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Week 1 Flashcards

1
Q

Where is the cavity “proper”?

A

Between the teeth

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2
Q

Where is the vestibule?

A

Outside the teeth

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3
Q

What 2 bones make up the hard palate?

A
  • Maxilla

- Horizontal plate of Palatine

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4
Q

What does the ramus of the Mandible divide into?

A
  • Condylar

- Coronoid

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5
Q

What does the mandibular foramen allow the passage of?

A

The inferior alveolar/dental nerve to the lower teeth

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6
Q

What lies in the submandibular fossa?

A

Submandibular gland

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7
Q

What attaches at the Mylohyoid line?

A

Mylohyoid muscle, forming the floor of the mouth

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8
Q

What lies in the sublingual fossa?

A

Sublingual gland

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9
Q

What attaches at the retromolar fossa?

A

Lower end of the pterygomandibular raphe, between buccinator and superior constrictor

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10
Q

What movements at the Temporomandibular joint close the mouth?

A

Retraction and Elevation

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11
Q

What movements at the Temporomandibular joint open the mouth?

A

Protrusion and Depression

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12
Q

What is the only muscle of mastication that opens the mouth?

A

Lateral Pterygoid muscle

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13
Q

What 3 muscles elevates the mandible to close the mouth?

A
  • Medial Pterygoid
  • Masseter
  • Temporalis
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14
Q

What is the name of the cheekbone?

A

Zygoma

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15
Q

What epithelium lines the mucous membrane internally?

A

Non-keratinised, stratified squamous

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16
Q

Describe the Buccinator?

A
  • Cheek muscle
  • Compresses the vestibule
  • Contributes to orbicularis oris
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17
Q

Describe the fibres of the upper buccinator in relation to the lips?

A

Upper fibres contribute to the upper lip, but also cross over into the lower lip

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18
Q

Name the point of cross over of the buccinator upper and lower fibres?

A

Modiolus

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19
Q

What is the fusion at the pterygo-mandibular raphe?

A

Buccinator and superior pharyngeal constrictor

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20
Q

What is the superior attachment of the pterygomandibular raphe?

A

Pterygoid hammulus (medial pterygoid plate)

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21
Q

What nerves cause the sensation to skin of cheeks and lips and internal mucous membrane?

A

Branches of Maxillary and Mandibular divisions of Trigeminal nerve (V2 & V3)

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22
Q

What’s the main muscle of the muscular “diaphragm” of the floor of the mouth?

A

Mylohyoid

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23
Q

What nerve supplies the Myohyoid muscle?

A

Mandibular division of the Trigeminal nerve (V3)

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24
Q

What main muscle does the tongue comprise of?

