HAD Unit I ReviewHAD Unit I Review

Tom Eck, ecktw@umdnj.edu

CALM ResourcesCALM Resources

http://njms.umdnj.edu/calm

I will email you the link again tonight.

Today’s review and a number of other resources should be up by tomorrow afternoon.

To activate your “clicker”To activate your “clicker”Press Ch – 52 – Ch

Unit I PrioritiesUnit I Priorities

1) Nervous System Principles2) Lymphatics3) Lungs4) Heart5) Mediastinum6) Back7) Upper Limb8) Surface Anatomy9) Embryology

Nervous System PrinciplesNervous System Principles the second most important content from

Chapter 1most important: anatomical terms, but they

are rarely tested directly the structure of peripheral nerves as they

exit the spinal cord the anatomical and functional distinctions

between the sympathetic and parasympathetic divisions of the autonomic nervous system

dermatomes (T4 = nipple; T10 = umbilicus) referred pain

To which segments does heart pain To which segments does heart pain refer?refer?

C1 – C5

C3 – C5

T1 – T4

T3 – T8

T6 – T12

0% 0% 0%0%0%

10Seconds

Remaining

1. C1 – C52. C3 – C5 3. T1 – T4 4. T3 – T85. T6 – T12

Remember: In referred pain, start by identifying the visceral nerves involved

Sympathetics

From there, identify the spinal segments representedby the nerve(s)

T1 – T4/T5

The pain will refer to the corresponding dermatomes.

Referred Referred PainPainA high-yield topic;

especially important in Unit III, but don’t neglect this

Which of the following, if cut, would block Which of the following, if cut, would block sensory perception in the corresponding sensory perception in the corresponding dermatome?dermatome?

ventra

l root

dorsal ro

ot

ventra

l ramus

dorsal ra

mus

0% 0%0%0%10

SecondsRemaining

1. ventral root2. dorsal root3. ventral ramus4. dorsal ramus

RhizotomyRhizotomy

The dorsal root of spinal nerves can be cut to relieve intractable pain

Alternately, the ventral root may be cut to treat spastic paralysis

S – Sensory D – DorsalA – Afferent A – Afferent M – Motor V – Ventral E – Efferent E – Efferent

LymphaticsLymphaticsDon‘t forget to study lymph!You can expect a few lymph questions on

every exam (~2-3), often relating to the spread of cancer

These tend to be challenging, detail-oriented questions

Major Topics◦ Lymph Drainage of the Lung◦ Lymph Drainage of the Axilla and Breast

Into which vessel does lymph from Into which vessel does lymph from the right arm empty?the right arm empty?

Thoracic Duct IV

C

Right J

ugular V

ein

Right S

ubclavian

Vein

0% 0%0%0%

1. Thoracic Duct2. IVC3. Right Jugular Vein4. Right Subclavian

Vein

:10

Lymph from the right arm drains to the right lymphatic duct, and to the right subclavian vein (at the venous angle) from there.

Which of the following correctly stages Which of the following correctly stages the path of pulmonary lymphatic flow?the path of pulmonary lymphatic flow?

0% 0%0%0%

:10

1. Pulmonary Tracheobronchial Bronchopulmonary

2. Paratracheal Tracheobronchial Deep Cervical

3. Tracheobronchial Paratracheal Deep Cervical

4. Pulmonary Paratracheal Aortic Arch

A patient presents with a severe case of A patient presents with a severe case of pneumonia. When you ask her to lift her arms, pneumonia. When you ask her to lift her arms, you notice that the veins in her upper limbs you notice that the veins in her upper limbs remain distended. You suspect radical remain distended. You suspect radical enlargement of which group of lymph nodes:enlargement of which group of lymph nodes:

Right P

ulmonary

Left Pulm

onary

Right B

ronch

opulmonar..

.

Left Bro

nchopulm

onary (...

Infe

rior T

rach

eobronch

ia...

