimetics (sympathetic agonists)
- These are substances that exert actions similar to sympathetic
stimulation.
- These drugs may act by one of the following mechanism:
(A)Drugs directly stimulating adrenergic receptors:

 
1 2 1 2
Adrenaline Adrenaline
Phenylephrine Salbutamol
(B) Drugs indirectly stimulating adrenergic receptors causing release of
noradrenaline from its stores at postaganglionic sympathetic nerve
endings e.g. Amphetamine.
(C) Drugs-acting by both mechanisms (Direct and indirect) i.e. dual effect
on adrenergic receptors.
e.g. ephidrine.
[II] Sympatholytics, Sympathetic blockers (adrenergic antagonists)
- Sympatholytics are drugs which block the action of sympathetic nervous
system.
- They include:
(A) Adrenergic receptor blocking drugs
- These are substances which combine with adrenergic receptors ( or )
to prevent the action of catecholamines
 
1 2 1 2
Phentolamine Propranolol (inderal)

66
(B) Adrenergic neuron blocking drugs
* These are substances interfere with their synthesis, storage and
release e.g.
Drug Mechanism of action
- Methyl DOPA (aldomet) Prevent synthesis
- Reserpine Prevent storage
- Guanithidine Prevent release.
N.B.: Ganglion blockers block the transmission of nerve impulse through
autonomic ganglia, thus, block both sympathetic and parasympathetic
activity.

67
 Horner's syndrome
• Def: It is a group of signs which results from interruption of sympathetic to head and neck.

• Side: at the same side of the lesion.

• Causes:

* Lesion in T1 and T2 segments.

* Lesion in SCG by disease OR experimentally by section in cervical sympathetic

chain.

• Signs:

1- Ptosis (i.e., dropping of upper eye lids) due to paralysis of superior tarsal muscles.

2- Miosis (i.e., constriction of pupil) due to paralysis of dilator pupillae muscle.

3- Anhydrosis (i.e., absence of sweat secretion): dryness of affected side of the

face.

4- Enophthalmos (i.e., sinking of eye ball into orbit) due to paralysis of Muller's
muscles.

5- Vasodilatation of skin blood vessels, due to loss of sympathetic vasoconstrictor

tone, so the skin becomes red and warm.

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Ptosis Miosis
69
 Fight & Flight
Divisions of autonomic nervous system:

Sympathetic parasympathetic

Fight or Flight Rest and digest

E division: D division:

 Exercise  Digestion
 Excitement  Defecation
 Emergency  Diuresis
 Embarrassment

We have two types of sympathetic discharge:

- Mass discharge:

 Occur when sympathetic nervous system discharges almost as a complete unit.

 Widespread response thought-out the body which prepares the individual for fight or
flight.

 Occurs in emergency conditions e.g. Severe muscular exercise, fear, flight.

- Isolated discharge: as sympathetic supply to hand during writing.

Fight & Flight: body’s response to perceived threat or danger, it includes:

- Hormonal: like adrenaline and cortisol.

- Nervous: sympathetic nervous system.

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 1. Stress causes sympathetic nervous signals to adrenal medulla.
2. Adrenal medulla release Catecholamine in blood stream.
3. Fight or flight response causes changes in multiple parts of the body.
Sympathetic effect

Effect Role

Pupil Dilatation to take in as much light as possible

Heart rate increase Pump more blood to the active

& Pressure organs.

Smooth muscle Relaxes (bronchodilatation) ↑ R.R in order to allow more oxygen

of airways into the lungs.

Liver Glycogenolysis Increase the blood-glucose level.

skin send more blood to major Responsible for the "chill" sometimes
muscle groups associated with fear.

Muscles tense up energized by adrenaline and glucose

(responsible for goose bumps when
tiny muscles attached to each hair on
surface of skin tense up, the hairs are
forced upright, pulling skin with them)

Nonessential (Like digestion and immune to allow more energy for emergency
systems system: shut down functions

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- Fight or flight response usually, it’s natural, healthy, and not a problem.

- Relaxation response can be triggered by using relaxation skills, such as deep breathing
or progressive muscle relaxation.

Biofeedback
- Biofeedback completes the loop between autonomic functions and conscious
awareness.

- Biofeedback training: learning process where people exert conscious control over
physiological function controlled by autonomic nervous system.

- With biofeedback, you're connected to electrical sensors that help you receive
information (feedback) about your body (bio). Biofeedback gives you the power to use
your thoughts to control
your body, often to
improve a health
condition or physical
performance.

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Types of biofeedback:

1- Brain waves: uses scalp sensors to monitor your brain waves using an
electroencephalograph (EEG).

2- Heart rate: sensors placed on your chest, lower torso or wrists use an
electrocardiograph (ECG).

3- Muscle contraction: placing sensors over your skeletal muscles with an

electromyograph (EMG) to monitor the electrical activity that causes muscle
contraction.

4- Sweat gland activity (EDA): Sensors attached around your fingers or on your palm
or wrist with an electrodermograph (EDG) measure the activity of your sweat glands
and the amount of perspiration on your skin, alerting you to anxiety.

5- Breathing: bands are placed around your abdomen and chest to monitor your
breathing patterns and respiration rate.

6- Temperature: Sensors attached to your fingers or feet measure blood flow and temp
of your skin.

Examples of diseases we can handle by Biofeedback mechanisms:

 Anxiety or stress.

 Chronic pain.

 Headache.

 High blood pressure.

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 Transport across cell membrane & Excitability
Types of transport:
1- Diffusion (passive transport): Movement of substances across the cell membrane
down its electrochemical gradient.

2- Active transport

3- Vesicular transport

Diffusion through the protein channels:

 Protein channels are watery pathways through the interstices of the protein
molecules

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 Leak ion channels Chemical-gated Voltage-gated
ion channel ion channel

Open in Always open Chemical substance Changes in cell

response : bind to its receptor membrane potential

Example: K+ channels K+ and Na+ channel at Na+ and K+ channels

neuromuscular junction

Importance: Resting membrane Graded membrane Action potential

potential.
potential e.g. motor
end plate potential

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 Factors affecting Excitability and conductivity of nerve fibers
1) Physical factors:

a) Thermal b) Mechanical

Warming: ↑es the excitability and conductivity by Deep pressure ↓es the
increasing the kinetics of ions leading to rapid excitability and conductivity
depolarization and repolarization of type A nerve fibers.

Cooling: ↓es the excitability and conductivity.

 It ↓es the metabolic reactions needed for the Na-K

pump → accumulation of the Na ions inside the
nerve fibers → loss of the RMP.

76
2) Chemical factors:

A) Local anesthetic drugs: e.g. cocaine, novocaine and xylocaine

decrease the excitability of nerve fibers by:
block Na channels and prevent depolarization.

B) Ions: Ca ions Na ions K ions (ECF)

Excitability: ↓ ↑ ↑

Cause: block Na channels Facilitating the process ↓ K efflux →↓es RMP

→↓es the membrane of depolarization. & When decrease
permeability to Na →↑es efflux of K ions
to outside producing
hyperpolarization→↓e
s excitability

C) H ion concentration:

Alkalinity→↓es free Ca→↑es excitability.

Acidity →↑es free Ca→↓es excitability.

D) O2 lack and CO2 excess: decreases excitability.

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3) Electrical factors:

Electrotonus: means the electrical and excitability changes which occur in the
nerve membrane due to its stimulation by a constant galvanic current of
subthreshold intensity.