A

Genioglossus

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25
What do extrinsic tongue muscles alter?
Position
26
What do intrinsic tongue muscles alter?
Shape
27
What muscles draw the tongue upwards and backwards?
- Palatoglossus | - Styloglossus
28
What muscle draws the sides of the tongue downwards?
Hyoglossus
29
What is the surface of the tongue covered by?
Different papillae
30
What nerve provides the motor supply to all tongue muscles except palatoglossus?
Hypoglossal (Cranial XII)
31
What nerve provides the motor supply to the palatoglossus muscle?
Vagus (X) via the pharyngeal plexus
32
What are the 3 extrinsic muscles of the tongue?
- Palatoglossus - Hyoglossus - Styloglossus
33
What are the 2 systems of veins draining the tongue and where do they drain to?
- Deep & dorsal | - Converge on internal jugular
34
What are the 3 Salivary Glands?
- Parotid (serous) - Submandibular (mucous & serous) - Sublingual (mucous)
35
What nerve supplies the salivary glands (PNS & secretomotor)?
Glossopharyngeal nerve IX (and facial nerve VII)
36
What makes up a large proportion of the soft palate?
Aponeurosis of tensor palati (covered by mucous membrane)
37
What muscle forms the palatoglossal arches?
Palatoglossus muscle
38
Describe the attachment of Tensor palati?
Attaches above medial pterygoid plate and cartilage of the auditory tube, and lies outside the med. pterygoid plate
39
What is the important thing to remember about lymph drainage of the tongue?
Crosses midine, drains to deep cervical nodes
40
Describe the nerve supply of sensation of the tongue?
- Anterior 2/3 is lingual branch of trigeminal, | - Posterior 1/3 glossopharyngeal
41
Which nerves supply the hard an soft palate?
Greater and lesser palatine branches of maxillary nerve
42
What occurs to close the oropharyngeal isthmus during chewing?
Palatoglossus and palatopharyngeus contract to draw palate down and draw together medially, tensor palati tenses so levator palati can close nasopharyngeal isthmus
43
What lies between the Palatoglossal and Palatopharyngeal arches in the oral cavity?
Palatine Tonsils
44
What are the 3 longitudinal muscles that elevate the larynx?
1. Palatoglossus 2. Palatopharyngeus 3. Salpingopharyngeus
45
Where is a common place in the pharynx for fish bones to become stuck?
Piriform fossa
46
Where is the Piriform fossa located?
Between the quadrangular membrane of the larynx and side wall of the pharynx
47
What holds the nasopharynx open?
Stiff Pharyngobasilar fascia
48
What are the 4 Pharyngeal Attachments?
1. Medial pterygoid plate of sphenoid 2. Pharyngobasilar fascia attaches to cartilage of auditory tube 3. Levator Palati from apex of petrous temporal bone 4. Fascia, and posterior, Midline pharyngeal raphe attaches to pharyngeal tuberacle
49
How is the midline pharyngeal raphe formed?
By the 3 constrictors
50
What part of the hyoid bone does the stylohyoid ligament attach?
Lesser Horn
51
Where does the superior constrictor attach?
To the Pterygmandibular raphe with buccinator
52
Where does the middle constrictor attach?
Hyoid bone and stylohyoid ligament
53
Where does the inferior constrictor attach?
Oblique line of thyroid cartilage, cricoid cartilage & fascia on cricothyroid
54
What does the internal laryngeal nerve & vessels pierce?
Thyro-hyoid membrane
55
What vessels pass through the "gaps" with the internal laryngeal nerve?
Superior laryngeal vessels
56
What vessels pass through the "gaps" with the recurrent laryngeal nerve?
Inferior Laryngeal vessels
57
What does the internal laryngeal nerve provide?
Sensation to larynx above the vocal folds
58
What does the external laryngeal nerve supply?
Cricothyroid muscle
59
Where does the recurrent laryngeal nerve travel?
Passes deep to inferior constrictor to reach the larynx
60
Which nerve supplies the 3 pharyngeal contrictors?
Pharyngeal branch of the Vagus (X)
61
What can uncoordinated contraction of cricopharyngeus cause?
Excessively raise pressure in the pharynx
62
What fascia lies outside the muscular pharynx and blends with pre tracheal fascia?
Buccopharyngeal fascia
63
What forms the upper oesophageal sphincter?
Inferior constrictor has a lower circular part- cricopharyngeus
64
What is the palatopharyngeal sphincter/ Passavant's muscle and what is it's function?
- Derived from superior constrictor/ palatopharyngeus | - Provides socket into which soft palate can be moved up into during swallowing
65
Describe where a pharyngeal diverticulum is likely to occur and why?
- Just above the cricopharyngeal sphincter - Superior constrictor ends & only 2 layers remain - This allows a potential weakness - Cricopharyngeal uncoordination may be issue
66
List what the Palatopharyngeus does?
- Elevates the pharynx & Larynx - Draws soft palate downwards - Brings palatopharyngeal arch towards midline to help palatoglossus separate the oral cavity and pharynx
67
How does the Stylopharyngeus descend?
From styloid process to between the superior & middle constrictors & fans into internal pharyngeal surface
68
How does the Salpingopharyngeus descend?
Into the pharynx from the cartilage of the auditory tube
69
What is the 2 main functions of the Salpingopharyngeus?
- Elevator of pharynx & Larynx | - Open auditory tube during swallowing for pressure equalisation in the middle ear
70
What nerve supplies the Salpingopharyngeus?
Vagus Nerve
71
What is the nerve supply of the Palatine tonsil? | Where is the referred pain?
- Glossopharyngeal IX | - To middle ear
72
What is Waldeyer's ring?
Ring of tonsillar tissue found in posterior 1/3 of tongue, roof of nasopharynx (adenoid) and opening of auditory tube
73
Swelling of which 2 tonsils may lead to mouth breathing and middle ear infections?
- Pharyngeal tonsil/ adenoid | - Tubal tonsil
74
What is the Vallecula?
Pit/fossa between the tongue and epiglottis
75
What happens is the pharynx is pierced when putting a catheter in the auditory tube?
Catheter could enter internal carotid artery
76
What is the blood supply of the upper pharynx?
Branches of External Carotid Artery
77
What is the blood supply of the lower pharynx?
Branches of Subclavian
78
Which lymph node drains the palatine tonsil?
Jugulodigastric
79
What is the venous drainage of the pharynx?
Pterygoid plexus, converges on facial and internal jugular veins