0% 0% 0%0%0%

101. Right Pulmonary2. Left Pulmonary3. Right Bronchopulmonary

(Hilar)4. Left Bronchopulmonary

(Hilar)5. Inferior Tracheobronchial

(Carinal)

SVC SyndromeSVC SyndromeVeins of head and upper

extremities become distended due to constriction of the SVC by a tumor or grossly enlarged lymph nodes

The bronchopulmonary nodes at the right lung hilus are in close proximity to the SVC

SVC

Hilar Nodes

The LungsThe LungsDifferences between Left and Right LungsLobes, SegmentsPleura, Reflections, RecessesPneumothorax: in tension pneumothorax,

mediastinum contralateral sideAspirated Objects Right Main Bronchus

Upon examining a patient with left-sided ptosis, Upon examining a patient with left-sided ptosis, miosis, and anhydrosis, a physician suspects a miosis, and anhydrosis, a physician suspects a growing superior lobe tumor. Which of the growing superior lobe tumor. Which of the following segments is most likely involved?following segments is most likely involved?

Apical

Posterio

r

Apicoposte

rior

Anterio

r

Superio

r Lingular

Infe

rior L

ingular

0% 0% 0%0%0%0%

10Seconds

Remaining

1. Apical2. Posterior3. Apicoposterior4. Anterior5. Superior Lingular6. Inferior Lingular

Horner SyndromeHorner SyndromeSympathetic Trunk

-Interruption of Sympathetics to Head causes Ipsilateral Ptosis (Lid Lag), Miosis (Pupil Constriction), and Anhydrosis (Lack of Sweating)

-often caused by Pancoast Tumor

-remember to study lung segments; you can expect a few questions testing their locations, both in the written exam and the practical

Which space is entered when a Which space is entered when a thoracentesis is performed at the MAL in thoracentesis is performed at the MAL in the 9the 9thth ICS? ICS?

Transverse

sinus

Cardiac n

otch

Costodiaphragmatic r

ecess

Costomediasti

nal rece

ss

Pericard

ial sa

c

0% 0% 0%0%0%

1. Transverse sinus2. Cardiac notch3. Costodiaphragmat

ic recess4. Costomediastinal

recess5. Pericardial sac

10Seconds

Remaining

The HeartThe Heartpathway of blood – valve pathologiescoronary vessels – consequences of

blockageauscultation sites – pathological heart

sounds (continuous machine-like murmer = patent ductus arteriosus)

radiographs and CTs especially important

Identify the heart chambers marked B Identify the heart chambers marked B and D:and D:

Right V

entricle

, Left Vent..

.

Right A

trium, L

eft Atrium

Right V

entricle

, Left Atri

um

Right A

trium, L

eft Ventricle

0% 0%0%0%

:10

D

B1. Right Ventricle, Left

Ventricle2. Right Atrium, Left Atrium3. Right Ventricle, Left

Atrium4. Right Atrium, Left

Ventricle

CT ScansCT ScansRight Ventricle is associated with the

anterior (sternocostal) surface of the heart

Left Atrium is associated with the posterior surface of the heart, just anterior to the esophagus

CT’s and Radiographs show up in the written exam and the practical

Be able to identify major structures

Which of the following will result a Which of the following will result a diastolic murmur at the apex of the diastolic murmur at the apex of the heart?heart?

Mitr

al Valve

Insu

fficie

ncy

Mitr

al Valve

Stenosis

Pulmonary Valve

Insu

ffi...

