RxPreps_2020_Course_Book_for_Pharmacist_Licensure_Exam_Preparation_201021182119.pdf

www.pharmacyprep.com Evaluating Exam Review Book 2018
Copyright © 2000-2018 TIPS Inc. Unauthorized reproduction of this manual is strictly prohibited and it is
illegal to reproduce without permission. This manual is being used during review sessions conducted by
PharmacyPrep.
1
Pharmacy Prep
Evaluating Exam
Review Book
Misbah Biabani, Ph.D
Toronto Institute of Pharmaceutical Sciences (TIPS) Inc.
Toronto, ON M2N 6K7
2018
Pharmacy Prep
Professional Exams Preparation Center
4789 Yonge St. Suites # 417, Toronto, ON, M2N 5M5
WWW.PHARMACYPREP.COM
416-223-PREP (7737)/647-221-0457
Toronto Institute of Pharmaceutical Sciences Inc.
© 2000 to 2018 TIPS Inc.All Rights Reserved.

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Disclaimer
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©2000-2018 TIPS Inc. All rights reserved.
Foreword by
Misbah Biabani, Ph.D
Coordinator, Pharmacy Prep
Toronto Institute of Pharmaceutical Sciences (TIPS) Inc
4789 Yonge St. Unit 415-417
Toronto ON M2N 6K7, Canada

PharmacyPrep.
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Content
Abbreviations
Part 1. Biomedical Sciences 15%
1. Human Anatomy
2. Gastrointestinal System
3. Nervous System
4. Cardiovascular System
5. Endocrine System
6. Renal System
7. Liver Function and Pathophysiology
8. Respiratory System
9. Urinary System
10.The Eye and Ear
11.Blood and Anemia
12.Biochemistry
13.Nutrition
14.Microbiology
15.Cell and Molecular Biology
16.Pharmacogenetics
17.Immunology and Immunizations
18.Biotechnology
19.Toxicology
Part 2. Pharmaceutical Sciences 25%
20.Pharmacokinetics
21.Rates and Orders of Reactions
22.Pharmacodynamics
23.Basics of Medicinal Chemistry
24.Medicinal Chemistry and Pharmacology of Autonomic Nervous System Drugs.
25.Medicinal Chemistry and Pharmacology of Histamines, Serotonin, Prostaglandin and
Non-Steroidal Anti-inflammatory Drugs

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26.Medicinal Chemistry and Pharmacology of Cardiovascular Drugs
27.Medicinal Chemistry and Pharmacology of Psychiatric & Neurological Drugs
28.Medicinal Chemistry and Pharmacology Endocrine Drugs
29.Medicinal Chemistry and Pharmacology of Respiratory Drugs
30.Medicinal Chemistry and Pharmacology of Musculoskeletal Drugs
31.Medicinal Chemistry and Pharmacology of Antimicrobial Drugs
32.Drug Metabolism
33.Biopharmaceutics
34.Physical Pharmacy
35.Pharmaceutical Excipient
36.Rheology
37.Pharmaceutical Dosage Forms
38.Drug Delivery Systems
39.Pharmaceutical Analysis
Part 3. Social/Behavioural/Administrative Sciences 10%
40.Canadian Healthcare System
41.Canadian Pharmacy Law and Jurisprudence
42.Pharmacist Scope of Practice in Canada
43.Pharmacy Management
44.Pharmacoeconomics
45.The New Drug Approval Process
46.Evidence Based Medicine and Epidemiology
47.Biostatistics
48.Hospital Pharmacy
Part 4a. Pharmacy Practice (50%)
Professional Practice Skills (15%)-workflow
49.Pharmacy Calculations. Basics
50.Pharmacy Calculations. Dose Calculations
51.Pharmacy Calculations. Dilutions and Allegations
52.Brand and Generic Name Indexes

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53.Prescription Processing and Medication Dispensing
54.Safety of Medications in Special Populations
55.Promoting Medication Adherence
56.Professional Pharmacy Communication Skills
57.Bioethics and Professional Ethics
58.Drug Information Resources and Literature Evaluation
59.Medication Errors and Patient Safety Practices
60.Health Promotion and Disease Prevention
61.Collaboration and Teamwork
62.Sterile Preparations
63.Compounding and Storage Conditions
Part 4b. Pharmacy Practice-Clinical Pharmacy (35%)
64.Pharmaceutical Care and Drug Related Problems
65.Adverse Drug Reactions and Management
66.Drug Interactions
67.Clinical Biochemistry and Therapeutic Drug Monitoring
68.Quality Assurance in Pharmacy Practice
69.OTC and Prescription Drugs for Dermatological and Foot Conditions
70.OTC and Prescription Drugs for Ophthalmic, Ear and Mouth Disorders
71.OTC Drugs Antihistamine, Decongestants, Antitussives, Expectorants
72.OTC Drugs for Nausea, Vomiting, Constipation, Diarrhea, Hemorrhoids
73.Analgesics, and Topical Pain Relievers
74.Asthma and Chronic Obstructive Pulmonary Disease (COPD)
75.Smoking Cessation
76.Insomnia
77.Eating Disorders
78.GERD, Ulcers, Inflammatory Bowel Disease (IBD) and Irritable Bowel Syndrome (IBS)
79.Diabetes Mellitus Type I and Type 2
80.Thyroid Disorders
81.Contraception
82.Gynaecologic and Genitourinary Disorders

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83.Rheumatoid Arthritis, Osteoarthritis and Gout arthritis
84.Osteoporosis
85.Hypertension
86.Coronary Artery Diseases
87.Stroke
88.Congestive Heart Failure
89.Cardiac Arrhythmias
90.Peripheral Vascular diseases
91.Neurological Disorders and Pain Management
92.Anxiety Disorder
93.Depression
94.Psychosis and Schizophrenia
95.Dementia
96.Seizures and Epilepsy
97.Parkinson’s Disease
98.Antimicrobial Agents
99.Anticancer Drugs and Chemotherapy
100. Pharmacognosy and Natural Products

Pharmacyprep.com Human Anatomy
Copyright © 2000-2018 TIPS Inc. Unauthorized reproduction of this manual is strictly prohibited and it is illegal to
reproduce without permission. This manual is being used during review sessions conducted by PharmacyPrep.
1-1
1
Human Anatomy
This chapter reviews essentials and definitions of systemic human anatomy terminology and provide a basic
understanding of how the human body is structured with emphasis on clinical applications. This chapter also
reviews cellular mechanism in human physiology. A special emphasis is on drug-induced diseases and effects of
adverse drug reactions on various organs.
Body Movements (Fig 1.1)
• Abduction: Movement away from the midline of the body.
• Adduction: Movement toward the midline of the body.
• Extension: Lengthening or straightening of a flexed limb.
• Flexion: Bending of a part of the body.
• Dorsiflexion: Backward (upward) bending of the foot.
• Plantar flexion: Bending of the sole of the foot downward toward the ground.
• Pronation: Act of turning the hand so that the palm faces downward.
• Supination: Act of turning the hand so that the palm is uppermost.
• Eversion: Outward turning.
• Fascia: Fibrous membrane separating and enveloping muscles.
• Anterior (ventral): Front side of the body (example: Abdomen is anterior to the spinal cord).
• Posterior (dorsal): Back of the body (example. Spinal cord is posterior to the stomach).
• Lateral view = from the side of the body
• Medial view = from the middle of body (between two legs)
• Deep: Away from the surface.
• Superficial: On the surface (example. Superficial veins can be viewed through skin).
Questions Alerts!
Common questions in pharmacy exam is to ask!
• Anatomy of body movements like abduction, adductions, supine and prone.
• Anatomical planes such as sagittal and midsagittal plane.
• Skeletal bones and joints. Patella (kneecap), hip joints or bowl and socket (ilium, ischium, pubis), skull
bones, knee joints have popliteal spaces.
• Muscles. Flexor and Extensor muscles, Actin and myosin muscle fibers for muscle contraction, masseter
muscles are attached to mandibles.

1-2
• Proximal: Near the point of attachment to the trunk or near the beginning of a structure (Example.
The proximal end of the stomach is at the esophagus or the proximal end of the upper bone joins
with shoulder bone).
Distal: Far from the point of attachment to the trunk or from the beginning of a structure (Example. The distal
end of the stomach is at the small intestine).
Inferior. Below another structure. Caudal (pertaining to the head) means inferior in human. (Example. The
urinary bladder lies inferior to the kidney)
Fig 1.1
opposite opposite
Abduction Adduction
Extension Flexion
Lateral Medial
Dorsal Ventral
Proximal Distal

1-3
Anatomical planes (Fig 1.1)
• Sagittal plane: Plane created by an imaginary line that is parallel to the median plane. Separates the body
into right and left portions.
• Midsagittal plane (median plane): Plane created by an imaginary line that divides the body into right and left
halves. Separates the body/body part into equal right/left portions.
• Parasagittal plane: Divides the body into unequal right and left portions.
• Coronal plane/frontal. Divides the body/body part into anterior and posterior portions.
• Transverse plane/horizontal. Divides the body/body part into superior and inferior portions.
• Oblique plane: Passes through the body/body part at an angle.
Anatomical positions
Postural: Positions such as standing, sitting, lying down, turning right or left.
Orthostatic: Standing upright and lying down supine.
Fowler’s position: Seated position with back support (Head elevated)
Trendelenburg position: Sleeping position with Feet elevated and head lowered.
Skeletal Joints (Fig 1.2)
Weight bearing joints
Shoulder joint: consists of humerus, scapula, synovial membrane, articular cartilage, articular capsule, articular
liquid, and ligament.
Knee joint: consists of femur (longest bone), tibia, patella, meniscus, articular cavity, serous bag, and articular
capsule & cartilage. Patella (knee cap) bone is present in knee joint. Popliteal spaces or nerves are present in
knee joint.
Hip joint (socket and ball): consists of Ilium, ischium, and pubis.
Shoulder joint Ball & socket (Rotary cuff: is a group of
muscles that stabilize the shoulder)
Knee joint Hinge joint
Hip joint Ball &Socket
The major skull bones include Cranial bones (8), Facial bones (14), Ossicles (ear bones) (3)
Cranial bones (protect brain): Frontal bones, parietal, occipital, temporal, sphenoid and ethmoid bone.
Parietal (2), Ethmoid, Sphenoid, Temporal (2), Occipital, Frontal
Tennis elbow (lateral epicondylosis): inflammation and pain of outer side of elbow involving humerus
and usu. This results from excessive use of forearm or twisting.
Tendons: Connect muscle to bone
Ligaments: Connect bone to bone
Anterior cruciate ligament is connecting between three bones of knee such as thighbone (femur), shinbone
(tibia) and kneecap (patella).
Muscles:
• Trapeziusà neck
• Triceps brachià shoulder (anterior). Triceps are in only in arms.
Cranial bones
“ PEST OF”

