Anatomy 100 Concepts Flashcards
1
Q
lumbar pucture (tap) and epidural anesthesia:
define
A
the needle enters the subarachnoid space to extract cerebrospinal fluid (CSF) or to inject anesthetic into epidural space, respectively
2
Q
at what level should you give a lumbar puncture/tap or epidural anethesia?
landmark?
why is this so critical?
A
- needle is usually inserted b/w L3/L4 or L4/L5
- landmark: level of horizontal line throug upper points of iliac crests
- important bc spinal cord may end as low as L2 in adults, or L3 in children
3
Q
how low does the dural sac extend?
A
extends caudally to the level of S2
4
Q
to what level does an epidural anestheisa injection go?
A
into the epidural space
(b/w the dura mater and the ligamentum flavum/lamina
5
Q
to what level does a lumbar spinal puncture go?
A
into the subarachnoid space (containing CSF)’
this is between the dura mater and the spinal cord/ filum terminale
6
Q
herniated intervertebral disc:
symptoms
A
- hx of back pain that may radiate down the lower limb
- pain begins soon after patient lifted something heavy
- lower limb reflexes are decreased on the affected side
7
Q
herniated intervertebral disc
where does it usually occur?
pathology?
A
- usually in lumbar (L4/L5 or L5/S1) or cervical (C5/C6 or C6/C7) of inidivduals younger than 50 y/o
- herniated lumbar disc usually compressed THE NERVE ROOT ONE NUMBER BELOW; traversing the root
8
Q
kyphosis
define and cause
A
- an exaggeration of the thoracic curvature
- may occur in elderly persons as a result of osteoporosis (multiply compression fracture of vertebral bodies) or disk degeneration.
9
Q
lordosis
define, cause
A
- an exaggeration of the lumbar curvature
- may be temporary and occurs as a result of pregnancy, spondylolisthesis, or potbelly.
10
Q
scoliosis
define, cause
A
- complex lateral deviation, or torsion
- caused by poliomyelitis, a limb-length discrepancy, or hip disease
11
Q
what are the sites of potential injury to major nerves in fractures of the humerus?
A
- surgical neck –> axillary nerve and posterior humeral circumflex artery
-
midshaft –> radial nerve and profunda brachii artery
- midshaft fx also affects origin of brachialis muscle
- supracondylar region –> median nerve and brachial artery
- medial epicondyle –> ulnar nerve
12
Q
what are the possible fractures of the distal radius?
A
- transverse fx w/in distal 2 cm of the radius
- smith’s fracture
- colles’ fracture
13
Q
what is the most common fracture of the forearm in patients over 50 y/o?
A
transverse fx w/in the distal 2 cm of the radius
14
Q
smith’s fracture
mechanism, define
A
- results from a fall or a blow on the dorsal aspect of the FLEXED WRIST and produces a ventral angulation of the wrist
- distal fragment of the radius is ANTERIORLY displaced
15
Q
colles’ fracture
mechanism, define
A
- results from forced EXTENSION of the hand, usually as a result of trying to ease a fall by outstretching of upper limb
-
distal fragment is displaced DORSALLY
- aka “Dinner fork deformity”
- often ulnar styloid is avulsed (broken off)
16
Q
scaphoid fracture:
mechanism of injury
A
result of a fall onto the palm when the hand is ABducted
17
Q
scaphoid fracture:
symptoms, diagnosis, sequelae
A
- Pain occurs primarily on the lateral side of the wrist, especially during wrist extension and abduction
- Dx: may not show on X-ray films for 2-3 wks,
but a deep tenderness will be present in the anatomical snuffbox - The proximal fragment may undergo avascular necrosis bc the blood supply is interrupted.
18
Q
boxer’s fracture
define, MOI
A
- necks of the metacarpal bones are frequently fractured during fistfights
- MOI
- Fx of 2nd and 3rd metacarpals –> professional boxers
- Fx of 5th and sometimes 4th metacarpals –> in unskilled fighters
19
Q
mallet or baseball finger
MOI, define
A
- MOI: the DIP joint is suddenly forced into extreme flexion (hyperflexion)
- e.g. baseball is miscaught or finger is jammed into base pad
- def: avulsion of the Extensor digitorum tendon attachment at base of distal phalanx –> so pt can’t extend DIPJ –> “mallet”
20
Q
rotator cuff muscles, and mnemonic
A
“SITS”
- Supraspinatus
- Infraspinatus
- Teres MINOR
- Subscapularis
21
Q
actions of the ROTATOR CUFF MUSCLES
A
- SUPPORT the shoulder joint by forming a musculotendinous rotator cuff around it
- REINFORCES JOINT on all sides **EXCEPT INFERIOR**, where dislocation is most likely to occur
22
Q
what muscle/nerve accounts for the
0-15 degrees of ABDUCTION of upper limb?
A
Abduction of the upper extremity is initiated by the supraspinatus muscle (suprascapular nerve)
23
Q
what muscle/nerve accounts for the
15-110 degrees of ABDUCTION of upper limb?
A
Further abduction to the horizontal position is a function of the deltoid muscle (axillary nerve)
24
Q
what muscle/nerve accounts for the
110-180 degrees of ABDUCTION of upper limb?
A
Raising the extremity above the horizontal position requires scapular rotation by action of the:
- trapezius (accessory nerve CNXI), and
- serratus anterior (long thoracic nerve)
25
**subacromial bursitis**
define, cause, sxs
* inflammation of the subacromial bursa
* due to **calcific supraspinatus tendinitis**
* causes **painful arc of abduction**
* same sxs in case of trauma or inflammation of supraspinatus tendon (MRI shows torn tendon)
26
what are the "three elbows" discussed?
* STUDENT'S elbow
* TENNIS elbow
* GOLF elbow
27
**olecranon**
* to which the triceps tendon attaches distally
* easily palpated
* It is separated from the skin by only the olecranon bursa, which allow the mobility of theoverlying skin.
28
STUDENT'S ELBOW
name, define
* SUBCUTANEOUS OLECRANON BURSITIS
* **repeated excessive pressure and friction** may cause this bursa to become inflamed --\> friction subcutaneous olecranon bursitis
29
TENNIS ELBOW
name, MOI, sxs
* LATERAL EPICONDYLITIS
* MOI: repeated forceful flexion and extenion of the wrist --\> strain attachment of common extensor tendon and inflammation of periosteum of lateral epicondyle
* sxs: pain felt over lateral epicondyl --\> radiates down posterior aspect of forearm; pain is felt when opening door or lifting a glass
30
origins of which muscles may be affected in tennis elbow?
* Extensor carpi radialis longus & brevis
* extensor digitorum
* extensor digiti minimi
* extensor carpi ulnaris
31
GOLFER'S ELBOW
name, MOI, origins of musc affected
* MEDIAL EPICONDYLITIS
* MOI: inflammation of the common flexor tendon of the wrist where it originates on the MEDIAL EPICONDYLE of the humerus
* Origins of muscles may be affected:
* pronator teres
* flexor carpi radialis
* palmaris longus
* flexor carpi ulnaris
32
**blockage of subclavian or axillary artery** can be bypassed by anatomoses b/w which branches?
(think: anastomoses of the scapula)
* branches of the **Thyrocervical** and **Subscapular** arteries
* Incl
* **Transverse cervical**
* **Suprascapular**
* **Subscapular**
* **Circumflex scapular**
33
**cubital fossa**
contents L--\> M
1. biceps brachii tendon
2. brachial artery
3. median nerve
34
**cubital fossa:**
subcutaneous structures from L--\> M
1. **cephalic vein**
2. **medial cubital vein:** joins cephalic and basilic veins
3. **basilic vein**
35
what is usually the site of venipuncture?
usually the **median cubital vein** bc it overlies bicipital aponeurosis, so deep structures are protected;
NOT ACCOMPANIED BY NERVES
36
**carpal tunnel syndrome:**
nerve most commonly affected
Median nerve is most sensitive structure in the carpal tunnel and is therefore most affected
37
**carpal tunnel syndrome:**
MOI, Clinical manifestations
* MOI: results from lesion that reduces the size of the carpal tunnel (fluid retention, infxn, dislocation of lunate bone)
* clinical manifestations:
* pins and needles, or anesthesia of the lateral 3.5 digits
* palm sensation is NOT affected bc superficial palmar cutaneous branch passes superficially to carpal tunnel
* **apehand deformity (absent of opposition)**
38
how to test PIP of the hand?
test the FDS
Flexor digitorum superficialis
39
how to test DIP of the hand?
test the FDP
**flexor digitorum profundus** is a muscle in the forearm of humans that flexes the fingers (also known as digits).
40
lesion of UL nerves
(**upper brachial palsy**)
define, MOI
* INJURY OF UPPER ROOTS AND TRUNK
* MOI
* from excessive **inc in angle b/w neck and shoulder** stretching or tearing the superior parts of the brachial plexus (C5 and C6 roots or superior trunk)
* May occur as birth injury (forceful pulling on infant's head)
41
**Erb-duchenne palsy**
define, nerve roots affected
* upper brachial palsy
* **paralysis of the muscles of the shoulder and arm supplied by C5 and C6 spinal nerve (roots) of the upper trunk**
* combination lesions of AXILLARY, SUPRASCAPULAR, and MUSCULOCUTANEOUS nerves w/ loss of shoulder movement and anterior arm
42
what type of palsy is associated with "WAITER'S TIP" hand? what is this sign?
* assoc w/ Erb-Duchenne palsy
* waiter's tip
* ADDUCTED shoulder
* MEDIALLY rotated arm
* EXTENDED elbow
* loss of sensation in the LATERAL ASPECT of the upper limb
43
**Klumpke paralysis**
define, MOI, roots affected
* lower brachial palsy/ injury of lower roots and trunk
* MOI: may occur when upper limb is suddenly pulled SUPERIORLY; stretching or tearing of the inferior parts of the brachial plexus **_(C8 and T1 roots or inferior trunk)_**
* e.g. grabbing support while falling from height, or
* birth injury, or
* (TOS) thoracic outlet syndrome
44
**klumpke paralysis:**
roots affected, symptoms
* all intrinsic muscles of the hand supplied by the **C8 and T1 roots of the lower trunk affected**
* Sxs
* combination lesions --\> ulnar nerve ("claw hand"), median nerve ("ape hand")
* loss of sensation in the MEDIAL ASPECT of the upper limb and medial 1,5 fingers
* may include **horner** syndrome
45
lesion of what nerve causes CLAW HAND?
lesion of what nerve causes APE HAND?
* claw hand
* ape hand
46
injury to **musculocutaneous nerve**
MOI, symptoms
* usually results from lesions of lateral cord
* sxs
* **weakens flexion of elbow** (biceps & brachialis muscles) and **supination of forearm** (biceps muscle)
* may have anesthesia over lateral aspect of forearm
47
which artery is used for **cardiac catheterization?**
(purpose)
* **FEMORAL ARTERY**
* can be cannulated for LEFT CARDIAC ANGIOGRAPHY, and also for visualizing the coronary arteries -
48
how is the cardiac catheter placed?
long, slender catheter is inserted percutaneously and passed up the EXTERNAL ILIAC artery, COMMON ILIAC artery, AORTA, to the **LEFT VENTRICLE** of the heart
49
what is a common fracture in elderly women with osteoporosis?
fracture of the **femoral neck**
50
what are the presentation, sequelae, and treatment of
FRACTURES OF FEMORAL NECK
* presentation: causes shortness of lateral rotation of the lower limb
* sequelae: disruption of blood supply to the head of the femur
* tx: **hip replacement**
51
how does a **transcervical** fracture of femoral neck disrupt the blood supply?
and sequelae
* disrupts the **RETINACULAR ARTERIES** (medial circumflex femoral artery) --\>
* may cause **AVASCULAR NECROSIS of the femoral head** if the blood supply through the ligament to the head is inadequate
52
injury to the **sciatic nerve:**
affects motion, MOI
* motion:
* weakened HIP EXTENSION and KNEE FLEXION
* FOOTDROP (lack of dorsiflexion)
* FLAIL FOOT (lack of both dorsiflexion & plantarflexion)
* MOI: cause by IMPROPERLY PLACED GLUTEAL INJECTIONS, but may result from posteiror hip dislocation
53
what is the most common injury of the glutel region?
