PBL Study Notes - KUSMS First Year

TOPIC 1: Why Is Zinc Given to Babies in Diarrhoea?

Source: Park's Textbook of Preventive and Social Medicine (p. 721 & Diarrhoeal Disease Control chapter)

"Zinc deficiency is common in children from developing countries due to lack of intake of animal food, high dietary phytate content, inadequate food intake and increased faecal losses during diarrhoea."

• Park's Textbook of Preventive and Social Medicine, p. 721

"Zinc supplementation in combination with oral rehydration therapy has been shown to significantly reduce the duration and severity of acute and persistent diarrhoea and to increase survival in a number of randomized control trials."

• Park's Textbook of Preventive and Social Medicine, p. 721

"Adequate zinc intake is essential for maintaining the integrity of the immune system."

• Park's Textbook of Preventive and Social Medicine, p. 721

"When a zinc supplement is given during an episode of acute diarrhoea, it reduces the episode's duration and severity. In addition, zinc supplements given for 10 to 14 days lower the incidence of diarrhoea in the following 2 to 3 months."

• Park's Textbook of Preventive and Social Medicine, Diarrhoeal Disease Control chapter

"WHO and UNICEF therefore recommend daily 10 mg of zinc for infants under 6 months of age, and 20 mg for children older than 6 months for 10-14 days."

• Park's Textbook of Preventive and Social Medicine, p. 885

TOPIC 2: Layers of the Abdomen (Anterior Abdominal Wall)

Source: Mulholland and Greenfield's Surgery - Scientific Principles and Practice, 7e (p. 3632-3639) & THIEME Atlas of General Anatomy

Layers (Superficial to Deep):

"The three muscles of the lateral aspect of the anterior abdominal wall are composed of a variable amount of muscle with a large aponeurosis. The aponeurosis is the tendon of insertion for the lateral muscles, and it also forms the sheath of the rectus abdominis. The midline decussation of the three aponeuroses forms the linea alba."

• Mulholland and Greenfield's Surgery, p. 3634

Central Muscle - Rectus Abdominis:

"The rectus abdominis forms the central and anchoring muscle mass of the anterior abdomen. The rectus muscle arises from the fifth to the seventh costal cartilages and inserts on the pubic symphysis and pubic crest. Each rectus muscle is segmented by tendinous intersections at the levels of the xiphoid process and the umbilicus and at a point midway between these two. The principal blood supply reaches the muscle from the superior and inferior epigastric arteries."

• Mulholland and Greenfield's Surgery, p. 3639

Diagram of Abdominal Wall Layers:

Figure 72.2 - Pattern of abdominal wall musculature: A) External oblique + Internal oblique; B) Transversus abdominis + Internal oblique; C) Transversus abdominis alone. Source: Mulholland and Greenfield's Surgery, 7e

Relationship to Spermatic Cord (Clinically Important):

Diagram showing abdominal wall layers, inguinal canal, and their derivatives into scrotal/testicular coverings. Source: THIEME Atlas of General Anatomy

TOPIC 3: Blood Culture and Sensitivity (Blood C/S)

Source: Tietz Textbook of Laboratory Medicine, 7th Edition & Roberts and Hedges' Clinical Procedures in Emergency Medicine

What is Blood Culture and Sensitivity?

Types of Bloodstream Infections (BSI):

"BSIs occur for a variety of reasons. In general, they can be categorised as either intravascular or extravascular. Intravascular infections include infective endocarditis and intravenous catheter-related infection. Extravascular BSI results when organisms multiply at a body site, are drained by the lymphatic system, and gain access to the bloodstream. Common extravascular sites that lead to BSI are abscesses, wounds, surgical wounds, the respiratory tract, and the genitourinary tract."

• Tietz Textbook of Laboratory Medicine, 7th Edition

Specimen Collection - Critical Points:

"A critical aspect of blood culture draws is the disinfection of the skin (for peripheral blood draws). The CDC recommends disinfecting the site with 70% alcohol and then using povidone-iodine. Alternative methods include the use of chlorhexidine and chlorine peroxide."

• Tietz Textbook of Laboratory Medicine, 7th Edition

"The most critical factor influencing the sensitivity of blood cultures for the detection of BSI is the volume of blood drawn."

• Tietz Textbook of Laboratory Medicine, 7th Edition

"In adults, a number of studies have assessed the blood volume required to maximize sensitivity and found that the ideal total volume for blood culture is 40 to 60 mL. Each draw should be 20 mL, with each bottle (aerobic and anaerobic) inoculated with 10 mL."