80
Which nerve supplies sensory the oropharynx, inferior aspect of the soft palate and posterior 1/3 of tongue?
Glossopharyngeal (IX)
81
What nerve gives sensory supply to the nasopharynx?
Maxillary (V2)
82
What nerve gives sensory supply to the laryngopharynx, vallecula and epiglottis?
Vagus (X)
83
Which 2 nerves supply parasympathetic secretomotor impulses to the pharynx?
- Vagus (X) | - Facial (VII)
84
What nerve give motor to supply to all but stylopharyngeus?
Vagus (X)
85
What is the only muscle supplied by the Glossopharygeal nerve (IX)?
Stylopharyngeus
86
What are the 6 steps to swallowing?
1. Bolus pushed backwards by mylohyoid & intrinsic tongue muscles 2. Styloglossus pulls tongue up & back to tip bolus through oropharyngeal isthmus 3. Soft palate tensed (tensor palati) & elevated (levator palati) to sit within Passavant's ridge, separating nasa from oropharynx 4. Palatoglossal & Palatopharyngeal arches relax & move laterally 5. Stylopharyngeus, Salpingopharyngeus, Palatopharyngeus, Stylohoid & Digastric elevate pharynx & larynx 6. Relaxation of elevators, contraction of constrictors
87
What are the Gastrointestinal (abdomen) questions you ask when taking a patients history?
- Abdominal pain - Anorexia & weight change - Dyspepsia/Indigestion - Dysphagia - Nausea & Vomiting - GI tract bleeding - Jaudice - Change in bowel habit (constipation/diarrhoea)
88
What are the Genitourinary questions you ask when taking a patients history?
- Urinary frequency - Dysuria - Nocturia - Incontinence - Hesitancy - Urinary urgency - Urinary flow - Haematuria - Loin pain
89
What are the other questions to consider during a Genitourinary history?
- Vaginal bleeding - Vaginal discharge - Menstrual history - Obstetric history - Sexually active? - Contraception - Last menstrual period (LMP)
90
What does "SOCRATES" for pain stand for?
1. Site 2. Onset 3. Character 4. Radiation 5. Associated symptoms 6. Timing 7. Exacerbators/relievers 8. Severity
91
What are the 9 regions of the Abdomen?
1. Right Hypochondrium 2. Epigastric 3. Left Hypochondrium 4. Right Lumbar (R. Flank) 5. Umbilical 6. Left Lumbar (L. Flank) 7. Right Iliac fossa 8. Hypogastric (suprapubic) 9. Left Iliac fossa
92
What are the 4 quadrants of the Abdomen?
1. Right upper 2. Left upper 3. Right lower 4. Left lower
93
What could pain radiation to the back indicate?
Pancreatitis
94
What could pain radiation to the shoulder tip indicate?
Diaphragmatic irritation
95
What could pain radiation from loin to groin indicate?
Renal Colic
96
What are the associated symptoms with GU and Abdomen problems?
- Sweating/Fevers - Vomiting/nausea - Diarrhoea - Urinary symptoms - Vaginal bleeding/discharge
97
What are common aggravating/exacerbating factors?
- Eating/not eating - Movement/lack of movement - Position - Exercise (cardiac disease) - Urination/ menstruation
98
What are the common relieving factors?
- Eating/not eating - Vomiting/opening bowels - Movement/ lack of movement - Position
99
What can be the causes of gaining weight?
- Fluid gain ie. cardiac failure, liver disease, nephrotic syndrome - Hypothyroidism - Depression - Increased energy input/output ratio
100
What can be the causes of weight loss?
- Malignancy - Malabsorption ie. chronic pancreatitis/ coeliac disease/Crohn's disease - Metabolic diseases ie. diabetes/hyperthyroidism/renal disease/chronic infection (TB/HIV) - Psychiatric causes ie. depression/dementia/anorexia nervosa - Malnutrition
101
What usually makes Dyspepsia/Indigestion worse/better?
- Triggered by food | - Relieved by antacid/"Gaviscon"
102
What is Dysphagia?
Difficulty swallowing
103
What could the oral causes of dysphagia be?
- Painful mouth ulcers - Tonsillitis - Pharyngitis - Glandular fever
104
What could the neurological causes of dysphagia be?
- CVA | - Bulbar or pseudobulbar palsy
105
What could the neuromuscular causes of dysphagia be?
- Achalasia - Pharyngeal pouch - Myasthenia Gravis - Diffuse oesophageal spasm
106
What could the mechanical causes of dysphagia be?
- Oesophageal carcinoma - Peptic oesophagitis - Benign stricture - Extrinsic compression (lung tumour, lymph nodes)
107
What is Odynophagia?
Painful swallowing in mouth or oesophagus. Can occur with/without dysphagia
108
What are the 3 different types of vomit?
1. Food 2. Bile 3. Blood ("coffee ground" or fresh red)
109
What does Haematemesis mean?
Vomiting blood
110
What are the different causes of Haematemesis?
- Gastric or duodenal ulcer - Gastric erosions - Varices - Mallory-Weiss syndrome - Reflux oesophagitis - Gastric carcinoma
111
What is the commonest cause of life-threatening GI bleeding?
Peptic ulceration
112
What does Melaena mean?
Passage of black tarry stools usually secondary to bleed in oesophagus, stomach or duodenum
113
What does lower GI tract bleeding commonly look like?
Fresh blood
114
What are the different causes of Lower GI tract bleeding?
- Haemorrhoids - Anal fissure - Diverticular disease - Large bowel polyps/carcinoma - Inflammatory bowel disease
115
What does painless Jaundice suggest?
Carcinoma of head of pancreas
116
What does Tenesmus mean?
Feeling of not fully emptying bowels
117
What are the common causes of Constipation?
- Diet/Dehydration - Painful anal conditions - Immobility - Medication ie. opiates - Hypothyroidism - Colonic/rectal carcinoma - Neuromuscular ie. spinal cord disease/Parkinson's disease - Hypercalcaemia - Irritable bowel syndrome
118
What are the common causes of Diarrhoea?
- Diet - Stress - Infection ie. viral gastroenteritis/food poisoning - Inflammation ie. UC/Crohn's - Endocrine ie. hyperthyroidism - Malabsorption ie. coeliac - Irritable bowel syndrome
119
What are the Upper GI tract red flags?
- Dysphagia - Blood loss - Weight loss - Upper Abdominal/epigastric mass - Back pain - Painless jaundice - Persistent vomiting - Iron deficiency anaemia - Worsening dyspepsia if >55 yrs old - New onset if >55 yrs old
120
What are the Lower GI tract red flags?
- Bleeding - Bowel habit - Mass - Iron deficiency anaemia - History of lower GI cancer with any other symptoms
121
What are symptoms of GU problems?
- Dysuria - Increased Urinary frequency - Urgency - Hesitancy - Nocturia - Urinary flow - Incontinence - Haematuria
122
What are the symptoms of a Lower UTI (cystitis)?