POSTERIOR HIP DISLOCATION is most common
54
MOI of posterior hip dislocations
* head-on collision that causes the knee to strike the dashboard may dislocate the hip when the femoral head is forced out of the acetabulum
* joint capsule **ruptures inferiorly/posteriorly** (**fx of ischium**), allowing femoral head to pass thru tear in the capsule (tearing of **ischiofemoral lig**)
* and over the posterior margin of the acetabulum onto the lateral surface of the ilum, **shortening and medial rotating of limb**
55
**superior gluteal nerve injury**
MOI, presentation
* MOI: may be injured during surgery, **posterior dislocation** of the hip or poliomyelitis
* presentation: paralysis of the **gluteus medius** and **gluteus minimus** muscles occurs so that the ability to pull the pelvis up and abduction of the thigh are lost
56
what type of sign results from superior gluteal nerve injury?
**TRENDELENBURG SIGN:**
* If the **superior gluteal nerve** on the **right** side is injured, the **left pelvis falls downward** when the patient raises the left foot off the ground.
* Note that side is **_contralateral_** to the nerve injury.
57
injury to INFERIOR GLUTEAL NERVE
MOI, presentation
* MOI: posterior hip dislocation, surgery in this region
* presentation:
* **weakened HIP EXTENSION** (gluteus maximus(
* most noticeable when **climbing stairs** or **standing from a seated position**
58
**injury of obturator nerve:**
MOI, presentation
* MOI: **anterior hip dislocation**, radical retropubic prostatectomia
* presentation:
* **difficulty adducting thigh** (e.g. crossing legs while sitting)
* **decreased sensation over the upper medial thigh**
59
where does an avulsion fracture of the hamstring muscles occur?
avulsion fractures occur WHERE MUSCLES ARE ATTACHED **_-- ischial tuberosities_**
60
**hamstring muscles**
names, action, innervation
* muscles:
* **biceps femoris**
* **semitendinosus**
* semimembranosus
* action: **extension of hip, flexion of knee**
* innervation: **tibial nerve**
* (short head of the biceps femoris is supplied by the **common fibular nerve**)
61
what are the structures **under the inguinal ligament,**
from lateral to medial
* iliopsoas musc
* femoral NERVE
* femoral artery
* femoral vein
* femoral CANAL
62
**femoral hernia**
define
* passes **below inguinal ligament** through the **femoral ring** into the femoral canal to form a swelling in the upper thigh inferior and lateral to the pubic tubercle
* hernial sac may protrude through the **saphenous hiatus** into the superficial fascia
63
**femoral hernia**
patient population, clinical significance
* occurs more frequently **in females** and is dangerous bc the hernial sac may be **strangulated**
* clinical significance: an **aberrant obturator artery** is vulnerable during surgical repair
64
**unhappy triad:**
define, MOI
* involves
* anterior cruciate ligament
* tibial collateral ligament (medial collateral ligament)
* medial meniscus
* \*\*bc the lateral side of the knee is struck more often (e.g. football tackle), so the TIBIAL COLLATERAL LIGAMENT is the most frequently torn ligament at the knee
65
**tibial collateral ligament** (medial collateral ligament):
action, course
* action: **limits extension and abduction of leg** at knee
* course:
* broad flat band extending from medial epicondyle of femur to medial condyle and shaft of tibia
* blends w/ capsule and **firmly attaches to medial meniscus**
66
**fibular collateral ligament (**lateral collateral ligament):
action, course
* action: **limits extension and ADDuction of leg** at knee
* course
* rounded cord b/w **lateral epicondyle of femur,** and **head of fibula**
* **does NOT** blend w/ joint capsule and **does NOT attach to lateral meniscus**
67
**positive anterior drawer sign** is indicative of what injury?
* with **rupture of anterior cruciate ligament**
* pos ant drawer --\> tibia can be pulled forward excessively on the femur
68
**positive POSTERIOR drawer sign** indicates what kind of injury?
* rupture of the POSTERIOR cruciate ligament
* occurs much less commonly than ACL
* pos posterior drawer --\> tibia can be PUSHED BACKWARD excessively on the femur
69
**prepatellar bursa:**
define
* b/w the superficial surface of patella and skin
* may become inflamed and swollen --\> "prepatellar bursitis"
70
**suprapatellar bursa**:
define
* superior extension of synovial cavity **b/w distal end of femur and quadriceps muscle and tendon**
* may become inflamed and swollen --\> suprapatellar bursitis
71
which bursa is the MC location for intra-articular injections in the knee?
* SUPRAPATELLAR BURSA (*usualplace for intra-articular injections)*
72
**knee jerk reflex**:
name, how, tests what spinal nerves?
* "PATELLAR REFLEX"
* tested by tapping patellar ligament w/ a reflex hammer to elicit extension at knee joint
* both afferent and efferent limbs of the reflex arch are in the FEMORAL NERVE (L2-L4)
* tests **_L2-L4_**
73
**ankle sprains**:
MOI, MC injured ligament
* MOI: **inversion** injury (accounts for almost all sprained ankles), involving twisting of the weight-bearing plantarflexed foot
* MC: **ligament ligament (anterior talofibular ligament**) is injured bc it is much weaker than the medial ligament
74
most common ankle injury?
what might be fractured in severe cases?
* MC ankle injuries --\> SPRAINS
* in severe sprains, the **lateral malleolus of the fibula may be fractured**
75
**pott's fracture:**
define, MOI
* fracture-dislocations of the ankle joint
* the **deltoid ligament** avulses the MEDIAL MALLEOLUS and after that, fibula fractures at higher level
* MOI: forced EVERSION (ABduction) of the foot
76
**ankle jerk reflex:**
name, how, spinal nerve level
* **achilles tendon reflex**
* tested by **tapping the calcaneal tendon** to elicit plantar flexion at the ankle joint
* tests spinal nerves **S1-S2**
77
**fracture of the fibular neck**:
may cause injury to what?
* injury to **common peroneal nerve****,** which winds laterally around neck of the fibula
* results in **paralysis** of all muscles in the **anterior and lateral compartments** of the leg (dorsiflexors and evertors of the foot), and **losing sensation on the dorsum of the foot**
* causes FOOT DROP
78
what happens with **avulsion or rupture of the calcaneal (Achilles) tendon?**
* disables the tricepts surae muscle (gastrocnemius and soleus), so patient CANNOT PLANTARFLEX the foot
79
what are the muscles of the superficial posterior compartment of the lower leg?
* **triceps surae**
* 2 heads of gastrocnemius muscle
* 1 head of soleus muscle
* **plantaris**
* small fusiform belly w/ long thin tendon;
* sometimes may become **hypertrophied**
80
**plantar fasciitis** (calcaneal spur):
frequency, define, presentation
* MC hindfoot problem in runners
* **pain on plantar surface of the foot and heel**
* presentation:
* point tenderness on proximal attachment of the **plantar aponeurosis** to the **medial tubercle of the calcaneus** and,
* on **medial surface of this bone**
81
**popliteal fossa:**
contents from superficial to deep
* tibial nerve
* popliteal vein
* popliteal artery
82
what results when the **tibial nerve** is injured?
* popliteal fossa: **loss of plantarflexion** of foot (mainly gastrocnemius and soleus muscles) and **weakened inversion** (tibialis posterior muscle) causing **calcaneovalgus**
* **unable to stand on toes**
* **loss of sensation** and paralysis of intrinsic muscles of the SOLE OF THE FOOT
83
what are the two terminal branches of the tibial nerve on the sole of the foot?
* medial plantar nerve
* lateral plantar nerve
84
what muscles and skin region is innervated by the **medial plantar nerve?**
muscles
* abductor hallucis
* flexor hallucis brevis
* flexor digitorum brevis
* 1st lumbrical muscles
skin of **medial 3.5 digits**
85
which muscles and skin region is innervated by the **lateral plantar nerve**?
muscles
* ALL INTRINSIC PLANTAR MUSCLES which are not innervated by medial plantar nerve
skin of **lateral 1.5 digits**
86
carcinoma of the breast:
histology
* carcinoma of breast is **malignant tumor**
* usually adenocarcinomas arising from epithelial cells of the lactiferous ducts in mammary gland lobules
87
**carcinoma of breast:**
growth and presentation
* enlarges, attaches to **suspensory (Cooper's) ligaments**
* produces shortening of the ligaments --\>
* causing depression or **dimpling of overlying skin**
88
what is the lymphatic drainage of the breast, and
why is this important?
* drainage:
* 75% of lymph (esp from lateral breast quadrants) --\> drains to **AXILLARY LYMPH NODES**, initially to **anterior (pectoral) nodes** for the most part
* remaining lymph (esp medial breast) drains to **PARASTERNAL LNs or** to the opposite breast
* \*\*IMPORTANT bc of its role in the **metastasis of cancer cells**
89
**radical mastectomy**:
define, what structures may be damaged?
* more extensive surgical procedure, involving removal of breast, pectoral musc, fat, fascia, and as many LNs as possible in the axilla and pectoral region
* can damage:
* **long thoracic nerve** --\> winged scapula due to serratus anterior m paralysis
* **intercostobrachial nerve** --\> skin deficit of medial arm
90
what occurs when **long thoracic nerve** is damaged?
* can be damaged during ligation of lateral thoracic artery
* results in
* winged scapula
* weakness in ABduction of arm above 90 degrees
* (paralysis of serratus anterior)
91
**mastitis**
define, presentation, causes, pts
* **infxn of the tissue of the breast;**
* **sxs: pain, swelling, redness, inc temp of breast**
* causes: when bacteria (often from baby's mouth), enters milk duct through crack in nipple
* occurs most frequently during time of breastfeeding (1-3 mo after delivery of baby); also occurs in women who have NOT recently delivered
92
describe the course and arrangement of the
## Footnote
**intercostal blood vessels and nerves**
* run between the **internal intercostal and innermost intercostal muscles** in the costal groove
* arranged from Superior to Inferior as VEIN, ARTERY, and NERVE
93
what are the most vulnerable structures in the intercostal spaces?
* INTERCOSTAL NERVE
* POSTERIOR intercostal artery
Because these are not covered by ribs
94
what can cause paralysis of HALF OF THE DIAPHRAGM,
and how is it detected?
* may result from injury or operative division of the **phrenic nerve** of the same side
* can be detected RADIOLOGICALLY
95
**PARADOXICAL MOVEMENT:**
define
dome of the diaphragm of injured side pushed superiorly by abdominal viscera during inspiration instead of descending
96
**phrenic nerve**
nerve roots, course
* arises from the anterior branches **C3-C5 nerves** and lies in front of the **anterior scalene muscle**
* runs **anterior to the root of the lung**, whereas the **vagus nerve runs POSTERIOR** to the root of the lung
97
what does the **phrenic nerve** innervate?
* innvervates the fibrous **pericardium**, **mediastinal** and **diaphragmatic pleurae** (sensory innervation),
* and the **diaphragm** for **motor** and its central tendon for **sensory**
98
**diaphragmatic ruptures**:
cause, epidemiology
* cause: result from either **blunt trauma**, or **penetrating trauma**
* 80-90% of blunt ruptrues from motor vehicle crashes
* produces large radial tears measuring 5-15 cm, most often at the **posterolateral aspect** fot he diaphragm
* epi: relatively rare**,**
99
**cardiac hypertrophy:**
define, diagnosis
* define: **left atrial enlargement** (hypertrophy) secondary to **mitral valve failure** may compress on the esophagus and manifest as dysphagia (difficult in swallowing)
* observed as filling defect in the esophagus by **barium swallow on the lateral thoracic X-ray**
100
what forms the **right border of the cardiac shadow**?