1-4
• Biceps brachià upper arm (biceps) and thighs.
• Femorus is present in back of thigh and leg.
• Quadriceps --> thighs
• Gluteus medium is in hip.
• Psoas muscleà hip
• Largest muscleàgluteus maximus (which forms part of the buttock).
• Fastest muscle isà eyelid elevator.
• Longest single muscleà Sartorius muscle (which stretches from the pelvis to below the knee (more than 15
inches or 40 cm long).
• Smallest muscle is stapedius (found inside the middle ear and less than 0.04 inch (1 mm) long).
• Strongest muscle: Masseter muscle (which elevates during mastication. It can exert a force equivalent in 100
kg (220 lbs).
• Muscles account for 40% of total body weight.
• Muscle fibers actin and myosin helps in muscle contraction.
Three types of muscle tissues
Skeletal muscle (muscle attached to skeleton tendons, bones); Voluntary
Smooth muscle (organs, stomach, blood vessels muscle): involuntary
Cardiac muscle (Heart muscle): involuntary
Types of tissues and functions. Four basic types of tissues, epithelial (covering), connective (support), muscle
(movement), and nervous (control/integration).
• Epithelium: its functions include covering, secretion, absorption, and sensitivity.
• Connective tissue: Support, cartilage, bone, blood, fibrous tissue of ligament (chondrocytes).
• Muscle tissue, skeletal muscle tissue, cardiac muscle tissue, smooth muscle tissues.
• Nervous: Control and integration.
Tissue functions: Protection, absorption, filtration, excretion, secretion, and sensory reception.
Epithelium tissue present at sites of rapid diffusion, such as the lining of lung alveoli.
Endothelium tissue present in the lining of blood vessels (arteries, veins, capillaries).
Mesothelium present at sites where very little activity is occurring, such as Bowman's capsule in the kidney and
the lining of major body cavities.
Epithelial tissue: Covering/lining or glandular, are 2 basic types endocrine "ductless" produce hormones.
Exocrine have ducts, sweat, oil, saliva, bile enzymes, mucin (mucus).

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• Connective Tissue: support protection, insulation, transportation. Characteristics, large extra cellular matrix.
Four basic classes of connective tissue:
• Connective tissue proper. Loose, adipose, areolar storage, support organs or vessels, Dense. Regular,
elastic (tendons and ligaments).
• Cartilage. Cushion, structure, support, and laid down before bone.
• Osseous (bone): Bring in beef bone, compact, rigid, and spongy marrow.
• Blood: RBCs, WBCs, and platelets, and plasma matrix.

1-6
Tips
1 Supination 2. flexion 3. Abduction
4 Extension 5. adduction 6. Parasagittal plane
7 Sagittal plane 8. Midsagittal plane 9. Kneecap
10 Biceps bronchi 11 Triceps bronchi 12 dysphagia
13 Joints 14 Hormone glands 15 Blood vessels
16 Extensor muscles 17 Flexor muscles 18 Pubis
19 Ilium 20 Ischium 21 transverse plane
22 Endocrine glands 23 Arteries 24 Skull bones
25 Moving away from
body
26 Moving closer to body 27 slicing vertically
28 slicing vertically from
middle line
29 Slicing vertically from side
lines
30 Slicing horizontal
31 dysuria 32 Dyspnea
• Adduction à ( )
• Abduction à ( )
• Sagital planes à ( )
• Para sagital plane à( )
• Mid sagital plane à( )
• Transverse plane à ( )
• Hip joints have à ( )
• Flexor muscles are present inà ( )
• Extensor muscles are present inà ( )
• Epithelial tissue is present in à ( )
• Endothelial tissues is present in à ( )
• Skull bones are à???
• Movement away from the midline of the body ( )
• Act of turning the hand so that the palm is uppermost ( )
• bending part of the body ( )
• movement toward the midline of the body ( )
• lengthening or straightening of the flexed limb ( )
• found in arms and thighs ( )
• Found in arms only ( )
• Separates the body into unequal right and left portions ( )
• Separates the body into equal right and left portions ( )
• Separates the body into right and left portions ( )
• It protects the front of the joint ( )
• Difficulty in breathing ( )
• Difficulty in swallowing ( )
• Difficulty in urination ( )
• Found in limbs, foot, arms ( )
• Hip joints have ( )
• Which one is a part of the shoulder? ( )
• Popliteal space is present knee ( )

PharmacyPrep.com Gastrointestinal System
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Gastrointestinal System
This chapter review anatomy, physiology and pathophysiology of the gastrointestinal system, common disease
that occurs in gastrointestinal tract.
Mouth
• Tongue has bony attachments (styloid
process, hyoid bone) attached to the floor of
the mouth by frenulum.
• Posterior exit from mouth guarded by a ring
of palatine/lingual tonsils.
• Ducted salivary glands open at various points
into the mouth. This process involves teeth
(muscles of mastication move jaws) and
tongue (extrinsic and intrinsic muscles).
• Mechanical breakdown, plus some chemical
(ptyalin, enzyme in saliva) secretion.
• Saliva amylase does hydrolysis of starch and
glycogen into maltose.
Esophagus
• The esophagus is about 10" long.
• Food moves through esophagus by peristalsis.
Questions Alerts!
• Stomach secretions (intrinsic factor, HCL, gastrin). Pepsin is digestive enzyme present in GIT break
downs proteins.
• Role of small intestine in absorption of nutrients, drugs and supplements
• Large intestine (colon) bacteria and excessive absorption of water that cause constipation.
• Disease of GI system like GERD, peptic ulcers, Crohn's disease, ulcerative colitis and irritable bowel
syndrome (IBS) symptoms.

2-2
Stomach
Fig 2.2
• Cardioesophageal sphincter guarding entrance from esophagus.
• Pyloric sphincter guarding the outlet is much better defined.
• Fundus, body and pylorus recognised as distinct regions.
• Stomach secretes both acid and mucus (for self protection).
• Surface area increased by rugae, which serves as temporary store for food.
Stomach Secretions Purpose Source
Mucus Lubricant, protects surface from acid. Mucus Cell
Intrinsic factor Vitamin B12 absorption (in small intestine ilium). Parietal cell
Acid (H+
) Kills bacteria, breaks down food, converts pepsinogen. Parietal cell
Pepsinogen Broken down to pepsin (a protease) Chief Cell
Gastrin Stimulates acid secretion (in response protein) G Cell
*Deficiency of intrinsic factors causes a type megaloblastic anemia i.e. pernicious anemia.
Gastric acid secretion mechanism. In the parietal cells CO2 and H2O are converted H+
and HCO3
-
catalyzed by
carbonic anhydrase. The parietal cells secrete HCl into the lumen of the stomach and concurrently absorb HCO3-
into the blood stream.
Gastric acid stimulations. Gastric acid production is stimulated by three mechanisms.
Vagal stimulation. Vagal nerve innervates parietal cells and stimulates H+
secretion directly.
Histamine release. Histamine is released from mast cells in the gastric mucosa and diffuses to nearby parietal
cells.
Gastrin: It is released in response to eating a meal (protein), thus stimulates parietal cells to secrete H+
.
Pathophysiology of gastric acid secretions causes gastric ulcer, duodenal ulcers and Zollinger-Ellison
syndrome.
Question Alerts!
1) Intrinsic factor secreted from parietal cells
deficiency cause?
2) Pernicious anemia should be treated by parenteral
(SC/IM) vitamin B12.
3) Elderly persons have deficiency of vitamin B12
4) Gastrin is secreted from pyloric gland of stomach.
5) What are stomach secretions occur in response to
protein diet? Gastrin and pepsin.
Question Alerts!
1) What enzymes are released into small intestines? Pancreatic and bile secretions.
2) A patient with ileostomy, what oral dosage is NOT suitable? Oral drugs especially Sustain release (SR,
CR MR CD) d f

2-3
Gastric emptying Time: The caudad region of stomach contract to propel food into the duodenum. The rate of
gastric emptying time is fastest if gastric content is isotonic. Fat inhibits gastric emptying time (i.e. increase
gastric emptying time).
Prokinetic drugs (metoclopramide, domperidone) decrease gastric emptying time
Small intestine: Consist of duodenum, jejunum, and ileum.
Duodenum: First part of the small intestine, C-shaped 10" (inch) long and curves around the head of
pancreas and the entry of common bile duct.
• Highest drug absorption in the body takes place here.
• Pancreases is a large glandular organ attached near the stomach.
• Pancreas secretes intestinal enzymes (pancreatic lipase, amylase, protease), and these helps in
the digestion of carbohydrates.
• Bile secretions are bile salts, bilirubin, phospholipids, and cholesterol.
Jejunum: It is 8 to10 feet long: The majority of food absorption takes place in the jejunum.
Secretion
• Secretin stimulates pancreas to produce watery fluid, high in bicarbonates concentration.
• Pancreozymin stimulates pancreas to produce a viscous fluid low in bicarbonate concentration.
Ileum: It is 12 feet long. Towards the end of the small intestine, accumulations of lymphoid tissue
(Peyer’s patches) are more common here.
Large Intestines: It is also known as colon.
• Jejunum terminates at caecum.
• Highest basic or pH.
• Animals digest cellulose in colon.
• The large intestine reabsorbs water then eliminates drier residues as feces.
• Its primary purpose is to extract (absorbed) water from feces.
• Colon consists of higher flora and fauna in GI tract 90 to 99% anaerobic bacteria. Example B. fragilis and C.
difficle anaerobic and aerobic E. coli.
• Colon bacterial produce vitamin K2 (menaquinone).
Diseases of the gastrointestinal system
Diseases of the Mouth and Jaw
• Oral thrush is caused by Candida albicans, and moniliasis.
• Gingivitis (gum inflammation) is caused by Fusobacterium sp.
• Stomatitis is Inflammation of mouth cavity. Herpes stomatitis caused by herpes infection, and aphthous
stomatitis caused by oral hygiene or damage to mucus membrane.
Disease of the Salivary Glands: Sjogren syndrome (dry mouth, dry eyes) is autoimmune disease, it is associated
with rheumatoid arthritis.
Stomach ---à (Pyloric sphincter)-à Duodenum à Jejunum àileum

2-4
Sialorrhea is an excessive secretion of saliva in infants, children, Parkinson’s disease. Can cause by mucosal
irritation.
Dyspepsia: Defined as pain or discomfort in the upper abdomen. Symptoms are nausea, fullness, early satiety,
bloating or regurgitation. The dyspepsia could be due to esophagitis, GERD, peptic ulcer (GU or DU) 15-25%,
Reflux esophagitis, 5-15%, gastric or esophageal cancer (<2%).
Diseases of the Esophagus: Gastro esophageal reflux disease (GERD) is reflux of gastric acid contents into
esophagus. Also referred as heartburn, or regurgitation. Extra esophageal symptoms include cough, laryngitis
and asthmatic syndrome. But the common symptoms are heartburn, regurgitation of acid or bile and hyper
salivation.
Diseases of the stomach.
• Gastritis (inflammation of gastric or stomach lining). Caused by NSAIDS, cigarette smoking, and heavy
alcohol.
• Gastroenteritis: Inflammation of entire GI tract.
• Peptic ulcer: There are two main causes of Helicobacter pylori infections or drug induced (NSAIDS).
Diseases of the small intestine.
• Duodenal ulcers are mainly caused by Helicobacter pylori and the second most common reason is
medications like NSAIDs.
• Zollinger Ellison syndrome is excessive secretion of HCl
• Celiac disease is caused by sensitivity to gluten in cereals. This is due to inability of absorption of gluten (it
mainly effects on upper part of small intestine).
Diseases of the Colon
• Inflammatory bowel disease (IBD): Consist of two conditions, Crohn’s disease and ulcerative colitis.
• IBD symptom are diarrhea, abdominal pain, and rectal bleeding and weight loss.
• Ulcerative colitis occurs mainly in colon and Crohn's disease occurs from esophageal to rectum.
• Crohn's disease (small intestine and colon), chronic inflammatory of ileum, and colon, this can lead to fistula.
ULCERATIVE COLITIS CROHN'S DISEASE
Localized to colon. Site of origin is
rectum.
Occurs from esophageal to rectum. Skip Patches are found entire GI
system. Site of origin is terminal ileum.
Fistula (ulcers in GI tissue) are present Crohn's.
Drug of choice 5ASA 5ASA or Oral prednisone
Fistula are treated by infliximab, adalimumab or metronidazole
10-20 liquid stools per day containing
blood and mucus.
Less common liquid stools per day containing blood and mucus.
Pain, diarrhea, blood in stools
(bloody diarrhea), weight loss
Crampy abdominal Pain, diarrhea, blood in stools, weight loss.
(Toxic megacolon).
Marked increase risk of colon cancer Slight increase risk of colon cancer.
Irritable bowel syndrome (IBS): This can cause severe chronic diarrhea, constipation, bloating and
cramps, nausea and vomiting (No bleeding).
Bristol-stool chart is used to determine severity.

