MUSCULOESKELETAL,SKIN,CONNECTIVE TISSUE Flashcards
What’s the most common injury at the knee In contact sports?
Lateral meniscus injury
What’s the unhappy triad?
LATERAL FORCE CAUSE:
ACL
MCL
Medial meniscus
Most common bone injured in the carpal zone?
Scaphoid
AVASCULAR NECROSIS
What have if there is a dislocation of lunate bone?
Cause carpal tunnel syndrome
What nerve is impaired in lesion of hook of the hamate?
Ulnar nerve damage
What’s the guyon canal sindrome?
Ulnar compression in cyclisits
Explain sites of upper extremity injury and its nerve injury (6)
Axiliary C5-C6Fractured surgical neck of humerus; anterior dislocation of humerus
musculocutaneusC5-C7 Upper trunk compression
radial C5-T1 Midshaft fracture of humerus;“Saturday night palsy”
median C5-T1 Supracondylar fracture of humerus (proximal lesion); carpal tunnel syndrome and wrist laceration (distal lesion)
Ulnar C8-T1 Fracture of medial epicondyle of humerus (proximal lesion); fractured hook of hamate (distal lesion)
Recurrent branch median nerve C5-T1 Superficial laceration of palm
Signs of injuries in brachial plexus (9)
- Erb palsy (“waiter’s tip”) UPPER TRUNK
- Claw hand (Klumpke palsy) LOWER TRUNK
- Wrist drop POSTERIOR CORD
- Winged scapula ROOT long thoracic nerve
- Deltoid paralysis AXILLARY
- “Saturday night palsy” (wrist drop) RADIAL
- Difficulty flexing elbow, variable sensory loss MUSCULOCUTANEUS
- Decreased thumb function, “Pope’s blessing” MEDIAN
- Intrinsic muscles of hand, claw hand ULNAR
Explain sites of lower extremity injury and its nerve injury (6)
Obturador L2-L4 Pelvic surgery
Femoral L2-L4 Pelvic fracture
Common peroneal L4-S2 lateral aspect of leg, fibular neck fracture
Tibial L4-S3 Knee trauma, Baker cyst (proximal lesion); tarsal tunnel syndrome (distal lesion)
Superior Gluteal L4-S1 intramuscular injection to upper medial gluteal region
Inferior Gluteal Posterior L5-S2 hip dislocation
Signs of lumbosacral radiculopathy 3
L3-L4 Weakness of knee extension, patellar reflex
L4-L5 Weakness of dorsiflexion, difficulty in heel-walking
L5-S1 Weakness of plantarflexion, difficulty in toe-walking, Achilles reflex
What nerve is affected in L3-L4 herniation?
L4!!!!!!!
How the sarcomere is divided?
MHAIZ
MHA MIOSINA
IZ ACTINA
What bands shrink ?
HI
What engines are activated in muscle contraction and relaxation?
Myosin-light-chain kinase CONTRACTION
Myosin-light-chain phosphatase RELAXATION
PTH actions depend of levels (2)
LOW INTERMITENT Anabolica
HIGH CONSTAT Catabolic
Gene implicated in achondroplasia ?
Activation of FGFR inhibit Chondrocyte proliferation
Diagnostic and causes of primary osteoporosis (1-4)
DEXA< 2.5
Steroids
Anticonvulsant
Anticoagulant
Thyroid replacement
What’s denosumab?
Antibody against RANKL (active osteoclasts)
Cause and treatment of osteoporosis
Mutation of carbonic anhydrise in osteoclasts
Bone marrow transplant
How pager disease cause heart failure ?
Bone fractures cause arterio-venus shunts
Causes of avascular necrosis of femur head ASEPTIC
Alcoholism Sickle cell disease Exogenous/ Endogenous corticosteroids Pancreatitis Trauma Idiopathic (Legg-Calvé-Perthes disease) Caisson
Difference between primary and secondary hyperparathyroidism Ca serum, PO4,ALP
primary ⬆️Ca serum ⬇️PO4 ⬆️ALP
secondary ⬇️Ca serum ⬆️PO4 ⬆️ALP
Age and principal characteristics of benign bone tumors
GIANT CELL 20-40 yrs
around knee. “Soap bubble”
OSTEOCHONDROMA Males < 25 years old.