1. SVC
2. right atrium
101
what forms the **LEFT BORDER** of the cardiac shadow?
1. Aortic arch
2. Pulmonary trunk
3. Left auricle
4. Left ventricle
102
where to ausculate the four heart valves?
"APT M"
* A - R 2nd ICS, *PCL*
* P - L 2nd ICS, *PCL*
* T - L 4th ICS, *PCL*
* M - L 5th ICS, *MCL*
103
a murmur is heard **DOWNSTREAM from the valve;**
what direction is STENOSIS?
what direction is INSUFFICIENCY?
* stenosis is **ORTHOGRADE direction** from valve --\>
* insufficiency is RETROGRADE direction from valve
104
**sinoatrial (SA) node**:
fxn, location
* fxn: site where contraction of the heart muscle is iniated (**pacemaker** of the heart)
* location: situated in the upper part of the sulcus terminalis just near to the **_opening of the SVC_**
105
**atrioventricular (AV) node**:
function, location
* fxn: this node receives impulses from the SA node
* location: situated in the lower part of the atrial septum **_near the coronary sinus_**
106
**atrioventricular bundle of his**:
location, bundle branches
* descends from the AV node to the membranous portion of the ventricular septum where it divides into the left and right bundle branches
* branches
* RIGHT bundle branch: passes down to reach the **moderator band** - right ventricle
* LEFT bundle branch: passes down left side of ventricular septum
107
what does the **RIGHT CORONARY ARTERY (RCA)** supply?
* supplies major parts of the **right atrium** and the **right ventricle**
* anastomoses w/ the marginal branch of the left coronary artery posteriorly
108
what are the branches of the **right coronary artery (RCA)?**
1. Anterior cardiac branches – supplies the right atrium
2. Nodal branch – supplies the (1) SA node, (2) AV node
3. Marginal artery – supplies the right ventricle
4. Posterior interventricular artery –supplies (1) diafragmatic (inferior) surface of both ventricles and (2) posterior 1/3 of the IV septum
109
**left coronary artery (LCA)**
branches, and supplies what?
1. **Anterior (descending) interventricular artery** – most common place of MI descends in the anterior interventricular sulcus and provides branches to the (1) anterior heard wall, (2) anterior 2/3 of IV septum, (3) bundle of His, and (4) apex of the heart.
2. **Circumflex artery** – winds around the left margin of the heart in the atrioventricular groove to anastomose with the right coronary artery posteriorly; supplies the **left atrium and left ventricle**
110
what is the blood supply of the conducting system?
* Sinoatrial node
* Atrioventricular node
* AV bundle (& moderator band)
* **Sinoatrial node** - Right coronary artery
* **Atrioventricular node** - Right coronary artery
* **AV bundle (& moderator band)** - Left coronary artery
111
**atrial septal defect (ASD)**:
epi, pathology, clinical significance
* epi: **less frequent** than VSD
* pathology
* failure to close of the foramen ovale after birth (**failure of the septum primum and septum secundum to fuse**)
* postnatally, ASDs result in left-to-right shunting (b/w right and left atrium) and are **non-cyanotic conditions**
* clinical significance: if small, has no clinical significance;
* if large, necessary surgical repair
112
**ventricular septal defect (VSD)**
epi, location, pathology
* epi: most common of the congenital heart defects
* location: may be found in the **membranous part of the ventricular septum** and results from failure to fuse of the membranous portion w/ the muscular portion of the ventricular septum
* pathology:
* present **_LEFT-TO-RIGHT shunt_** (Right ventricular hypertrophy) and again **non-cyanotic**
* necessary surgery for **large defects**
113
**patent ductus arteriosus (PDA)**:
pathology
* It results from failure of the ductus arteriosus (a connection between the pulmonary trunk and aorta) to constrict and
close after birth.
* Prostaglandin E and low O2 tension sustain patency of the ductus arteriosus in the fetal period
114
**patent ductus arteriosus (PDA**):
epi, presentation, tx
* PDA is common in premature infants and in cases of maternal rubella infection.
* Left –to-right shunt increased pressure in pulmonary circulation (pulmonary hypertension) and is non-cyanotic
* Tx: surgical division and ligation imperative. In great danger is left recurrent nerve (wrapping aorta arch). Injure of this nerve results in hoarseness.
115
**aneurysm of the aortic arch**:
pathology
* compresses the left recurrent laryngeal nerve, leading to coughing, hoarseness, and paralys is of the ipsilateral vocal cord.
* It may cause dysphagia (difficulty in swallowing), resulting from pressure on the esophagus, and dyspnea (difficulty in breathing), resulting from pressure on the trachea, root of the lung, or phrenic nerve
116
**aneurysm of the thoracic aorta**:
pathology
may compress and tug on the trachea with each cardiac systole so that the aneurysm can be felt by palpating the trachea at the sternal notch (T2).
117
**abdominal aortic aneurysm**:
define, location
* It is a localized dilatation of the aorta.
* It is typically happened just above of the bifurcation at level of L4 and crossed by 3rd part of duodenum.
118
**abdominal aortic aneurysm:**
diagnosis, sequelae, tx
* pulsations of a large aneurysm can be detected to the LEFT OF THE MIDLINE at the umbilical region
* **acute rupture** of an abdominal aortic aneurysm is associated w/ severe pain in the abdomen or back (mortality rate is nearly 90%)
* **tx:** repair aneurysm by opening it and inserting a **prosthetic graft**
119
**coarctation of the aorta**:
define, diagnosis
* It results from congenital narrowing of the aorta distal to the offshoot of the left subclavian artery
* Coarctation of the Aorta characteristic X-ray picture: serrated appearance of inferior borders of ribs (**rib notching)**
120
**coarctation of the aorta:**
cardinal clinical sign
Cardinal clinical sign:
* higher blood pressure in the upper limbs compared to the lower limbs.
* results in the intercostal arteries providing collateral circulation between the internal thoracic artery, and the thoracic aorta to provide blood supply to the lower parts of the body
121
**aspiration of foreign bodies**
epi, pathology
* inhalation of foreign bodies into LOWER RESPIRATORY TRACT is common, esp in children
* more likely to enter the **RIGHT PRIMARY BRONCHUS** and pass into the **middle or lower lobe bronchi**
* if the vertical position of the body, the foreign body usually falls into the **posterior basal segment** of the **right inferior lobe**
122
how many pulmonary segments are in the RIGHT LUNG?
Superior lobe:
* 1. Apical
* 2. Anterior
* 3. Posterior
Middle lobe:
* 4. Lateral
* 5. Medial
Inferior lobe:
* 6. Superior
* 7. Anterior basal
* 8. Posterior basal
* 9. Lateral basal
* 10.Medial basal
123
how many pulmonary segments are in the **LEFT LUNG**?
Superior lobe:
* 1. Apicoposterior
* 2. Anterior
* 3. Superior lingular
* 4. Inferior lingular
Inferior lobe:
* 5. Superior
* 6. Anterior basal
* 7. Posterior basal
* 8. Lateral basal
* 9. Medial basal
124
**pneumonia:**
define, causes, sxs, diagnosis
* def: **inflammation of the lung**,
* caused: by infxn or chemical injury to the lungs; common causes are **bacteria, viruses, and fungi**
* sxs: **cough, chest pain,** fever, and difficulty breathing
* dx: chest xrays show areas of **opacity** (seen as white) of the large parenchyma adn **enlargement** of bronchomediastinal **lymph nodes** (mediastinal widening)
125
**bronchogenic carcinoma**:
define, sxs
* arises int he mucosa of the large bronchi
* sxs: produces as persistent, productive cough or hemoptysis
126
**bronchogenic carcinoma**:
metastasis
* Early metastasis to thoracic (bronchomediatinal) lymph nodes
* Hematogenous spread to the brain, bones, lungs, suprarenal glands
* A tumor at the apex of the lung **(Pancoast tumor)** may result in thoracic outlet syndrome
127
what are the 6 conditions that **bronchogenic carcinoma** can lead to?
* **thoracic outlet syndrome (TOS)**
* **horner syndrome**
* **superior vena cava syndrome**
* dysphagia as a result of esophageal obstruction
* hoarseness as a result of recurrent laryngeal nerve involvement
* paralysis of the diaphragm as a result of phrenic nerve involvement
128
**thoracic outlet syndrome (TOS):**
define
* It can cause pressure on the **lower trunk** of the brachial plexus C8-T1 and subclavian artery by **cervical rib or pancoast tumor.**
* It results in **pain** down the **medial side** of the forearm and hand and **atrophy of the intrinsic hand muscles**)
129
**horner syndrome**:
symptoms
* **miosis** - constriction of the pupil due to paralysis of the dilator pupillae muscle
* **ptosis** - drooping of the eyelid due to paralysis of the superior tarsal muscle
* **hemianhydrosis** - loss of sweating on one side
130
**superior vena cava syndrome:**
define
causes **dilation** of the head and neck veins, facial swelling, and cyanosis
131
where to place stethoscope to listen to breath sounds of
SUPERIOR LOBES of right and left lungs?
the stethoscope is placed on the superior area of the anterior chest wall (above the 4th rib for the right lung & above 6th for the left one).
132
where to place stethoscope to listen to breath sounds of
MIDDLE LOBES of right and left lungs?
the stethoscope is placed on the **anterior chest wall between the 4th and 6th ribs**
133
where to place stethoscope to listen to breath sounds of
INFERIOR LOBES of right and left lungs?
breath sounds are primarily heard on the posterior chest wall.
134
135
**pneumothorax:**
define
* entry of **air into a pleural cavity** causing lung collapse
136
**open pneumothorax:**
pathology
* due to stab wounds of the thoracic wall which pierce the parietal pleura so that the pleural cavity is open to the outside air via the lung or through the chest wall.
* Air moves freely through the wound during inspiration and expiration.
137
how does air move in the lungs in open pneumothorax?
* During inspiration, air enters the chest wall and the mediastinum will shift toward other side and compress the opposite lung.
* During expiration, air exits the wound and the mediastinum moves back toward the affected side.
138
what might be affected in the case of **improper subclavian venipuncture?**
cervical pleura may be affected
139
**costodiaphragmatic recess**:
define
* the chest wall, there are two rib interspaces separating the inferior limit of parietal pleural reflections from the inferior border of the lungs and visceral pleura
* two on the image
140
where are the following lines?
* **midclavicular line**
* **midaxillary line**
* **paravertebreal line**
* **midclavicular line -** between ribs 6-8
* **midaxillary line -** between ribs 8-10
* **paravertebreal line** - between ribs 10-12
141
**parietal pleura**:
define, and components of parietal pleura
* define: sensitive to general sensitivities (pain, temp, touch, and pressure) - somatic sensory innervation
* components & innervation:
* **costal pleura:** _intercostal nerves_ block may be used to decrease thoracic pain
* **mediastinal pleura:** _phrenic nerve_
* **diaphragmatic pleura:** _phrenic nerve_ over the domes and lower 6 intercostal nerves around the periphery
142
**visceral pleura:**
innervation
* sensitive to stretch but insensitive to general sensibilities;
* autonomic nerve supply from pulmonary plexus
143
what upper part and lower part structures may be affected by **improperly done sternal puncture?**
(can affects structures related to the posterior surface of the manubrium sternum)
* upper part: **LEFT BRACHIOCEPHALIC vein**
* lower part: **AORTIC ARCH**
144
**thoracic duct:**
function
* conveys to the blood **all lymph** from:
* the lower limbs,
* pelvic cavity,
* abdominal cavity,
* **left side of the thorax,**
* **left side of head and neck**
* **left upper limb (3/4 of the body)**
145
**thoracic duct:**
tributaries
at the root of the neck
* **left jugular** lymph trunk
* **left subclavian lymph** trunk
* **left bronchomediastinal** lymph trunk
146
what are the sites of the esophagus where ingested **foreign bodies** can lodge, or where **strictures** may develop?
what causes this?