Catelectrotonus Anelectrotonus

Def.: changes which occur at the region changes which occur at the region
of the cathode of the anode

Mech.: RMP decreases by addition of RMP increases by addition of more

negative charges to the outer +ve charges on the outer surface of
surface of the membrane i.e. the membrane i.e. localized area
localized area of depolarization. of hyperpolarization.

Excitability: • ↑ed excitability. - ↓ed excitability.

• So, weaker stimuli - So, stronger stimuli (more than

(subthreshold( can excite the threshold) are needed to excite
nerve fibers. the nerve fibers.

78
79
 Nerve block
Definition: failure of conduction of nerve impulses from one place to another.
• It also means failure of excitability of the nerve fibers.
-There is no generation or propagation of nerve impulses.

Methods of producing nerve block:

1) Physical methods: -Thermal: Sever cooling.

- Mechanical methods: -Application of pressure on the nerve

-Injury or crushing of the nerve fibers.

2) Chemical methods (membrane stabilizers):

- Local anaesthetic drugs

- Increased Ca ions

- Decreased Na ions

- Decreased K ions

3) Electrical causes: strong anelectrotonus.

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 Nerve conduction velocity
Action potential is usually propagated without decrement in amplitude or velocity.

Types of Nerve Fibers:

Type A Type B Type C

Thick myelinated Thin myelinated Unmyelinated

Diameter: (2 – 20 µm ) (1 – 3 µm ) (0.5 – 1 µm )
20 2 1

Velocity: ( 15 – 120 m/sec ) ( 3 – 15 m/sec ) ( 0.5 - 2 m/sec )

100 10 1

Subdivided: A alpha (α); beta (β)

gamma (γ) and delta
(δ).

81
Factors affecting velocity or speed of the propagated (conducted) nerve impulse:

• Diameter of the nerve fiber

• Presence of a myelin sheath

- The fastest nerve fibers have large diameters and are myelinated;
for example, the motor nerve fibers that supply skeletal muscles.

- The slowest nerve fibers have small diameters and are unmyelinated; for
example, sensory nerve fiber from the stomach.

Types of conductions:

1- Continuous conduction.

2- Saltatory conduction: Faster d2 presence of myelin sheath.

- Ion channels present at the nodes of Ranvier allow the movement of

sodium and potassium ions across the membrane.

- Action potential moves from node to node by jumping.

This is referred to as saltatory conduction and is much quicker than the
continuous conduction.

82
Clinical application: Multiple sclerosis (MS):

- Autoimmune disorder causing damage of the myelin sheath and failure to

conduct nerve impulse.

- Pathology: Myelin sheath degeneration.

Nerve conduction Velocity

Name of experiment: Nerve conduction Velocity.

Name of devices:

1- Stimulator.

2- Biopac

3- Stimulator probe.
cathode: black

Connections:

1- Channel one: to stimulator

2- Channel two: 3 electrodes (Red, white & black)

83
Positions of electrodes:

Sites of stimulation:

84
Uses of this experiment:

- Nerve conduction study (NCS) is an electro-physiological test commonly used to

evaluate the function of peripheral nerves whether sensory or motor nerves.

- As in (along with electromyography) :

- Nerve and muscle function: in nerve compression, when there is pain in

the limbs, weakness.

- Carpal tunnel syndrome.

Principle:

1- Velocity = distance / time

2- Distance: between site of stimulation and site of response.

- Response obtained by: recording the motor (EMG) response of a muscle.

3- Nerve stimulated: Ulnar nerve.

4- Muscle evaluated: abductor digiti minimi.

5- Stimulation occurs at two sites: as we need to measure velocity of nerve itself.

And so overcome synaptic delay at neuromuscular junction d2 release of
neurotransmitter, binding to receptors, end-plate potentials, etc.

6- Duration: Delta T in seconds: from the start of stimulus to the start of the
response waveform for each site.

85
 7- A response may be indicated by involuntary twitching of the fingers.

8- The response may have one or two upward peaks followed by a downward
deflection.

9- Curve ‫األحمر‬: measure electrical activity in ulnar nerve.

10- Curve ‫األزرق‬: measure electrical activity in Abductor digiti minimi

Calculation

- NCV= Distance/Duration.

- NCV = Distance between S2 and S1 / (Delta T for S2 - Delta T for

S1 ) in M/Sec.

86
 Microtechniques
Methods by which tissue is transformed into hard substance to be cut into thin
sections.

 Preparation of Tissue for Light Microscopic Examination

Types:
a. Paraffin Techinque:
- Advantages: easy and rapid
- Disadvantages: not suitable for studying fat or enzymes (due to xylol and
heat).

a. Specimen (Tissue collection) (small specimens)

b. Fixation
Fixatives are chemicals used to preserve the shape and structure of the
specimens

Example: 10% formalin

87
Effect:
1. Destroy the enzymes that cause autolysis and bacteria that cause
putrefaction
2. Harden the tissue
3. Increase affinity of tissue to stain

c. Dehydration

d. Clearing

e. Paraffin impregnation and embedding

g. Sectioning (Using Microtome)

The sections floated on warn water, then are picked on glass slides.
Then slides are kept to dry in an incubator

88
 Staining different components in the cells

Steps of Staining
1. Deparaffinize in xylol
2. Hydrate in descending grades of alcohol
3. Stain in H. for 2 min
4. Blue section in tap water
5. Stain in Eosin for ½ min
6. Wash in distilled water
7. Dehydrate in ascending grades of alcohol
8. Clear in Xylol

89
90
 Microscopy
Types of Microscopes:
1. Light microscope student microscope
Magnification 40, 100, 400, 1000
2. Electron microscope
Magnification up to 50.000 times
a. Transmission Electron microscope:
 The image appears in white, black colors and shades of grey.
 Dark components in the electron micrograph are called electron
dense
 White components are called electron lucent
b. Scanning Electron microscope:
Allows 3 dimensional visualization of the surface of a fixed specimen.

91
 Membranous Cell organelles
Cell membrane
EM:
- Cell membrane is trilaminar (outer
and inner electron dense separated
by electron lucent layer).

Mitochondria
EM:
- Membranous vesicles surrounded by double membranes.
- The outer membrane is smooth while the inner one shows shelf like projections
called cristae.
- The matrix is moderate electron dense.

92
 Rough endoplasmic reticulum
EM:
- Parallel flattened membranous cisternae.
- Electron dense granules (ribosomes) attached to the outer surface.

Smooth endoplasmic reticulum

EM:
- Narrow membranous tubules.
- Smooth outer surface (no ribosomes).

93
 Golgi apparatus
EM:
- Membranous cell organelle
- Composed of 3 components:
1. 4-10 flattened membranous saccules forming a stack.
2. Transfer vesicles (microvesicles)
3. Secretory vesicles (macrovesicles)

Primary and secondary lysosomes

 1ry lysosomes are spherical
and small with homogenous
electron dense granular core.
 2ry lysosomes are spherical
and larger than 1ry
lysosomes with
heterogenous electron dense
granular core.

94
 Heterolysosomes
EM:
 Cytoplasmic membranous vesicles
containing heterogeneous
electron dense core
 Formed by union of phagosome +
primary lysosome
 Heterolysosomes with Undigested
contents is called (residual
bodies).

Multivesicular bodies
EM:
 Cytoplasmic membranous organelle enclosing a number of small pinocytotic
vesicles.
 Formed by union of primary lysosome + pinocytotic vesicles.

95
 Autophagic vacuoles
EM:
Cytoplasmic membranous vesicles containing dead mitochondria, effected RBCs or
endoplasmic reticulum.

Peroxisomes
LM: H&E: cannot be seen.
EM:
- Cytoplasmic spherical membranous vesicles.
- Surrounded by a single unit membrane and contain moderate electron dense
finely granular material.
- They have a more electron dense semicrystalline core called nucleoid.