Aortic V

alve Stenosis

Aortic V

alve In

suffi

ciency

0% 0% 0%0%0%

1. Mitral Valve Insufficiency2. Mitral Valve Stenosis3. Pulmonary Valve

Insufficiency4. Aortic Valve Stenosis5. Aortic Valve Insufficiency

:10

Note: 2 is also correct

Aortic Valve InsufficiencyAortic Valve Insufficiencyblood rushes back into the left ventricle as

the ventricle relaxesmurmur is heard at the apex (not at the right

upper sternal border) because the blood flow causing the murmur is reversed (APTM 2245 does not always apply)

associated with a collapsing pulsecauses left ventricular hypertrophy, as the

heart attempts to compensate for decreased pumping efficiency

Insufficiency = Backflow of Blooda.k.a. incompetence, regurgitation

A patient is diagnosed with left atrial A patient is diagnosed with left atrial hypertrophy. Which of the following valve hypertrophy. Which of the following valve defects is most likely to have caused this defects is most likely to have caused this condition?condition?

Tricusp

id Valv...

Mitr

al Valve

S...

Pulmonary Valv.

..

Aortic V

alve S...

Aortic V

alve I..

.

0% 0% 0%0%0%

:10

1. Tricuspid Valve Insufficiency

2. Mitral Valve Stenosis3. Pulmonary Valve

Insufficiency4. Aortic Valve Stenosis5. Aortic Valve Insufficiency

Mitral Valve StenosisMitral Valve StenosisCauses left atrial hypertrophy; the left

atrium grows larger to generate the force necessary to push past the obstruction

Stenosis is often associated with hypertrophy of the preceding chamber

Following an acute myocardial infarction, Following an acute myocardial infarction, necrosis develops at the apex of the necrosis develops at the apex of the heart. Which vessel was likely occluded?heart. Which vessel was likely occluded?

Left Circ

umflex

Coronary

sinus

Anterio

r Inte

rventricu

lar

Posterio

r Inte

rventricu

lar

Right c

oronary

0% 0% 0%0%0% 10Seconds

Remaining

1. Left Circumflex2. Coronary sinus 3. Anterior

Interventricular4. Posterior

Interventricular 5. Right coronary

The Anterior Interventricular Artery (LAD) supplies the anterior two-thirds of the interventricular septum, the apex, and the anterior left and right ventricles. It is the most commonly occluded coronary artery.

The MediastinumThe Mediastinumbe able to trace the course of the

major structures that pass through the mediastinum

localize structures to each mediastinal compartment

At which level does the trachea At which level does the trachea bifurcate?bifurcate?

T2/T3

T3/T4

T4/T5

T5/T6

T6/T7

0% 0% 0%0%0%

10

1. T2/T32. T3/T43. T4/T54. T5/T65. T6/T7

divides the mediastinum into superior and inferior compartments

passes through the T4/T5 intervertebral disk posteriorly and sternal angle anteriorly

bifurcation of the tracheaboundary between cardiopulmonary and

abdominopelvic sympathetics (greater, lesser, and least splanchnic nerves)

Remember: cardiopulmonary = postsynaptic; abdominopelvic = presynaptic

Transverse Thoracic PlaneTransverse Thoracic Plane

You see a patient with a hoarse voice and a You see a patient with a hoarse voice and a detectable suprasternal pulse. Which of the detectable suprasternal pulse. Which of the following diagnoses might explain these following diagnoses might explain these symptoms?symptoms?

Coarctati

on of the A

orta

Aortic A

neurysm

Tumor Impinging on th

e ...

Lung A

bscess

0% 0%0%0%

:10

1. Coarctation of the Aorta2. Aortic Aneurysm3. Tumor Impinging on the

Left Subclavian Artery4. Lung Abscess

Aortic AneurysmsAortic Aneurysms

Localized dilation of the aorta If in the vicinity of the aortic

arch, it may impinge on the left recurrent laryngeal nerve, causing hoarseness

If the aneurysm grows large enough, it may lead to a detectable pulse suprasternally

A patient has been diagnosed with an A patient has been diagnosed with an esophageal hernia, a condition in which part of esophageal hernia, a condition in which part of the stomach passes through an enlarged the stomach passes through an enlarged esophageal hiatus. At which spinal segment has esophageal hiatus. At which spinal segment has the herniation occurred?the herniation occurred?