Un cachito epifisis
Age and principal characteristics of malign bone tumors
OSTEOSARCOMA 10-20yrs >65
Around the knee metaphysis
Codman triangle elevation of periosteum
EWING SARCOMA
Boys<15 yrs diaphysis scapula pelvis ribs
Onion skin periosteum reaction
t11:22
Genetic association or rheumatoid arthritis
HLA-DR4
Antibodies in sjogren syndrome (2)
SS-A(anti-Ro)
SS-B (anti-La)
How are the crystals in gout
Negative birefringent
Articulation and microscopic difference between gout and pseudogout
Gout : MTP big toe yellow parallel light negative birefringent
Pseudogout: knee blue parallel light positive birefringent
What’s the triad of Reiter syndrome
Conjunctivitis
Urethritis
Arthritis
Wghats group of patients and lab findings in sarcoidosis?
Black females ⬆️ACE ⬆️CD4/CD8 ratio Hypercalcemia Bilateral adenopathy in CRX
Whats polymialgia rheumatica
Pain in shoulders and hips
Fever
No muscular weakness
Women >50 yrs
Tto low dose corticosteroids
Fibromyalgia presentation
Chronic widespread musculoskeletal pain
Lab findings in polymiositis (5)
⬆️CK ⊕ ANA ⊕ anti-Jo-1 ⊕ anti-SRP ⊕ anti-Mi-2 antibodies
What’s adding in lab findings in dermatomyositis?
CD4 ✅
Difference between myasthenia gravis and lambert-Eaton myasthenia syndrome 4
myasthenia gravis antibody ACh receptor, worse with muscle use Thymoma,drug reversal symptom edrophonium
lambert-Eaton myasthenia syndrome antibody Ca canal, improve whit muscle use,oat cell cancer, drug do not reversal symptoms
Layers of the skin
Corneum (keratin)
Lucidum
Granulosum
Spinosum (desmosomes)
Basale (stem cell site)
What components are in adherents junction?
Cadherins
Ca dependent adhesion proteins
Looss of E-cadherin promotes metastasis
What’s parakeratosis?
Hyper keratosis whit retention of nuclei in stratum corneum
What’s espongiosis ?
Epidermal accumulation of edematous fluid in intercellular spaces
What’s acantolysis?
Separation of epidermal cells
Spinosum stratum
What stratum grow most inn achantosis?
Spinosum
What kind of allergic is neomycin allergic?
Contact dermatitis
Type IV hypersensitive
Cause of Rosacea?
Alcohol
Heat
Difference between staphylococcal scalded skin syndrome and toxic epidermal necrolysis?
staphylococcal scalded skin syndrome destruction of keratinocyte attachment in Granulosum
toxic epidermal necrolysis destruction of epidermal-dermal junction
What virus is responsible by moluscum contagiosum?
Poxvirus
What virus is associated whit hairy leukolakia?
EBV
HIV patients
How you see bullous pemphigoid immunofluorecense ?
Linear pattern in epidermal-dermal junction
What kind Of Ig and what associated disease are in dermatitis herpetiformis ?
Deposits of IgA at tips of dermal papillae.
Associated with celiac disease.
Infection association of erythema multiforme (2)
Mycoplasma pneumoniae
HSV
What’s actinic keratosis?
Pre malign lesion Leading to squamous cell carcinoma
6P’s of linchen Planus
Pruritic Purple Polygonal Planar Papules and Plaques
How lichen planus is seen in microscopi?
Sawtooth infiltrate of lymphocytes at dermal-epidermal junction. Associated with hepatitis C.
Clinical presentation of basal cell carcinoma
nonhealing ulcers
scaling plaque
Clinical presentation of squamous cell carcinoma
Ulcerative red lesions with frequent scale.
What’s the ABCDE of melanoma ?
Asymmetry Border irregularity Color variation Diameter > 6 mm Evolution over time
What’s the mutation and the treatment for melanoma
BRAF mutation
Vemurafenib inhibitor or BRAF kinase
Which Drugs can ⬆️ Uterine tone?
Dinoprostone PGE2.
Carboprost PGF2
Which analog of prostacyclin can ⬇️vascular tone and platelet aggregation?