* location:
* **C6:** where the pharynx joins the upper end (6" from the upper incisors)
* **T4 - T5:** where the aortic arch and left main bronchus cross its anterior surface (10" from the upper incisors)
* **T10:** where it passes through diaphragm into the stomach (16" from the upper incisors)
* can develop following ingestion of caustic fluids, common sites of **esophageal carcinoma**
147
what is found in the
**RIGHT UPPER** quadrant of abdomen?
* liver
* gallbladder
148
what is found in the
RIGHT LOWER quadrant of abdomen?
* CECUM
* APPENDIX
149
what is found in the
LEFT UPPER quadrant of abdomen?
* STOMACH
* SPLEEN
150
what is found in the
LEFT LOWER quadrant of abdomen?
* END of the descending colon
* sigmoid colon
151
where is referred pain from
**FOREGUT**-derived structures in the abdomen?
EPIGASTRIC region
## Footnote
*(green)*
152
where is referred pain from
MIDGUT-derived structures in the abdomen?
UMBILICAL REGION
## Footnote
*(red)*
153
where is referred pain from
HINDGUT-derived structures in the abdomen?
HYPOGASTRIC REGION
(*blue)*
154
what is the nerve supply of the
ANTERIOR ABDOMINAL WALL?
where is this located
7 nerves in total
* **lower 5 intercostals**
* **1 subcostal**
* **L1** (iliohypogastric and ilioinguinal)
All nerves and deep blood vessels lie in the NEUROVASCULAR PLANE, b/w internal oblique and transversus muscles
155
how is L1 anaesthetized?
by injecting 1 inch (2.5 cm)
superior to the anterior superior iliac spine (ASIS)
156
what are the important SUPERFICIAL arteries
that supply the skin fo the anterior abdominal wall?
1. superficial epigastric
2. superficial circumflex iliac
157
what are the important DEEP ARTERIES of the anterior abdominal wall.
where are these found?
deep arteries
1. **Superior epigastric**
2. **posterior intercostals arteries**
3. **lumbar arteries**
4. **deep circumflex iliac artery**
5. **inferior epigastric**
Found in the _neurovascular plane_
158
what are the 3 parts of a hernia?
define each
* **hernial sac:**
* a pouch (diverticulum) of **peritoneum** and has neck and body
* **hernial contents:**
* may consist of the structure found in the abdominal cavity (more often - l**oops of small intestine** and piece of omentum major)
* **hernial coverings:**
* formed from the layers of the abdominal wall through which the hernial sac passes
159
what is the FIRST STRUCTURE which is crossed by any abdominal hernia?
TRANSVERSALIS FASCIA
160
**indirect inguinal hernia:**
define, epi
# define:
* passes through the deep inguinal ring **lateral to the inferior epigastric vessels**, inguinal canal, _superficial inguinal ring_ and **descend into to scrotum**
epi:
* MC form of hernia
* congenital in origin (boys 0-3 y/o)
* 20x more common M\>F, nearly 1/3 are bilat
* R \> L, because the right processus vaginalis becomes obliterated after the left; the right testis descends later than the left
161
**direct inguinal hernia:**
define, epi
define
* the abdominal contents will protrude through the weak area of the posterior wall of the inguinal canal **medial** to the **inferior epigastric vessels** in the **inguinal [hesselbach's] triangle** and after that through superficial inguinal ring
* it never descends into the scrotum
epi
* 15% of all hernias are direct
* "**disease of old men**" w/ weak abdominal muscles
* very rare in women, most are bilateral
162
what are the 2 ligaments of the
LESSER OMENTUM?
1. hepatoGASTRIC
2. hepatoDUODENAL
163
what are the contents of the LESSER OMENTUM?
* **Right and left GASTRIC vessels**
* Connective tissue and fatty tissue
* **Portal triad**
* bile duct
* portal vein
* proper hepatic artery
164
what are the borders of the
EPIPLOIC (WINSLOW'S) FORAMEN?
* anterior: **free border of the hepatoduodenal ligament,** containing **portal triad (D,V,A)**
* posterior: **IVC**
* superior: **caudate lobe of the liver**
* inferior: **1st part of the duodenum**
165
**douglas (rectouterine) pouch**
define, and clinical correlate
* **_deeper point of peritoneal space_** in vertical position of FEMALE body b/w rectum and cervic of the uterus
* CC: space of **pelvic abscess location,** collecting inflammatory fluid because it is the lowest portion of the female peritoneal cavity
166
**culdocentesis:**
define
aspiration of fluid from the "cul-de-sac" of Douglas (rectouterine pouch) by a needle **puncture of the posterior vaginal fornix** near the midline b/w the uterosacral ligaments
167
which abdominal structures are derived from the FOREGUT?
* ESOPHAGUS
* STOMACH
* DUODENUM (1st and 2nd parts)
* LIVER
* PANCREAS
* BILIARY APPARATUS
* GALLBLADDER
168
which abdominal structures are derived from the MIDGUT?
* DUODENUM (2nd, 3rd, 4th)
* JEJUNUM
* ILEUM
* CECUM (with appendix)
* ASCENDING COLON
* TRANSVERSE COLON (proximal 2/3)
169
what are the abdominal structures derived from the HINDGUT?
* TRANSVERSE COLON (distal 1/3)
* DESCENDING COLON
* SIGMOID COLON
* RECTUM (anal canal above pectinate line)
170
**posterior gastric ulcer:**
pathology/ sxs
* this ulcer may erode through the posterior wall of the stomach into the OMENTAL BURSA (lesser peritoneal sac) and affect PANCREAS, resulting in referred pain to the back
* can erode the SPLENIC ARTERY (*due to proximity of this artery to this wal*l)
171
**congenital diaphragmatic hernia:**
define, epi
* hernia of the stomach or intesting through a **posterolateral defect in the diaphragm (foramen of bochadelk)**
* epi: seen in infants, mortality rate is high due to **lung hypoplasia**
172
**sliding hiatal hernia:**
path, sequelae, epi
* path: **hernia of cardia of the stomach into the thorax through the esophageal hiatus of the diaphragm**
* sequelae: can damage the **vagal trunks** as they pass through the hiatus and result in hyposecretion of gastric juice
* epi: occurs in individuals past middle age
173
**meckel's diverticulum:**
define, location, epi
* def: congenital anomaly representing persistent portion of the VITELLOINTESTINAL DUCT; approx 2 inches (5 cm) long
* loc: **on the ileum** about 2 ft BEFORE the ileocecal junction and SMA supply;
* epi: occurs in 2% of patients
174
**meckel's diverticulum**:
sxs, clinical correlate
* sxs: often asymptomatic, but occasionally becomes inflamed if it contains **ectopic gastric, pancreatic, or endometrial tissue --\> can produce ulceration\**
* cc: **diverticulitis,** liberatoin, bleeding, perforation, and obstruction are complications requiring surgical intervention and frequently **mimic sxs of acute appendicitis**
175
what are the features of the LARGE INTESTINE?
1. **appendices of epiploic**
2. **sacculations (haustra)**
3. **taenia coli:**
* *the taenia coli meet together at base of the appendix where they form a complete longitudinal muscle coat for the appendix*
176
describe the components and orientation of the COLON
* ASCENDING colon:
* **retro**peritoneal, lacks mesentery
* continuous w/ T.C. @ R hepatic flexure
* TRANSVERSE colon (TC):
* has it's own mesentery (transverse mesocolon/ **intraperitoneal** position)
* continuous w/ DC at L splenic flexure
* DESCENDING colon (DC):
* **retroperitoneal**
* SIGMOID colon:
* suspended by sigmoid mesocolon
* **intraperitoneal** position
177
what is the **FIRST PAIN** of appendicitis?
what is the **SECOND** PAIN?
* FIRST PAIN = referred around the umbilicus
* **visceral** pain in appendix is produced by distention of the lumen or spasm of its muscle
* afferent pain fibers enter the spinal cord at level of T10 segment --\> **vague referred pain** is felt in region of umbilicus
* SECOND PAIN = later if **parietal** peritoneum gets involved,
* then pain is shifted laterally to the **McBurney's point**
178
what is **McBurney's point?**
* where appendicitis pain is precise, severe, and localized (SECOND PAIN)
* indicates surface marking of the **base of the appendix**
* at junction b/w lateral 1/3 and medial 2/3 of a line joining the r**ight anterior superior iliac spine** w/ the **umbilicus**
179
**volvulus:**
define
* when the jejunum, ileum, and sigmoid colon ROTATES AROUND ITS MESENTERY --\> can result in **avascular necrosis** of the corresponding part of the intestine
* (due to extreme mobility of these organs)
* may correct itself spontaneously, or the rotation may continue until the blood supply of the gut is cut off completely
180
**hirschsprung disease**:
define, pathology, epi
* def: **inadequate motility resulting in obstruction** --\> intestines do not work normally
* path: due to **aganglionic section** (congenital absence of **postganglionic parasympathetic** neurons inside the intestinal wall) of the intestines resulting in **MEGACOLON**
* epi: rare, congenital
181
**hirschsprung disease:**
sxs, tx
sxs: in newborn, main signs are:
* **failure to pass a meconium stool** w/in **1-2 days** after birth,
* **reluctance ot eat,**
* **bile-stained (green) vomiting**, and
* **abdominal distension**
tx: **removal of the aganglionic** portion of the colon
182
what are the branches of the abdominal aorta?