T8 T9 T10

T11 T12

0% 0% 0%0%0%

10Seconds

Remaining

1. T82. T93. T104. T115. T12

I Ate Ten Eggs AT Noon I 8 10 E A2T 12T8: IVC (“Caval Opening”)T10: Esophagus (Vagus too) (“Esophageal

Hiatus”)T12: Aorta, Azygos Vein, Thoracic Duct

(“Aortic Hiatus”)

Structures that pass through the Structures that pass through the DiaphragmDiaphragm

In which compartment of the In which compartment of the mediastinum is the IVC located?mediastinum is the IVC located?

Superio

r

Anterio

r

Middle

Posterio

r

0% 0%0%0%

101. Superior2. Anterior3. Middle4. Posterior

Superior

Thymus, Phrenic Nerve, Vagus Nerve, Esophagus, Trachea, Thoracic Duct, Azygos Vein, SVC, Aortic Arch,

Brachiocephalic Vein, Left Common Carotid Artery, Left Subclavian Artery

Anterior Thymus

Middle Heart, Phrenic Nerve, Ascending Aorta, SVC, IVC, Pulmonary Arteries/Veins

Posterior Descending Aorta, Esophagus (With Vagus Nerve), Thoracic Duct, Azygos Vein, Splanchnic Nerves

Mediastinal Mediastinal CompartmentsCompartments

Bolded structures are exclusive to that compartment.

The BackThe BackMorphological distinctions between

cervical, thoracic, lumbar, sacral, and coccygeal vertebrae

CurvaturesSpinal Cord StructureVascular Supply: vertebral arteries,

segmental medullary arteries (especially the artery of Adamkiewicz)

Which of the following prevents Which of the following prevents posterior displacement of the posterior displacement of the dens?dens?

Posterio

r arch

Anterio

r arch

Late

ral m

asses

Vertebra

prominens

Transverse

ligament

0% 0% 0%0%0%

10

1. Posterior arch2. Anterior arch3. Lateral masses4. Vertebra

prominens5. Transverse

ligament

In a case of suspected meningitis In a case of suspected meningitis where should a lumbar puncture be where should a lumbar puncture be performed?performed?

L1/L2

L2/L3

L3/L4

L4/L5

L5/S

1

0% 0% 0%0%0%

10

1. L1/L22. L2/L33. L3/L44. L4/L55. L5/S1

Lumbar PunctureLumbar Puncture

Spinal Cord ends at L1/L2

What landmarks are used to What landmarks are used to find the location for a spinal find the location for a spinal tap?tap?

Anterio

r superio

r iliac s

p...

Posterio

r superio

r iliac s

...

Iliac c

rests

Spinalis

parts o

f ere

ctor ..

.

0% 0%0%0%

10

1. Anterior superior iliac spines

2. Posterior superior iliac spines

3. Iliac crests4. Spinalis parts of

erector spinae muscles

High points of iliac crest correspond to L4 spinous process

A patient is suffering from a herniation A patient is suffering from a herniation of the L4/L5 IV disc. Which nerve root of the L4/L5 IV disc. Which nerve root is most likely compressed?is most likely compressed?

L2 L3 L4 L5

0% 0%0%0%

10

1. L22. L33. L44. L5

In a herniated disc of the lumbar vertebrae the nerve that exits at that level is spared, while the nerve root one segment below is often compressed

For lumbar roots, that means a herniation of IV disc L2/L3 will compress the L3 root

The rule applies the same for cervical vertebrae: C5/C6 C6 root

For cervical vertebrae, however, it is the nerve exiting at that level is actually compressed; it is only because there is one “extra” cervical nerve that the rule still applies