2-5
Pseudo membranous colitis. Clostridium difficile over growth (produce exotoxin) cause diarrhea. C.
difficile is communicable disease. The drug of choice is metronidazole po, vancomycin po.
• Amebic colitis is caused by Entamoeba histolytica
• Cholera is caused by Vibrio cholera.
Hernia: a perturbation of GI tract at the junction of esophagus and stomach.
Fig 2.3
TYPES OF HERNIA
Inguinal Near the opening of the inguinal canal More common in elderly
Femoral Occurs in the femoral canal
Umbilical Occurs at Navel
Incisional Occurs at site of previous surgical incision
Diaphragmatic
(epigastric)
Upper abdomen at midline
Hiatal hernia Occurs when part of the stomach pushes up
through the diaphragm into chest.
Digestion and Absorption
Digestive enzymes are classified based on their target substrates
• Proteases and peptidases split proteins into small peptides and amino acids.
• Lipases split fat into three fatty acids and a glycerol molecule.
• Carbohydrases split carbohydrates such as starch and sugars into simple sugars such as glucose.
• Nucleases split nucleic acids into nucleotides.
GI secretions include saliva, gastric secretions, pancreatic secretions and bile.
Carbohydrates digestion: The most common site of carbohydrate absorption is small intestine. Only
monosaccharides such as glucose, fructose, and galactose are absorbed.
Amylase: Hydrolyse starch and glycogen into maltose. There is amylase in saliva and stomach.
• Maltase: Converts maltose into glucose + glucose
• Sucrase: Converts sucrose into glucose + fructose.
• Trehalase: degrades carbohydrate to glucose.
• Glucosidase: breakdown sucrose and starch to glucose (Acarbose inhibits alpha glucosidase).
• Lipase is released mainly from the pancreases into the GI track to help breakdown fat. (Orlistat, Xenical
inhibit lipase)
• Lactase: Converts lactose (milk) into glucose + galactose.
Pancreatic Secretions (High HCO3 isotonic, pancreatic lipase, amylase, proteases).

2-6
Disorder of carbohydrate absorption. Lactose
intolerance results from absence of brush
border lactase. Thus, non-absorbed lactose
cause osmotic diarrhea.
Milk intolerance can result from 2 reasons. 1)
Lactose intolerance 2) milk protein allergies
Lipid Absorption. Bile acids emulsify lipids in the small intestine, increase surface for digestion. Pancreatic
lipases, hydrolyse, lipids to fatty acids, monoglycerides, cholesterol and lysolecithin.
Lipid absorption disorders. Malabsorption of lipids thus causing fatty stools, this also referred as stethorrhea.
Stethorrhea can cause by
• Pancreatic diseases such as pancreatitis, and cystic fibrosis.
• Hyper secretion of gastrin
• Ileal resection
• Bacterial overgrowth
Absorption of Proteins (small intestine): Trypsin and chymotrypsin are secreted by pancreas, which helps in
digestion of proteins.
• Trypsin is secreted in the inactive form as trypsinogen and is converted to trypsin by enzyme enterokinase.
• Chymotrypsin is secreted in the inactive form as chymotrypsinogen and converted to chymotrypsin by
trypsin.
Absorption of nucleic acid:
• Nucleaseà Nucleic acid into nucleotide.
• Ribonuclease à Hydrolyses RNA
• Deoxyribonuclease à Hydrolyses DNA
Absorption of water (H2O): It is isosmotic in the small intestine and gallbladder.
Absorption of Vitamins and Nutrients: Fat soluble vitamins (ADEK) are absorbed in small intestine along
with other lipids. Vitamin B12 is absorbed in the ileum and that requires intrinsic factor.
Absorption of calcium: Mainly occurs in small intestine, which assisted by active form of vitamin D3, 1,
25-dihydroxycholecalciferol, which is produced in kidney. Chronic renal failure or vitamin D deficiency
results in inadequate intestinal Ca2+
absorption, causing rickets in children and osteomalacia in adults.
The mechanism of calcium absorption is passive absorption.
ENZYME ENZYME PRODUCT
Amylase Starch and glycogen Maltose
Maltase Maltose Glucose + glucose
Sucrase Sucrose Glucose + Fructose
Lactase Lactose Glucose + galactose
Pepsin Trypsin and chymotrypsin
Proteins ………..> Proteins and oligopeptides ………………….> oligopeptide à amino acids
(stomach) (small intestine)

2-7
Absorption of Iron: It is absorbed as heme iron (iron bound to hemoglobin or myoglobin) or as free
Fe2+
. In intestinal cells, heme iron is degraded to Fe2+
and released. The free Fe2+
binds to apoferritin
and is transported into the blood.
The iron absorbed from small intestine in the form of ferrous Fe2+
Transferrin: Free Fe2+
circulates binds transferring and transports it from small intestine to its storage
sites in the liver and from the liver to the bone marrow for the synthesis of hemoglobin.
Innervations of GI tract. Autonomic innervations.
Cholinergic: It is usually excitatory on functions of GI tract. It is carried via the vagus and pelvic nerves.
• Vagus nerve innervates the esophagus, stomach, pancreases and upper large intestine
• Pelvic nerve innervates the lower large intestine and rectum, and anus.
Adrenergic
• It usually inhibitory on the functions of GI tract
• Direct post ganglion adrenergic innervations of blood vessels and some smooth muscles.
Tips
Practice answering tips from table:
1. diarrhea 2. constipation 3. Bloating
4. cramps 5. Proteases 6. nuclease
7. 2 glucoses 8. Colon 9. gluten present in cereal
10 Alpha glucosidase 11 95-100% anaerobic
bacteria
12 Fructose + glucose
13 Peptidase 14 Enterokinase 15 Chymotrypsin
16 Trypsin 17 Vitamin D3 18 Deficiency of intrinsic factors
19 Parenteral vitamin
B12
20 Alcohol dehydrogenase 21 wheat
22 rye 23 oats
• The most basic part of the GI tract ( )
• Irritable bowel disease symptoms ( )
• The proteins are digested by ( )
• What converts nucleic acid into nucleotides ( )
• The pernicious anemia is caused by ( )
• What digest peptides into amino acids ( )
• pernicious anemia is treated by ( )
• What converts inactive trypsinogen into trypsin ( )
• What enzyme oxidizes alcohol to aldehyde and acids ( )
• What are the major bacteria present in colon ( )
• Breakdown sucrose & starch to glucose ( )
• Gluten is present in ( )
• Allergic component in milk ( )

2-8
• Celiac is caused by ( )
• Soya milk allergies due to ( )
• A patient with chronic renal failure have deficiency of vitamin? ( )
• Pernicious anemia is caused by à ( )
• Pernicious anemia is treated by à ( )
• Maltase breakdowns maltose to à ( )
• Sucrase breakdowns sucrose to à ( )
• Alcohol dehydrogenase: ethanol à acetaldehyde à acetic acid
• Irritable bowel symptoms (IBS) include à ( )
• Active Vitamin D is à ( )
• Bacteria in colon makes --> ( )

PharmacyPrep.com Nervous System
reproduce without permission. This manual is being used during review sessions conducted by
PharmacyPrep.
3-1
3
Nervous System
Fig 3.1
Fig 3.2
Questions Alerts!
• What section of brain controls voluntary and involuntary movements?
• Blood brain barrier definition and functions
• Peripheral nerves, radial nerves, ulnar nerves. Sciatica. Cranial nerves.
• Types of Neurological disorders: Multiple sclerosis, Chronic spasticity, Bell's Palsy, Neuralgia, Seizures
or epilepsy, Fibromyalgia, and Parkinson's disease.
• Sciatica pain site is buttocks and back of thighs.
• Causes of multiple sclerosis
Question Alerts!
1) Voluntary and involuntary movements are controlled by?
2) What section of brain coordination and control balance?

PharmacyPrep.
3-2
Nervous system divided into central nervous system and peripheral nervous system. The central nervous system
consists of brain and spine.
Brain
• Cerebrum: largest section of brain and controls voluntary (Think and
decide what to say) and involuntary movements (autonomic
functions).
• Brain stem: Is the posterior part of the brain consist of pons and
medulla oblongata and mid brain.
• Cerebellum: Controls balance (GAIT) and modifies body movements
(Motor). Maintain body coordination and balance.
• Spinal cord. Vertebral column, epidural space, meninges, spinal cord,
dorsal vertebra, and spinal nerve.
• Thalamus: affects sensory levels, awareness and alertness.
Corpus Collasum connects and communicates between right and left hemisphere of brain.
Mesolimbic pathways are
present in? Frontal lobes
Medulla oblongata is present
in? Temporal lobe
Frontal lobe: Motor, cognitive,
behavioral and arousal.
Temporal lobe (auditory,
speech, memory information
retrieval)
Brain stem ( breathing, digestion, heart control, blood vessel control, alertness)
Occipital lobe (visual reception, interpretation)
Parietal lobe (processing sensory input, sensory discrimination, body orientation, somatic area).
Wernicke’s area: In temporal lobe language comprehension.
Vestibular system: Reflex adjustment of head, eyes and postural muscles provide a stable visual image and
steady posture.
Vestibular ocular reflexes. Nystagmus
The direction of the nystagmus is defined as the direction of the fast (rapid eye) movement. Therefore, the
nystagmus occurs in the same direction
as the head rotation. Normally initial
rotation of the head causes the eyes to
move slowly in the opposite direction to
maintain visual fixation.
Meninges
• The meninges are three concentric
membranes that surround and protect brain and spinal cord.
• The dura mater: outer most membrane.
Frontal lobe
Motor Cognitive Behavior Arousal
Voluntary movements Memory Personality Attention
Planning, Initiation Problem solving Social and sexual
Spontaneity Judgment Impulse control
Language Abstract Mood and affect
Language expression Abstract thinking
Eye movement Executing
functions
Question Alerts!
1) Blood brain barrier is present at?
2) Drugs that cross BBB. Rifampin, Cefuroxime sodium, Cefotaxime,
Carabapenam, Atropine, physostigmine, Diphenhydramine, and
ethanol.