96
 Non membranous organelles
Ribosomes
EM:
 Electron dense granule.

 Polyribosomes: Electron

dense granules attached

together by thin electron

dense Filament of mRNA

forming whorl's figures.

97
 Microfilaments
EM:
Shape: slender rods.
Site: The microvilli show longitudinally arranged actin microfilaments

Microtubules
EM:
 Appear as hollow tubules.
 In cross section, appear as tiny
circles.
 The wall consists of 13
protofilaments.

98
 Pair of centrioles
 The two centrioles appear as short cylinders which are perpendicular to each
other i.e. one is cut L.S. and the other T.S.

LS
TS

Centriole (T.S)

Centriole T.S
E.M:
 The wall of the centriole is
composed of 27 microtubules
arranged in 9 peripheral
bundles.
 Each bundle is formed of
3 microtubules called triplets
 No central singlet

99
 TS in the shaft of cilia
E.M.:
Cross section of the shaft of each cilium contains 20 microtubules arranged in:
-9 peripheral doublets and 2 single central microtubules.

Scanning EM of Cilia and microvilli

Shows a 3 dimensional picture of:
- Cilia; larger in size and longer
- Microvilli (MV); smaller in size and shorter.

100
 Cell inclusions
Glycogen granules
LM:
- Site: Hepatocytes
- H&E Stain: glycogen is dissolved during preparation leaving empty vacuoles
- Best’s carmine: red.

E/M: glycogen granules appear in two forms:

A. Alpha glycogen particles: B. Beta glycogen particles:
- They are found in liver cells. - They are found in muscle
- They appear as aggregated fibers.
electron dense particles - They appear as single electron
forming rosettes. dense granules.

101
 Lipid globules

LM:
 H & E: empty spaces
 Special stains: (fresh frozen sections)
- Sudan III: orange
- Sudan black:  black

102
 The Nucleus
LM: Shape of the nucleus

LM: Appearance of the Nucleus

EM: Appearance of the Nucleus

103
EM structure:
1. Nuclear membrane
2. Peripheral chromatin
3. Nucleolus
4. Nuclear sap

104
 Nuclear membrane
The nuclear membrane consists of:
 Outer membrane: Continuous with rER.
 Inner membrane: Chromatin is attached to it.
 The two membranes are interrupted by many nuclear pores covered by a
diaphragm and separated by perinuclear space.

Epithelium
Simple squamous epithelium
Simple squamous epithelium appears as a single layer of flat cells with
central flat nuclei.

105
 Simple cubical epithelium
Simple cubical epithelium is formed of a single layer of cubical cells with
central rounded nuclei.

Simple columnar secretory epithelium

Simple columnar secretory epithelium is formed of single layer of
columnar cells with basal oval nuclei and vacuolated cytoplasm.

106
 Simple columnar absorptive epithelium
with goblet cells
 Simple columnar absorptive epithelium is formed of single layer of columnar
cells with basal oval nuclei and apical brush border.
 Goblet cells are present between the columnar cells.

Pseudostratified columnar ciliated epithelium

with goblet cells
 Pseudostratified columnar ciliated epithelium is formed of single layer of
crowded columnar cells with their nuclei appear at different levels
 Cilia project at the free surface of cells.
 Goblet cells are present between the columnar cells.

107
 Stratified squamous keratinized epithelium
 Stratified squamous keratinized epithelium has a wavy basement membrane
and is formed of:
 Basal layer of columnar cells with basal oval nuclei.
 Intermediate layer of polyhedral cells with rounded nuclei.
 Top layer of squamous cells with flat nuclei covered by layer of keratin.

Stratified squamous non-keratinized epithelium

Stratified squamous non-keratinized epithelium has a wavy basement membrane:
 Basal layer of columnar cells with basal oval nuclei.
 Intermediate layer of polyhedral cells with rounded nuclei.
 Top layer of squamous cells with flat nuclei.

108
 Transitional epithelium
Transitional epithelium has an ill-defined basement membrane and is formed of:
- Basal layer of short columnar cells with basal oval nuclei.
- Intermediate layer of polyhedral cells with central rounded nuclei.
- Top layer of cubical cells with central rounded nuclei.

109
 Neuroepithelium
 The taste buds appear as oval pale structures.
 It is formed of 3 types of cells:
- Sensory cells. - Supporting cells. - Basal cells.

Connective tissue
White fibrous C.T

White fibrous C.T. is formed of parallel collagenous fibers and

fibroblasts are present between them.

110
 Yellow elastic C.T. (Van Geison’s stain)

Yellow elastic C.T. is formed of yellow elastic fibers and fibroblasts are
present between them.
Elastic fibers are stained yellow with van Geison’s stain

White adipose C.T.

White adipose C.T. is formed of lobules of fat cells with peripheral flat
nuclei (signet ring appearance).

111
 Mucoid C.T. (Umbilical Cord)

The umbilical cord is formed of 2 umbilical arteries and one vein.

The mucoid C.T. is present between them.

112
 The Skin
Thick Skin
1. Thick epidermis formed of:
- Stratified squamous epithelium.
- Covered with very thick horny layer.
2. The dermis contains:
- Numerous sweat glands.
- No hair, hair follicles or sebaceous glands.

Layers of the epidermis:

1. Basal cell layer
2. Prickle cell layer
3. Granular cell layer
4. Clear layer
5. Horny layer

113
 Layers of the dermis:

1. Papillary layer
2. Reticular layer

Thin Skin
1. The epidermis:
 Epithelium: Stratified squamous keratinized epithelium with thin horny
layer
2. The dermis contains:
 Hair follicles cut in different directions, sebaceous glands and few sweat
glands.

114
Differences between thick & thin skin

115
 Laboratory Safety
Safe working protects:
– You
– Other lab workers
– Cleaners
– Visitors
– Your work
General Lab Hazards:
1. Biological: exposure to blood and body fluids and specimens that may
contains pathogenic bacteria and viruses.
2. Chemical: acids, alkalis and toxic chemicals.
3. Radiological: ineffective radioactive waste disposal.
4. Accidents: Fire and electrical.

How to do a Risk Assessment?

– Determine hazards and evaluate risks
– Use all relevant available data
– Determine controls needed to minimise those risks
– Document the assessment
– Agree it with your supervisor
– Use those control measures
Control Measures (in order of preference):
1. Use a less risky substance
2. Use a safer form of that substance (e.g. solution instead of powder)
3. Totally enclose the process (e.g. a glove-box)
4. Partially enclose the process (e.g. with a fume cupboard)
5. Ensure good general ventilation
6. Safe systems of work
7. Reduce exposure times, increase distance, reduce volumes
8. Personal protective equipment (as a last resort for primary protection

116
General Safety Rules:
1. Read instructions carefully before starting your experiment.
2. Wear a protecting lab coat, hand gloves, face mask and hair cap.
3. After handling chemicals, always wash your hands with soap and water.
4. During lab work, keep your hands away from your face.
5. Never mix chemicals together unless you are told to do so.
6. Notify your teacher if any spills or accidents occur.
7. Clean up your lab area at the end of your experiment.

Protecting yourself:
- Wear the clothing and protective wear identified in your risk assessment.
- Laboratory coats must be kept fastened.
- Don’t wear sandals or open shoes.
- Long hair must be tied back.
- Remove your gloves before using instruments, telephone, and leaving the
laboratory

Laboratory hygiene:
- Never eat, drink or smoke in a laboratory
- Never apply cosmetics
- Never touch your face, mouth or eyes
- Never suck pens or chew pencils
- Always wash your hands before you leave and especially before eating.
117
General Tidiness:
- Keep your workplace tidy
- Clear up waste, deal with washing up and put things away as you finish
with them
- Make sure everything is safe before you leave.
- A tidy laboratory avoids accidents to everyone

Laboratory Equipment:
- Never use any laboratory equipment unless you are trained & have
been authorized to do so.
- As well as injuring yourself you may cause very costly damage.