- Dysuria - Increased Frequency - Urgency - Suprapubic discomfort - Possibly haematuria
123
What are the symptoms of an Upper UTI (pyelonephritis)?
- Loin pain - Fevers - Rigors - Flank tenderness - Increased Urinary frequency - Dysuria - Possibly haematuria
124
What are the symptoms of Prostatism (enlarged prostate)?
- Irritative (urgency, dysuria, frequency, nocturia) - Obstructive (reduced force, hesitancy, interruption of stream during) - Perineal pain
125
Describe Loin pain? | What are the different causes?
- Side of back, below ribs | - Pyelonephritis/renal calculo/hydronephrosis/renal tumour/renal abscess/referred pain from back
126
Describe Haematuria? | What are the different causes?
- Frank red blood/dipstick testing - UTI/Urinary tract calculi/bladder carcinoma/glomerulonephritis/renal carcinoma/benign prostatic hypertrophy/prostatic carcinoma
127
What are the GU red flags?
- Any age with painless macroscopic haematuria - Haematuria & symptoms of UTI but sterile urine - Testicular swelling - Abdominal mass thought to be from urinary/genital tract - Hard irregular prostate - Normal prostate, but rising/raised age specific PSA with/without lower urinary tract symptoms - High PSA - Postmenopausal bleeding - Persistent intermenstrual bleeding - Palpable pelvic mass/cervical lesion/vulval mass
128
What are the exocrine secretions of the salivary glands?
- Salt - Water - Mucus - Amylase
129
What is the function of Amylase?
Polysaccharide-digesting enzyme
130
What is the exocrine secretion of the oesophagus?
Mucus
131
What is the exocrine secretions of the stomach?
- HCl - Pepsin - Mucus
132
What is the function of HCl secretion in the stomach?
Solubilisation of food particles, kills microbes
133
What is the function of Pepsin secretion in the stomach?
Protein-digesting enzyme
134
What is the function of Mucus secretion in the stomach?
Lubricate and protect epithelial surface
135
What are the exocrine secretions of the small intestine?
- Enzymes - Salt - Water - Mucus
136
What is the exocrine secretions of the large intestine?
Mucus
137
What are the exocrine secretions of the pancreas?
- Enzymes | - Bicarbonate
138
What is the function of enzyme secretion in the pancreas?
Digest carbohydrates, fats, proteins & nucleic acids
139
What is the function of bicarbonate secretion in the pancreas?
Neutralize HCl entering small intestine from stomach
140
What are the exocrine secretions in the liver?
- Bile salts - Bicarbonate - Organic waste products trace metals
141
What is the function of bile salt secretion in the liver?
Solubilise water-insoluble fats
142
What is the function of organic waste secretion in the liver?
Elimination in feces
143
What is the function of the gallbladder?
Store & concentrate bile between meals
144
Describe the purpose of motility?
Propulsion of ingested food from mouth to rectum mixing and reduction in particle size to optimise time for digestion and absorption
145
Describe the purpose of digestion?
Ingested food is digested into absorbable molecules
146
Describe the purpose of absorption?
Nutrients, electrolytes and water are absorbed from intestinal lumen into bloodstream
147
What are the 5 Major Physiological processes of the GI tract?
1. Motility 2. Secretion 3. Digestion 4. Absorption 5. Excretion
148
What is the Mucosal immune system (GALT) in the GI tract?
- Organised aggregates of lymphoid tissue (Peyer's patches) | - Diffuse populations of immune cells (lymphocytes & mast cells)
149
What does "GALT" stand for?
Gut-associated lymphoid tissue
150
What are the non-immunologic protective mechanisms for the GI tract?
- Gastric acid - Mucin - Peristalsis - Epithelial cell layer barrier
151
What is the lamina propria?
Underlying loose connective tissue with capillaries, enteric neurones and immune cells
152
What is the muscularis mucosae (lamina muscularis)?
Thin smooth muscle layer of the mucosa
153
What is the submucosa layer?
- Loose connective tissue - Larger blood vessels - Lymphatics - Secretory glands - Enteric neurones in submucosa
154
What is the muscularis externa (muscle layer)?
- Inner layer of circular muscle - Outer layer of longitudinal muscle - Enteric neurones between the muscle layers (myenteric plexus)
155
What is the serosa layer?
- Outer layer of connective tissue covered with squamous epithelial cells
156
List the 9 layers of the GI tract most superficial to deep?
1. Epithelium 2. Lamino propria 3. Muscularis mucosae 4. Submucosa 5. Submucosal plexus 6. Circular muscle 7. Myenteric plexus 8. Longitudinal muscle 9. Serosa
157
What is the ANS extrinsic component of GI tract innervation?
- Sympathetic | - Parasympathetic
158
What is the Intrinsic component of GI tract innervation? | Enteric Nervous System
- Submucosal plexus (Meissner's plexus): small & large intestine - Myenteric plexus (Auerbach's plexus): between circular & longitudinal muscle layers throughout GI tract
159
What nerves does the parasympathetic innervation of GI tract originate?
Vagus nerve/ Pelvic splanchnic nerves
160
Where does the sympathetic innervation of GI tract originate?
Sympathetic ganglia
161
What 4 things control the intrinsic (enteric) nervous system of the GI tract?
1. Secretory cells 2. Endocrine cells 3. Mechanoreceptors 4. Chemoreceptors
162
How many ml of water are lost in feces per day? | How many g of solids are lost in feces per day?
- 100ml | - 50g
163
What are the stimuli for secretion of gastrin hormone?
- Protein - Nerve supply - Distention of stomach
164
Where is the gastrin hormone secreted?
- G cells of the antrum - Duodenum - Jejunum
165
What are the actions of gastrin hormone?
Stimulates gastric acid secretion and mucosal growth
166
What are the stimuli for secretion of cholecystokinin hormone?
- Protein - Fat - Acid
167
Where is Cholecystokinin hormone secreted?
- I cells of duodenum - Jejunum - Ileum
168
What are the actions of Cholecystokinin hormone?
- Stimulates pancreatic enzyme secretion, bicarbonate secretion, gallbladder contraction, growth of exocrine pancreas. - Inhibits gastric emptying
169
What are the stimulus for the secretion of secretin hormone?
- Acid | - Fat
170
Where is secretin hormone secreted?
- S cells of duodenum - Jejunum - Ileum
171
What are the actions of secretin hormone?