Herniated DiscsHerniated Discs

The Upper LimbThe Upper Limbquestions almost entirely neuromuscular (nerve

deficits are BIG) BRACHIAL PLEXUSBRACHIAL PLEXUSknow the spinal segments represented by major

nerves (e.g. long thoracic, suprascapular, dorsal scapular, radial, axillary, median, ulnar, musculocutaneous, phrenic)

know major actions of each muscle (groupings and locations help)

memorize the innervation of each muscle◦ Innervation gives clues about action, vice

versaattachments

A young man notices that following a stab injury he A young man notices that following a stab injury he has difficulty doing push-ups, noting that his right has difficulty doing push-ups, noting that his right shoulder blade tends to “stick out.” Which nerve shoulder blade tends to “stick out.” Which nerve was most likely injured to cause this deficit?was most likely injured to cause this deficit?

Dorsa

l Sca

pular

Long T

horacic

Subsca

pular

Vagus

Phrenic

0% 0% 0%0%0%

10

1. Dorsal Scapular2. Long Thoracic3. Subscapular4. Vagus5. Phrenic

Winged ScapulaWinged Scapula

= Long Thoracic Nerve (C5, C6, C7)

“5-6-7, wings to heaven”

A patient presents with a medially rotated, A patient presents with a medially rotated, adducted arm and extended, adducted forearm. adducted arm and extended, adducted forearm. Which spinal segments are represented in the Which spinal segments are represented in the injury?injury?

C3, C4

C4, C5, C

6

C5, C6

C7, C8

C8, T1

0% 0% 0%0%0%

10

1. C3, C42. C4, C5, C63. C5, C64. C7, C85. C8, T1

C5, C6 = “waiter’s tip” sign

Medially rotated arm due to loss of Infraspinatus (Suprascapular Nerve)

Adducted arm due to loss of Deltoid (Axillary Nerve)/ Supraspinatus (Suprascapular Nerve)

Extended forearm due to loss of forearm flexors (Musculocutaneous)

Klumpke palsy = C8, T1 (symptoms similar to ulnar nerve palsy)

Erb-Duchenne PalsyErb-Duchenne Palsy

Which of the following does not branch Which of the following does not branch off from or derive from the medial off from or derive from the medial cord?cord?

1. Median2. Lateral Pectoral3. Medial Pectoral4. Ulnar5. Medial

Antebrachial

Median

Late

ral Pecto

ral

Medial P

ectora

l U

lnar

Medial A

ntebra

chial

0% 0% 0%0%0%

10

Which of the following muscles rotates Which of the following muscles rotates the glenoid cavity superiorly?the glenoid cavity superiorly?

1. Levator Scapulae

2. Trapezius3. Spinalis4. Rhomboid major5. Rhomboid minor

Levato

r Sca

pulae

Trapezius

Spinalis

Rhomboid major

Rhomboid minor

0% 0% 0%0%0%

10

Descending fibers elevate the scapula and rotate the glenoid cavity superiorly

CN XI Palsy makes arm abduction more difficult

Which of the following does not insert into Which of the following does not insert into the intertubercular groove of the humerus?the intertubercular groove of the humerus?

Latissi

mus dorsi

Pectora

lis m

ajor

Teres major

Teres minor

0% 0%0%0%

10

1. Latissimus dorsi2. Pectoralis major3. Teres major4. Teres minor

“lady between two majors” teres major, latissimus dorsi, and pectoralis major

insert in the intertubercular groove

attachments are likely to appear in 3 or 4 questions

learn the “hotspots”: intertubercular groove, greater and lesser tubercles of humerus, supra- and infra-glenoid tubercles, coracoid process, coronoid process, olecranon, medial epicondyle of humerus, lateral epicondyle of the humerus, extensor expansion

for most other attachment sites, a more general idea will suffice (i.e. what bone(s))

AttachmentsAttachments

After fracture of the clavicle, which After fracture of the clavicle, which muscle is responsible for the palpable muscle is responsible for the palpable fragment?fragment?