Epoprostenol PGI2
Function of PGE1
⬇️vascular tone
ALPROSTADIL
Difference between zileuton and montelukast
Zileuton inhibit lipooxigenase (⬇️ bronchial tone⬇️neutrophil chemotaxis)
Montelukast just ⬇️ bronchial tone
Doses of aspirin
Low dose (< 300 mg/day): platelet aggregation. Intermediate dose (300–2400 mg/day): antipyretic and analgesic. High dose (2400–4000 mg/day): anti-inflammatory.
Intoxication by aspirin
Tinnitus
Acute renal failure
Reye syndrome
First respiratory alkalosis
Then acidosis mixta
Toxicity by bisphosphonates
Corrosive esophagitis
Osteonecrosis of jaw
Mechanism of action of allopurinol and febuxotat
Inhibit xanthine oxidase
⬆️hypo xanthine
⬆️[ ] 6MP and azathioprine
Mechanism of action of probenecid
Inhibit reabsortion of Uris acid in proximal tubule
What are TNF-alpha inhibitors?
Etanerceb
Infliximab
Adalimumab
How chronic use of glucocorticoids drecrese bone density?
⬇️ GI absorption of calcium
⬇️ collagen synthesis
⬇️ GnRh
⬆️ urinary calcium loss
How ankylosing spondylitis can be monitored , same as complications (3)
Limited chest wall expansion
Ascending aortitis whit aortic insufficiency
Anterior Uveitis
Principal clinical features of fibromyalgia (3)
Widespread musculoskeletal pain
Fatigue
Neuropsychiatric disturbances
> 3 MONTHS!!!!!
What features of rheumatic fibromyalgia are characteristics (4)
> 50 yrs
Subacute pain and stiffness
Weigh loss
FEVER!!!
What antibodies are implied in Polymiositis?(2)
Antinuclear antibodies (ANA) Anti-histidil-tRNA (anti-Jo-1)
How UV rays can cause DNA damage?
PYRIMIDINE DIMERS!!!!!!!
What’s caudal regression syndrome?
Risk factor: uncontrolled diabetes in pregnancy
Agency of sacrum , lumbar spine
Flaccid legs urinary incontinence
What are the elements underlie in the pathophysiology of acne (4)
Follicular epidermal proliferation
Excessive sebum production
Inflammation
Propionibacterium acnes
What type of muscle fibers there are?
Type I slow full of myoglibin poor in glycogen POSTURAL
Type II fast poor in myoglobin full off glycogen
IIa intermediated
IIb anaerobic
What type of t helper cells and its cytokines are implied in Psoriasis?(2,5)
Th1 Th17 TNF-alpha IL-12 IFN-gamma IL-23 IL-17
Leading to keratinocyte proliferation
Treatment of psoriasis pharmacological group
Vit D analogs (inhibition of keratinocyte proliferation stimuli its differentiation)
Calcipotriol
Calcitriol
Tacalcitol
CICLOSPORINE Inhibit IL-2. T cell differentiation
What drugs provide repaid relief of rheumatic symptoms?(2)
Glucocorticoids
NSAIDs
What drugs are consider DMARDs (4)
Hydroxicloroquine
Methotrexate
Minocycline
Sulfasalazine
How is the diagnosis of giant cell arteritis? (3)
⬆️ erythrocyte sedimentation rate
⬆️ C-reactive protein
Bx intimal thickening Elastic lamina fragmentation, multi-nucleated giant cells
Tto glucocorticoids
What muscle disease is linked whit giant cell arteritis ?
Polymialgia rheumatica
What are late symptoms of LYME disease?
Mono arthritis
KNEEE!!!!
How hemorrhage cutaneous lesions are classified ?(3)
Petechia <5mm diameter
Purpura 5-10 mm diameter
Ecchymosis >1cm diameter
What antiviral drugs require viral kinase
And what do not?
CLOVIR ends needs viral kinase
FOVIR ends DO NOT NEED VIRAL KINASE
What’s the most common tendon muscle affected in rotator cuff syndrome?
Supraspinatus tendon
Evaluated whit “empty-can” test
Why COX 2 selective are linked whit thrombosis and stroke?