• Tietz Textbook of Laboratory Medicine, 7th Edition

"Most institutions encourage the order of two blood culture sets that include both aerobic and anaerobic bottles. These cultures should be collected from two distinct sites (i.e., a peripheral venous draw from the right and left arm or a central line and peripheral venous draw)."

• Tietz Textbook of Laboratory Medicine, 7th Edition

"These paired cultures help the provider differentiate between contamination and true infection. True bacteraemia will result in multiple positive cultures, whereas single positive cultures with skin or respiratory microbiota suggest contamination."

• Tietz Textbook of Laboratory Medicine, 7th Edition

• In typhoid fever: only 40-60% sensitive (Harrison's Principles of Internal Medicine, 22e)
• With proper technique and adequate volume: up to 80% per set, nearly 99% with two sets of 20 mL each

"An individual set is typically not more than 80% sensitive... sensitivity is typically at approximately 99% with two sets consisting of 20 mL of blood per set."

• Roberts and Hedges' Clinical Procedures in Emergency Medicine

Summary Diagram: Blood Culture Process

PATIENT (suspected BSI/sepsis)
          ↓
SKIN DISINFECTION
(70% alcohol → povidone-iodine OR chlorhexidine)
          ↓
BLOOD DRAW (2 separate sites)
    SET 1 (Left arm)      SET 2 (Right arm)
    ↓           ↓         ↓           ↓
 Aerobic    Anaerobic  Aerobic    Anaerobic
 bottle     bottle     bottle     bottle
 (10 mL)    (10 mL)   (10 mL)    (10 mL)
          ↓
   INCUBATION (5 days, continuously monitored)
          ↓
   ORGANISM IDENTIFIED
          ↓
   ANTIBIOTIC SENSITIVITY TESTING
   (MIC determined → report Sensitive / Intermediate / Resistant)
          ↓
   TARGETED ANTIBIOTIC THERAPY

"Levels of bacteremia are typically 10-fold higher in neonates than in adults. The sicker the child, the greater the likelihood of a high level of bacteremia."

• Roberts and Hedges' Clinical Procedures in Emergency Medicine

Quick Summary Table for PBL Revision

Paracetamol (PCM) Toxicity - Complete PBL Notes

PART 1: Therapeutic vs Toxic vs Lethal Doses

Source: The Essentials of Forensic Medicine and Toxicology, 36th Edition (2026) - Table 31.1 & Sleisenger and Fordtran's GI and Liver Disease

"When a large dose (>150 mg/kg or >10g in an adult) is taken, it causes serious toxicity. Fatality is common with doses >250 mg/kg."

• P.C. Dikshit Textbook of Forensic Medicine and Toxicology, p. 578

"Overdoses of 20 g or more are potentially lethal."

• P.C. Dikshit Textbook of Forensic Medicine and Toxicology

PART 2: Toxic Dose in an ALCOHOLIC Person - Why is it LOWER?

Source: Sleisenger and Fordtran's Gastrointestinal and Liver Disease & Goldman-Cecil Medicine

"Among heavy drinkers, daily acetaminophen doses of 2 to 6 g have been associated with fatal hepatotoxicity."

• Sleisenger and Fordtran's GI and Liver Disease, p. 1670

"In chronic alcoholics, even 5-6 g/day taken for a few days can cause hepatotoxicity."

• P.C. Dikshit Textbook of Forensic Medicine and Toxicology

1. CYP2E1 induction: Alcohol induces (upregulates) the CYP2E1 enzyme. This pushes MORE paracetamol down the toxic pathway, producing MORE NAPQI than normal.
2. Glutathione depletion: Chronic alcohol use depletes hepatic glutathione stores, so even normal NAPQI production cannot be neutralised.

"Excessive ethanol intake can induce CYP2E1, resulting in a greater fraction of the dose being converted to NAPQI. Patient-specific factors that can significantly reduce the dose threshold for acetaminophen toxicity include poor nutrition and fasting (depleting glucuronidation substrates) as well as excessive ethanol intake."

• Goldman-Cecil Medicine, International Edition

Risk Factors That Lower the Toxic Threshold (Table from Sleisenger & Fordtran)

PART 3: Mechanism of PCM Toxicity - FLOWCHART

Source: The Essentials of Forensic Medicine and Toxicology, 36th Ed. (Fig. 31.1) & Goldman-Cecil Medicine & Rosen's Emergency Medicine

Fig. 31.1 - Metabolism pathway of paracetamol. Source: The Essentials of Forensic Medicine and Toxicology, 36th Ed.