- Stimulates pepsin secretion, pancreatic bicarbonate secretion, billary bicarbonate secretion, growth of exocrine pancreas - Inhibits gastric acid secretion
172
What is the stimulus for the secretion of gastric inhibitory peptide hormone?
- Protein - Fat - Carbohydrate
173
What is the site of secretion for gastric inhibitory peptide hormone?
- K cells of duodenum | - Jejunum
174
What is the action of gastric inhibitory peptide hormone?
- Stimulates insulin release | - Inhibits gastric acid secretion
175
What is the stimulus for the secretion of motilin hormone?
- Fat - Acid - Nerve
176
Where is motilin hormone secreted from?
- M cells of duodenum | - Jejunum
177
What is the action of motilin hormone?
Stimulates gastric motility and intestinal motility
178
What does the WHO constitution (2006) say about Health & Human rights?
The enjoyment of highest attainable standard of health is a functional right of every human being
179
List 2 historic global declaration & 2 global legalising documents which address Health & Human rights?
1. WHO constitution (2006) 2. Universal Declaration of Human rights (UN) (1948) 1. International Covenant on Economic, Social & Cultural Rights (1976) 2. UN Convention on the Rights of the Child (1990)
180
Why are infectious diseases a global ethical issue?
- "Unrivalled consequences" - Violation of important rights - Justice - Do not respect boundaries
181
What are the 3 rights violated during infectious diseases?
1. Right to freedom of movement 2. Right to privacy 3. Right to informed consent
182
What 6 considerations regarding ethics of isolation and quarantine did Micheal Selgelid raise?
1. Must be effective in controlling disease 2. If less restrictive measures achieve same effect, use them 3. Consequences of not quarantining must be severe 4. Must be implemented in an equitable manner 5. Must be minimally burdensome 6. Those contained must receive compensation
183
What are the 3 good moral reasons for carrying out research in developing countries?
1. Global health inequalities 2. Disproportionate burden of disease 3. Value of research in developing countries
184
What are the 3 other reasons for carrying out research in developing countries?
1. Less stringent ethical standards 2. Cost 3. Number of participants, particularly drug-naive
185
What are the important considerations regarding research & clinical trials?
- Ethical review & protection of participants - Healthcare infrastructure - Valid consent - Community engagement - Benefits to participants after trial/research is over - Importance of collaborating with local scientists
186
What is the key trial regarding the control question in clinical trials of developed and developing countries?
076 protocol (1994)- published 1997 NEJM. | Using AZT to prevent maternal-child transmission of HIV
187
What does section 33 of the updated Declaration of Helsinki (2013) say about the use of Placebo?
Use of any intervention less effective than the best proven one, placebo, or no intervention is necessary to determine the efficacy/safety of an intervention
188
What are the medical ethics in times of armed conflict (war)?
Identical to medical ethics in times of peace, as stated in the International Code of Medical Ethics of the WMA
189
What are the 2 main points stated in WMA Guidelines for Disaster & War?
- Primary obligation is to their patients | - Primary task is to preserve health and save life
190
What are the issues and questions regarding Ebola and Health & Human rights?
- Outbreak centred around poorest countries - Originally not regarded as Western problem - Should Western healthcare workers working in affected countries be transferred back to Western healthcare facilities? - Who should receive the limited experimental treatments?
191
What is the main question regarding Ebola and Quarantine/Isolation?
Should healthcare workers returning from Ebola treatment centres be quarantined?
192
What is the issues regarding Ebola and Research & Clinical trials?
- WHO (2014) determining whether it was ethical to administer experimental drugs despite potential for unknown side effects & determine who should receive priority - Study design was also controversial (RCT "gold standard" or not)
193
What are the main point in BMA toolkit for "Ethics & Medical electives in resource poor countries"?
- Stay within your competence - Maintain ethical standards - Develop "cultural competence" - Minimise burden on host country
194
What structures are in the right upper quadrant of the abdomen?
- Liver | - Gall bladder
195
What structure is in the left upper quadrant of the abdomen?
Jejunum
196
What structures are in the right lower quadrant of the abdomen?
- Ileum - Caecum - Appendix
197
What structure is in the left lower quadrant of the abdomen?
Sigmoid colon
198
Where is the subcostal plane?
Below the costal margin at L3
199
Where is the inter (trans) tubercular/Supracristal plane?
Between iliac crests at L4/5
200
Describe the skin of the abdomen?
Loosely attached to underlying structures except at umbilicus allowing movement and distention
201
What does the "scar" at the umbilicus represent?
Site of attachment of the umbilical cord in the foetus
202
Is there a definite deep fascia in abdominal wall?
No, as it would be too restrictive
203
What is Camper's fascia?
Superficial, fatty layer
204
What is Scarpa's fascia?
Deeper, membranous layer
205
What abdominal fascia lies deep too muscles, outside the peritoneum?
Endo-abdominal/Transversalis fascia & then extraperitoneal fat
206
What is the Camper's fascia replaced by in the scrotum?
Dartos muscle
207
What happens to the Scarpa's fascia at the penis and scrotum?
- At penis it's Colles' fascia - At scrotum it's Perineal fascia - Fuses with fascia lata of the thigh below inguinal ligament, and also with the perineal body
208
What does bruising trapped under Scarpa's fascia look like?
Blue swimming trunks but front only
209
Describe the Thoracolumbar fascia?
Passes from iliac crest to 12th rib & is 3 layers that surround the back muscles & fuse together
210
What 2 muscles does the thoracolumbar fascia give origin to?
Transversus abdominis & internal oblique
211
Describe the Transversalis fascia?
Thin layer that lines transversus abdominis muscle & is continuous with a similar layer lining the diaphragm & iliacus muscle