PharmacyPrep.
3-3
• The arachnoid: middle layer, transparent, flexible
• The pia mater: inner layer, is fine, and delicate.
Cerebro Spinal Fluid (CSF): The CSF is outside of the brain and circulates through the cavities inside the brain
called ventricles.
Blood brain barrier: The blood brain barrier (BBB) is the barrier between cerebral capillary blood and
cerebrospinal fluid (CSF). BBB is formed by capillary endothelial cells that line cerebral micro vessels form tight
junctions and lacks large intracellular spaces. Further neural tissue covers capillaries. Together constitutes forms
BBB.
The CSF fills the ventricles and the subarachnoid space. Three functions of BBB
• Protects brain from endogenous or exogenous toxins. It prevents escape of neurotransmitters from CNS into
blood circulations.
• Lipids soluble drugs cross faster than water-soluble (polar) drugs.
In capillary lining of BBB have, enzymes such as monoamine oxidase (MAO), cholinesterase and some other
enzymes. These enzymes prevent catecholamines, serotonin, and acetylcholine, to enter into brain.
Peripheral Nervous System: All nerves of the body residing outside of the brain and
spinal cord comprise the peripheral nervous system.
Periphery can be divided into sensory (somatic) and autonomic.
• Ulnar nerve: Passes through the shoulder, elbow to wrist.
• Sciatic nerve runs through buttock, thighs down to foot. It divides into tibia and
common fibular nerve. Which supplies the muscles of posterior thigh and all of the
leg and foot.
• Intercostal nerve is that anterior divisions of the thoracic spinal nerves.
• Radial nerve runs through forearm, wrist to finger tips. It supplies to muscles of
forearm.
• Popliteal nerve. Passes in knee joint.
• Axillary nerve (circumflex): It supplies the deltoid and teres minor muscles, shoulder joint, and skin on back
of arm.
• Phrenic nerve: connect from neck down to lungs. Phrenic nerve injuries can result in to brachial palsy.
(phrenic nerve palsy)
• Vagus nerve: A parasympathetic nerve innervate four organs liver, GI, Heart, and lungs.
PERIPHERAL NERVE COMMENTS
Radial nerve damage cause Wrist drop
Ulnar nerve damage cause Claw hand (small fingers hand contract)
CRANIAL NERVES
CRANIAL NERVE: origin from brain and spread to facial function.
Olfactory smell
Optic vision

PharmacyPrep.
3-4
Oculomotor: Eye upward, medial, downward movement
Trochlear: Eye down and in movement
Trigeminal: Touch forehead and cheek, clench teeth
Abducens Look side to side
Facial Taste for the anterior 2/3 of tongue
Acoustic Hearing
Glossopharyngeal: Posterior 1/3 of the tongue
Vagus Defecation, slowed heart rate
Spiral accessory: shoulder shrug
Hypoglossal: tongue movement
Nerve Cell: Nerve cell consists of dendrite, cell body, axon, myelin sheath, and synapse.
Pathology of neurological disorders
Degenerative diseases: Alzheimer’s, Parkinsonism, Multiple sclerosis, and ALS (Amyotrophic lateral sclerosis).
Alzheimer’s: deficiency of acetylcholine
Parkinson’s: deficiency of dopamine
Multiple sclerosis: autoimmune or degeneration of myelin sheet
ALS: unknown
Fig 3.2
Fig 3.3
Question Alerts!
Myelin sheath damage is associated with?
MS

PharmacyPrep.
3-5
Seizures or epilepsy: Excessive excitation of neurons due to disorderly inhibition of cortical neurons.
Parkinson's disease: Decrease in dopamine or imbalance of dopamine negrostratial pathway.
Suppressing (antipsychotic drugs) the dopamine cause extra pyramidal symptoms (EPS)
Extra pyramidal symptoms (EPS is side effect of antipsychotic drugs) "Akathisia, Dystonia, Parkinsonism, Tardive
Dyskinesia". These symptoms are the side effect of antipsychotic drugs like haloperidol.
Akathisia = restlessness or cannot sit still.
Parkinsonism: (“TRAP”) Tremors (hand shaking), rigidity, ataxis, postural instability, Dyskinesia = involuntary
movement or shaking
Dystonia = involuntary muscle spasm
Tardive dyskinesia = involuntary movement of lips, tongue, and chewing motion.
Ataxia = lack of muscle coordination in voluntary movements.
Migraine Headache: Vasodilatation of intracranial extra cerebral blood vessels.
Vertigo: False sensation of moving or spinning or object moving usually accompanied by nausea and loss of
balance.
Meniere's disease produces sudden episode attack of vertigo along with ringing in ears (tinnitus) and
progressive deafness. Episodes can last from minutes to hours. Associated with nausea and vomiting. Beta-
histine is used for treatment.
Chronic spasticity: Spasticity is an involuntary velocity dependant increase in muscle tone resulting in injury to
motor pathway in brain or spinal cord. It is common in MS, stroke, spinal cord injury and cerebral palsy. It can
impair feeding, dressing, bowel function, hygiene and gait.
Bell's Palsy: Paralysis of lower motor neuron of facial nerve (effects on eye). It is often due to herpes simplex
virus (HSV1) infection causing inflammation and edema.
Multiple Sclerosis: The multiple sclerosis (MS) is characterized by destruction of myelin sheet (demylenation)
and axonal degeneration & loss in CNS. The MS is chronic and can be caused by autoimmune mediated action.
Treatment: Interferons beta (first line therapy), glatiramer acetate (Immunomodulators similar to interferon
beta), Mitoxantrone, natalizumab, Fingolimod (spingosine-1-phosphate receptor agonist), Teriflunomide, and
laqinimod.
Temperature regulation: The homeostatic mechanisms regulate body temperature (37.5 °C) or 98.6 °F
Sympathetic nervous system innervate heat loss by vasodilatation and sweat production. Sympathetic nervous
system innervate adrenal gland than increase metabolic rate.
Thalamus à pituitary gland à thyroid à Increase metabolic rate.
Hyperthermia = >38.2 °C or 100 °F
High fever is defined >40.5 °C
Hyperpyrexia (fever) = a fever >41.5 °C are rare
Hypothermia = <35 °C, if <32 °C it can cause ventricular arrhythmias.
(CTMA p85)
Drug induced reaction characterized by genetic susceptibility to generalized and sustain skeletal muscle
contraction after exposure to depolarizing muscle relaxants such as succinylcholine, halothane or isoflurane.

PharmacyPrep.
3-6
Malignant hyperthermia is the side effects of drugs that cause fever symptoms. Example. Halothane, and
succinylcholine.
Treatment: Dantrolene 2.5 mg/kg for Q5min
Neuroleptic malignant syndrome (NMS) induced by antipsychotic drugs. Characterized by hyperthermia or
hyperpyrexia (>41.5 °C) and muscle rigidity, autonomic instability e.g. cardiac arrhythmias.
Treatment: Bromocriptine 2.5-20 mg TID.
Heat stroke: Core body temp. >40.6 °C
Antipyretics (NSAIDs) reduce fever by inhibiting cyclooxygenase, this inhibits prostaglandin synthesis. Therefore,
analgesics decrease set-point temperature. In response that cause heat loss in the form of sweating,
vasodilatation.
Diagnostic techniques.
Electroencephalograph (EEG): The EEG consist of alternating excitatory and inhibitory synaptic potential in the
pyramidal cells of the cerebral cortex.
CT scan (computed tomography) of brain. Demonstrates generalized waves of spike and wave discharge.
Cerebrospinal fluid (CSF) sample is taken by Lumbar puncture.
FMRI. The functional MRI is used brain scanning.
Tips
1. Sciatic nerve 2 Blood brain barrier 3 Adrenal medulla
4 Tardive dyskinesia
5
Protects brain from endogenous
&exogenous toxins
6 Bradykinesia
7 Nissl substance 8 Multiple sclerosis 9 Cerebrum
1
0
it prevents escape of
neurotransmitter from CNS
into blood circulations
1
1
lipid soluble drugs cross faster
than H2O soluble drugs
• What is the barrier between cerebral capillary blood and cerebrospinal fluid (CSF) the CSF fills the ventricles
& the subarachnoid space ( )
• A CNS disease where the myelin sheath of motor neurons is degenerating or being destroyed, which
interferes with neuronal impulses ( )
• The nerve that pass through buttocks, thighs down to foot ( )
• What part of brain controls voluntary and involuntary movements ( )
• Inappropriate posture of neck, face and limbs is referred as ( )
• Functions of blood brain barrier ( )
• Slow movement ( )
• The dark granular inside neuronal cell bodies ( )
• Sciatica is à ( )
• The longest and largest nerve is --> ( )

PharmacyPrep.Com Cardiovascular System
4-1
4
Cardiovascular System
Question Alerts!
Carotid artery supply
blood to? Brain
What arteries supply
blood to eyes?
external carotid
artery

4-2
Conduction System of the Heart (fig 4.4)
Fig 4.4
Fig 4.5
Questions Alerts!
• Definitions and disease associated with thrombus, embolus, ischemia, aneurism, atherosclerosis,
plaques, and edema.
• Concept of depolarization and repolarization
• Electrode potential curve (P wave is atrial depolarization, QRS is ventricular depolarisation, QT wave
is mechanical contractions of ventricles).
• Diagnostics. ECG. Electrocardiography, and Echocardiography and biological markers.

4-3
Blood flow sequence: Vena cava à right atrium à right ventricle à left pulmonary arteryà LUNGS à left
pulmonary vein à left atrium à left ventricle à aorta à systemic circulation
Septal defect: Ventricular septal defect is a hole in the wall separating the two lower chambers of the heart.
Types of pacemakers
Natural (main) pacemaker of heart is SA node. Latent pacemaker of heart is AV node, bundles of His and
purkinje fibres.
• Pulse direction’s SA node à AV node à Bundles His à Purkinje
fibres
Depolarization (inward current): Carrying +ve charge into cell
Increase Na+
influx into cell
Decrease K+
efflux out to cell
Repolarization (outward current or hyper polarization). Take +ve charge out of cell
Increase K+
efflux out to cell
Increase Cl-
influx into cell
Myocardial action potential curve: Myocardial action potential
curve reflects action potential, which describes electrical activity
of five phases. This occurs in atrial and ventricular myocytes and
purkinje fibers.
• Phase 0: Rapid depolarization: Na+
enters the cell
• Phase 1: Early rapid repolarisation: K+
leaves the cell
• Phase 2: Plateau: Ca2+
enters the cell
• Phase 3: Final rapid repolarisation: K+
pumped out of
the cell
• Phase 4: Slow depolarization: K+
inside the cell and
Na+
, Ca2+
outside the cell.
Phase 1 to starting phase 3 is absolute refractor period or
effective refractory period. The cell cannot respond to any stimuli. (NO action potential can be initiated).
During Phase 3 is relative refractory period. The cell ability to respond stimuli increases or cell can respond to
strong stimuli.
Electrocardiograph Wave Forms: The electrical activity occurred during depolarization and repolarization
transmitted through electrodes attached to the body and
transformed by an electrocardiograph (ECG) in to series of
waveforms.
• P wave indicates atrial depolarization.
• PR interval indicates the spread of the impulse from
the atria through Purkinje fibres. (Beginning of initial
depolarisation of ventricle).
• QRS complex indicates ventricular depolarization.
• ST segment indicates phase 2 of the action potential
the absolute refractory period.
• T wave shows phase 3 of the action potential
ventricular repolarization.
Important concept!
Depolarisation and repolarisation?