Normally COX2 leads to ⬆️ prostacyclin (PGI2) vasodilate and ⬇️platelet aggregation
Complications of psoriasis (3)
Psoriatic arthritis distal interphalgical joints
Nail changes
Inflammatory eyes
Types of xanthomas (4)
Eruptive yellow papules
Tuberous and tendinous
Plane skin folds related whit primary biliary cirrhosis
Xanthelasma eyelid
Whats the innervation and function of latissimus dorsi (ancho dorsal)
Thoracodorsal nerve c6-c8
Extension , addiction ,internal rotation of humerus
What nerve an muscle are injured in whiplash lesson (latigazo)
XI cranial nerve
Trapezius
Elevate, rotate, stabilize the scapula
Through what muscles via sciatic nerve pass
Piriformis
Superior gemellus
What are the major flexor of the hip?
Iliacus and psoas
Microscopic findings in celiac disease (3)
Atrophy of intestinal villus
Crypt hyperplasia
Intraepithelial lymphocytes
Cutaneous associations of ulcerative colitis (2)
Erythema nodosum
Pyoderma gangrenosum
Malignant capacity of lentigo melanoma
LOW
Melanoma in situ
Which ligaments stabilizing the ankle (7)
LATERAL
Anterior Talofibular (most sprain)
Calcaneofibular
Posterior Talofibular
MEDIAL Anterior Tibiotalar Tibionavicular Tibiocalcaneo Posterior Tibiotalar
How radial and median nerves are injured in elbow fractures?
RADIAL Anterolateral displacement of distal diaphysis humeral
MEDIAN Anteromedial displacement of distal diaphysis humeral
Which later muscular changes are present un Duchenne disease?
Pseudohypertrofy of Calf
Fat connective tissue replacement of hypertrophic calf muscle
Which is the cause of androgen in alopecia and which drugs can diminish the substance implied?
To much dihydrotestosterone
5alpha - reductase inhibitors FINASTERIDE
Treatment for alopecia aerate
Topical corticoids
What’s the hallmark of atopic dermatitis?
INTENSE PRURITUS!!!!!!!
What’s the allergic triad?
Atopic disease
Allergic rhinitis
Asthma
How osteocytes remain connected each other?
GAP JUNCTIONS!!!!
What are the embryologic source of melanocytes?
NEURAL CREST!!!!!
What are the complications associated to polymiositis ?(2)
Interstitial lung disease
Myocarditis
What mediator is linked which giant cell arteritis? And what drug target this substance ?
IL-6!!!!
Tocilizumab Ac IL-6
How osteoclastic activity can be messured?(3)
Tartrate-resistant acid phosphatase
Urinary hydroxiproline
✅Urinary deoxypyridinoline
What is the consequence of miastenia gravis in the action potential?
⬇️ the end plate potential under the threshold
Mechanism of action of scopolamine ?
Selective muscarinic ACh receptor ANTAGONIST
Mechanism of action of biphosphonate?
Inhibition of mature osteoclasts
Mechanism of action Of estrogens in osteoporosis management?
Inhibition of osteoclastic differentiation.
Inhibition of RANKL
How is the pain in bursitis?
Diminish the ACTIVE range of motion
No pain in PASIVE MOTION
What are the side effects of colchicine?
Nausea
Vomit
Diarrhea
Mechanism of action of probenecid ?
⬇️Proximal tubular Uric acid Reabsortion
Drugs contraindicated in ACUTE gout crisis ?(2)
Allopurinol
Probenecid
Dugs which inhibit DHF reductase? (4)
Methotrexate
Trimethoprim
Pirimetamine
Phenytoin
Side effect of hidroxicloroquine?
Irreversible retinopathy
Substance responsible for Keloid formation?
TGF-Beta
Inflammatory cell and infections related with Erithema Multiforme? (1,2)
CD8 Lymphocytes
Herpes simplex
Mycoplasma
Acute cardiac complications in rheumatic fever? (2)
Mitral regusrgitation
Pancarditis
Common Hemangiomas in adult,children,pregnant patients?🍒🍓🕷
Adult. 🍒Cherry Hemangiomas
Children. 🍓Strawberry Hemangiomas first grow and then regress
Pregnant -OCPs- liver disease.🕷Spider Hemangiomas
Which congenital diseases are related whit cystic hygroma? (2)
Turner syndrome
Down syndrome
Fisopathology in Charcot-Mary-tooth disease?
Abnormal myelin synthesis
PIE DE ARCO
What are the auto antibodies in dermatitis herpetiform?
Ac Transglutaminase
What are the Drugs which cause Drug-induced Lupus? (4)
Procainamide
Hydralazine
Isoniazid
D-procainamide
The vertebral artery go through what bone structures in the neck?