212
Describe the Extraperitoneal fascia?
Thin layer that contains variable amount of fat & lies between transversalis fascia & parietal peritoneum
213
Describe Parietal peritoneum?
Thin serous membrane that lines walls of abdomen & encloses peritoneal cavity
214
List the 4 muscles of the anterior abdominal wall?
1. External oblique 2. Internal oblique 3. Transversus abdominis 4. Vertical Rectus abdominis muscle (& Pyramidalis)
215
What are the 3 functions of the muscles of anterior abdominal wall?
1. Support contents, raise intra-abdominal pressure, withstand pressure from descent of diaphragm 2. Support vertebral column, flexing, laterally flexing & rotating trunk against resistance 3. Respiration
216
What are the attachments of External oblique muscle?
- Lower 8 ribs - Lateral lip of iliac crest - Aponeurosis to linea alba via rectus sheath - Forms Inguinal ligament NOT to thoracolumbar fascia
217
Describe the direction of fibres of the External oblique?
Pass downwards & medially
218
What is the nerve supply of the External oblique & Rectus Abdominis?
T7-12
219
What are the attachments of the Internal Oblique muscle?
- Thoracolumbar fascia - Iliac crest - Lateral 2/3rd of inguinal ligament - Lower 3/4 ribs & costal cartilages - Aponeurosis to linea alba via rectus sheath - Pubic crest behind superficial inguinal ring via conjoint tendon
220
Describe the direction of the fibres of Internal oblique muscle?
Pass upwards & medially to ribs, but downwards to conjoint tendon
221
What can injury to iliohypogastric nerve cause?
Weaken the conjoint tendon & predispose to inguinal hernias
222
What are the attachments of Transversus Abdominis?
- Thoracolumbar fascia - Iliac crest - Lateral 1/3 or 1/2 of inguinal ligament - Lower 6 ribs & costal cartilages - Aponeurosis to linea alba via rectus sheath - Pubic crest behind superficial inguinal ring via conjoint tendon
223
Describe the direction of the fibres of Transversus Abdominis?
Pass transversely to ribs, linea alba & conjoint tendon
224
What is the nerve supply of Transversus Abdominis muscle & Internal Oblique muscle?
T7-12 & L1 | iliohypogastric nerve
225
How is the Conjoint tendon (Inguinal Falx) formed?
From the aponeuroses of internal oblique & transversus abdominis
226
Where does the Conjoint tendon attach?
Pubic crest & pectineal line behind the superficial inguinal ring, therefore supports the ring
227
What are the attachments of the Rectus Abdominis (& Pyramidalis) muscle?
- Costal cartilages of ribs 5 to 7 - Xiphoid - Pubic symphysis - Pubic crest - Pectineal line
228
Describe the direction of the fibres of Rectus Abdominis (& Pyramidalis) muscle?
Pass vertically, but interspersed with tendinous intersections
229
What is the linea alba?
A midline fusion of external oblique, internal oblique & transverses abdominis muscles
230
What happens at the arcuate line?
- All the aponeuroses pass anteriorly and the posterior sheath ends - Inferior epigastric vessels enter the sheath, behind rectus abdominis
231
Describe the inguinal canal/tunnel?
- Created by descent of testis | - 2 openings (deep & superficial rings), each "protected" by 2 of the 3 muscles
232
What does the inguinal canal contain?
- Vas deferens - Testicular vessels in male/round ligament in female - Ilio-inguinal nerve
233
What is the deep inguinal ring?
- Opening in, or evagination of transversalis fascia | - Transmits vas deferens & gonadal vessels
234
What is the superficial inguinal ring?
Triangle opening in external oblique aponeurosis, base on pubic crest
235
Describe the relationship between the internal oblique & transversus abdominis to the inguinal canal?
The muscle fibres start anterior to spermatic cord in canal, then arch over it to form the conjoint tendon posteriorly
236
What happens to the internal oblique and transversus abdominis lower fibres during coughing, micturition, defecation and parturition?
They contract, flattening out arched roof so its lowered toward the floor (can close canal)
237
What is a hernia?
Protrusion of a viscus through the wall of its containing cavity
238
Where is an inguinal hernia usually located?
Above & medial to pubic tubercle
239
Where is a femoral hernia usually located?
Below & lateral to pubic tubercle
240
Describe a direct inguinal hernia?
Through the posterior wall of the inguinal canal MEDIAL to the inferior epigastric vessels
241
Describe an indirect inguinal hernia?
Through the deep inguinal ring LATERAL to inferior epigastric vessels
242
When can hernias increase in size?
During coughing/straining
243
What happens if the hernia causes obstruction?
- Colicky abdominal pain - Distension & vomiting - Hernia is Tense, tender & irreducible
244
What happens to the hernia when strangulation occurs?
Lump becomes red & tender
245
What are the 3 skeletal muscles of the posterior abdominal wall?
1. Quadratus lumborum 2. Psoas major & minor 3. Iliacus
246
What is the function of Quadratus lumborum muscle?
Stabilises 12 rib for diaphragmatic movement in respiration & may weakly laterally flex the trunk along with psoas minor
247
What is the function of Psoas major & iliacus?
Pass to lesser trochanter together & are powerful hip flexors
248
Describe the attachment of the iliolumbar ligament?
Transverse process of L5 to posterior superior iliac spine
249
What is the nerve supply of the quadratus lumborum?
T12 & L1-4
250
What is the nerve supply of the Psoas Major?
L1-3
251
What is the nerve supply of the Iliacus?
Femoral nerve L2,3,4
252
What is the femoral sheath an extension of?
Abdominal transversalis fascia
253
What special lymph node does the femoral canal contain?
Cloquet's lymph node
254
What are the 4 different boundaries of the femoral canal?
1. Medial- Lacunar ligament 2. Lateral- Femoral vein 3. Posterior- Pectineus/pectineal ligament 4. Anterior- Inguinal ligament
255
What passes through the intervertebral foramen?
Mixed spinal nerve
256
What is the subcostal nerve?
T12
257
What is the epigastric dermatome? | Where is the referred pain?
- T7 | - Stomach & Oesophagus
258
What is the Umbilical dermatome? | Where is the referred pain?
- T10 | - Appendix, gonad, small intestine
259
What is the suprapubic dermatome? | Where is the referred pain?
- T12 | - Lower colon, bladder, uterus