92
 First Aid:
 All laboratory workers should undergo simple first aid training:
- For ALL chemical splashes, wash with plenty of water for 10
minutes
- Control bleeding with direct pressure, avoiding any foreign
bodies such as glass
 Report all accidents to your supervisor or doctor.
 Burns: Immediately flush with cold water.
 Cuts, bruises: Do not touch an open wound without safety gloves.
Pressing directly on minor cuts will stop bleeding in a few minutes.
Apply cold compress to bruises to reduce swelling.
 The eyes: Flush eyes immediately with plenty of water for several
minutes. If a foreign object is lodged in the eye, do not allow the eye
to be rubbed.

Protecting your health:

 If you have an allergy to lab materials or suffer from a medical
condition which may affect you in the laboratory (e.g. diabetes or
epilepsy), ensure that your doctor knows

93
 Detection of Glucose in Body Fluids

Case Scenario
Alia is a 40-year-old lady, complaining of Thirst, increase frequency of
urination and weight loss despite eating too much. She was presented to
outpatient clinic.
 What is your provisional Diagnosis?
 Suggest the biochemical tests done by the internal medicine and lab
doctors and mention their principle?

Blood glucose or blood sugar?!

 Glucose is referred to as “blood sugar” because it circulates in
bloodstream as a source of readily available energy.
 It is also stored in the body as glycogen for energy reserves during
times when sufficient glucose may not be available in the blood.

94
 Principle of Glucose Measurement:
{Glucose Oxidase Method}

LAB techniques based on glucose oxidase method:

1. Glucometer.
2. Urine dipstick test.
3. Colorimeter.

1. Glucometer (Glucose meter):

 It is a simple method of monitoring blood sugar at home.
 Most glucometers use an electrochemical method. They analyze a
drop of capillary blood.
 The glucose in the blood reacts with an enzyme electrode containing
glucose oxidase.

95
Requirements:
 Glucometer (Glucose Meter)
 Test strip
 Lancet device
 Needle (Lancet)
 Alcohol swab
 Dry swab

Steps of measurement:

96
 Wash your hand with soap and water (before and after).
 Take one finger with an alcohol swab.
 Press the lancet device against the side of your finger.
 To release the needle, push the button.
 Squeeze your finger to get a drop of blood.
 Touch the end of the glucometer strip to the drop of blood.
 Over the puncture site, apply a dry swab.
 The level of your blood glucose level is displayed.

97
Comment on the providing readings?

98
 2. Urine Dipstick Test (Urine Test Strips):
 The urine dipstick test is the quickest
way to test urine.
 Plastic strips have pads impregnated
with chemicals that react with the
compounds present in urine producing
a characteristic color.
 In case of glucose detection, Active
reagents are Glucose oxidase and
peroxidase.
 The chemicals in the pads indicate the
presence of specific substances in the
urine such as glucose, protein, blood ,
etc. The strips can also indicate the pH
and specific gravity of the urine.

99
Steps:
1. Fill a sterile specimen container with urine.
2- Dip the test strip into the urine at the thick
end.
2. Once saturated, remove it from the
container. Drag the strip along the edge of the
container. Then Use an absorbent material e.g
Filter paper, to soak up the excess urine.
3. Wait 1-2 minutes to read the test strip results.
4. Compare the test squares to the color chart
and interpret the results (The color chart
values are mg/dl for glucose).
- Normally, Test result is negative. No glucose
should be detected in urine (trace
amount).
- If test is positive, this means urine
contains glucose (glucosuria) and
this occurs when blood glucose
level exceeds the renal threshold
for glucose (> 180 mg/dl) or in
case of diseased kidney.

100
Could you interpret the result?

101
3. Colorimeter:

 A colorimeter is used to determine the concentration of

compounds in solution.
 Certain reagents are added on the biological samples to produce
colored products when certain compounds are present in the
sample.
 Then by measuring the absorbance of the colored products at a
specific wavelength of light, the concentration can be calculated.
 N.B: colored solutions can absorb lights at certain wavelengths.
 The amount of light absorbed is proportional to the solute
concentration present in solution.
 Based on Glucose Oxidase method, the intensity of the colored
product is proportional to the glucose concentration and is
measured photometrically between 490 and 540 nm.

102
Non-Invasive Glucose Monitoring Devices
(Diabetic watch)

Could you interpret the results?

103
 Identification of protein in Body Fluids
Case Scenario
A 68 years old Diabetic patient presented with whitish foam in urine, nausea,
vomiting, swelling of both ankles and the face with puffy eye lids. His blood
glucose levels are uncontrolled over the last 10 years, you expected the white
foam is due to protein in urine.
 What is your provisional diagnosis?
 Suggest suitable biochemical tests to be done for detection of
albuminuria.

Body Fluids Protein

 Biological fluids (Serum, Plasma, Cerebrospinal fluid, Urine, Bile,
Synovial fluid, Tears, Saliva and Amniotic fluid) are in close contact
with the tissues.
 Protein analysis of human body fluids is important as disease
biomarker because the protein components of the tissues may be
liberated and affected by diseases.

104
Principle for Protein Identification:
 “Biuret method”.
 The principle of the Biuret
method is based on the binding of
Cu2+ to the N atoms involved in
peptide bonds.
 The formation of copper-protein
complex requires two peptide
bonds in an alkaline media and
produces a violet-colored product.
 The intensity of the violet color is proportional to the number of
peptide bonds which reflects protein concentration.
 This method cannot detect urine or cerebrospinal fluid protein except
in high concentrations only.

105
 1. Plasma Protein Measurement:
 The normal range for total plasma protein is 6.0-8.0g/dl.
 There are different types of plasma protein (Albumin , globulin and
fibrinogen)
 Albumin composes 50%-60% of blood plasma proteins. The normal
range for plasma albumin is 3.5 to 5.5 g/dl.

Colorimetric assay:
 The Biuret test is a traditional method
used to determine the plasma protein
concentration (reference method).
 The measured absorption of the
wavelength 540 nm is proportional to the
concentration of total plasma protein.

106
About Colorimeter:
 A colorimeter is used to determine the concentration of compounds in
solution.
 Certain reagents are added on the biological samples to produce
colored products when certain compounds are present in the sample.
 Then by measuring the absorbance of the colored products at a
specific wavelength of light, the concentration can be calculated.
 N.B: colored solutions can absorb lights at certain wavelengths.

Detection of specific Plasma Protein:

A. Plasma Protein Electrophoresis:
 This method depends on the different mobility of proteins in the
electric field.
 In an alkaline media, proteins migrate from the cathode (-) to the
anode (+).
 Six fractions of plasma proteins can be distinguished by protein
mobility: albumin, α-1, α-2, β-1, β -2 and γ globulins.

107
 B. Immunochemical Methods: e.g. ELISA.
 These methods are the most accurate and are depending on the
reaction of the protein with the specific antibody for detection of
proteins present in very low concentrations.

2. Urinary Protein (albumin) Identification

 Normally very little protein is found in
urine. A normal total protein amount
in urine is <150 mg/day while albumin
in urine is <20 mg/day.
 The determination of protein
(albumin) is one of the most
important basic urine examinations,
since it can reveal a developing renal
pathology at an early stage.