Through transversal foramina whiting the transverse process 6 to 1 at cervical vertebra
Muscles inervated by Axiliary nerve ?(2)
Deltoid
Infraspinatus
Tracks involved in sudacute combined degeneration by B12 deficiency? (3)
Dorsal columns
Corticospinal
Spinocerebellar
What is the mos community bone cancer in middle age and older adults localized in pelvic bones and is radiolucent ?
CHONDROSARCOMA!!!!
What tumor is related whit myasthenia gravis?
THYMOMA!!!!
How is call the marked thickened of the epidermis presented in psoriasis?
ACANTHOSIS!!!!
In what day after MI there is the point Maximus of ventricular wall weaknesses, and can occur a tamponade?
Day 5!!!!
Mechanism of action of alendronate ?
Bone resorption inhibitor
Stabilator hidroxyapatite bone structure
Induces secretion of osteoclast inhibitors
Which cells have increase activity in PAGET DISEASE in each phase?
- Osteolitic OSTEOCLASTS!!!!
- MIXED
- Osteosclerotic OSTEOBLASTS!!!
What symptoms persist in chronic use of opiods?
CONSTIPATION
MIOSIS
Which muscle structures are anterior and posterior to the brachial plexus and can participate in thoracic outlet syndrome?
ANTERIOR SCALENE
MIDDLE SCALENE
Microscopic finding in dermatitis herpetiform
Sub epithelial blister with neutrophils in dermal papilla
Very specific autoantibody found in Rheumatoid Artritis?
Ac - Citrullinated peptides
Types of exocrine glands?
Merocrine: exocytosis 🔹salivary and sweat glands
Apocrine: membrane bound vesicles 🔹Mammary glands
Holocrine: cell lysis 🔹Sebaceous glands
Nerve and artery damaged in midshaft humerus fracture
Radial nerve
Deep bronchial artery
Pathognomonic sign in myotonic dystrophy?
Abnormal slow relaxation of muscles
Inability to release the doorknob
Cataracts
Frontal balding
Gonadal atrophy
Type 1 muscle fibers atrophy
Cause of congenital torticollis?(2)
Birth trauma
Malposition in Utero
What type of clinical macroscopic findings can be seen in MEN2B?
Mucosal neuromas
Marfanoid habitus
Medullary thyroid cancer
Pheochromocytoma
Best site to anesthetics femoral nerve?
Inguinal crease (pliegue)
What are the features of actinic keratosis ?
Rough sandpaper-like texture
Hyper keratosis-cutaneous horns
Structures that are compromised in acute compartment syndrome of the leg?(3)
ANTERIOR COMPARTMENT
Extensors muscles
Anterior tibial artery
Deep peroneal nerve
Want autosomic dominant genetic disease has skin and mucosal telangectasias and recurrent severe nosebleeds?
Hereditary hemorrhagic telangectasias
OSLER-WEBER-RENDU
What’s Pierre robin secuence?
Micrognatia
Glossoptosis (posterior displacement)
U shaped cleft palate
Which vascular disease has impossibility to wrist extension (wrist drop)?
Hurt-Strauss =eosinophilic granulomatosis whit polyangiitis
Asthma history
ANTIBODIES NEUTROPHIL MYELOPEROXIDASE p-ANCA
Action of osteoprotegerin in osteoporosis ?
🚫osteoporosis
Osteoprotegerin block RANK ( important to osteoclast formation)
Explain peptides responsibles for localized amyloidosis in cardiac atria,thyroid gland, pancreas,cereebrum,pituitary gland.
cardiac atria : atrial natriuretic peptide
thyroid gland: calcitonin ( medullary carcinoma)
pancreas: amylin (associated with DM2)
cerebrum: beta-amyloid (Alzheimer)
pituitary gland : prolactine
How is the presentation in train of four stimulation of depolarizing and non-depolarizing NMJ blockers ?
depolarizing EQUUAL REDUCTION THEN PROGRESSIVE REDUCTION
non-depolarizing PROGRESSIVE REDUCTION
Difference between Duchenne and Becker talking about its protein issue?
🚫Duchenne lack of distrophin
⬇️ Becker decrease synthesis of dystrophin
Management of restless leg syndrome?
PRAMIPEXOLE
dopamine agonist!!!