260
What must you do if surgically splitting rectus abdominis muscle?
Fibres pushed laterally, toward nerves, to avoid denervation
261
How do the nerves pass between the rectus abdominis & internal oblique muscles?
Forwards & medially
262
Where does the iliohypogastric nerve pierce?
External oblique aponeurosis above superficial inguinal ring
263
Where does the ilio-inguinal nerve emerge?
Through the superficial ring
264
Where is the lumbar plexus formed and located?
Formed in Psoas, located on posterior abdominal wall
265
Where is appendicectomy incisions performed?
1/3 up the line from ASIS to umbilicus at McBurney's point
266
Describe the superior epigastric artery?
- Branch of internal thoracic (mammary) - Enters upper rectus sheath between sternal & costal origins of diaphragm - Descends behind rectus - Supplies upper central anterior abdominal wall
267
What anatomises may form a collateral circulation for an obstructed aorta?
Superior Epigastric Artery & Inferior Epigastric Artery
268
What artery supplies the upper, lateral abdominal wall?
Musculophrenic branch of internal thoracic artery
269
Describe the inferior epigastric artery?
- Branch of external iliac - Runs upwards & medially along medial side of deep inguinal ring - Pierces transversalis fascia to enter rectus sheath - Ascends behind rectus muscle - Supplies lower central anterior abdominal wall
270
Describe the deep circumflex iliac artery?
- Branch of external iliac above inguinal ligament - Runs upward & laterally toward ASIS & along iliac crest - Supplies lower, lateral abdominal wall
271
Where do the superficial epigastric & superficial circumflex iliac arteries arise from?
Femoral just below inguinal ligament
272
What arteries supply the lateral abdominal wall?
Lower 2 posterior intercostal & 4 lumbar arteries
273
What abdominal wall veins drain into the proximal end of the great saphenous?
- Superficial epigastric - Superficial circumflex - Superficial - Deep external pudendal (ALL IMPORTANT IN VARICOSE VEIN SURGERY)
274
What forms an important portosystemic venous anastomosis?
Para-umbilical veins connect the system through umbilicus to portal veins of liver
275
What would obstruction of the portal vein cause?
Venous back pressure into veins of abdominal wall, resulting in a Caput Medusae
276
What is the anterior abdominal wall superficial lymph drainage?
ABOVE umbilicus to the axillary nodes, BELOW umbilicus to the superficial inguinal nodes
277
What is the posterior abdominal wall superficial lymph drainage?
ABOVE the iliac crests to axillary nodes, BELOW the iliac crests to superficial inguinal nodes
278
What is the inferior abdominal wall deep lymph drainage?
External iliac --> para-aortic nodes
279
What is the superior abdominal wall deep lymph drainage?
Parasternal nodes --> mediastinal nodes
280
When is a Kocher anterior abdominal wall incision used?
Removal of the gall bladder
281
When is a Thoraco-abdominal anterior abdominal wall incision used?
Accessing oesophagus
282
When is a midline anterior abdominal wall incision used?
Rapid access through almost avascular line alba, POOR HEALING
283
When is the muscle splitting loin anterior abdominal wall incision used?
Appendicectomy, STRONG HEALING
284
When is the Pfannenstiel anterior abdominal wall incision used?
Gynaecological & pelvic procedures
285
When is the Paramedian anterior wall incision used?
Like midline incision but avoiding linea alba for better healing, fibres of rectus abdominis are split/reflected laterally towards nerve supply
286
What do you need to maintain when performing a skin flap?
Vascular pedicle, both arterial & venous
287
What is the difference between Isolation & Quarantine?
ISOLATION- separate people who are ill from those who are healthy. QUARANTINE- separating & restricting movement of people who are well as they have been exposed and may develop it.
288
How is the rectus sheath formed?
By the aponeuroses of the transverse abdominis, external & internal oblique muscles
289
What is the difference between peritoneum of a male and female?
Males is closed cavity but females have communication with exterior via uterine tubes, uterus & vagina
290
What lies between the parietal peritoneum and transversalis fascia?
Extraperitoneal fascia/tissue
291
What are the 2 parts of the peritoneal cavity?
1. Greater Sac | 2. Lesser Sac
292
Where is the Greater sac of the peritoneal cavity?
Diaphragm --> Pelvis
293
Why would the greater sac be used for dialysis?
Due to its great surface area
294
Where is the lesser sac of the peritoneal cavity?
Behind the stomach & lesser omentum, extends slightly into greater omentum
295
How do the greater and lesser sacs communicate?
Via epiploic foramen (of Winslow)
296
Give examples of structures that the peritoneum forms?
- Omenta - Mesenteries - Ligaments
297
What is the omenta?
Two-layered folds of peritoneum that connect the stomach & 1st part of duodenum to other structures
298
Where is the greater omentum derived from?
Dorsal mesentery
299
What is the clinical significance of the omenta?
It's drawn to diseased/perforated structures to seal them off
300
What 2 things may the lesser omentum be referred as?
Hepatogastric & Hepatoduodenal ligaments
301
What is the mesentery?
Fan shaped double-layered fold of peritoneum that connects jejunum & ileum to posterior abdominal wall
302
What does the mesentery contain?
- Superior mesenteric artery as a series of anastomotic arcades - Superior mesenteric vein
303
What differences in mesentery aid the surgeon in identifying parts of the intestine?
JEJUNUM- mesentery has few arcades with long vasa recta ILEUM- mesentery has many many arcades with short vasa recta
304
What is the root of the Sigmoid mesocolon & what does it transmit?
- Root is left iliac fossa | - Transmits sigmoid branches of inferior mesenteric vessels & nerves & lymphatics
305
What is the root of the Transverse mesocolon & what does it transmit?
- Root is inferior to pancreas - Transmits branches of middle colic vessels - Divides peritoneal cavity into supra & infra colic compartments
306
What does the supra colic compartment contain?
- Liver - Stomach - Spleen
307
What does the infra colic compartment contain?
- Jejunum - Ileum - Ascending & descending colon
308