108
Urinary protein (albumin) could be detected by:
a. Urinary test strips.
b. The Biuret test.
c. Heat coagulation test.
d. Colorimetric and Immunochemical methods

A. Urine test strips for protein

 Active reagent: Tetra-bromophenolblue (<1%).
 The indicator color changes to green when proteins are present in
urine. It is highly sensitive to albumin and less sensitive to hemoglobin
and globulins.
 The strip usually captures albumin concentrations over150mg/dl.

109
B. Biuret Test for albuminuria

110
C. Heat Coagulation Test for albuminuria
 Fill ¾ of a test tube with clear urine. Heat the upper 1/3 of the urine
only . Do not boil.
 The development of turbidity may be due to coagulation of proteins
or due to phosphates.
 Add a few drops of 10% acetic and if turbidity persists it is due to
proteins while the phosphates will dissolve.

111
 DNA Extraction
Definition:
Isolation of DNA by breaking the cell membrane and nuclear membrane with
the help of chemicals, enzymes or physical disruptions is defined as DNA
extraction.

Importance of DNA Extraction:

DNA extraction is the first step for subsequent molecular or forensic analysis.
The extracted DNA is used for:
1. Rapid detection of genetic disorders in a patient.
2. Analysis of forensic evidence.
3. Study of a gene involved in cancer.
4. DNA fingerprinting to identify individuals (e.g. Paternity test).

112
Samples for DNA Extraction:
DNA can be extracted from any living or dead organism.Common sources for
DNA isolation include:
1. Body fluids (Blood, Urine, Saliva, Semen)
2. Tissues
3. Bones
4. Nails

5. Buccal swabs (swabbing the inside of cheeks(

6. Hair (follicles and shafts)

DNA extraction methods:

113
Spin-column DNA extraction
 Type: Chemical DNA extraction (inorganic)

 Sample: Any biological sample

 Purity of DNA: Excellent (~1.8(

 Yield of DNA: Good

 Principle: DNA extraction by Spin-column is based on binding of DNA

molecules to silica-gel membrane in the presence of certain salts and
under certain pH conditions.

 Procedure:
1. Lysis of blood cells using lysis buffer.
2. Binding of DNA to the membrane of spin column.
3. Wash: using wash buffer.
4. Elution of pure DNA.

114
Procedure of Spin-column DNA extraction:

Spin-column

Extraction of DNA from whole blood sample:

I. Components of DNA Extraction Kit:
1. Proteinase K (optional)
2. Lysis Buffer
3. Wash Buffer 1, 2
4. Elution Buffer
5. Spin Columns
6. Collection Tubes
II. Protocol of DNA
Extraction from blood

1. Cell Lysis:

 Pipette 300 µL of whole blood in an Eppendorf (1.5 ml centrifuge tube),

then mix by vortexing.

115
 Add Lysis Buffer, then mix well by vortexing.

 Incubate sample at 56°C for 15 minutes in a heat block or warm water

bath with frequent mixing (i.e. invert the tube every 3 min.)

 Add ice cold absolute ethanol and mix by pipetting and vortexing.

2. DNA binding to silica-gel membrane:

 Transfer the prepared mixture to a spin column with collection tube.

 Centrifuge, replace the collection tube by a new one.

3. Membrane washing:

 Add wash buffer 1 to the spin column and centrifuge.

 Discard the flow-through.

 Add wash buffer 2 to the spin column and centrifuge.

 Discard the flow-through and centrifuge the empty spin column to dry it
from residual ethanol.

4. Elution of DNA:

 Replace the collection tube by a new eppendorf for DNA elution.

 Add 50-100 μl of elution buffer to the center of the silica-gel membrane,

incubate for 2 minutes at room temperature, and then centrifuge.

 Discard the spin column and store DNA at -20°C.

116
Required Equipment:
1. Centrifuge /microcentrifuge.
2. Vortex
3. Heat block
4. Automatic pipettes
5. Tips
6. Eppendorf

117
Determination of DNA concentration and purity:
 NanoDrop Spectrophotometer is used for measurement of both
concentration and purity of DNA samples.

Nanodrop
 The concentration of DNA is assessed by measuring the absorbance at
260 nm.
 The purity of DNA is assessed by measuring two absorbance ratios:

1. A260 / A280 = ~1.8

2. - A260 / A230 = 2.0 – 2.2

118
Assessment of DNA integrity:
The integrity of DNA is assessed by agarose gel electrophoresis.

119
 Genetics: DNA Identification, Electrophoresis
DNA identification techniques:
Probe based techniques:
1. Blotting techniques
2. DNA microarray (DNA Chips
3. DNA sequencing.
Electrophoresis:
 Definition
 Principle
 DNA separation:
- Gel electrophoresis apparatus
- Process of gel electrophoresis
Probe based techniques
 The properties of probe:
- Single-strand of DNA or RNA.
- Complementary to specific sequences (target sequences) and can base
pair with it (hybridization).
- Labeled with radioactive or fluorescence label.

120
 1. Blotting techniques:
 Blotting is the process of separating biological macromolecules by size,
usually through gel electrophoresis, and then transferring them to a
solid membrane.
 After transfer, a specific probe is used for detection of the molecule of
interest.

2. DNA microarray (DNA Chips):

 Thousands of arranged spots on a glass chip, each representing a single
gene.
 Produce a ‘‘genetic portrait’’ by screening for thousands of genes
simultaneously using specific probes.

121
 3. DNA sequencing:
 Determination of the sequence of bases in a given DNA molecule.
Methods:
1. Conventional DNA sequencing
methods:
- Maxam-Gilbert sequencing
- Sanger sequencing
2. Automated DNA sequencing.

Electrophoresis
Definition:
 Electrophoresis is an essential technique
for separation and analysis of charged bio-
macromolecules (as DNA, RNA, and
proteins) and their fragments, under the
influence of an applied electric field.

Principle:
 Gel electrophoresis uses a supporting
media (gel) with pores through which the
migration and separation of molecules occur.

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 The rate of migration depends on several factors, mainly the charge and
size of the molecules.
 According to charge, the +ve charged particles (cations) move to cathode
(-) and –ve charged particles (anions) to anode (+).

 According to size, smaller molecules migrate more rapidly than the

larger molecules.

123
DNA separation:

 The fixed –ve DNA charge makes the separation of the DNA chains to
occur on the basis of the molecular size (bp).

124
Gel electrophoresis apparatus:

125
  Casting tray: is made up of glass or plastic.
 Comb: contains number of teeth to form the wells.
 Buffer solution: for passage of electric current and maintenance of a
relatively constant pH.

Supporting media (gel):

1. Agarose (agarose gel electrophoresis).
2. Polyacrylamide (Polyacrylamide gel electrophoresis, PAGE).

The used type of supporting media depends on type of molecules to be

separated.
 Because the pores of an agarose gel are large, agarose is used to
separate macromolecules such as larger DNA molecules, large proteins
and protein complexes.
 Polyacrylamide, which makes a small pore gel, is used to separate most
proteins and smaller DNA molecules (Very efficient separation).

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Process of gel electrophoresis:
1. Gel preparation:
 Agarose is a heteropolysaccharide, available as a white powder which
dissolves in near-boiling water (buffer), and forms a gel when it cools.

Process of gel electrophoresis

127
128
 2. Agarose solution is poured into the casting tray (with the combs) and
allowed to solidify.

3. Setting up the electrophoresis chamber.

4. The wells are loaded with few μls of sample, using pipettes.

5. Turning on the power supply (30-60 mins).

Gel electrophoresis

Visualization of DNA bands:

 DNA fragments of the same length form a "band" on the gel, which can
be seen by eye if the gel is stained with a DNA-binding dye (ethidium
bromide).
 UV-trans-illuminator is used to visualize the stained product.