4-4
• Q-T interval. Mechanical contraction of the ventricles (Torse de pointes).
• U wave caused by hypokalemia.
Torsade de pointes: This is also called the Q-T interval. A problem in one of the ion channels can prolong the Q-T
interval. A prolonged Q-T interval can increase risk for a type of arrhythmia called torsade de pointes.
• Thrombus is blood clot.
• Embolus is moving blood clot.
• Aneurysm is abnormal dilatation of arteries. Can cause stroke.
• Stenosis is constriction or narrowing of opening.
Atherosclerosis is increased in LDL, progressively hardens the
arteries and veins. Cause CAD (angina, MI), stroke, ischemia,
and PVD.
Plaques are progressive accumulation of lipids and inflammatory cells. Site of injuries in arteries results
formation of plaques. Sheer stress may result in plaque rupture, collagen exposure, platelet aggregation,
and clot formation. Examples of diseases that comes from plaques are angina, myocardial infarction, atrial
fibrillation, cerebral stroke, embolism and peripheral vascular diseases (DVT and PE).
Cardiac oxygen consumption: When increased size of the heart.
Laplace's Law: Laplace's law describes how tension in the vessel
wall increases with Trans mural pressure. According to Laplace’s law, tension is proportional to the radius of a
sphere.
Autonomic effects on heart rate and conduction velocity.
Inotropic: Force of contraction (The ability of the cardiac muscle to develop force at given muscle length).
Positive (+ve) inotropics: Digoxin, ACEI, DHP-CCB
Negative (-ve) inotropics: BBs, verapamil, diltiazem
Chronotropic: Heart rate (the number of action potential that occur per unit time).
Positive (+ve) chronotropic. DHP-CCB
Negative (-ve) chronotropic: Amiodarone, BBs, NDHP-CCBs, digoxin, "(ABCD)"
Dromotropic: Conduction
Positive (+ve) dromotropic: amitriptyline
Negative (-ve) dromotropic: Na+
& K+
channel blockers.
Stroke volume: The volume of blood ejected from the ventricle on each beat. (Pulse).
Question Alerts!
1) Definition of Atherosclerosis.
2) Diseases that cause by plaques?
Angina, MI, ischemic stroke.

4-5
Ejection fraction: The fraction of end-diastolic volume ejected in each stroke volume. Ejection fraction in
congestive heart failure is <40%.
Ejection fraction: Stroke volume/end diastolic volume
Cardiac output: stroke volume x heart rate
Pre-load = Volume of blood fills in ventricles in diastolic state
After load= Force to overcome peripheral resistance.
Example: Vasodilators (hydralazine, nitrates, CCBs) decrease preload and after load.
Diagnostics
Blood pressure. Sphygmomanometer.
Normal 120/80
BP is diagnosed in 2 office visits if BP average >140/90 mm Hg, in presence of DM, renal, atherosclerosis, and
cerebrovascular.
If the average SBP/DBP is 140-159/90-99 mmHg, treatment is recommended in the presence of risk factors
smoking, FH, truncal obesity, sedentary lifestyle, male >55 yo, female >60yo.
Coronary artery disease: ECG and biological marker (Troponin and Creatine kinase CK-MB)
Electrocardiogram (ECG), and measures cardiac rhythms.
ECG - used for excluding atrial fibrillation.
Echocardiogram: Shows the presence of regional valve motion abnormalities, size of heart chambers.
Echocardiogram allows for identification of valvular abnormalities and other MI problems.
MRI, MR angiography (MRA), or CT angiography used for confirmation of degree of arterial occlusion or
neurologic conditions like cerebral ischemia.
Tips
Find answers from the table.
1. Absolute refractory period 2. Repolarization 3 arrhythmia
4. Phase 0 5. Phase 1 to starting phase 3 6 Relative refractory period
7. Phase 3 8. + ve inotropic 9 –ve inotropic
10 Digoxin 11 ACEI 12 Dihydropyridine CCBs
13 Beta blockers 14 stroke 15 brain attack
16 cerebral embolism
• Absence of rhythm ( )
• Drugs that cause +ve inotropic effect ( )
• Rapid depolarization ( )
• Increase in force of contraction ( )
• The cell cannot respond to any stimuli ( )
• The cell ability to respond stimuli increases or cell can respond to strong stimuli ( )
• Decrease in force of contraction ( )
• Excessive negative charge in cell occurs ( )

4-6
Select True/False Statements
• A brain attack that occurs when a wandering clot (embolus) or some other particle forms in a blood vessel
usually in the heart and flow into in the brain cerebral vessel is cardiogenic cerebral embolism. True/False
• Drugs that cause –ve chronotropic effect (digoxin, beta blockers) True/False
• Stroke or brain attack happens when brain cells die because of inadequate blood flow to the brain
(True/False)

PharmacyPrep.Com Endocrine System
Copyright © 2000-2018 TIPS Inc. Unauthorized reproduction of this manual is strictly prohibited and it is illegal
to reproduce without permission. This manual is being used during review sessions conducted by PharmacyPrep.
5-1
5
Endocrine System
Definitions
• Amniocentesis: surgical puncture of the amniotic sac
• Cystoscopy: process of viewing the urinary bladder
• Dysmenorrhea: Painful periods
• Embryology: study of the growth and development of the human organism
• Gynecologist: specialist in the diseases of the female reproductive system
• Hydrocele: accumulation of water in the scrotum;
• Menorrhagia: Excessive bleeding during menstruation
• Nephritis: Inflammation of the kidney
• Primigravida: first pregnancy
• Spermatogenesis: creation of new sperm
• Urology: study of urinary tract
Endocrine system
Consists of a group of organs that have NO DUCTS and therefore are also known as DUCTLESS GLANDS
that secrete hormones directly into the blood stream..
Major endocrine glands: Pituitary Gland (present under hypothalamus), the master endocrine gland.
Testes, Ovaries, Thyroid Gland (neck), Adrenal Gland (on kidney), Pancreas Gland (endocrine and
exocrine)
Other glands
• Parathyroid Gland (neck)
• Thymus Gland (chest)
• Pineal Gland (brain)
Questions Alerts!
• Hormone of anterior and posterior pituitary gland, thyroid hormone, Insulin, corticosteroid hormones.
• Hypothyroid and hyperthyroidism symptoms. Lab investigations of serum TSH
• Hypoglycemia and hyperglycemia symptoms.
• Insulin function, Pathophysiology of diabetes and diabetic ketoacidosis
• Hypo corticosteroids (Addison diseases) and hyper corticosteroids (Cushing's disease).

5-2
Pituitary Gland
• Located at the base of the brain.
• Consists of two parts: anterior lobe and posterior lobe.
• It is sometimes known as the master gland.
• It controls the functions of other endocrine glands and is in turn controlled by the hypothalamus.
Endocrine
Gland
Types of hormone Target tissue Physiologic actions
Hypothalamus Houses releasing and
inhibiting hormones
Anterior
pituitary
Controls release of anterior pituitary hormone
Anterior
Pituitary gland
Thyroid-stimulating
hormone (TSH)
Thyroid Production of thyroid hormone (T4 and T3, and
calcitonin).
Adrenocorticotropic (ACTH) Adrenal
cortex
Secretion of cortisol
Growth hormone (GH) Bones; soft
tissues
Stimulates growth of bones and soft tissues
Follicle-stimulating hormone
(FSH)
Females;
ovary
Males:
Testes
Promotes growth of ovarian follicle;
Stimulates estrogen secretion
Stimulates sperm production
Luteinizing hormone (LH) Females:
Ovary
Stimulates ovulation
Stimulates progesterone secretion
Males.
Testes
Stimulates testosterone secretion
Prolactin Females:
breast
Promotes breast development; stimulates milk
secretion
Posterior
Pituitary gland
Vasopressin (antidiuretic
hormone)
Kidney Causes water retention
Oxytocin (formed in
hypothalamus and stored in
posterior pituitary gland).
Uterus Causes contraction
Breasts Causes ejection of milk
Pineal Melatonin Brain; anterior
pituitary;
reproductive
organs;
possibly other
sites.
Sets the body’s “time clock”.
Causes sleep in response to darkness
Thyroid Thyroid hormone (Triiodo T3
and levothyroxine T4), and
calcitonin.
Most cells Increases the metabolic rate; necessary for
normal growth and development.
Calcitonin takes Ca from Blood à Bones
Parathyroid Parathyroid hormone (PTH) Bone; kidney;
intestine
Increase amount of calcium in the bloodstream.
↓ amount of phosphate in the bloodstream
↑ PTH = ↑ Ca (by bone resorption)
↑ PTH = ↓ phosphate
Thymus Thymosin T lymphocytes Enhances the production of T lymphocytes

5-3
Pancreas Insulin
Secreted from beta cells
Most cells Promotes use and storage of nutrients
particularly glucose, after eating
Glucagon
Secreted from alpha cells
Most cells Maintains glucose levels in the bloodstream
during periods of no food
Somatostatin and gastrin
Secreted from delta cells
F cells? pancreatic
polypeptides
Digestive
system
Inhibits digestion and absorption of nutrients.
Inhibit secretion of insulin, glucagon and gastrin.
Somatostatin are growth hormone inhibiting
hormone (GHIH).
Adrenal
Medulla
Epinephrine Kidney Increases Na+
retention and K+
excretion
Adrenal cortex Zona
glomerulosa
(out)
Aldosterone Kidney Increases Na+
retention and K+
secretion
Z. fasciculata Cortisol Most cells Increases glucose in the bloodstream
Z. reticularis Androgens Females: bone
and brain
Puberty growth spurt and sex drive in females.
Testes (male) Testosterone Male sex
organs; body as
a whole.
Stimulates production of sperm; responsible for
development of sex characteristics. Promotes
sex drive.
Ovaries
(female)
Estrogen Female sex
organs; body as
a whole
Stimulate uterine and breast growth;
responsible for sex characteristics.
Progesterone Uterus Prepares for pregnancy
Physiological effects of some pituitary hormones
• Somatostatin: opposes the effects of Growth Hormone-Releasing Hormone (GHRH)
• Prolactin: It is synthesized and secreted by lactotrope cells in the anterior pituitary gland, breast and the
deciduas.
Effects
• Stimulates the mammary glands to produce milk (lactation).
• Provides the body with sexual gratification after sexual acts
• immune tolerance of the fetus by the maternal organism during pregnancy.
• Stimulate proliferation of oligodendrocyte precursor cells which differentiate into oligodendrocytes, the
cells responsible for the formation of myelin coatings on axons in the central nervous system.
Thyroid Gland (Fig 5.3): Secretes thyroid hormones (LEVOTHYROXINE, TRIIDOTHYRONIN AND CALCITONIN),
which in turn control the body’s metabolic rate.
Question Alerts!
1) Insulin & glucagons released from? Beta cell & alpha cells
2) Epinephrine released?
3) Aldosterone hormones released from?
4) Aldosterone antagonist spironolactone act on collecting duct and prevent K+ secretion causes
hyperkalemia.