What is the Right posterior subphrenic/ Hepatorenal space (Morison's Pouch)?
- Potential space with the epiploic foramen in it | - Pus may collect here forming abscesses
309
What is the vesico-uterine pouch (in females)?
Separating bladder from uterus
310
What does the median umbilical fold contain?
Urachus
311
What ligaments connect the liver to the diaphragm?
By falciform ligament, coronary ligaments, right & left triangular ligaments
312
What do the splenorectal & gastrosplenic ligaments connect?
Spleen to the posterior abdominal wall & stomach
313
What organ is said to be truly intraperitoneal?
Ovary as its absorbed its peritoneal covering
314
What are 4 primary retroperitineal urinary organs?
1. Adrenal glands 2. Kidneys 3. Ureter 4. Bladder
315
What are the 2 primary retroperitoneal circulatory vessels?
1. Aorta | 2. Inferior vena cava
316
What are the 2 primary retroperitoneal digestive organs?
1. Oesophagus | 2. Rectum (middle 1/3, lower 1/3 extraperitoneal)
317
What are the 3 secondarily retroperitoneal organs?
- Head, neck, body of pancreas - Duodenum (except proximal 1st) - Ascending & descending colon
318
What is the parietal peritoneum sensitive to?
- Pain - Temperature - Touch - Pressure
319
What is the nerve supply of the parietal peritoneum at the pelvis?
Obturator nerve (L2,3,4)
320
What is the visceral peritoneum sensitive to?
- Stretch | - Tearing
321
What are the 3 main changes that occur to the trilaminar disk?
1. Neural tube & body wall are dervived from ectoderm (epiblast) 2. Cardiovascular, musculoskeletal systems and the body cavities (coeloms) are derived from mesoderm 3. GI, respiratory and reproductive tracts are derived from endoderm
322
Describe the crucial events occuring at day 17?
- Notochord burrows from primitive node, between ecto- and endoderm. - It induces overlying ectoderm to become neutral plate
323
How are coeloms formed?
- Mesoderm cavitates | - In abdomen intra-embryonic coelom becomes peritoneal cavity
324
When does cephalocaudal folding begin?
End of 3rd week ie. day 18
325
What does cephalocaudal folding create?
- Endodermal tube of pharynx - Oesphagus - Stomach - Intestinal tract - GI Glands
326
What is Exomphalos/Omphalocele?
Failure of intestine to return to abdomen, lies within peritoneum & amnion in umbilical cord
327
What is Gastroschisis?
Failure of abdominal wall, contents not covered by peritoneum or amnion
328
Which structures have a ventral mesentery?
Stomach & proximal part of duodenum
329
What does the ventral mesentery become?
Lesser omenum & falciform ligament
330
All of the contractile tissue in the GI tract is smooth muscle, apart from where?
- Pharynx - Upper 1/3 oesophagus - External anal sphincter
331
Describe the function/structure of single unit smooth muscle?
Contain gap junctions which allow propagation of electrical signals so that when one muscle cell is depolarised so is it's neighbour
332
Describe the 4 stages of calcium activation of myosin in smooth muscle?
1. Ca2+ bind to calmodulin creating a complex 2. This activates myosin light chain kinase 3. Which then activates myosin by phosphorylation 4. Phosphorylated myosin binds to actin generating contraction
333
What is Latch state in smooth muscle contraction?
Maintaining high tension due to decrease detachment rate of myosin heads
334
What is the advantage of latch state in smooth muscle contraction?
High force, low energy consumption (ATP)
335
What is Myosin Phosphatase?
Enzyme that dephosphorylates myosin light chain kinase for smooth muscle relaxation
336
What cells are the origin/initiation of slow waves in smooth muscle?
Interstitial cells of Cajal (ICC)
337
What are Interstitial cells of Cajal (ICC) and where are they mainly found?
- Pacemaker cells | - Myenteric plexus
338
What is the intrinsic firing rate of the ICC cells in the stomach?
3 waves per min
339
What is the intrinsic firing rate of the ICC cells in the duodenum?
12 waves per min
340
What effect does neural/hormonal input have on frequency of slow waves & action potentials in smooth muscle?
- Slow wave Frequency UNAFFECTED | - Action potential Frequency AFFECTED (strength of contraction)
341
What are the 6 steps in slow wave generation?
1. Increase in intracellular Ca2+ conc 2. Opening of Ca2+ dependent K+ channels 3. Increased K+ permeability leads to slow hyper polarisation 4. Voltage gated Ca2+ channels close & intracellular Ca2+ conc falls 5. Ca2+ dependent K+ channels close 6. Voltage gated Ca2+ channels open
342
What is the smooth muscle membrane potential at rest during slow wave generation?
Between -50mV & -40mV
343
What are the 3 things smooth muscle action potentials and depolarisation are stimulated by?
1. Stretch 2. Acetylcholine 3. Parasympathetics
344
What are the 2 things smooth muscle hyperpolarisation is stimulated by?
1. Norepinephrine | 2. Sympathetics
345
What chemical in saliva acts as a lubricant?
Mucin (glycoprotein)
346
Which 2 enzymes are found in saliva which initate digestion?
1. Amylase | 2. Lipase
347
Describe involuntary swallowing?
Sensory information relayed from mechanoreceptors to brain stem, initiates reflex oscillatory pattern of activity in chewing muscles
348
In the afferent pathway, where is the sensory information from touch receptors near?
Pharynx
349
Where is the swallowing centre?
Medulla & lower pons
350
What does the efferent motor pathway in swallowing involve?
Cranial innervation of pharynx & upper oesophagus & vagal motor innervation of lower oesophagus
351
Describe the 6 stages of swallowing?
1. Upper oesophageal sphincter opens to allow bolus to enter 2. Upper oesophageal sphincter closes 3. Primary peristaltic contraction mediated by swallowing reflex creating high pressure behind bolus (accelerated by gravity) 4. Lower oesophageal sphincter opens mediated by peptidergic nerves in vagus releasing VIP 5. Receptive relaxation of orad region of stomach 6. Lower oesophageal sphincter closes
352
What is VIP?
Vasoactive intestinal peptide, inducing smooth muscle relaxation
353
What is the definition of Achalasia?
Absence of relaxation
354
What could be a possible cause of Achalasia?
Selective loss of neurons which regulate the lower oesophageal sphincter by releasing VIP

MD3002 (15 decks)

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