PARACETAMOL (PCM) ingested
          |
          ├──────────────────────────────────────┐
          ▼                                      ▼
   ~90% SAFE PATHWAY                     ~10% TOXIC PATHWAY
          |                                      |
   Conjugation with                    CYP2E1 (P450 enzyme)
   GLUCURONIC ACID                     oxidizes PCM
   and SULFATE                                   |
          |                                      ▼
   NON-TOXIC metabolites            NAPQI formed
   excreted in urine                (N-Acetyl-p-Benzoquinone Imine)
                                               |
                                    ┌──────────┴───────────┐
                                    ▼                      ▼
                             NORMAL DOSE               OVERDOSE
                             (Glutathione              (Glutathione
                              adequate)                 EXHAUSTED)
                                    |                      |
                                    ▼                      ▼
                           NAPQI neutralized          NAPQI accumulates
                           by glutathione             freely in liver cells
                                    |                      |
                                    ▼                      ▼
                           CYSTEINE +                COVALENT BINDING
                           MERCAPTURIC ACID          to liver cell proteins
                           (non-toxic, excreted)     (especially mitochondria)
                                                           |
                                                           ▼
                                                    OXIDATIVE STRESS
                                                    ↓
                                                    CENTRILOBULAR HEPATIC NECROSIS
                                                    ↓
                                                    RENAL TUBULAR NECROSIS
                                                    ↓
                                                    ACUTE LIVER FAILURE → DEATH

"N-acetyl-benzoquinone-imine is a highly reactive arylating minor metabolite of paracetamol, which is detoxified by conjugation with glutathione. When a very large dose is taken, hepatic glutathione is depleted and this metabolite binds covalently to proteins in liver cells and renal tubules causing necrosis. Toxicity thus shows a threshold phenomenon, manifesting only when glutathione is depleted to a critical point."

• P.C. Dikshit Textbook of Forensic Medicine and Toxicology, p. 578

"The binding of acetaminophen to hepatocyte macromolecules leads to hepatocyte necrosis... Mitochondrial enzymes are a particular target of NAPQI."

• Harrison's Principles of Internal Medicine, 22E & Sleisenger and Fordtran's

PART 4: Clinical Stages of PCM Poisoning

Source: The Essentials of Forensic Medicine and Toxicology, 36th Ed. - Table 31.2

PART 5: Why is N-Acetylcysteine (NAC) Given?

Source: P.C. Dikshit Textbook of Forensic Medicine and Toxicology & The Essentials of Forensic Medicine, 36th Ed.

"N-acetylcysteine... replenishes the glutathione stores of the liver and prevents binding of the toxic metabolite to other cellular constituents."

• P.C. Dikshit Textbook of Forensic Medicine, p. 578

"Acetaminophen toxicity is due to the depletion of hepatic glutathione, resulting in the accumulation of toxic metabolic intermediates."

• Morgan and Mikhail's Clinical Anesthesiology, 7e

NAC Dosing (from Textbooks):

• Loading: 150 mg/kg IV over 1 hour
• Then: 50 mg/kg over next 4 hours
• Then: 100 mg/kg over 16 hours
• Total: 21-hour regimen (FDA-approved)

• Loading: 140 mg/kg, then 70 mg/kg every 4 hours
• Duration: 24-72 hours (6-18 doses)

"Treatment should be started as early as possible as it is practically ineffective if started 16 hours or more after paracetamol ingestion."

• P.C. Dikshit Textbook of Forensic Medicine, p. 578

"Most beneficial when administered within 8-10 hours of overdose."

• The Essentials of Forensic Medicine and Toxicology, 36th Ed.

PART 6: Glossary of Technical Terms Used

Quick Summary for PBL

NORMAL ADULT:  Toxic >150 mg/kg (>10 g single dose); Lethal >350 mg/kg
ALCOHOLIC:     Toxic at just 5-6 g/day (threshold massively reduced)
REASON:        Alcohol → ↑CYP2E1 → ↑NAPQI + depleted glutathione
ANTIDOTE:      NAC - replenishes glutathione; must give within 8-10 hours

• P.C. Dikshit Textbook of Forensic Medicine and Toxicology (p. 578)
• The Essentials of Forensic Medicine and Toxicology, 36th Edition (2026) (Table 31.1, 31.2, Fig. 31.1)
• Goldman-Cecil Medicine, International Edition
• Sleisenger and Fordtran's GI and Liver Disease (Table 88.5, p. 1670)
• Rosen's Emergency Medicine
• Morgan and Mikhail's Clinical Anesthesiology, 7e

• Acetaminophen (PCM) at the top splits into 3 paths:
  • Left - Conjugated to sulfate (safe, non-toxic)
  • Right - Conjugated to glucuronide (safe, non-toxic)
  • Middle (the dangerous path) - Goes through CYP2E1 enzyme → produces NAPQI (the toxic metabolite)
• NAPQI is then neutralized by Glutathione → forms non-toxic metabolites (safely excreted)
• NAC (N-Acetylcysteine) shown on the left feeds into glutathione - this is exactly why NAC is the antidote. It replenishes glutathione so it can keep neutralizing NAPQI.