5-4
Thyroxin or Levothyroxine (T4): Naturally occurs in levo (L) isomer form produced in the thyroid gland.
T4 Converts in the liver and other organs to T3 by deiodination (deiodinase).
• Controls the rate of metabolism in the body.
Triiodothyronine (T3): Metabolically active form.
Calcitonin (a peptide): Hypocalcemic hormone.
• Secreted by parafollicular cells (C-cells).
• Reduces blood calcium ion concentration by moving Ca from
blood to bones.
• Used in treatment of osteoporosis associated vertebral
fracture.
• Hypercalcemia stimulates calcitonin production.
Functions of thyroid hormones:
• Growth and development
• Proper function of all body system
• Maintenance of all body tissues.
Carbohydrate, fat, protein, and
vitamin metabolism (Basal Metabolic Rate).
• Affects the secretion of other hormones (insulin, NE, Epi, cortisol, estrogen and
testosterones.
Mechanism of action
• At the target cell, proteases split protein carrier off from the thyroid hormone and most of T4 is
deiodinated to T3.
• T3 (and probably some T4) enter the cell through membrane transport proteins and bind to a
specific nuclear receptor.
Hypothyroidism Hyperthyroidism
Thyroid gland is under active and
produces insufficient thyroid hormone.
Overactive thyroid gland causing an
abundance of thyroid hormone.
Thyrotoxicosis is the general term for over
activity of the thyroid gland.
Symptoms Fatigue
Sensitivity to cold
Dry flaky skin and Coarse hair
Slowed speech (deep voice)
Puffy face, hands, feet
Hearing loss
Decreased libido
Weight gain
Constipation
Impaired memory
Hypertension, bradycardia
Slow return of deep tendon reflexes
Heat intolerance
Profuse sweating
Diffusely enlarged nontender goiter.
Nervousness, irritability, anxiety and
insomnia
Weigh loss in spite of increased appetite
Tremor and muscle weakness
Tachycardia
Diarrhea
Question Alerts!
1) Conversion of T4 to T3 by deiodination.
2) Calcitonin production is stimulated by?

5-5
Diseases Hashimoto (autoimmune, the most
common type of hypothyroidism.
Common on in elderly).
Myxedema (If untreated Myxedema
and coma may develop.
Dwarfism
Mental retardation
Graves disease (diffuse toxic goiter) the
most common form of hyperthyroidism,
autoimmune disorder. Antibodies (long-
acting thyroid stimulators) bind to and
activate TSH receptors.
Plummer’s disease (toxic nodular goiter)
Serum TSH assay The most sensitive test for detecting
the hypothyroid state. ↑ serum TSH
↓ serum TSH
Sensitive TSH
assay
Commonly used in patient receiving
replacement therapy (levothyroxine) to
control treatment.
Sensitive TSH assay
Free thyroxin
index (FTI)
This is not separate test but estimation
of free T4 level mathematical
interpretation of relationship of RT3U
and serum T4 levels.
(Free T4) Serum free thyroxine ↓ FT4 Elevated T4 indicates hyperthyroidism
(TT3) Serum total triiodothyronine ↓ TT3 Disproportionate rise indicated
hyperthyroidism.
Useful in early detection and rule out of
hyperthyroidism
Pregnancy Levothyroxine is used to treat.
Adequate dose thyroxin, necessary for
development of the fetal brain.
Propylthiouracil the treatment of choice.
Serum TSH >6 mU/L <0.3 mU/L
Thyroid function tests (normal serum TSH is 0.3 to 6 mU/L)
Parathyroid Glands: Four tiny glands in the posterior surface of the thyroid gland, which is positioned on
the esophagus, produce parathyroid hormone (PTH), which regulates the calcium metabolism in the
body.
Parathyroid hormone: Reabsorbs calcium in kidney.
Hypoparathyroidism Hyperparathyroidism
Decrease production of PTH
Decrease blood calcium
Increase blood phosphate levels
Causes convulsions
Causes hypokalemia
Causes neuromuscular irritability
Increase production of PTH
Increase blood calcium levels
Decrease blood phosphate levels
Causes muscle weakness
Causes muscle atrophy
Causes fatigue

5-6
Parathyroid hormone analog: Teriparatide.
Pancreas: In the pancreas the acini which produces digestive enzymes. Islets produce 3 types of hormones.
o Insulin produced by beta cells
o Glucagon produced by alpha cells
o Somatostatin produced delta cells (extra pancreatic cells)
Insulin
• Increase glucose uptake into cell.
• Glycogenesis: Increased glycogen storage in liver, and muscle.
• Decrease gluconeogenesis: Decrease synthesis of glucose from non-carbohydrate source.
• Lipogenesis: Fat/triglyceride storage (adipose tissue).
Insulin
• Insulin acts on liver, adipose tissue and muscles.
• Produced by beta cells of islets of langerhans.
• Insulin is peptide
• Stored in vesicles in combination with zinc
• 51 amino acid chain
• Half life insulin is 3 to 5 min Controls blood glucose concentration
• Decrease insulin secretion
Insulin function in carbohydrate, protein and fat metabolism
Carbohydrate metabolism Protein metabolism: Fat metabolism:
Increase glucose uptake
Decrease glycogenolysis
Decrease ketogenesis
Decrease glucogenesis
Increase lipogenesis
Increase RNA and DNA synthesis
Increased protein synthesis
Increased cell growth
Increased amino acid transport
Increase storage of fatty acid in
adipose tissue
Increase lipogenesis
Decrease lipolysis
↑ glucose uptake
↓ glycogenesis
↓ gluconeogenesis

5-7
Glucagon
• Stimulated breakdown of glycogen to glucose (glycogenolysis) in the liver
• Increase blood glucose levels.
DIABETES MELLITUS
This is a primary disorder of carbohydrate metabolism that exhibits the following characteristics. A defective
or deficient insulin secretory response. Glucose underutilization and hyperglycemia.
Types of diabetes:
§ Insulin-Dependent/Type 1 (IDDM)
§ Non-Insulin Dependent/Type 2 (NIDDM)
§ Secondary Diabetes (e.g. pancreatic disease)
§ Impaired Glucose tolerance
§ Gestational diabetes (i.e. glucose intolerance w/onset during pregnancy)
Diabetic Patient
HYPOGLYCEMIA HYPERGLYCEMIA
Autonomic
FPG <4 mmol/L
<70 mg/dL
Sweating, palpitation, fatigue, hungry, tremors
(shaking).
Polyphagia, polyuria, hyperglycemia,
glycosuria, polydipsia
CNS
FPG <2-3 mmol/L
<50 mg/dL
Confusion, nervousness, disorientation. Dizzy,
anxious, headache, irritable, blurred vision.
Treatment GLUCOSE TAB, DEXTROSE TAB
FPG: Fasting blood glucose level (8 hours without calories intake); Normal glucose FPG: 5 to 6 mmol/L or 80 to
120 mg/dL.
Insulin or resistance
Influx of glucose inside the cell
Cell starvation
Glucose in blood (hyperglycemia)
Glucose in urine (glycosuria)
* Polyuria (profound loss of water and electrolytes)
* Polydipsia (intense thirst)
* Polyphagia (increased appetite)
Osmotic diuresis

5-8
Diabetic microangiopathy, atherosclerosis, myocardial infarction, cerebral stroke, gangrene of the lower
extremities.
• Diabetic nephropathy, Progressive proteinuria and chronic renal failure (CRF)
• Diabetic retinopathy, cataract formation or glaucoma
• Diabetic Neuropathy pain (numbness, tingling,
pin feeling and burning).Symmetric peripheral
neuropathy affects motor and sensory nerves of
the lower extremities. Schwann cell injury, myelin
degeneration, axonal damage.
• Autonomic neuropathy, sexual impotence, bowel and bladder dysfunction.
• Effects of insulin deficiencies. Cataract, retinopathy (blindness), neuropathy, nephropathy premature
atheroma (increase blood fatty acids) and cardiovascular.
Diabetes Insipidus (DI): Anti diuretic hormone (vasopressin) deficiency causes diabetes insipidus
Insufficient ADH due to dysfunction of hypothalamic nuclei (e.g. tumors, hydrocephalus, histocytosis, trauma).
Passage of large volumes of dilute urine. Decrease in ADH causes large volume of dilute urine, Polyurea,
Polydipsea, and Polyphagea.
Treatment: Anti diuretic hormone
Diabetes insipidus central Diabetes insipidus nephrogenic
There is NO ADH production ADH present but kidney does not respond.
Autoimmune Acquired or drugs (lithium)
THYMUS GLAND
• Regulates the development of T-lymphocytes in immune system
PINEAL GLAND
• Small cone shaped gland
• Smallest of all glands located in mid brain
• Large in children and begins to shrink at puberty
• Only brain structure that does not come in a pair
• Produces melatonin and dimethyl tryptamine in the dark
Functions
• Influences circadian rhythms e.g. sleep and temperature
• Sexual development
• metabolism
• Regulates the mating behavior
• Regulates day and night cycle.
Insulin requirement increase Insulin requirement decrease
Heavy meals
Emotional Stress
Infections
Pregnancy
Physical activity
Exercise
Question Alerts!
What is NOT complication of
hyperglycemia?
Question Alerts!
What decreases insulin
requirement?