Trapezius

Stern

ocleidomas

toid

Pec Majo

r

Pec Minor

0% 0%0%0%

10

1. Trapezius2. Sternocleidomasto

id3. Pec Major4. Pec Minor

Sternocleidomastoid

What nerve may be injured following What nerve may be injured following fracture of the surgical neck of the fracture of the surgical neck of the humerus?humerus?

Axillary

Radial

Median

Ulnar

0% 0%0%0%

10

1. Axillary2. Radial3. Median4. Ulnar

What nerve may be injured following What nerve may be injured following fracture of the medial epicondyle of the fracture of the medial epicondyle of the humerus?humerus?

Axillary

Radial

Median

Ulnar

0% 0%0%0%

10

1. Axillary2. Radial3. Median4. Ulnar

What nerve may be injured following What nerve may be injured following fracture of the radial groove of the fracture of the radial groove of the humerus?humerus?

Axillary

Radial

Median

Ulnar

0% 0%0%0%

10

1. Axillary2. Radial3. Median4. Ulnar

Surgical neck – axillaryRadial groove – radialDistal end of humerus – medianMedial epicondyle - ulnar

A man fractures his humerus at the spiral groove. A man fractures his humerus at the spiral groove. What neurological problem is likely to be observed?What neurological problem is likely to be observed?

Claw hand

Simian hand

Hand of b

enediction

Wris

t dro

p

0% 0%0%0%

10

1. Claw hand2. Simian hand3. Hand of

benediction4. Wrist drop

This would damage the radial nerve leading to loss of extension at the wrist (wrist drop)

the radial nerve innervates extensors of the forearm, wrist, and most extensors of the phalanges

Following a laceration to the palm just medial Following a laceration to the palm just medial to the thenar eminence, which of the to the thenar eminence, which of the following intrinsic movements of the thumb is following intrinsic movements of the thumb is likely to be fully intact?likely to be fully intact?

Oppositi

on

Abduction

Flexio

n

Adduction

0% 0%0%0%

10

1. Opposition2. Abduction3. Flexion4. Adduction

opponens policis, abductor policis brevis, and flexor policis brevis are all innervated by the recurrent branch of the median nerve (which is likely to have been lacerated here)

Adductor policis is innervated by the ulnar nerve

Recurrent Branch of Median Recurrent Branch of Median NerveNerve

A complete avulsion of the lateral epicondyle would A complete avulsion of the lateral epicondyle would be least likely to disrupt the functioning of which be least likely to disrupt the functioning of which muscle?muscle?

Extenso

r digi

toru

m

Supinato

r

Extenso

r carp

i ulnaris

Extenso

r pollic

is longus

Extenso

r digi

ti minim

i

0% 0% 0%0%0%

10

1. Extensor digitorum

2. Supinator3. Extensor carpi

ulnaris4. Extensor pollicis

longus5. Extensor digiti

minimi

Extensor pollicis longus does not have its origination at the lateral epicondyle; all others listed do

Which of the following resists inferior Which of the following resists inferior displacement of the humeral head in the displacement of the humeral head in the glenoid cavity?glenoid cavity?

Long h

ead of the tr

iceps..

.

Medial h

ead of tric

eps b...

Late

ral head of t

riceps b

...

0% 0%0%

10

1. Long head of the triceps brachii

2. Medial head of triceps brachii

3. Lateral head of triceps brachii

stabilizes the head of the abducted humerus in the glenohumeral joint, resisting inferior displacement

attaches to the infraglenoid tubercle

Long Head of the TricepsLong Head of the Triceps

The nerve that provides sensory innervation The nerve that provides sensory innervation to the posterolateral forearm branches from to the posterolateral forearm branches from the…the…

Posterio

r cord

Medial C

ord

Radial nerve

Ulnar

nerve

Muscu

locutaneo...