Metabolism of Paracetamol (PCM) in a Normal Person

Textbook Diagram (Figure 43.2):

Reading the Chart Step by Step:

"Acetaminophen is normally metabolized in the liver to glucuronide (50 to 60%) and sulfate (<30%) conjugates. A smaller amount (<10%) is metabolized by a cytochrome P450 mixed-function oxidase pathway... forming NAPQI. This intermediate normally undergoes electrophilic conjugation with glutathione and then subsequent transformation to cysteine and mercapturic acid conjugates of acetaminophen."

• Tietz Textbook of Laboratory Medicine, 7th Edition

The NAPQI pathway in a NORMAL person (safe outcome):

PCM → CYP2E1 → NAPQI
                  ↓
             + Glutathione (abundant in normal liver)
                  ↓
     Acetaminophen-glutathione conjugate
                  ↓
     Acetaminophen-CYSTEINE conjugate
                  +
     Acetaminophen-MERCAPTURIC ACID conjugate
                  ↓
          Safely excreted in URINE

Why does this go wrong in overdose?

"With acetaminophen overdose, the sulfation pathway becomes saturated; consequently, a greater portion is metabolized by the P450 mixed-function oxidase pathway. When the tissue stores of glutathione become depleted, arylation of cellular molecules by the benzoquinoneimine intermediate leads to hepatic necrosis."

• Tietz Textbook of Laboratory Medicine, 7th Edition

PCM Metabolism in a Normal Person

The Diagram (from Tietz Textbook of Laboratory Medicine, 7th Ed.):

Simple Explanation:

                    PCM taken orally
                          |
                    Absorbed from gut
                          |
                    Reaches LIVER
                          |
          ┌───────────────┼─────────────────┐
          ▼               ▼                 ▼
    ~50-60%           ~30%              ~10%
  GLUCURONIDATION    SULFATION        CYP2E1 enzyme
       ↓                ↓                 ↓
  PCM-glucuronide   PCM-sulfate         NAPQI
  (safe, harmless)  (safe, harmless)      ↓
       ↓                ↓           + Glutathione
  Excreted in      Excreted in           ↓
    URINE             URINE        PCM-mercapturic acid
                                   (safe, harmless)
                                         ↓
                                   Excreted in URINE

In Simple Words:

Source: Tietz Textbook of Laboratory Medicine, 7th Edition, Figure 43.2

Figure 43.2 - Tietz Textbook of Laboratory Medicine, 7th Edition

Step-by-Step Simple Explanation

STEP 1 - You swallow a PCM tablet

STEP 2 - The liver breaks PCM down into 4 routes

🔵 STREAM 1 - The Biggest Safe Route (~50-60%)

• The liver sticks a molecule called glucuronic acid onto PCM
• This makes PCM water-soluble (dissolves in water)
• The kidney then flushes it out in your urine
• Completely harmless

Terms defined:

Glucuronidation - A process where the liver adds glucuronic acid to a drug to make it water-soluble so the kidneys can remove it. Think of it as "gift wrapping" the drug so the kidney can throw it away.

UDP-glucuronosyltransferase - The enzyme (a biological tool/machine) in the liver that performs glucuronidation. "UDP" is just the energy molecule that powers this reaction.

Conjugation - The general word for "joining/attaching" one molecule to another. Glucuronidation and sulfation are both types of conjugation.

🟡 STREAM 2 - Second Safe Route (~30%)

• The liver sticks a sulfate group (a sulfur-containing molecule) onto PCM
• Again becomes water-soluble → flushed out in urine
• Completely harmless

Terms defined:

Sulfation - Similar to glucuronidation, but instead of glucuronic acid, a sulfate molecule is attached to PCM. End result is the same - PCM is made harmless and removed in urine.

Sulfotransferase - The enzyme that performs sulfation in the liver.