* **Celiac trunk (CA)** originates from the aorta at the lower border of **_T12_** vertebra
* **Superior mesenteric artery (SMA)** originates at the lower border of **_L1_** vertebra
* **Renal arteries** originate at approximately **_L2_** vertebra
* **Inferior mesenteric artery (IMA)** originates at **_L3_** vertebra
* Two terminal branches are **common iliac arteries** at the level of **_L4_** vertebra
183
**celiac trunk**:
origin, course/branches
* origin: **T12**, just below the aortic opening of the diaphragm
* course/branches: celiac artery passes above the superior border of the pancreas and then divides into the following branches
1. **left gastric artery**
2. **common hepatic artery**
3. **splenic artery**
184
**left gastric artery**:
origin, course/branches
* course: courses upward to the left to reach the lesser curvature of the stomach and may be subject to erosion by a **penetrating ulcer** of the **lesser curvature of the stomach**
* branches:
* **esophageal branches (2) -** to the abdominal part of the esophagus
* **gastric branches (3) -** supply to the left side of the **lesser curvature** of the stomach and make **anastomosis** with **right gastric artery**
185
**common hepatic artery**
course, branches
* course: passes to the Right to reach the superior surface of the first part of the duodenum, where it divides into its two terminal branches
* branches
* proper hepatic artery(2)
* gastroduodenal artery (3)
186
**proper hepatic artery**
course, branches
course: proper hepatic artery gives off **right gastric artery (2)**, and then ascends w/in the hepatoduodenal ligament of the **lesser omentum** to reach the **porta hepatis**, where it divides into the RIGHT and LEFT hepatic arteries
branches:
* Right and left arteries enter the **TWO LOBES OF THE LIVER**, right hepatic artery gives **cystic artery** to the gallbladder
* **Right gastric artery (2)** supplies the right side of the **lesser curvature** of the stomach where it anastomoses the **left gastric artery**
187
**gastroduodenal artery:**
course, branches
descends posterior to the first part of the duodenum (may be subject to erosion by a penetrating ulcer in this place)
branches:
* **right gastroepiploic artery:** supplies the right side of the greater curvature of the stomach where it _anastomoses_ the left gastroepiploic
* **superior pancreaticoduodenal arteries (3)**: supply the head of the pancreas, where they _anastomose_ the **inferior pancreaticoduodenal arteries** from the **SMA**
188
describe the **ligature of the hepatic artery,**
and clinical significance
* **hepatic artery** may be ligated proximal to the origin of its gastroduodenal branch, a **collateral circulation** to the liver is established through the LEFT AND RIGHT GASTRIC arteries, LEFT AND RIGHT GASTROEPIPLOIC and GASTRODUODENAL ARTERIES
* CC: **_right hepatic artery_** may be mistakenly ligated during **holocystectomy in Calot triangle** together w/ **cystic artery, right lobe hepatic necrosis commonly occurs**
189
**splenic artery**:
course, branches
* this is (1)
* **retroperitoneal** until it reaches the TAIL of the PANCREAS, where it enters the SPLENORENAL LIGAMENT to enter the hilum of the **spleen**
* branches
* branches to the **spleen (2)**
* branches to neck, body, and tail of **pancreas (3)**
* **left gastroepiploic artery (4)** that supplies the LEFT SIDE of the GREATER CURVATURE of the stomach where it anastomoses the right gastroepiploic
* **short gastric (5)** branches that supply fundus of the stomach
190
**mesenteric ischemia:**
what causes it, what does it affect, patient population
* caused by atherosclerosis --\> ischemia (blood can't flow through arteries as well as it should and organs aren't receiving enough oxygen)
* usually involves SMA and SMALL INTESTINE;
* affects organs that are far away from anastomoses with Celiac Artery and IMA
* e.g. blood supply of jejunum and ileum is most compromised
* epi: patients \>60 y/o w/ smoking & high cholesterol
191
**bile:**
secretion, storage/conc, delivery
* secreted by liver cells (hepatocytes)
* stored and concentrated in GALLBLADDER
* delivered through CYSTIC DUCT to DUODENUM
* cystic duct joins common hepatic (from left and right hepatic) due to form the COMMON BILE DUCT
192
**gallbladder:**
location
lies in it's fossa on the VISCERAL surface of the liver right side of quadrate lobe
193
describe the BILIARY SYSTEM
components
* **_common bile duct:_** descends the hepatoduodenal ligament, then passes posterior to the first part of the DUODENUM
* penetrates the head of the pancreas, where it joins the MAIN PANCREATIC DUCT --\> form hepatopancreatic ampulla (sphincter of Oddi) --\>
* drains into posteromedial wall the second part of the duodenum at the major duodenal papilla
194
**cholelithiasis (gallstones)**
common site(s), sxs
* loc: distal end of hepato-pancreatic ampulla (Bile duct)
* bc it's the narrowest part of biliary passages, \*MC site
* sxs: YELLOW EYES, JAUNDICE (*as result of common hepatic, bile duct, or hepatopancreatic ampulla obstruction)*
* loc: cystic duct
* sxs: biliary colic (intense, spasmodic pain in gallbladder), NO JAUNDICE
195
what results when gallstones are in:
FUNDUS of the gallbladder?
the fundus is in contact w/ the transverse colon, and thus gallstones erode through the posterior wall of the gallbladder and ENTER THE TRANSVERSE COLON --\>
tx: passed naturally to the rectum, through the descending colon and sigmoid colon
196
what results when gallstones are in:
BODY of the gallbladder?
in the body of gallbladder, these gallstones may ulcerate through the posterior wall of the body of the gallbladder into the DUODENUM
(bc gallbladder body is in contact w/ the duodenum) and may be held up at the ileocecal junction --\> producing **intestinal obstruction**
197
what is the nerve supply of the liver and gallbladder?
* sensory
* parasympathetic
* sympathetic
1. sensory: by the **right phrenic nerve (C3-C5);** pain may radiate to RIGHT SHOULDER
2. parasympathetic: from the **vagi nerves** **(CN X),** reaching it thru **celiac plexus** around the supplying arteries --\> these synapse on the cells of the **uxtramural plexuses** in the hilum of the liver, and short **postganglionic fibers supply organs**
3. sympathetic: of preganglionic neurons **T5-T9 segments (IML)** come through sympathetic trunk and form greater splanchnic nerves; contribute to CELIAC PLEXUS, where postganglionic neurons are located; branches of celiac plexus reaches the liver wrapping around the branches of the celiac
198
**portal HTN:**
patho, tx
* patho: **common clinical condition**
* tx
* **extrahepatic portocaval shunt** for tx; the splenic vein may be anastomoses to the LEFT renal vein after removing the spleen
* **intrahepatic portocaval shunt** b/w portal vein and hepatic veins
199
most common site of LARGE INTESTINE CANCER?
LIVER
* Metastases of the Large intestine cancer typically rich the **Liver** via portal venous system:
* **Rectum - IMV - splenic vein - portal vein - Liver**
200
what can occur if there is an **obstruction to flow** through the portal system (portal HTN)?
what are the sites of these?
blood can flow in a retrograde direction, and pass through ANASTOMOSES to reach the CAVAL system --\> sites of anastomoses
* esophageal veins
* paraumbilical veins
* rectal veins
201
**esophageal anastomoses:**
define, clinical correlate
* def: can form anastomoses b/w the tributaries of the LEFT GASTRIC VEIN (portal vein) and the tributaries of the AZYGOUS VEIN (SVC) in the wall of the lower end of the esophagus
* CC: these veins in the esophagus enlarge in portal HTN --\> later burst into lumen of esophagus (**esophageal varices)** --\> **hematemesis** (vomiting red blood)
202
**umbilical anastomoses:**
define, clinical correlate
* def: anastomosis b/w **paraumbilical veins** (portal vein) and the **superior and inferior epigastric veins** (SVC and IVC) in anterior abdominal wall around the umbilicus
* CC: portal HTN --\> anastomoses gets enlarged and dilated veins form **CAPUT MEDUSAE around umbilicus**
203
**rectal anastomosis:**
define, clinical correlate
* def: anastomoses b/w **superior rectal vein** (inferior mesenteric vein and then **portal vein)** and the **inferior rectal vein** --\> drains into internal iliac vein (from IVC system)
* CC: **chronic alcoholics** --\> anastomoses gets dilated --\> **internal hemorrhoids** and BLEEDING from the anus from SUPERIOR RECTAL VEIN
204
**PANCREAS**
head and uncinate process
* HEAD of the pancreas rests w/in the C-SHAPED area formed by the duodenum and is traversed by the COMMON BILE DUCT
* UNCINATE process: part of the head; crossed by the SUPERIOR MESENTERIC VESSELS
205
what occurs due to cancer of the HEAD OF THE PANCREAS?
* cancer will COMPRESS the **bile duct** and result in OBSTRUCTIVE TYPE of JAUNDICE
* usually AFEBRILE
* **pain** will be conveyed to sensory neurons **T5-T9 dorsal root ganglia** via **celiac plexus**, and **greater splanchnic nerve**
206
how to distinguish between jaundice caused by CANCER versus HEPATITIS?
* cancer is usually AFEBRILE
* hepatitis is usually presenting with jaundice AND FEVER
207
where is the neck of the pancreas in respect to the portal vein?
site of formation of the **portal vein** is POSTERIOR TO THE NECK of the pancreas?
208
how is the portal vein formed?
the **splenic vein** joins with the **superior mesenteric vein** to form the PORTAL VEIN
209
what structures are in relation to the body of the pancreas?
* body passes to the LEFT and ANTERIOR to the AORTA and the LEFT KIDNEY
* the splenic artery undulates along the superior border of the body of the pancreas with the splenic vein coursing POSTERIOR to the body
210
where is the **TAIL OF THE PANCREAS** in relation to other structures/landmarks?
clinical correlate?
* the tail enters the SPLENORENAL LIGAMENT to reach the HILUM OF THE SPLEEN
* CC: the tail of the pancreas may be mistakenly removed during spleenectomy (ligation of splenic artery and vein) and resulting in sugar diabetes bc it contains a lot of endocrine cells
211
how does the TAIL of the pancreas differ from the body, head, and neck?
the tail of the pancreas is the only part that is INTRAPERITONEAL;
the majority is retroperitoneal
212
what is the arterial supply of the HEAD OF THE PANCREAS and DUODENUM?
1. **Superior pancreaticoduodenal arteries** - branches of gastroduodenal artery.
2. **Inferior pancreaticoduodenal arteries** - branches of SMA
* This region is important for **collateral circulation** because there are anastomoses between these branches of the **CA and SMA**
213
what is the arterial supply of the
## Footnote
**pancreas (neck, body and tail)?**
pancreatic branches of the **SPLENIC ARTERY**
214
**annular pancreas:**
pathology, symptoms, epi
* path: caused by malformation during the development of the pancreas before birth
* occurs when the ventral & dorsal pancreatic buds form a RING around the DUODENUM, thereby causing an obstruction of the duodenum and **polyhydramnios**
* sxs:
* FEEDING INTOLERANCE in newbords
* fullness after eating
* nausa and **bile-stained vomiting**
* epi
* half of cases are not diagnosed until sxs occur in adulthood
215
**spleen:**
location
* peritoneal organ in the UPPER LEFT QUADRANT
* deep to the left 9th, 10th, and 11th ribs
* follows the contour of the RIB 10 (axis of the spleen)
216
**splenic rupture:**
clinical correlate
* cause:
* spleen may rupture from LEFT 9TH and 10TH RIB FRACTURE or blunt trauma of the LEFT UPPER abdomen
* sxs
* when blood collected deep to diaphragm, PHRENIC NERVE irritates & pain can irradiate to LEFT SHOULDER (left shoulder pain)
* tx: spleen cannot be sutured, so after rupture it has to be removed
217
describe the borders of the spleen in relation to the ribs?
spleen follows the **contour of the 10th rib** and extends from the **superior pole of the left kidney** to just **posterior to the midaxillary line**
218
what is the border b/w the spleen adn the upper pole of the LEFT KIDNEY?
11TH RIB
219
**kidney:**
typical color, size, shape
* color: reddish brown
* size
* 11-12 cm length
* 5-6 cm width
* 2.5-3 cm thick
* shape
* lateral border is CONVEX
* medial border is convex at both ends, but concave at midline where HILUM of kidney is (\***L1)**
220
where are the kidneys in relation to ribs?
extend from level of:
* **T12 to the level of L3,**
* the right kidney is about 2-3 cm LOWER than the left one
221
what are the anterior relations of the
RIGHT KIDNEY?
1. right suprarenal gland
2. **_2nd part of the duodenum_**
3. right lobe of the liver
4. **right colic flexure**
5. **small intestine**
222
what are the anterior relations of the
LEFT KIDNEY?
1. left suprarenal gland
2. stomach
3. **_spleen_**
4. body of pancreas and splenic vessels
5. descending colon
6. small intestine
223
**renal fascia:**
define, clinical correlate
* membranous condensation of the extraperitoneal fascia --\> enclosing the perinephritic fat
* CC: renal fascia MUST BE INCISED in any surgical approach to the kidney
* renal fascia is (3) in the image
224
where are the SUPRARENAL GLANDS found?
enclosed in the renal (GEROTA) fascial compartment,
usually separated from the kidneys by a thin septum
(4 in the image)
225
**perinephric abscess**:
define, descending, ascending
* def: most infxns of this space occur as result of extension of an ascending **UTI**, commonly assoc w/ **nephrolithiasis or tuberculosis**
* typically descend down b/w 2 sheets of renal fascia along the PSOAS MAJOR muscle
* types
* if abscess locates BEHIND the psoas major --\> it **descends down** --\> can affect **_hip joint_**
* if abscess **spreads UP -**-\> reach the diaphragm, irritate phrenic nerve --\> pt will feel referred pain in the **_shoulder_**
226
**nephrolithiasis:**
define, types, treatment
* def: **renal calculi** are solid concretions (crystal aggregations) formed in kidneys from dissolved urinary minerals
* types:
* majority are CALCIUM OXALATE stones
* CALCIUM PHOSPHATE
* tx:
* typically pass in the urine, many are formed and passed asymptomatic
* if sufficient size (at least 2-3 mm), can cause **obstruction of the ureter** (renal colic)
227
what are the 3 constrictions of the ureter?
recall: the ureter is located on the ANTERIOR SURFACE of the psoas major muscle; 3 constrictions
1. **PELVIURETERIC** junction: L1 level
2. **PELVIC BRIM** junction: level of sacroiliac joint
3. where ureter lies obliquely in **wall of urinary bladder**: level of ischial spine
228
**staghorn calculi:**
define, pathology
* def: renal stone develops in **renal pelvis and greater calices**, has advanced branching configuration which resembles the **antlers of a stag**
* path:
* composed of **magnesium ammonium phosphate**, forms in urine w/ abnormally high pH (above 7.2)
* high pH develops bc of recurrent UTI w/ microorganism e.g. proteus mirabilis
229
**suprarenal glands:**
define, function
* def: endocrine glands having cortex and medulla
* fxn:
* **adrenal cortex** secretes aldosterone, corticosteroids, & genital hormones
* **adrenal medulla** (chromaffin cells) secrete catecholamines: epinephrine, norepi
230
what organ produces the catecholamines?
what effect do these have?