0% 0% 0%0%0%

10

1. Posterior cord2. Medial Cord3. Radial nerve4. Ulnar nerve5. Musculocutaneous

nerve

The posterior antebrachial cutaneous nerve arises from the radial nerve

major nerves of the upper limb often terminate as cutaneous nerves

knowing the distribution of these sensory nerves helps to identify the major nerve involved in the deficit

Describe the anatomical location Describe the anatomical location of the long head of the triceps.of the long head of the triceps.

Anterio

r to both

tere

s m...

Posterio

r to both

teres .

..

Anterio

r to te

res major ..

.

Anterio

r to te

res minor a

..

0% 0%0%0%

10

1. Anterior to both teres major and teres minor

2. Posterior to both teres major and teres minor

3. Anterior to teres major and posterior to teres minor

4. Anterior to teres minor and posterior to teres major

Teres minorTere

s major Lon

g head

Humerus

Quadrangular SpaceQuadrangular Space Teres minor wraps

around the back to the greater tubercle

Teres major passes anteriorly to the intertubercular groove

The long head of the triceps passes in between

Know the quadrangular space

The medial humeral circumflex artery and axillary nerve pass through this window

Which part of the hand would Which part of the hand would experience paresthesia in carpal tunnel experience paresthesia in carpal tunnel syndrome?syndrome?

Thenar eminence

Dorsa

l surfa

ce

Hyp

othenar r

egion

Nail b

ed of middle finger

Tip of little finger

0% 0% 0%0%0%

10

1. Thenar eminence2. Dorsal surface3. Hypothenar

region4. Nail bed of

middle finger5. Tip of little finger

The following patient presents with no loss of The following patient presents with no loss of consciousness, no visible trauma, and no consciousness, no visible trauma, and no sensory deficits. What is the likely problem?sensory deficits. What is the likely problem?

10

1. Ulnar n. damage2. Median n.

damage3. Volkmann’s

contracture4. Dupuytren’s

contracture

Ulnar

n. damage

Median n. d

amage

Volkmann’s

contra

cture

Dupuytre

n’s co

ntractu

re

0% 0%0%0%

Not due to nerve damage because no associated sensory loss

In Volkmann’s you would expect to see wrist involvement as well and would expect a preceding ischemic event, such as the improper wrapping of a tourniquet

In Dupuytren’s, also look for the presence of subcutaneous nodules

Dupuytren’s ContractureDupuytren’s Contracture

EmbryologyEmbryologydon’t neglect; a significant portion of the testquestions are generally straightforward,

focusing on the precursors of adult structures as well as abnormalities

heart embryology is especially important for this exam

In which of the following conditions does the In which of the following conditions does the body compensate by opening up a collateral body compensate by opening up a collateral pathway for blood flow?pathway for blood flow?

Tetralogy o

f F...

Patent D

uctus .

..

Patent F

oramen...

Coarctati

on of...

Aortic S

tenosi.

..

0% 0% 0%0%0%

101. Tetralogy of Fallot2. Patent Ductus Arteriosus3. Patent Foramen Ovale4. Coarctation of the Aorta5. Aortic Stenosis

Coarctation of the AortaCoarctation of the Aorta Diminished femoral pulses

and rib notching due to increased blood flow = classic signs of coarctation

Collateral Circulation: Aorta Subclavian Internal Thoracic Anterior Intercostal Posterior Intercostal

Note: the Supreme Intercostal Arteries represent an additional pathway

Collateral circulations are HUGE; know these

The chest radiograph of a cyanotic newborn is The chest radiograph of a cyanotic newborn is shown below. Immediately suspecting a shown below. Immediately suspecting a congenital abnormality, you anticipate four congenital abnormality, you anticipate four pathological conditions. Which of the following pathological conditions. Which of the following would you NOT expect to find:would you NOT expect to find:

Right V

entricu

lar Hyp

er...