🟢 STREAM 3 - Tiny Unchanged Route (<5%)

• A tiny bit of PCM escapes the liver without being changed at all
• Goes straight out in urine as PCM
• Harmless (too small an amount to matter)

🔴 STREAM 4 - The Important Dangerous Route (<10%)

PCM → CYP2E1 → NAPQI (toxic!)
                  ↓
           Glutathione grabs it
                  ↓
        PCM-Glutathione conjugate
                  ↓
    PCM-Cysteine + PCM-Mercapturic acid
                  ↓
           Out in URINE (safe ✅)

All Technical Terms - Simple Definitions

The One-Line Summary

In a normal person, 90% of PCM is safely converted to harmless products (glucuronide + sulfate) and flushed out in urine. The remaining 10% becomes toxic NAPQI, but the liver's glutathione immediately destroys it before it can cause any harm.

CPK, ALP, and TLC - Complete Notes for PBL

1. CPK (Creatine Phosphokinase) = Also called CK (Creatine Kinase)

What is it?

"Creatine kinase (CK) catalyzes the reversible phosphorylation of creatine by ATP... Physiologically, when muscle contracts, ATP is converted to ADP, and CK catalyzes the re-phosphorylation of ADP to ATP using creatine phosphate as the phosphorylation reservoir."

• Tietz Textbook of Laboratory Medicine, 7th Edition

Where is it found in the body?

Normal Range

Males: 46-171 U/L | Females: 34-145 U/L (Tietz Textbook of Laboratory Medicine, 7th Edition)

CPK Isoforms (Sub-types) - Very Important!

When does CPK INCREASE?

"An elevated serum creatine kinase (CK) concentration can result from recent exercise, electromyography (EMG), intramuscular injection, liver disease, or myocardial infarction (MI) as well as from a primary muscle disease."

• Bradley and Daroff's Neurology in Clinical Practice

"CK-MB is no longer a recommended marker for the initial diagnosis of NSTEMI. It lacks specificity because it is present in both skeletal and cardiac muscle cells... Troponin is the recommended biomarker for assessment of myocardial necrosis."

• The Washington Manual of Medical Therapeutics

2. ALP (Alkaline Phosphatase)

What is it?

Where is it found?

"Alkaline phosphatase (ALP) is expressed in liver, bile ducts, bone, intestine, placenta, kidney, and leukocytes."

• Sabiston Textbook of Surgery, The Biological Basis of Modern Surgical Practice

Normal Range

30-140 IU/L

• Bailey and Love's Short Practice of Surgery, 28th Edition - Table 69.1

ALP Isoforms by source:

When does ALP INCREASE?

"The serum ALP is particularly elevated with cholestatic liver disease or biliary obstruction."

• Bailey and Love's Short Practice of Surgery, 28th Edition

• Pregnancy (placental ALP - normal)
• Prostate cancer with bone metastasis

"It is important to note that routine laboratory analysis of ALP is not isoform specific and so ALP from a skeletal source may also lead to elevation, particularly Paget's disease and prostate cancer."

• Bailey and Love's Short Practice of Surgery, 28th Edition

• If GGT is also raised → ALP is from the liver
• If GGT is normal → ALP is from bone

3. TLC (Total Leukocyte Count) = WBC Count (White Blood Cell Count)

What is it?

Normal Range

4,500 - 10,000 cells/μL (mean = 7,500/μL)

• Goldman-Cecil Medicine, International Edition

WBC Differential (breakdown of types):

"The normal peripheral white blood cell count ranges between 4500/μL and 10,000/μL, with a mean of 7500/μL, and is composed of neutrophils, lymphocytes, monocytes, basophils, and eosinophils. Because neutrophils usually represent about 60% of the peripheral WBC, derangement in the WBC usually reflects elevation or reduction in the absolute neutrophil count."

• Goldman-Cecil Medicine, International Edition

When TLC INCREASES (Leukocytosis = WBC > 10,000/μL):

"Many acute bacterial infections can present with leukocytosis with a 'left shift', referring to the circulation of more immature myeloid cells."

• Goldman-Cecil Medicine, International Edition

When TLC DECREASES (Leukopenia = WBC < 4,000/μL):

Quick Summary Table

• Tietz Textbook of Laboratory Medicine, 7th Edition (CPK normal range, isoenzymes)
• Bailey and Love's Short Practice of Surgery, 28th Edition (ALP normal range, Table 69.1)
• Goldman-Cecil Medicine, International Edition (TLC normal range, leukocytosis)
• Sabiston Textbook of Surgery (ALP sources)
• Bradley and Daroff's Neurology in Clinical Practice (CPK causes)