Iron supplement
Injury in specific arteries in femoral neck fracture leads to femur head Osteonecrosis ..(2)
Ascending cervical and retina ulnar from MEDIAL CIRCUMFLEX ARTERY !!!
Important artery that can be injured in femur neck fracture in the child?
Lifpamentus teres artery from OBTURADOR ARTERY
epiphyte all growth plate
what are glomangioma ?
tumor of glomus
encapsulated neurovascular organs in dermis which act in thermoregulation
tipically seen under the nails.
Femoral nerve pass through what important muscular structures?
ILIOPSOAS MAJOR !!!!
What’s Dupuytren contracture?
Fibroproliferative disease of the palmar fascia leading to fingers flexion
Blotchy every muscle fibers on glomori thrichrome stain are characteristic in ?,…..
MITOCHONDRIAL MYOPATHIES!!!
How is the superficial lymphatic drainage of the lower extremity?
MEDIAL ⏩ inguinal lymphonodes
LATERAL⏩popliteal nodes ⏩ inguinal lymphonodes
Pathophysiology of keloid formation
⬆️⬆️TGF-Beta to much collagen deposit
In the PROLIFERATIVE PHASE OF HEALIG
3 days to 3 weeks
Principal features of Lambert-Eaton Myasthenic syndrome?(4)
Proximal muscle weakness (gait, climb stairs)
🚫 oculobulbar nerve (diplopia , ptosis)
Dysarthria disphagia
Disautonomic (Dry mouth , Impotency )
How osteoprotegerin (OPG) block the osteoclast maduration? And wha drug can induce the same outcome?
OPG bind RANK-L
Block the interaction whit RANK
DENOSUMAB
monoclonal antibody
Medications linked with osteoporotic factures?(8)
⬆️ Vit D catabolism :Anticonvulsants
⬇️ Estrogens: Aromatase inhibitors , Medroxiprogesterone
⬇️ Testosterone and estrogen: GnRH agonist
⬇️ Ca Absortion: omeprazol
⬇️ Bone formation: glucocorticoids, HBPM, thiazolidinediones
What’s myasthenic crisis and Cholinergic crisis? And how is it tested?
Myasthenic crisis ⬇️ACh. Improve with edrophonium
Cholinergic crisis ⬆️⬆️ACh insensitivity Doesn’t improve with edrophonium
Mutation related with amyotrophic lateral sclerosis ?
Mutation of the gene that codes for cooper-zinc superoxide dismutase SOD1
Mechanism of action of pancuronium and tubocurarine?
Nicotinic receptor antagonist
Mechanism by morphine induces allergies?
Ig-E Independent mast cell activation
Pathognomonic skin lesions after lighting ?
Lichtenberg figures⚡️⚡️⚡️
Cause of wrinkles in older people?
Decrease of collagen fibril production
⬆️up regulation of matrix metalloproteinases
Degradation of type I and type III collagen and elastin
Different kind of nevi. (3)
Junctional Nevus NEVUS CELLS IN DERMOEPIDERMAL JUNCTION flat , darker center
Compound Nevus NEVUS CELLS EXTENDS FROM EPIDERMIS TO DERMIS papules
Intradermal Nevus NEVUS CELLS JUST AT DERMIS pedunculate
What’s the triad of McCune-Albrigth syndrome? And it’s cause?
Fibrous dysplasia (Osteolitic lesions at hip and pelvis) Endocrine abnormalities (precocious puberty, hyperthyroidism) Cafe-Au-lait spots
GNAS gene –constitutive activation of G protein
Muscles of rotator cuff which inserts in greater and lesser tuberosity?
GREATER. Supraspinosum, infraspinosum, Teres minor
LESSER. Subscapularis
In hyperparathyroidism what kind of Osseous reabsortion is seen?
Subperiosteal reasorption with cystic degeneration
Histologic finding in contact dermatitis?
ACUTE ESPONGIOSIS
Eosinophilis and lymphocytes infiltrates
CRHONIC
achantosis (thickening of stratum Spinosum)
Hyperkeratosis (thickening of stratum corneum)
Where is seen hypergranulosis?
Lincoln planus
clinical complex of tuberous sclerosis? (5)
renal angiomiolipomas brain hemartomas cardiac rhabdomiomas facial angiofibromas leaf-shaped patches of skin
which arteries conform kiesselbach plexus?(3)
anterior ethmoidal
sphenopalatine
superior labial (facial)