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For gel electrophoresis, two dyes are used:
1. Ethidium bromide (EtBr): It is used for visualization of DNA using a UV-
transilluminator. The mode of binding of EtBr is intercalation between
DNA base pairs.

2. Loading dye (as Glycerol & bromophenol blue): It is mixed with DNA
samples and generally contains a dye to assess how "fast" the gel is
running and a reagent to render the samples denser than the running
buffer (so that the samples sink in the well).

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Genomic (total) DNA

131
 Genetics: Polymerase Chain Reaction (PCR)

What is DNA amplification?

 It means production of numerous copies of a segment of DNA.
 Mainly there are two methods:
1. In vivo (cloning):

2. In vitro (PCR):

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What is PCR?
 Polymerase chain reaction (PCR) is an in vitro technique that amplifies
specific sequences of DNA in short time.
 In vitro: a laboratory version of DNA replication in cells, since it occurs
in a test tube).

 At the end of the PCR reaction, the specific sequence will be

accumulated in billions of copies (amplicons). After 20 cycles, PCR
product can be about a million (220) copies of the target.

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  It copies only a very specific sequence from a template DNA, targeted
by PCR primers that flank the fragment of DNA to be amplified (target
DNA).
 Primer: single-stranded nucleic acid that is complementary to the
target sequence.

What are the requirements for PCR?

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1. DNA template: the DNA sample contains the target
sequence.
2. Taq DNA polymerase:
A thermo-stable enzyme synthesizes new strands of DNA
complementary to the target sequence.
3. Two synthetic oligonucleotide primers:
Short pieces of single-stranded DNA (20-30 nucleotides)
Complementary to the target sequence.
4. Deoxynucleotide triphosphates nucleotides (dNTPs):
single units of the bases (A, T, G, and C), which are
essentially "building blocks" for new DNA strands.
5. Buffer: for mantainance of PH, MgCl2, and H2o.
6. PCR tubes.
7. Thermal cycler (PCR machine or DNA amplifier):
It is programmed to raise and lower the temperature over
a number of cycles.

135
PCR components:

What are the steps of PCR technique?

 The PCR is a cyclical process.
 Subsequent cycles contain the same three steps:

136
PCR cycle steps:

PCR program:

137
How you will make sure that you target sequence is amplified?
PCR product detection:
 The results of a PCR reaction are usually visualized using gel
electrophoresis.
 The gel electrophoresis separates DNA fragments according to size
(bp).
 A standard, or DNA ladder:
1. Containing known lengths of DNA.
2. Used to determine the size of PCR products.

DNA ladder

138
 DNA fragments of the same length form a "band" on the gel, which
can be seen by eye if the gel is stained with a DNA-binding dye
(ethidium bromide).

 UV-transilluminator is used to visualize the stained product.

139
140
What are the applications of PCR?
1. Detection of pathogenic microorganisms.
2. Gene expression studies.
3. Detection of mutations relevant for inherited
diseases or malignant transformation.
4. In forensic medicine, as paternity test and
crimes.
5. Tissue typing for transplantation.
6. DNA analysis of archaeological specimens.

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 Karyotyping
Definition: study of the number andmorphology (shape) of chromosomes of
the individuals.

A Karyotype: Is the complete set of chromosomes of an individual, arranged

as homologous pairs
According to their length:
 Lymphocytes are taken to represent somatic cells.
(White blood cells are used most frequently because they are easily induced to
divide and grow in tissue culture).
 A sample of venous blood+ Heparin.
 Blood is centrifuged.
 The cells are induced to divide (in cell cultures) by phytohaemagglutinin
(mitogen), the cultured cells incubated three days.
 Mitosis (cell division) is arrested at metaphase by colchicine.
 The cultured cells are put in a hypotonic medium causing swelling and
rupture of cells.
 Cells are flattened and broken between a glass slide and a cover slip to
release chromosomes.
 The chromosomes are fixed and stained, then photographed
 Chromosomes are matched into identical pairs, then counted and
individually studied.
 This is done by computer, using an image analyzer system.

142
 How to write a person's karyotype?
 Total number of chromosomes, followed by sex chromosomes.
 The normal male karyotype:: 46, XY.
 The normal female karyotype: 46, XX.
 Shorter arm the letter p.
 Longer arm the letter q

Morphology of metaphase chromosome

 Each chromosome (d-chromosome) is made of two identical halves
called sister chromatids, which are joined at primary constriction known
as the centromere
 Each chromatid consists of a tightly coiled molecule of DNA.
 The terminal end of the chromatid is called telomere which :
 is a repeated DNA sequences added by telomerase enzyme.
 It protects and stabilizes the end of the chromosome.
 Diploid cells are called so because each cell contains two copies of every
chromosome. A pair of such chromosomes is called a homologous pair.

143
 In a homologous pair of chromosomes, one homologue originates from
the maternal parent, the other from the paternal parent.
 In humans, there are 46 chromosomes (23 homologous pairs).
 In males, there are only 22 homologous pairs (autosomes) and one pair
of the sex chromosomes of X and Y.

 Some chromosomes have a secondary constriction, on upper arms

(chromosomes: 13, 14, 15, 21 & 22).
 The terminal portion is called a satellite.

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Chromosomal anomalies
Def.: deviation from the normal number or morphology (shape) of
chromosomes.

Types:
1. Numerical (abnormal number).
2. Structural (abnormal shape).
May affect autosomes or sex chromosomes.

Causes:
1. Radiation.
2. Infection with German measles.
3. Pregnancy in old age.
4. Autoimmune diseases.
5. Family history of chromosomal abnormalities.

Types:
I. Numerical
A-Sex chromosome:
 Male: Klinefelter’s syndrome and YY syndrome
 Female: Turner’s syndrome and Multiple X syndrome
B-Autosome: Down’s syndrome

II. Structural
 Wolf syndrome
 Cri –du-chat
 Philadelphia chromosome

145
 Klinefelter’s YY syndrome Turner’s Multiple X
syndrome syndrome syndrome

Def: A condition in A condition in A condition in A condition in

which a male has which a male has an which a female which a female
an extra X extra Y has only one X has an extra X
chromosome (i.e. chromosome (i.e. instead of XX in chromosome
XXY) in his cells. XYY) in his cells. her cells. (i.e. XXX) in her
cells.
Causes: Nondisjunction of Nondisjunction of Y Nondisjunction of Nondisjunction
X chromosome at chromosome at the X chromosomes of X
one of the meiotic second meiotic during the chromosome
divisions or may division YY sperm. formation of ova. during the
be both. formation of
ova.
Karyotype: 47, XXY 47, XYY 45, XO 47, XXX
48, XXXY 48, XXXX
49, XXXXY 49, XXXXX
Features:  Subnormal  Tall individuals.  Short females.  Mental
intelligence or  Subnormal  Normal level of retardation
mental intelligence. intelligence.  May be
retardation.  May show  Infertility. infertile
 Sterility aggressive
(infertility). tendency or
antisocial
behavior.

146
 Numerical aberrations of autosomes
Down’s syndrome (Mongolism or Trisomy 21):
The most common chromosomal abnormality and its risk increases with
increase the age of the pregnant mother.

Def.: a condition in which there is an extra chromosome 21 in each cell i.e.

trisomy.

Cause: nondisjunction of chromosome 21 during the meiotic division (an

ovum with 24 chromosomes + normal sperm a fertilized ovum with 47 chrom.)