5-9
Adrenal Gland (Fig 5.4): Two adrenal glands one on top of each kidney.
Adrenal gland Control by Hormones HYPER HYPO
Adrenal medulla Sympathetic
(chromaffin cells)
Epinephrine Hypertension
Pheochromocytoma
hypotension
Cortex: outer Renin-angiotensin Aldosterone Ascites Hyperkalemia
Middle layer ACTH Corticosteroids Cushing Syndrome Addison Disease
Inner layer ACTH Androgens Gynecomastia hypogonadism
Inner part (medulla): Secretes epinephrine (adrenalin)
Epinephrine increases BP, HR, vasoconstriction and blood supply to skeletal muscle. Norepinephrine increases
effects of epinephrine.
Adrenal Cortex:
Outer layer: secrete aldosterone
Middle layer: Corticosteroids
Inner layer: Androgen
§ ACTH regulates the secretion of mineral corticoids. e.g. aldosterone helps regulate salt and water
balance by retaining salt and water and excreting potassium.
Glucocorticoids
§ Control glucose metabolism and protein synthesis.
§ The principle glucocorticoids are cortisol and cortisone.
● Androgens are male sex hormones mainly testosterone.
Functions of ACTH: The ACTH stimulates the cortex of the adrenal gland and boosts the synthesis of
corticosteroids, mainly glucocorticoids but also mineral corticoids and sex steroids (androgens).
• ACTH is also related to the circadian rhythm in many organisms.
• The half-life of ACTH in human blood is about 10 minutes.
Hypo corticosteroids: Addison's disease (chronic adrenal insufficiency, or hypocortisolism).
Causes auto immune reaction, HIV and tuberculosis.
Signs and symptoms: Chronic fatigue that gradually worsens, Muscle weakness, weight loss and loss of appetite,
nausea, diarrhea, or vomiting.
Treatment: Replacement of missing cortisol and fludrocortisones.
Hypercorticosteroids: Cushing's syndrome or hypercortisolism or hyperadrenocorticism is caused by high levels
of cortisol in the blood.
Signs and symptoms: Rapid weight gain, Moon face, Buffalo hump, reduced libido and Easy bruising.
Treatment. Removal of adrenals. Post operative steroid replacement (hydrocortisone or prednisolone).
Ovaries: Produces two hormones estrogen and progesterone.
Estrogen: Controls the development of female sex characteristics and reproductive system.
Progesterone: Prepares the lining of the uterus for implantation of a fertilized egg.

5-10
HYPER HYPO
Estrogen Weight gain
Increase risk of blood clot, mood
changes, breast cancer, headache,
edema
Hot flushes, night sweat, dry skin, mood swings,
vaginal atrophy, dryness, bone loss, yeast
infection. Urinary incontinence
Progestins Most of symptoms of estrogen
deficiency. +
Breast tenderness, acne
Infertility, vaginal bleeding or spotting.
OCP side effects Menopause symptoms
Dysmenorrhea
• Menstrual pains are referred as dysmenorrhea.
• It is most common from age 20 to 25.
• Primary when no underlying cause is found.
• Secondary when a cause is identified as a gynecological disorder.
Endometriosis: associated with dysmenorrhea, menstrual pain, infertility.
Common cause of secondary dysmenorrhea. Endometriosis gives pelvic pain, spotting before normal periods
and may cause infertility.
Ovulation cycle and menstruation
• During the menstrual cycle estrogen is
produced by the ovarian follicles.
• After ovulation estrogen is produced by
the corpus luteum.
• During pregnancy ovulation does not occur. It is suppressed by high levels of estrogen and
progesterone's.
Pregnancy test: Human chorionic gonadotropin (hCG) hormone levels are elevated in first 3 months of
pregnancy (first trimester). Progestin's in pregnancy is produced by ovaries, corpus luteum and placenta.
Question Alerts!
Ovulation Tests detects? LH
Question Alerts!
Hormone that detected in pregnancy tests? hCG

5-11
Menstrual cycle
Menopause: Cessation of menstrual periods for at least 6 mo, is referred as menopause. Occurs when the
ovaries stop producing estrogen. Ovarian follicles are depleted at approximately 51 year of age.
Most common vasomotor symptoms: Hot flushes, night sweat, mood swings, sleeplessness, lethargy, and
depression. Urogenital atrophy (this leads to dryness of the vagina, dyspareunia (painful intercourse).
Hormones Deficiencies Excessive (over production)
Thyroids Myxedema
Hoshimoto
Serum TSH ↑
Graves
Serum TSH ↓
Adrenal corticoids Addison disease Cushing syndrome
Insulin DM Hypoglycemia
Glucagon Hyperglycemia
Anterior pituitary Acromegaly
ADH Diabetes insipidus SIDH

5-12
Tips
1. adrenal medulla 2. pituitary gland 3. posterior pituitary gland
4. diabetes insipidus 5. glucose 6. H2O + CO2
7. excessive urination 8. outer adrenal cortex 9. sensitivity to cold
10. bradycardia 11 Weight gain 12. Glycogen
13. constipation 14 dry skin 15. weight loss
16. tachycardia 17. diarrhea 18. sensitivity to heat
19. sweating 20. palpitation 21. fatigue
22. polyhagia 23. polyurea 24. Blurred vision
25. polydipsea
• Glycolysis; Glucose→( )
• Glycogenesis; Glucose→( )
• Glycogenolysis; Glycogen→( )
• Gluconeogenesis: fats & proteins→( )
• Epinephrine is released from? ( )
• Aldosterone is released from? ( )
• ACTH is secreted by? ( )
• Oxytocin is secreted from? ( )
• ADH is secreted from? ( )
• Deficiency of ADH gives… ( )
• Symptom of diabetes insipidus ( )
• Symptoms of diabetes mellitus ( )
• Symptoms of hypoglycemia ( )
• What hormones are released from posterior pituitary gland? ( )
• Hypothyroidism laboratory investigation include ( )
• Epinephrine is released from? ( )
• Aldosterone is released from? ( )
• Testosterone to 5-hydroxy testosterone is catalyzed by? ( )
• Diabetes mellitus symptoms? ( )
• Hypoglycemia symptoms? ( )
• Symptoms of hyperthyroidism? ( )
• Symptoms of hypothyroidism? ( )
• Symptoms of Cushing syndrome? ( )
• Addison disease is à ( )

PharmacyPrep.Com Renal System
6-1
6
Renal System
Nephron. A nephron is the basic unit of renal function.
There are millions of nephron present in each kidney.
Nephron has three major functions.
• Filtration
• The filtration occurs at glomerular or
bowman capsules.
• Creatinine clearance is the measure of glomerular filtration rate (eGFR). Normal creatinine
clearance is 80 to 120 mL/min.
Fig 6.1
Fig 6.2
Questions Alerts!
• Filtration, Secretion and Reabsorption process.
• Types and causes of acute renal failure. Symptoms of chronic renal disease and acute renal
failure (pre-renal acute renal failure is due to lack of blood perfusion).
• Creatinine clearance in renal diseases
• Metabolic acidosis (increase in CO2) and alkalosis (Increase in HCO3).
Question Alerts!
What factors does NOT effect on
reabsorption?

6-2
• Reabsorption
• Transportation of ions or drugs back into blood from nephron is referred as reabsorption.
• Secretion
• Secretion of ions or small molecular drugs into nephron from nephron walls.
Acute Renal Failure (ARF): The acute renal failure (ARF) is rapid decline in the renal ability to clear the blood of
toxic substances, causing accumulation of metabolic waste products, like blood urea nitrogen.
Three types of ARF
• Prerenal ARF (occurs due to problems in organs liver, heart and blood
circulations).
• Intrinsic ARF (occurs due to problems in kidney). Drugs such as
aminoglycoside, NSAIDs. Sepsis.
• Post-renal ARF (occurs due to problems in organs after kidney like ureter or bladder).
Prerenal ARF is characterized by inadequate blood circulation (perfusion) to the kidneys, which leaves them
unable to filter the blood properly. Many patients with prerenal ARF are critically ill and experience shock (very
low blood pressure). There is often poor perfusion within many organs, which may lead to multiple organ
failure.
Causes. Some of the most important causes of prerenal ARF are dehydration, heart failure, sepsis (severe
infection), and severe blood loss.
Prerenal ARF is associated with a number of pre-existing medical conditions, such as atherosclerosis
("hardening" of the arteries with fatty deposits), which reduces blood flow. Dehydration caused by drastically
reduced fluid intake or excessive use of diuretics (water pills) is a major cause of prerenal ARF. Many people
with severe heart conditions are kept slightly dehydrated by the diuretics they take to prevent fluid build up in
their lungs, and they often have reduced blood flow (under perfusion) to the kidneys.
Symptoms of prerenal ARF include the following: Dizziness, dry mouth, Low blood pressure (hypotension), rapid
heart rate, slack skin, thirst, weight loss. Urine output is usually low in people with prerenal ARF. The patient
also may have symptoms of heart or liver disease.
Chronic kidney diseases (CKD): Slow progressive decline in kidney function can cause accumulation of metabolic
waste like BUN. (CrCl >30 and <60 ml/min)
Albumin creatinine ratio (ACR) >200 mg/mmol (non-diabetic nephropathy), ACR >3 mg/mmol (diabetic
nephropathy).
Risk Factors
• High blood pressure (uncontrolled)
• Atherosclerosis
• Blood loss
PRE-RENAL ARF INTRINSIC ARF POST ARF
In adequate blood perfusion, CHF,
hemorrhagic, hypovolemia, severe blood loss,
dehydration, sepsis.
Aminoglycosides, NSAIDS
Infections, sepsis
Cancers in ureter or bladder.
Question Alerts!
What causes of pre-renal acute
renal failure?

6-3
• Chronic liver disease
• Heart disease
• Blood sugar (diabetes)
• Autoimmune disease like systemic lupus erythromatus
Chronic kidney disease affects blood.
• ↑ urea (azotemia or uremia) and creatinine concentration
• Anemia (↓ erythropoietin’s)
• ↑ blood acidity (acid-balance)
• ↓ absorption Ca and vitamin D3 concentration
• ↑ Parathyroid hormone (PTH)
• Normal or slightly ↑ K concentration
CKD can cause azotemia, anemia, vitamin D3 deficiency, decrease Ca concentration, and increased blood activity
(acidosis).
CKD can cause decrease drug (metabolite) clearance and drug half-life (T1/2) increase.
The drug of choice to treat chronic kidney disease are ACEi or ARBs.
Nephrotic syndrome: Severe prolonged loss of protein into urine decrease blood proteins like albumin.
Chronic nephritis syndrome: Glomeruli are damaged and kidney function degenerates over a period of time.
Symptoms are vomiting, nausea, edema, high blood pressure, difficulty in breathing, itchy and fatigue.
Electrolytes and Disorders
Electrolytes present in blood Na+
, K+
, Ca2+
, Mg2+
, Cl-
, and CO3
-
.
Calcium (Ca2+
): In normal adults, there are approximately 1400 g of calcium in the body, of which 99% in bones.
The total of 0.1% calcium is present in blood (plasma). The most common source of calcium is dairy products.
Calcium plays an important role in propagation of neuromuscular activity and regulation of endocrine functions.
Parathyroid hormone (PTH) helps to dissolve calcium ion from bones and moves calcium to blood, thereby hyper
PTH can cause hypercalcemia. Helps in calcium reabsorption in kidney.
Calcitonin is secreted from thyroid gland. It helps in movement of
calcium ion from the blood to bone formation. Thereby
hypercalcemia stimulates secretion of calcitonin from thyroid
gland.
Vitamin D: The active form of vitamin D is 1, 25-dihydroxy vitamin
Electrolytes
Extracellular (interstitial and plasma)
Na+
, Cl-
, Ca2+
Intracellular
K+
, Mg2+
, Phosphate
Question Alerts!
Drug that case hypercalcemia?
Hydrochlorothiazide
Chlorothiazide
Metolazone