* **epinephrine and norepinephrine** are produced by the chromaffin cells of the **adrenal medulla**
* affect the smooth muscle, cardiac muscle, and glands in the same way as **sympathetic stimulation**
231
describe sympathetic stimulation or hypersecretion of catecholamines
* e.g. tumor of the adrenal medulla or sympathetic chain ganglia)
* resulting in --\> episodes of tachycardia, sweating, high BP
232
what are the unpaired tributaries of the inferior vena cava?
**(1) RIGHT SUPRARENAL vein** and **(2) RIGHT GONADAL vein** drain directly into the IVC (these are the unpaired IVC tributaries)
233
describe the right renal and left renal veins
* RIGHT RENAL vein is much SHORTER than the left;
* LEFT RENAL vein is joined by the left suprarenal, and left gonadal (testicular or ovarian) veins before it reaches the IVC
Both right and left veins lie anterior to the corresponding artery in hilum of kidneys
234
**varicocele**:
define, clinical correlate
* def: **enlargement of the pampiniform plexus** that produces a **wormlike scrotal mass** and enlargement of the **spermatic cord**; --\>
* can cause low sperm count
* usually on LEFT SIDE, & can disappear in supine position
* CC: may indicate **kidney disease** or may signal a retroperitoneal malignancy obstructing the testicular vein
235
**pampiniform plexus:**
define, clinical correlate
* coalescence of this forms each testicular or ovarian vein; the testicular at the deep inguinal ring, the ovarian at the margin of the superior aperture of the pelvis
* veins run accompanied by corresponding arteris
* LEFT paminiform plexus enters the LEFT RENAL VEIN
* RIGHT pampiniform plexus enters directly into IVC inferior to renal vein
* CC: varicosity more often on left (engorgement of the pampiniform plexus producing scrotal mass)
236
**hydrocele**:
def, diagnosis
* def: swelling of the scrotum when fluid collects w/in the **tunica vaginalis testis** or other remnants of the processus vaginalis may form this
* dx: in the scrotum w/ **transillumination --\>** reddish glow
* (whereas light doesn't penetrate hematocele, solid tumor, herniated bowel)
237
**hydrocele of spermatic cord**
it is a **sausage-shaped structure** that persists under gentle compression and doesn't disappear in supine position
238
describe venous drainage from rectum:
## Footnote
**above pectinate line**
* **superior rectal vein --\> into portal system**
239
describe venous drainage from rectum:
## Footnote
**below pectinate line**
inferior rectal vein --\> inferior vena cava
240
**hemorrhoids:**
define, causes
* def: masses typically protrude from anus during defacation
* causes: **constipation**, extended **sitting** and straining at the toilet, **pregnancy**, and disorders that hinder venous return
241
**external hemorrhoids:**
define
* dilated tributaries are the **inferior rectal veins (IRV)** below the pectinate line
* painful bc the mucosa is supplied by somatic afferent fibers from the inferior rectal nerves (from the pudendal)
242
**internal hemorrhoids:**
define, sxs, causes
* def: dilated tributaries of the **superior rectal veins (SRV) above the pectinate line**
* sxs: NOT PAINFUL bc the mucosa is supplied by visceral afferent fibers
* causes: frequently occur in **chronic alcoholics** bc of liver cirrhosis and portal HTN syndrome
243
formation and contents of the
## Footnote
**DEEP PERINEAL POUCH**
* formation:
* formed by the fasciae and muscles of the urogenital diaphragm
* contents:
* **sphincter urethrae musc**
* **deep transverse perineal muscle**
* **BULBOURETHRAL (COWPER) glands** - *\*in the male only*, ducts perforate perineal membrane and enters bulbar urethra
244
what are the 3 muscles of the
## Footnote
**superficial perineal pouch?**
1. **ISCHIOCAVERNOUS muscle**
2. **BULBOSPONGIOSUS muscle**
3. **SUPERFICIAL TRANSVERSE PERINEAL MUSCLE**
245
what structures are the following muscles related to?
1. **ischocavernosus musc**
2. **bulbospongiosus musc**
3. **superficial transverse perineal musc**
1. **ischocavernosus musc :** related to CRUS OF THE PENIS (male), and CRUS OF THE CLITORIS (female)
2. **bulbospongiosus musc**: related to the BULB OF THE VESTIBULE (female) and BULB OF THE PENIS (male)
3. **superficial transverse perineal musc:** related to PERINEAL BODY (both genders)
246
describe the MOI causing urine leaks,
pathophys,
and where it collects?
1. MOI: crushing blow or penetrating injury
2. pathophys: ruptures the **spongy urethra** w/in the **bulb of the penis**
3. urine leaks into **superficial perineal pouch,** which keeps it from passing into the thigh or anal triangle --\>but after distending scrotum/penis --\> urine can pass over the pubis into the ANTERIOR ABDOMINAL WALL deep to the layer of superficial abdominal fascia
247
**ischiorectal abscess:**
define, treatment, clinical correlate
* def: important surgical condition infxn thru external sphincter ani into the ischiorectal fossa
* tx: **surgical emergency** and must be IMMEDIATELY DRAINED w/ wide cruciate incision thry skin of base of fossa to avoid fistula formation
* CC: should AVOID LATERAL WALL of ischiorectal fossa bc the PUDENDAL (ALCOCK'S CANAL) w/ **pudendal nerve** and **internal pudendal artery** is found here
248
**cystocele :**
define, sequelae
* def: **hernia of bladder; loss of bladder support (**in females) by damage to **pelvic floor** during childbirth
* MOI: e.g. laceration of perineal musc or a lesion of the nervous supply
* sequelae: can result in **protrusion of the bladder** onto the **anterior vaginal wall** and **loss of urine** when a woman strains or coughs
249
describe the **paracentesis of urinary bladder**
* WITH SUPRAPUBIC ASPIRATION
* urine can be removed from the bladder without penetrating the peritoneum by inserting a needle **JUST ABOVE the pubic symphysis**
* needle passes thru:
* SKIN,
* SUPERFICIAL & DEEP layers of superficial fascia,
* linea alba,
* transversalis fascia,
* extraperitoneal CT,
* wall of bladder
250
**prostate cancer:**
origin, early sxs/dx, and metastasis
* typically begins in **posterior lobe of the gland**
* sxs: can be asymptomatic early on
* dx: **digital rectal examination**
* metastasis:
* to **vertebrae** and **brain** (typically)
* (bc the **prostatic venous plexus** has numerous connections w/ the **vertebral venous plexus via sacral veins)**
251
**benign prostatic hypertrophy (BPH)**
define, epi, sxs, dx
* def: **prostate adenoma** (benign hypertrophy) usually involves **_median lobe_**
* epi: **men after middle age**
* sxs: **urethral obstruction**, leading to **nocturia, dysuria, and urgency**
* dx: examined for enlargement/tumors with **DIGITAL RECTAL exam**
252
**prostatectomy:**
approach, clinical correlate(s)
* approach:
* SUPRAPUBIC,
* PERINEAL, or
* TRANSURETHRALLY
* CC: damage to nerves in prostate capsule & around urethra (**cavernosus nerves**) --\> **impotence/ erectile dysfxn** and/or **urinary incontinence**
* CC: **pelvic splanchnic nerves** may be injured w/ intense dissection of the pelvic lymph nodes (prostatic cancer ectomy) --\> autonomic innervation of **hindgut** derivatives may be affected)
253
male urethra:
**prostatic 1st part**
(describe size/shape, features of posterior wall)
* size/shape
* **widest and most dilatable part**
* **spindle**-shaped (middle pt is dilated)
* features:
1. seminal colliculus
2. **openings of the 2 ejaculatory ducts** seen on each side of the seminal colliculus
3. ducts of the prostate gland open into male urethra
254
male urethra:
**membranous 2nd part**
(size/shape, relations)
* passes through **urogenital diaphragm** to enter bulb of the penis
* **narrowest, shortest** and **least dilatable part**
* relations
* surrounded by **external sphincter urethra**
* **bulbourethral glands** lie posterolateral to this part inside of urogenital diaphragm (depe perineal pouch)
255
male urethra:
**spongy 3rd part**
(size/shape, relations)
* size/shape
* **longest part** (avg is 15 cm in length)
* relations
* passes thru bulb and corpus spongiosum of penis
* opens at external urethral orifice on tip of GLANS PENIS
* ducts of the **bulbourethral glands open** into floor of the spongy part in its beginning
256
what are the 2 dilatations of the
**spongy 3rd part of the male urethra**?
* **bulbar fossa** (in the beginning)
* **navicular fossa** (in glans penis)
257
what are the differences between the
**internal and external urethral sphincters**?
* **internal**
* composed of **smooth muscles** in neck of the **bladder**
* sympathetic innervation
* **external**
* composed of **skeletal muscles** and surrounds **membranous part of urethra**
* **perineal branch of pudendal nerve (**innervation)
258
**ejaculatory duct:**
desc, formation, fxn
* very narrow duct (2 cm long)
* formed by union of **ductus deferens and duct of seminal vesicle**
* fxn: allows passage of **seminal fluid** from **_ductus deferens to prostatic urethra_**
259
what is the **principal somatic** (motor/sensory)
**nerve to supply _perineum_**_?_
describe its course
* **PUDENDAL NERVE (S2-S4)**
* Course
* lies in ischial spine --\>
* as it passes thru lesser sciative foramen to --\>
* traverse pudendal canal on lateral wall of ischiorectal fossa
260
what are the branches of the
## Footnote
**PUDENDAL NERVE (S2-S4)**
1. **INFERIOR RECTAL nerve**
* supplies external anal sphincter muscle and skin around the anus
2. **PERINEAL nerve**
* deep branch is motor nerve to muscles of urogenital triangle
* superficial branch gives cutaneous **_posterior scrotal/ labial branches_**
3. **DORSAL** nerve of the penis or clitoris
* supplies body, prepuce, and glans of penis or clitoris
261
**pudendal nerve block**
purpose, and 2 ways
* to **relieve pain** for the mother and prepare for an **episiotomy,** may admin this during early labor
* two ways to block pudendal nerve:
* piercing the **vaginal wall** posterolaterally near the **ischial spine**, or
* **percutaneously** along the medial side of the **ischial tuberosity**
262
clinical correlate of **pudendal nerve block** effects
**pain from uterine contractions is UNAFFECTED** because pelvic visceral pain is carried by afferent fibers accompanying autonomic nerve fibers
263
describe the **nerve supply of the pelvic viscera:**
**_parasympathetic_**, sympathetic, sensory
* parasymp
* **preganglionic** neuron are located in **sacral parasymp n (S2-S4)** in the spinal cord
* processes run into **pelvic** splanchnic nerves and relay w/ postganglionic neurons located inside the pelvic organs in the **intramural plexus**
264
describe the nerve supply of the pelvic viscera:
parasympathetic, **_sympathetic_**, sensory
symp
* Sympathetic fibers of **_preganglionic_** neurons T12 L2 segments (IML) come through the sympathetic trunk and form sacral splanchnic nerves.