Features:
Short. Mental retardation.
Characteristic facial features: as protruding tongue, upward slanting eye
lids. Broad, short hands with a single crease in the palm.

Karyotype:
47, XY+21 (male Mongol). 47, XX+21 (female Mongol).

Structural chromosomal aberrations:

a. Anomalies due to deletion:
Wolf syndrome Cri-du-chat syndrome
Cause Partial deletion of the short Partial deletion of the short arm
arm of chromosome no. 4. of chromosome no.5.
Features  Mentally retarded  Mentally retarded
 The baby cries like a cat →Cri-
du-chat
Karyotype
 Male 46, XY, 4p- 46, XY, 5p-
 Female 46, XX, 4p- 46, XX, 5p-

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 b. Anomalies due to translocation:

Philadelphia chromosome (PH):

 It is present in the majority of patients with chronic myeloid leukemia.

 Cause: translocation of half of the long arm of chromosome no. 22 to

chromosome no.9.
 The abnormality appears only in bone marrow cells and granular white
blood cells. So, karyotyping should be done from these cells.

 Karyotype: 46, XX (or XY) , t (9 ; 22).

 Other body cells are not affected and show normal Karyotype.

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 Hereditary
Def: the passing of traits from one generation to the next.
Trait: A trait is a specific characteristic that is unique.
- Affect the way we look.
- Affect how our bodies function.

Examples are hair color, eye color, handedness, etc.

Gene & Genome
- The trait information is passed on from generation to generation in the
form of genes.
- Gene → a functional unit of DNA; a segment of DNA sequence encoding
a single specific protein. Located on the chromosome.
- Genome → the entire set of genes in an organism.

Genotype vs. Phenotype

Genotype:
 The genetic makeup of an organisms. Alleles carried by an individual eg.
RR, Rr, rr. (Internal information).

Phenotype:
 The physical appearance of an organism (Genotype + environment). eg.
Round, wrinkled
 An individual needs 2 genes for each trait – one gene from each parent.
 This gene pair is called an allele.
 One gene comes from the sperm cell (from the Father)
 One gene comes from the egg cell (from the Mother)

Types of traits
Traits are either Dominant or Recessive.
A dominant trait is a trait that is always expressed, or shown.

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Examples: are brown hair, brown eyes, right handed
A recessive trait is a trait that is covered up or seems to disappear.
Examples are blonde hair, blue eyes, left handed

How we write our genes:

 Use a capital letter for the dominant trait to represent the dominant
gene.
 Use a small version letter for the recessive gene.
 Example: Right-handedness is the dominant trait so use R for the
dominant gene and use r for the recessive gene for Left-handedness.

Homogeneous, (pure)
- Pure Dominant: the individual only has genes for the dominant trait.
- Example: TT = a pure tall individual has only tall (T) genes.
- Pure Recessive: the individual only has genes for the recessive trait.
- Example: tt = a pure short individual has only short (t) genes.

Heterogeneous, (mixed)
- A heterozygous individual has one dominant gene and one recessive
gene for a trait. The result is the dominant gene is the one expressed,
or shown.
- Example: Tt = a heterozygote tall individual has both tall (T) and short
(t) genes but looks tall.
How we predict offspring
A Punnett Square is a way to show the possible combinations of genes that
offspring of parents could have.

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Pedigree chart
Genetic traits can be traced through families by using a pedigree chart.

Definition:
A family tree that shows the transmission of genetic traits within a family over
several generations.
Pedigree Analysis
- Useful in detecting autosomal dominant mutations, autosomal
recessive mutations, X linked recessive mutations
- Used to trace the hereditary pattern of particular genetic traits.
Rules for pedigree
- Females are represented by circles.
- Males are represented by squares.
- Mother/Father couples are connected by a line.
- Offspring are shown oldest on the left to youngest on the right.
- Half-shaded circle represents a female carrier for the trait.
- Half-shaded square represents a male carrier for the trait.
- Full-shaded circle represents a female with the trait.
- Full-shaded square represents a male with the trait.

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Mendelian Inheritance in Humans
 Over 4,500 human traits are known to be inherited according to
Mendelian principles.
 The human ABO blood system is an example of a simple Mendelian
inheritance.
 The A and B alleles are dominant to the O allele.
 Neither the A or B allele are dominant to one another; They are co-
dominant and both traits are expressed.

Non-Mendelian Genetics
 Mendelian Genetics (Complete Dominance):
 Only 2 possible Phenotypes: either dominant or recessive!
 But, not all inheritance is based on the rules of Complete Dominance!!
 There are other types of inheritance that Mendel never considered:
- Incomplete Inheritance
- Co dominance
- Multiple Alleles
- Polygenic Traits
- Sex-linked
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Incomplete Inheritance (Incomplete Dominance)
The hybrid (heterozygous) offspring displays a THIRD Phenotype!! Neither trait
is completely dominant, as a result, there appears to be a blending phenotype.
The hetereozygoteis intermediate in phenotype.
Red Flower X White Flower = Pink

Co Dominance
 Both traits are dominant, and show up in the phenotype together. Co
means “together”
 In either allele is dominant or recessive so they both influence the
phenotype. Both alleles of a gene are expressed
 Hetereozygote simultaneously expresses the phenotypes of both parents.
E.g. Red Flower crossed with a White Flower
 Black CowX White Cow = SpottedCow

Multiple Alleles
 When more than 2 varieties exist in a trait. Many animals have a variety of
coat colors.
 Blood type displays both co-dominance and complete dominance
 Human Blood Type
A, B, O, or AB
Multiple alleles
- A, B, and O
- A and B dominant
- recessive
 3 alleles & 4 phenotypes.
 Codominance ,A and B alleles,,,, AB blood type

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Polygenic inheritance
 Polygenic inheritance occurs when multiple genes are involved in
controlling the phenotype of a trait. Referred to as polygenic traits
 The phenotype is an accumulation of contributions by multiple genes.
Require more than one gene to determine trait.
 This creates an additive effect of two or more genes on a single
phenotypic character. E.g. skin color and height.
 Skin color is a common example of a polygenic trait it is governed by 6 loci
and at least 12 alleles.

Sex-Linked Genetics
Sex is determined by sex chromosomes X and Y
XX= female
XY = male
The X chromosome contains many important genes that are unrelated to sex
determination
These genes are required for both males and females.
A male receives ALL of his X-linked genes from his mother while a female
receives her X-linked genes from both parents.
Sex-linked Inheritance
Genes for some traits are found on the sex chromosomes (X)
Most of these traits are recessive the normal gene is dominant
 Heterozygous Females (XX) are carriers. They do not show the trait, but
carry a gene for the trait.
 Homozygous Females (XcXc) have the trait.
 Males with the gene (XcY) have the trait. They do not have another X to
counterbalance the affected gene.