6-4
D3 (chole-calciferol). It enhances absorption of calcium when calcium is low in the blood. Calcium is primarily
absorbed by carrier-mediated diffusion at small intestine (jejunum, and duodenum).
* Blood coagulation
* Bone and tooth structural integrity
* Normal values. 8.8 to 10.3 mg/dL or 2.20 to 2.56 mmol/L.
Hypercalcemia
Causes. Malignancy or metastatic bone disease.
• Hyperparathyroidism. Excessive parathyroid hormone secretion. Drugs that cause hypercalcemia are
Thiazide diuretics (Increase Ca reabsorption therefore decrease Ca secretion). Vitamin D intoxication can
cause excessive absorption of Ca.
• Treatment: Hypercalcemia can be treated with drugs such as calcitonin, bisphosphonates, zoledronic acid,
corticosteroids, and prednisone.
• PTH Increase Ca2+
reabsorption by activating adenylate cyclase in the distal tubule.
Hypocalcemia
Causes. Due to deficiency of vitamin D.
• Hypoparathyroidism (due to decrease in PTH secretion).
• Drugs that can cause hypocalcemia are corticosteroids. The corticosteroids counteract the effects of vitamin
D. Loop diuretics increase Ca2+
excretion therefore cause hypocalcemia (furosemide, ethacrynic acid).
Excess of phosphate in total parenteral nutrition.
Phosphorus
• Phosphorus is an intracellular ion. Phosphorus is found primarily in bone (85%) and soft tissues (14%).
Hypophosphatemia
• Hyperparathyroidism (excessive PTH) causes hypophosphatemia.
• Hypophosphatemia (seen mostly in primary hyperparathyroidism and malignancy-associated
hypercalcemia). Exacerbates hypercalcemia by increasing renal synthesis of 1, 25-dihydroxycholecalciferol,
reducing bone formation and increasing bone resorption.
Hyperphosphatemia
• Occurs due to hypoparathyroidism (low PTH).
• Drugs that prevent bone resorption (death) are referred as antiresorptive agents.
• Antiresorptive agents are bisphosphonates, clodronate disodium, pamidronate disodium and zoledronic
acid.
Potassium (K+
): Potassium distributed primarily in intracellular (98%) and extracellular (2%) in muscle tissues.
• Major cation in intracellular space.
• Maintenance of proper electrical conduction in cardiac and skeletal muscles (muscle and nerve excitability).
• Plays a role in acid base equilibrium acidosis.
• Range of normal value 3.5 to 5 mEq/L.
Potassium regulated by.
• Kidneys (renal function)
• Aldosterone

6-5
• Arterial pH
• Insulin (insulin decrease K+
inblood by shifting K+
into cell.)
• K+
supplement intake
• Sodium delivery to distal tubule
Aldosterone increase K+
secretion. Drugs that inhibits or blocks aldosterone hormone can cause hyperkalemia
such potassium sparing diuretics, ACEi, and ARBs.
Hyperkalemia
Causes. Renal insufficiency and drugs. The drugs that cause hyperkalemia includes K+
sparing diuretics
(Spironolactone, Triamterene, and Amiloride), ACEi, and ARBs etc.
• Adrenal insufficiency (aldosterone hormones)
• During vigorous exercise
• Cellular breakdown (tissue damage, hemolysis, burns, infections)
• Metabolic acidosis, and cardiac arrest.
Hypokalemia
Symptoms: Malaise (feeling NOT well), confusion, dizziness, ECG changes, muscle weakness and pain.
Causes: Excessive mineral corticoid activity, vomiting, and diarrhea
Drugs that cause hypokalemia. Diuretic Thiazide, loop diuretics, and acetazolamide increase secretion of K+
.
Corticosteroids, penicillin (piparicillin, ticaracillin), beta2 agonist, and amphotericin.
• Glucosuria
• Alkalemia
• Administration of insulin and glucose
Chloride (Cl-
)
• The most abundant extracellular anion is Cl-
(Na+
is the most abundant extracellular cation).
• Maintenance of acid base balance relationship between Na, and Cl.
Hyperchloremia (Cl-
excess) and hypernatremia (Na+
excess in the blood)
Caused by:
• Renal insufficiency when chloride intake exceeds excretion
• Dehydration
• Excessive salt intake
Hypochloremia
Caused by:
• Excess loss of GI fluids
• Diuretic therapy: Thiazide, and loop diuretics. Hypochloremic alkalosis is caused by: thiazides.
• Fasting
• Adrenal insufficiency
Sodium (Na+
)
• Sodium is the predominant cation of the extra cellular fluid (ECF).
• Norma sodium levels (135 to 147 mEq/L or mmol/L).
• Sodium is essential in establishing osmotic pressure relation between intracellular and extra cellular fluid.

6-6
Hyponatremia
• Caused by cirrhosis, CHF, nephrosis or the administration of osmotic active solutes such as albumin or
mannitol (osmotic diuretic).
Hypernatremia
Caused by:
• Loss of free water (not body fluid)
• Loss of hypotonic fluid
• Excessive sodium intake
• Drugs that contain (beta lactam, ticaracillin, antacids such as sodium carbonate).
HYPO HYPER
CALCIUM LOW PTH, FUROSEMIDE,
CORTICOSTEROIDS,
HIGH PTH, THIAZIDES,
POTASSIUM THIAZIDES, LOOP, K+ SPARINGS, ACEI, ARB,
PHOSPHATE HIGH PTH
SODIUM DEHYDRATION CKD
Acid Base Disorders
Body produces two types of acids; volatile (CO2) and non-volatile or fixed acids (HCl. phosphoric acid, sulfuric
acid).
Normal blood pH 7.35 – 7.45
Metabolic acidosis: ↓ Bicarbonates (HCO3
-
) in blood and↑ CO2 in blood
pH of blood is reduced (↓) in metabolic acidosis (acidic) pH of urine is increased (alkaline).
Carbonic anhydrase, is present in most cells, catalyzes the reversible reaction between CO2 and H2O ---
>HCO3
-
Drugs that ↓ Bicarbonates (HCO3
-
) cause metabolic acidosis are acetazolamide, amiloride, triamterene,
spironolactone (potassium sparing), and ↑ CO2 overdose of ASA, lactic acidosis, and ketoacidosis.
Treatment: Sodium bicarbonate (NaHCO3).
Metabolic alkalosis (pH >7.45): ↑ Bicarbonates (HCO3
-
) in blood and ↓ CO2 in blood.
Drugs and disease that cause metabolic alkalosis. Thiazide and loop diuretics, hypercalcemia, high concentration
of alkali administration, and vomiting.
Treatment: Ammonium chloride (NH4Cl) or ascorbic acid (vitamin C).
Respiratory Acidosis:
This occurs due to inadequate ventilation of CO2 by lungs. Predisposing factor for respiratory acidosis such as
asthma, beta-blockers, sleep apnea, CNS depressants, pulmonary edema or embolism, and cardiac arrest.
Respiratory Alkalosis
Due to increase secretion of CO2. HYPERVENTILATION.
Not very common
Example: Over dose of ASA

6-7
CO2 HCO3 pH ventilation
Metabolic acidosis ↑ ↓ ↓ normal
Metabolic alkalosis ↓ ↑ ↑ Normal
Respiratory acidosis ↑ normal ↓ Hypoventilation
Respiratory alkalosis ↓ normal ↑ Hyperventilation
Tips
1. Hypokalemia 2. in kidneys 3. Creatinine clearance
4. ↓HCO3 ↑CO2 5. ↑HCO3 ↓ CO2 6. Azotemia
7. Renal perfusion 8. Ureter 9. Bladder or prostate
10 Flow rate 11 pH 12 Tonicity
13 Metabolism 14 Hypocalcemia 15 Hypercalcemia
• Excessive blood urea nitrogen in blood ( )
• The most common cause of pre-renal acute renal failure is due to ( )
• What happens in metabolic acidosis? ( )
• What happens in metabolic alkalosis? ( )
• Intrinsic acute renal failure occurs in? ( )
• Post renal acute renal failure can occur in? ( )
• Factors that affect reabsorption ( )
• Glomerular filtration (GFR) measures…( )
• Chronic renal disease may cause…( )
• Adrenal gland cancer (pheochromocytoma) may cause…( )
• Due to deficiency of Vit D ( )
• Stimulates secretion of calcitonin from thyroid gland ( )
• albuminuria is --> ( )
• Albuminuria is indicator of --> ( )
• The most common extra cellular cation is--> ( )
• The most common extra cellular anion is--> ( )
• What happens in metabolic acidosis? ( )
• What happens in metabolic alkalosis? ( )
• Write the examples of drugs that cause metabolic acidosis? ( )
• Write the examples of drugs that cause metabolic alkalosis? ( )
• What is the abundant metal in body? ( )
• Pre-renal ARF is due to à ( )
Select True or False statements
• Normal serum potassium levels à ( )
• If it is defect in renal filtration, CrCl à ( )
• Normal CrCl is à ( )
• In renal disease CrCl is à ( )
• Azotemia or uremia is à ( )
• Potassium sparing diuretics gives à ( )

6-8
• Pyuria and dysuria is symptoms of à ( )
• Lactic acidosis is SE of à ( )
• Summary of electrolytes action in kidney (True/ False)
• Proximal convoluted tubule = Reabsorbs Na+
, Cl-
, Ca2+
(True/ False)
• Distal convoluted tubule = Reabsorbs Na+
, Cl-
, Ca2+
(True/ False)
• Thin descending loop of Henle = Reabsorbs H2O (True/ False)
• Thick ascending loop of Henle = Reabsorbs: Na+
, K+
, Cl-
, Mg2+
, Ca2+
(True/ False)
• Collecting tubule = Reabsorbs Na+
in exchange of K+
or H+
(regulated by aldosterone). Reabsorption of H2O is
regulated by ADH (vasopressin). (True/ False)

www.pharmacyprep.com Liver function and Pathophysiology
7-1
7
Liver and Chronic Liver Diseases
Definitions
• Necrosis cellular breakdown example: Acetaminophen
• Steatosis: Hepatocytes filled with small droplet of
lipid. Example: Tetracycline’s
Drugs transportation into the bile from the liver
• There are transporters for anions, bile salts, cations,
and neutral organic compounds.
• Release small intestine.
Oral drugs passage to liver: Mesenteric veins à portal veins à liver à hepatic vein à heart à systemic
circulationà Renal or hepatic elimination.
Enterohepatic recirculation
• This term refers to drugs emptied via bile into the small intestine and then reabsorbed from the intestinal
lumen into PORTAL VEIN to the systemic circulation.
Questions Alerts!
• Causes of chronic liver diseases like ascites (peritonitis).
• Hepatitis A, B, C infections causes of infections
• Hepatitis A and B vaccines and treatment.
Question Alerts!
1) Enterohepatic recirculation is recirculation bile from small intestine to liver.
2) Drugs that involve in enterohepatic recirculation? Increase action of oral drugs with phase II metabolism.
3) Erythromycin estolate cause cholestatic jaundice.
4) Sulfa drugs in last trimester of pregnancy can cause KERNECTERUS.
5) Cholestyramine binds with bile and prevents reabsorption of bile into liver.
6) Decrease in blood flow to liver alters extent of drug metabolism.

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