* They contribute to the inferior hypogastric plexus, where **_postganglionic_** neurons are located.
* Branches of inferior hypogastric plexus reach organs wrapping around the branches of the internal iliac artery
265
describe the nerve supply of the pelvic viscera:
parasympathetic, sympathetic, **_sensory_**
sensory
* The sensory fibers from **S2-S4 dorsal root ganglia** move together **_with parasympathetic_** and carry **pain** sensations from the organs.
266
which nerves **facilitate _emptying_** in the
## Footnote
**micturition reflex**
* _Parasympathetic fibers_ (pelvic splanchnic nn.) **_stimulate DETRUSOR MUSCLE_** [1] contraction and involuntary relax internal sphincter [2].
* _Somatic motor fibers_ (pudendal nerve) cause voluntary **relaxation of external** [3] urethral sphincter.
267
which nerves **_inhibit emptying_** in the
## Footnote
**micturition reflex**
* **sympathetic fibers** (sacral splanchnic nn) inhibit detrusor muscle [1] and **stimulate internal** sphincter [2]
268
what are the **afferent fibers** in
erecton and ejaculation?
* dorsal nerve of penis or clitoris from **_pudendal nerve (DRG S2-S4)_**
269
what are the **efferent fibers** in
**_erection_**?
Erection:
* **_Parasympathetic fibers (S2-S4)_** from the **_Pelvic splanchnic nerves_** dilate arteries supplying erectile bodies of the penis, allowing them to fill with blood.
* **_Somatic motor (S2-S4) fibrous from the pudendal nerves_** cause contraction of ischiocavernosus and bulbospongiosus muscles to press the root of the penis and relax external urethral sphincter.
270
what are the **efferent fibers** in
**_ejaculation_**?
Ejaculation:
* **Sympathetic fibers (L1-L2)** from the **Inferior hypogastric plexus (Sacral splanchnic nerves)** cause **contraction of smooth muscle** of epididymis, ductus deferens, seminal vesicles, and prostate; sympathetic nerve fibers **stimulate internal urethral sphincter** to prevent semen from entering bladder or urine entering prostatic urethra.
271
**cryptorchism:**
define, epi, sequelae
* def: **undescended testes** when the **testes fail to descend** into the scrotum, and may be found in abdomsinal cavity or in **inguinal ligament**
* epi: normally occurs w/in 3 mo after birth
* sequelae:
* neglected, malignant transformation may occur in undescended testes
* **spermatogenesis is arrested**, and spermatogenic tissue is damaged --\> permanent **sterility in bilat** cases
272
what are the
**main components of the SPERMATIC cord**?
* **ductus deferens**
* **testicular artery - direct branch of aorta**
* **pampiniform plexus** to become single testicular vein
* right --\> IVC,
* left --\> LEFT RENAL VEIN)
273
**torsion of the spermatic cord:**
sxs, treatment
* sxs: acute pain w/ swelling bc of **twisting of testicular** artery; can result in **testicular avascular necrosis**
* tx: requires **high scrotal incision** to **untwist the cord,** and the testis is sutured to the scrotal septum to prevent recurrence
274
describe the lymphatic drainage of the following:
## Footnote
**testis and epididymis**
**lumbar** lymph nodes
275
describe the lymphatic drainage of the following:
## Footnote
**scrotum**
**superficial inguinal** nodes
276
describe the lymphatic drainage of the following:
## Footnote
**penis**
**(*skin, glans, body/roots)***
* skin: **superficial inguinal** nodes
* glans: **deep inguinal nodes**
* body/roots: **internal iliac** nodes
277
describe the lymphatic drainage of the following:
## Footnote
**prostate gland & bladder**
**internal iliac** nodes
278
describe the lymphatic drainage of the following:
## Footnote
**anal canal**
*(above pectinate, below pectinate)*
* above pectinate - **INTERNAL ILIAC**
* below pectinate - **SUPERFICIAL INGUINAL** nodes
279
describe the lymphatic drainage of the following:
## Footnote
**ovary and uterine tubes**
LUMBAR lymph nodes
280
describe the lymphatic drainage of the following:
**uterus**
1. *lateral angle/ teres ligament,*
2. *fundus/upper part,*
3. *lower pt,*
4. *cervix*
1. *lateral angle/ teres ligament - **SUPERFICIAL INGUINAL lymph nodes***
2. *fundus/upper part, - **LUMBAR lymph nodes***
3. *lower pt, - **EXTERNAL ILIAC lymph nodes***
4. *cervix* - ***SUPERFICIAL INGUINAL NODES***
281
describe the lymphatic drainage of the following:
## Footnote
**vagina**
*(superior to hymen, inferior to hymen)*
* superior to hymen : **EXTERNAL** and **INTERNAL** **ILIAC**
* inferior to hymen : **SUPERFICIAL INGUINAL nodes**
282
describe the lymphatic drainage of the following:
## Footnote
**all external genitalia (female)**
**\*\*except glans clitoris**
* all external genitalia (female) - **SUPERFICIAL INGUINAL LYMPH NODES**
283
describe the lymphatic drainage of the following:
## Footnote
**glans clitoris (female)**
DEEP INGUINAL
284
arterial supply of the uterus
almost exclusively supplied by the **uterine arteries
[1] (from internal iliac artery):**
* Uterine a. crosses pelvic floor in **cardinal ligament [2]**
* **Ureter** passes superior and anterior to uterine artery[3]
* **Ascending branch [4]** of uterine artery comes along lateral wall of uterus within broad ligament.
285
**hysterectomy:**
define, clinical correlate
* def: surgical removing of **_uterus_** and may incl removal of **cervix (total)** and **vagina** **(radical)**
* blood supply to ovaries is preserved in **partial hysterectomy** (**ovarian suspensory ligament**) should be left intact bc it contains **ovarian** **artery** (direct branch of abdominal aorta) and vein
* CC: in case of **total hysterectomy**, pelvic splanchnic nerves may be affected --\> bladder dysfxn due to detrusor urine muscle loose parasympathetic innervation
286
describe the 4 parts of the
UTERINE TUBE
1. **Uterine part**
* Pierces uterine wall to open into uterine cavity
2. **Isthmus**
* arrowest part of tube just lateral to uterus
3. **Ampulla**
* Medial continuation of infundibulum comprising about half of uterine tube
* **\*\*Usual site of fertilization**
4. **Infundibulum**
* Funnel-shaped expansion of lateral end, fringed with fimbriae
* Overlies ovary and **receives oocyte at ovulation**
287
**hysterosalpingography:**
define
* imaging for the uterus, cervix
* The **instillation of viscous iodine** through the **external os** [1] of the **_uterine cervix_** allows the lumen of the **cervical canal [2], the uterine cavity [3]**, and the different parts of the **uterine tubes [4]** to be visualized on X-ray.
288
what are the ANTERIOR division branches of the
INTERNAL ILIAC ARTERY
289
what are the branches of the POSTERIOR DIVISION
of the INTERNAL ILIAC ARTERY
290
what is the presentation of a
fx of the **anterior cranial fossa**?
this is a fracture of the **CRIBRIFORM PLATE OF ETHMOID BONE**
* **anosmia** (partial or complete loss of sense of smell)
* **periorbital swelling** (raccoon eyes)
* **CSF leakage** from the nose (rhinorrhea)
291
**scaphocephaly:**
define
* cranial malformation in which there is **premature closure of the _SAGITTAL_ suture**
* anterior fontanelle is SMALL or ABSENT --\> **long, narrow, wedge-shaped cranium**
292
**oxycephaly:**
define
* cranial malformation in which there is **premature closure of the CORONAL suture --\>**
* **high, tower-like** cranium
293
**plagiocephaly:**
define
* cranial malformation in which there is premature closure of the coronal or the **lambdoid** suture occuring on ONE SIDE ONLY --\>
* cranium is **twisted and asymmetrical**
294
**epidural hematoma:**
MOI, sxs, dx
* MOI: skull fx near **pterion** --\> causes this hematoma from torn **MIDDLE MENINGEAL ARTERY (foramen spinosum)**
* sxs: **unconsciousness and death (rapid)** --\> bc bleeding dissects WIDE SPACE, strips dura from inner surface of the skull --\> puts pressure on the brain
* dx: **BICONVEX PATTERN on computed tomography**
295
which structures might be affected by
**CAVERNOUS SINUS THROMBOSIS**?
structures that pass THROUGH THE SINUS DIRECTLY
* **Internal carotid artery** (in case of laceration --\> _AV fistula_)
* **ABDUCENS nerve CN VI** (in case of lesion - _internal squint_)
structures on LATERAL WALL OF SINUS
* **oculomotor nerve (CN III)**
* **trochlear nerve (CN IV)**
* **V1**
* **V2**
296
**dangeous triangle of the face:**
define, clinical correlate
* Middle third of the face is a "danger area“
* bc infxn there may produce thrombophlebitis of the facial vein --\>
* this infxn can spread to the cavernous sinus via ophthalmic veins or pterygoid venous plexus
* CC: septicemia leads to meningitis and cavernous sinus thrombosis --\> can cause neurological damage and are life threatening
297
**pituitary gland tumor:**
growth, treatment
* may extend superiorly through opening in the diaphragma sella, --\> disturbancing endocrine system
* Superior extension of a tumor may cause visual deficit owing to pressure on the optic chiasm [2], the place where the optic nerve fibers cross
* TX: **transsphenoidal operation** is MC operation for **pituitary tumor**
* surgical approach is through nose, nasal cavity, and **sphenoidal sinus**
* **\*best exposure of tumor at lowest risk**
298
how do releasing and inhibiting factors from neurosecretory cells from HYPOTHALAMUS reach the
## Footnote
**pituitary gland?**
**actions?**
* through special capillary network called **_HYPOPHYSEAL PORTAL SYSTEM_**;
* control the production of ADENOHYPOPHYSEAL hormones (ACTH, FSH, LH, TSH, prolactin, and somatotropin)
299
what are the hormones of the **NEUROHYPOPHYSIS?**
how do they travel?
* antidiuretic hormone (ADH) and oxytocin
* secreted in hypothalamus --\>
* transported through axons to pituitary gland
300
what are the 3 branches of the **TRIGEMINAL NERVE, and what does it supply?**
BRANCHES
1. Ophthalmic nerve [V1]
2. Maxillary nerve [V2]
3. Mandibular nerve [V3]
SUPPLY
* skin of face; EXCEPT for small area over angle of the mandible --\> supplied by **great auricular nerve (C2-C3) of cervical plexus**
301
**bell's palsy:**
define, affected nerves
* def: **idiopathic unilateral facial paralysis**
* affected nerves:
* terminal branches of CN VII --\> injured by **PAROTID CANCER or inflammation (**parotitis) by surgery to remove a **parotid tumor** **_(stylomastois foramen)_**
302
**bell's palsy:**
manifestations
manifestations:
* unable to close lips and eyelids on affected side
* eye on affected side is not lubricated (Dry eye)
* unable to whistle, blow a wind instrument, or chew effectively
* facial distortion due to contractions of unopposed contralateral facial muslce
303
**epistaxis:**
define
* nosebleed;
* most often occurs from the anterior nasal septum **(Kiesselbach's area),** where branches of the **_sphenopalatine_**, **anterior ethmoidal, greater palatine, and superior labial** (from facial) arteries converging
304
**sinusitis sphenoiditis:**
clinical correlation
* relationships are CLINICALLY important; bc potential **_injury during pituitary surgery_** and the possible spread of infxn
* CC: infxn can reach the sinuses through their ostia from the **nasal cavity** or through their floor from the **nasopharynx**
* CC: infection may erode the walls to reach the cavernous sinuses, **_pituitary gland_**, **optic nerves**, or **optic chiasma**
305
**ethmoiditis:**
define, sequelae
* def: infxn in the **ethmoidla sinuses** can erode the **_medial wall_** of the orbit --\> **orbital cellulitis** --\> can spread to cranial cavity
* sequelae: may erode structures related to the medial orbital wall
* **medial rectus muscle**
* **superior oblique muscle**
* **nasociliary nerve**
306
**cheeks**:
define
* from the **lateral, movable walls** of the oral cavity and the zygomatic prominences of the cheeks over the **zygomatic** bones
307
what are the components of the
CHEEKS?