154
X-Linked Recessive Disorder
 Males will show this trait if they have the recessive allele on the X
chromosome
 Female swill show this trait if they have the recessive allele on both X
chromosomes
Homozygous recessive
 Hemophilia: Inability to have clotting of blood, xh
 Color blindness: xc

155
 Good communication skills.

Case scenario
A Chest specialist nurse has presented a case to the hospital clinical ethics
committee: A 16-year- old girl, Nadai, who has suffered from bronchial
asthma since she was ten. Nadia has previously had well- controlled Asthma
levels with daily regime & diet control. Over the last year, however, the
nurse has become very concerned about a decline in Karma’s physical
health.
She thinks that Nadia is not taking her inhaler regularly as she is gaining
weight and her asthma have risen. She has also missed several important
appointments including one with the pediatric consultant. Whenever the
nurse tries to discuss her asthma control, Nadia closes up and insists her
medication control is fine.
Define communication?
……………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………

156
 Communication
……………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………

Goals of communication:
 …………………………………………………………………………………………………………
 …………………………………………………………………………………………………………
 …………………………………………………………………………………………………………
 …………………………………………………………………………………………………………
 …………………………………………………………………………………………………………

157
How Do We Communicate?
Techniques for verbal communication Skills

Nonverbal communication

Body Language Standing – Sitting

 …………………………………………………………………………………………………………
 …………………………………………………………………………………………………………
 …………………………………………………………………………………………………………
 …………………………………………………………………………………………………………
 …………………………………………………………………………………………………………

158
Body Language:
 …………………………………………………………………………………………………………
 …………………………………………………………………………………………………………
 …………………………………………………………………………………………………………
 …………………………………………………………………………………………………………
 …………………………………………………………………………………………………………

Tips for good communication:

 …………………………………………………………………………………………………………
 …………………………………………………………………………………………………………
 …………………………………………………………………………………………………………
 …………………………………………………………………………………………………………
 …………………………………………………………………………………………………………

159
 Communication barriers.
Clinical Correlate:
An Old aged woman (Alya, 60 years old) was brought to the emergency
department by her daughter due to chest pain. They had come to the USA
from Brazil to visit their relatives. Elias (Alya’s daughter), said that she would
translate for her mother because her English was better than hers. Dr. Ahmed
was the chief emergency resident at the hospital. He asked questions about
her pain: when it started; its exact site, its nature (constant or intermittent)
etc……..

Alya mentioned that the pain had started early that morning (without
asking her daughter). Then, he began to translate Dr. Ahmed’s questions in
Portuguese. Alya pointed to the site of pain, but Dr. Ahmed got no specific
answers to his questions. Alya did not seem to understand what Dr. Ahmed
wanted to know, despite that Elias repeated the questions several times,
using what sounded to Dr. Ahmed (who understood no Portuguese) like
different words.
Dr. Ahmed asked whether Alya had vomited or had
diarrhea. Elias said: No. Dr. Ahmed asked when Alya about her menopuese,
Elias seemed unable to interpret the question for her mother. “Could she be
cardiac problem?” Dr. Ahmed asked. “No, she is not,” Elias said. Ahmed
responded “I believe an interpreter would help us with technical questions
to take accurate history from your mother Also, I would need Alya’s consent
to make ECG & blood samples to test for infection.”!!!!!!!!!!!!!!

160
ILOs 1
Demonstrate the importance of effective communication.
Communication:
- It is the art of transmitting knowledge, ideas, information and thoughts
from one person to another.
- The transfer should be such that the receiver understands the meaning
and the intent of the message and give proper feedback.
Importance:
To deal clearly and effectively with:
1. Family members
2. Physicians
3. Nurses
4. Pharmacists
5. Other health care professionals
ILOs2
Recognize barriers and factors affecting communication.
Barriers:
- A barrier (interference) is anything that gets in the way of clear
communication between sender and receiver.
- Barriers to communication can be defined as the conditions that
interfere with effective exchange of ideas or thoughts.

161
Factors affecting communication:
- Environmental Technological
- Organizational Jargons External noise
- Emotions Distance Personal interest
- Halo effect Misinterpretation
- Fear
- Stress status
- Sequence of knowledge Trust issues
- Negative self-image
ILOs 3
Classify types of barriers to communication and identify the solutions to
avoid or repair them.
Classification of barriers:
1. Physical barriers 2. Language barriers 3. Emotional barriers
4. Gender barriers 5. Perceptual barriers 6. Cross-cultural barriers

1. Physical Barriers

The major physical barriers are:

a. Time
b. Place
c. Noise
d. Distance (Space)
e. Defect in the media
f. Physical disability (such as hearing problems or speech
difficulties.)

162
How to overcome?
a. To be updated with latest technologies.
b. Choose a suitable environment.
c. Remove obstacles.
d. Make signs easier to read, example, you could supplement written
signs with pictures and visual signs.
e. Self-motivation.
2. Language Barriers:

 Different Languages
 No Clarity in speech
- Inability to converse in a language that is known by both the sender &
receiver is the greatest barrier to effective communication.
- When a person uses inappropriate words.
How to Overcome?
a. Speak slowly and clearly.
b. Ask for clarification.
c. Frequently check for understanding.
d. Be specific.
e. Choose your medium of communication effectively.
f. Be patient.
Emotional barriers
The emotional state may influence your capacity to make yourself
understood by others.
- Fear/ insecurity Mistrust.
- Stress Anger.
- Low self esteem.

163
How to overcome
 Be aware of the feelings that arise in yourself and in others as you
communicate & attempt to control them.
 Peer support.
 Motivation and commitment to change.

164
 Spikes for breaking bad news
Case Scenario
A 64-year-old male patient has been suffering from progressive shortness
of breath over the last few months and also losing weight.
He is an ex-smoker and used to work in the pits. The GP had requested a
chest X-ray which has shown a mass in the left lung suspicious of cancer.
He comes to see you for the results and you need to tell him what the X-ray
showed and also what is the management of his illness.
Learning outcome 1:
Define bad news:
Bad News Any news that drastically and negatively alters the patients’
view regarding their future.
Examples of bad news:
1. ……………………………………………………………………………………
2. ……………………………………………………………………………………
Learning outcome 2:
Recognize the importance and difficulty of breaking bad news.
An important communication skill:
1. ……………………………………………………………………………………………

Do You Tell?

But the most important is How to tell?

Why breaking bad news is so difficult?
It is a difficult task because:

165
We are anxious and afraid of negative evaluation:

It is a difficult task because?

Learning outcome 4:
Apply a systematic standardized approach to break bad news
1. Introduce yourself
2. Look to comfort and privacy.
3. Determine what the patient already knows.
4. Warn the patient that bad news is coming.
5. Break the bad News.
6. Identify the patient’s main concern.
7. Summarize and check understanding.
8. Offer realistic hope.
9. Arrange follow up and make sure that someone is
with the patient when he leaves.

What are the mistakes? Not to do?

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 Performance Checklist for Professionalism and Communication

We expect that adult learners in our program will demonstrate abilities and skills in professionalism and
communication in addition to basic academic skills. To meet these expectations, you must:

PROFESSIONAL BEHAVIOR Acceptable Needs Improvement

1. attend regularly

2. arrive/leave on time

3. dress modestly and neatly

4. demonstrate coping skills for

high-stress situations

5. display flexibility (be able to

change when necessary)

6. show compassion (express

concern for others)

7. finish assignments completely

and on time

8. practice cultural sensitivity

9. participate fully in classroom

activities and discussions without
hesitation or distraction

10. ask about ways to improve

your work
11. never use cell phones for
personal communication during
class time
12. seek opportunities to help
others
13. look for solutions to problems

14. be willing to try or learn

something new

NOTES
COMMUNICATION SKILLS Acceptable Needs Improvement

1. ask others, “What do you

need?” and “How can I help
you?”

2. restate and confirm your own

understandng when listening to
others

3. check for understanding when

speaking

4. pronounce English so that

most can understand without
trouble

5. follow instructions as given

6. explain procedures clearly

7. never speak poorly of

classmates or teachers

8. not participate in blaming or

arguments with raised voices or
physical contact

9. demonstrate understanding of
confidentiality and/or specific
workplace issues such as patient
rights, HIPAA, and/or workplace
safety regulations
10. Use language appropriate to
the workplace

NOTES

SIPDC – 2011. Modified from a handout prepared by Highline Community College, Washington, Fall 2011.