* **Buccinator [1]** – **_principal_** muscle of the cheek.
* **Buccal pad of fat** – encapsulated collection of fat superficial to buccinator.
* **Parotid duct [2]** from **Parotid gland [3]** perforate buccinator and opens in inner surface of the cheek right **opposite 2nd upper molar** tooth
308
what are the 4 muscles of mastication of the TMJ?
innervation?
muscles
1. **Temporalis** - elevation & retraction
2. **Masseter -** elevation
3. **Medial pterygoid -** elevation
4. **Lateral pterygoid -** protrusion
innervated by **_V3 - Mandibular nerve_**
309
what occurs with **mandibular nerve** damage?
the mandible (when it protrudes) will deviate **TOWARD** the side of the lesion bc of **LATERAL PTERYGOID** weakness
310
what is the innervation of the
**SENSORY ANTERIOR 2/3** of the tongue?
* general – lingual n. (V3),
* taste – chorda tympani (CNVII)
311
what is the innervation of the
**SENSORY POSTERIOR 1/3** of the tongue?
* general and taste **– glossopharyngeal (CNIX)**
312
what is the **MOTOR INNERVATION**
of the tongue?
* hypoglossal (CN XII)
313
describe what occurs with lesion of the:
* chorda tympani
* lingual nerve
* hypoglossal canal
* A lesion of the chorda tympani – **lose of the taste sensation anterior 2/3 of the tongue**
* A lesion of the lingual nerve – **lose of both general and taste sensation anterior 2/3 of the tongue**
* A lesion of CN XII (hypoglossal canal) allows the **contralateral, unparalyzed genioglossus muscle to pull the protruded tongue toward the paralyzed side (deviation and atrophy of the tongue).**
314
**gag reflex:**
define
touch the posterior part of the pharynx results in muscular contraction of each side of the pharynx -
* **afferent limb: CN IX**
* efferent limb: CN X
315
injury to which nerve will result in a
## Footnote
**negative gag reflex**
injury to the **GLOSSOPHARYNGEAL NERVE (CN IX)**
causes negative gag reflex
316
**palatine tonsils:**
blood supply,
lymph drainage,
nerve supply
* blood supply: **tonsillar branch of facial artery**
* lymph drainage: mainly to **jugulodigastric lymph node,** which is the body's most frequently enlarged lymph node
* nerve supply: branches of **CN IX and CN X** forming a tonsillar plexus of nerves
317
**palatine tonsillectomy:**
procedure, injuries
* procedure: the **peritonsillar space facilitates tonsil removal**, except after capsular adhesion to the superior constrictor
* tx:
* **glossopharyngeal nerve (CN IX) injury:** taste and general sensation from posterior 1/3 of the tongue are lost
* **hemorrhage:** usually from the **tonsillar branch of the facial artery;** superior constrictor is penetrated, a high **facial artery** or tortuous **internal carotid artery** may be injured
318
what are the muscles of the **soft palate:**
1. **tensor veli palatini**
2. **levator veli palatini -** _elevates the soft palate during swallowing_ to prevent food entering to the nasopharynx
3. **palatoglossus**
4. **palatopharyngeus -** _depress soft palate_ and pulls walls of pharynx superiorly
5. **uvular muscle -** shortens uvula and pulls it superiorly
319
**lymph drainage from facial structures**
1. **preauricular (parotid)** - located on front of auricle, receive lymph from **anteriolateral part of scalp** (incl eyelids)
2. **submandibular (**in digastric or submandibular change) - from all air sinuses, nosne, and adjacent cheek, upper lip and lateral parts of the lower lip
3. **submental** (in submental change) - from the chin, _tip of the tongue and central part of the lower lip_
320
**blow-out fracture:**
define, structures that may be affected
* def: fx of the **orbital floor**
* typically involves the orbital rim
* caused by blunt trauma to the orbital contents (e.g. by a handball)
* content of orbital cavity blow-out in **maxillary sinus**
* blow-out **fx may damage:**
* **_inferior rectus muscle_**
* **infraorbital nerve (**from maxillary V2)
* **infraorbital artery** (hemorrhaging)
321
what are the muscles of the orbit
and the motions and innervation
322
**strabismus**:
other name, manifestations
* aka **OCULOMOTOR NERVE PALSY (CN III)**
* manifestations:
* **ptosis**
* fully **dilated pupil**
* and eye is fully depressed and abducted (**"down and out")** due to unopposed actions of superior oblique and lateral rectus
323
**trochlear nerve palsy (CN IV):**
define, signs
* def: lesion of CN IV (4) or its nucleus --\> paralysis of the **superior oblique**; impairs the ability to turn the affected eyeball infero-medially
* pupil looks superio-laterally
* sign: **DIPLOPIA** (DOUBLE VISION) when looking down (e.g. when going down stairs)
324
how does a person compensate for **DIPLOPIA?**
the person can compensate for the diplopia by INCLINING the head anteriorly and laterally toward the side of the normal eye
325
**abducens nerve palsy (CN VI)**
define, presentation
* aka **internal squint**
* injury to abducens nerve --\> paralysis of **lateral rectus** --\> inability to abduct the affected eye
* presentation:
* affected eye is fully ADDUCTED by the unopposed action of the medial rectus that is supplied by the CN III
326
**horner syndrome**:
MOI, pathology
* MOI: penetrating injury to the neck, **PANCOAST tumor,** or **thyroid carcinoma** may cause this
* PATHO: these interrupt the **ascending preganglionic sympathetic fibers** anywhere between their origin in the T1 segment (IML) of the spinal cord and their synapse in the **SUPERIOR CERVICAL GANGLION**
327
**horner syndrome**:
signs
"SAMPLE"
* redness and increased temperature of the skin (**sympathetic nerve fiber injury**)
* absence of sweating (**anhidrosis**)
* constriction of the pupil (**miosis**)
* drooping of the superior eyelid (**ptosis**)
* **loss** of ciliospinal reflex
* **enophthalmos**
328
**otitis media:**
pathology, sxs
* sxs:
* **hearing is diminished** bc of pressure on the eardrum & reduced movement of the ossicles
* **taste may be altered** bc of the **chorda tympani** being affected
* patho:
* infxn spreading posteriorly causes **MASTOIDITIS**
* infxn spreading to **MIDDLE CRANIAL FOSSA** can cause meningitis or temporal lobe abscess, and infxn moving through the **floor** may produes **sigmoid sinus thrombosis**
329
**perforation of tympanic membrane:**
causes, sequelae, tx
* causes:
* may result in otitis media and is one of several causes of middle ear (conduction) **deafness**
* **foreign bodies** in external acoustic meatus, excessive pressure (as in diving), **trauma**
* sequelae:
* **chorda tympani** directly relates to the posterior surface of the **tympanic membrane** -- it may be damaged and resulting in **loss of taste over anterior 2/3 of the tongue,** and secretion of the **sublingual and submandibular** **glands**
* tx: minor perforation heals spontaneously; large ones require surgery
330
**thyroid** gland is the body's largest endocrine gland;
what does it produce?
* **thyroid hormone (T3, and T4)**
* these control the rate of metabolism
* increase the temperature of the body
* **calcitonin**
* controlling calcium metabolism
* reducing blood calcium Ca2+
331
what are potential complications after a
## Footnote
**total thyroidectomy?**
* **LOWER BODY TEMP** (due to lack of T3/ T4)
* **HYPERCALCEMIA** (due to lack of calcitonin)
332
what is the function of the hormone produced by the
**parathyroid glands**?
* hormone is **para****thyroid hormone** (parathormone) - PTH;
* controls the metabolism of phosphorus and calcium in the blood
* **increases Ca2+ level**
333
what are the anatomical relations of the thyroid gland?
anterolateral,
posterolateral,
medial
posterior
* Anterolateral – **infrahyoid muscles**
* Posterolateral – **COMMON CAROTID ARTERY [1]**
* Medial – **larynx, TRACHEA [2]**, pharynx, esophagus, cricothyroid muscle, recurrent laryngeal nerve [3]
* Posterior – **parathyroid glands [4]**
334
**median cervical cyst:**
patho, presentation, tx
* patho: remnant of the **thyroglossal canal** (thyroid gland originally from epithelium of the tongue)
* presentation:
* presents as **painless _midline_ mass** on the anterior aspect of the neck just **below the hyoid bone**, moves during **swallowing** together w/ thyroid gland bc of relation w/ pretracheal layer of cervical fascia and infrahyoid muscles of the neck
* tx: **surgical excision**
335
what are the possible variations of the
## Footnote
**parathyroid glands position?**
* The superior parathyroid glands, more constant in position than the inferior ones.
* The inferior parathyroid glands are usually near the inferior poles of the thyroid gland, but they may lie in various positions
* In 1-5% of people, an inferior parathyroid gland is deep in the superior mediastinum inside the thymus because of common embryonic origin.
336
what are the folds and "rimas" of the **larynx?**
Cavity of the Larynx - 2 Folds:
* **Vestibular folds [1]** (false vocal cords)
* **Vocal folds [2]** (true vocal cords)
"Rima" meaning "cleft":
* **Rima vestibuli –** gap between the vestibular folds
* **Rima glottidis [3]** – gap between the vocal folds anteriorly and vocal processes of the arytenoid cartilages posteriorly is most narrow place in the larynx (it limits size of intubation tube during endotrachial anaesthesia)
337
what are the muscles of the larynx?
* **ABDUCTORS**
* **_Posterior cricoarytenoid_** – abducts vocal folds (the only abductors of the vocal folds)
* It is innervated by **_recurrent laryngeal nerve_** (CNX vagus).
* Interruption of recurrent laryngeal nerve results in **_hoarseness_** because the corresponding vocal fold does not abduct and deviate toward the midline.
338
**cricothyrotomy:**
define, procedure
* def: an emergency procedure that **relieves an airway obstruction** (e.g. swallowed foreign bodies or abnormal tissue growths).
* procedure: A hollow needle is inserted into the midline of the neck, just below the thyroid cartilage (needle cricothyrotomy).
* More frequently, a small incision is made in the skin **over the Cricothyroid membrane**, and another one is made **through the membrane between the cricoid and thyroid cartilage**.
* A **tube** that enables breathing is inserted through incision
339
**retropharyngeal space:**
define, clinical correlate
* def: the interval b/w pharynx (bucco-pharyngeal fascia) and **pre-vertebral fascia**
* CC: may provide a passageway of infxn from **pharynx to posterior mediastinum**
* mediastinitis ~ 90% mortality rate
340
**axillary sheath:**
derived from..., contains
* derived from the **prevertebral fascia**
* encloses the:
* **subclavian artery and brachial plexus** as they emerge in the interval b/w the scalenes anterior and medius muscles (interscalenus space)
* extends into axilla
341
what are the contents of the
## Footnote
**posterior triangle of the neck**
* Veins – **external jugular vein, subclavian vein.**
* Arteries – **occipital artery**
* Nerves – **_Accessory nerve (XI), t_**runks of the brachial plexus, branches of cervical plexus, phrenic nerve.
* Lymph nodes – superficial cervical nodes along external jugular vein.
* **_CN XI (accessory nerve)_** supply:
* **Sternocleidomastoid** muscle - face looks upward to the opposite side
* **Trapezius** - superior fibers elevate, middle fibers retract, and inferior fibers depress scapula.