Overri

ding of the Aorta

Pulmonary St

enosis

Mitr

al Stenosis

Ventricu

lar Septa

l Defect

0% 0% 0%0%0%

1. Right Ventricular Hypertrophy

2. Overriding of the Aorta

3. Pulmonary Stenosis4. Mitral Stenosis5. Ventricular Septal

Defect

10

Boot-Shaped Heart

Indicates right ventricular hypertrophy seen in Tetralogy of Fallot. (A similar radiograph is in the lab. Remember to review all of these.)

Pulmonary Artery StenosisRight Ventricular HypertrophyOverriding of the AortaVEntricular Septal Defect

Which aortic arch gives rise to the Which aortic arch gives rise to the stapedial artery?stapedial artery?

First

Arch

Seco

nd Arch

Third A

rch

Fourth

Arch

Fifth Arch

Sixth

Arch

0% 0% 0%0%0%0%

10Seconds

Remaining

1. First Arch2. Second Arch3. Third Arch4. Fourth Arch 5. Fifth Arch6. Sixth Arch

Aortic Arch DerivativesAortic Arch DerivativesRemember MSCARD

MaxillaryStapedialCommon Carotid (External Too)Arch of Aorta (and Right Subclavian)RegressesDuctus Arteriosus (and Pulmonary

Arteries)

Which of the following vessels has Which of the following vessels has the highest oxygen saturation?the highest oxygen saturation?

Pulmonary Veins

Pulmonary Arte

ries

Ascending Aorta

Right C

oronary Arte

ry

0% 0%0%0%

101. Pulmonary Veins2. Pulmonary Arteries3. Ascending Aorta4. Right Coronary Artery

An embryo successfully reaches the blastula An embryo successfully reaches the blastula stage but fails to implant itself in the stage but fails to implant itself in the endometrium. Which of the following events endometrium. Which of the following events may have failed to occur?may have failed to occur?

Cleavage

Disa

ppearance

of the Z.

..

Fusio

n of Male and Fe

ma..

Form

ation of Germ

Layers

0% 0%0%0%

101. Cleavage2. Disappearance of the Zona Pellucida3. Fusion of Male and Female Pronuclei4. Formation of Germ Layers

The blastocyst must “hatch” by dissolving the zona pellucida before implantation

A newborn suffers from excessive A newborn suffers from excessive accumulation of saliva and mucous in nose and accumulation of saliva and mucous in nose and mouth, gagging, cyanosis after swallowing mouth, gagging, cyanosis after swallowing milk, abdominal distension after crying, and milk, abdominal distension after crying, and reflux of gastric contents into lungs. Which reflux of gastric contents into lungs. Which congenital abnormality may be to blame?congenital abnormality may be to blame?

Pulmonary H

ypoplasia

Transpositi

on of the G

re..

Congenital D

iaphragmat.

.

Tracheoeso

phageal Fist

ula

0% 0%0%0%

101. Pulmonary Hypoplasia2. Transposition of the Great Vessels3. Congenital Diaphragmatic Hernia4. Tracheoesophageal Fistula

Tracheoesophageal Tracheoesophageal FistulaFistula

In most common form (seen at left), esophagus ends in blind pouch

Trouble with feeding a prominent symptom at birth

The patient with the herniated disc asks you The patient with the herniated disc asks you about the embryological precursor to the about the embryological precursor to the substance coming out of the disc (naturally, of substance coming out of the disc (naturally, of course). What should be your response?course). What should be your response?

Neuro

ectoderm

Noto

chord

Inte

rmediate

Meso

derm

Late

ral Plate

Meso

derm

0% 0%0%0%

10

1. Neuroectoderm2. Notochord3. Intermediate

Mesoderm4. Lateral Plate

Mesoderm

Nucleus Pulposus is the only remnant of the notochord in the adult human

Remember your germ layers

Which of the following is not derived from Which of the following is not derived from neural crest cells?neural crest cells?

Dorsa

l Root G

anglia

Ente

ric G

anglia

Moto

r Neuro

ns

Melanocy

tes

0% 0%0%0%

10

1. Dorsal Root Ganglia2. Enteric Ganglia3. Motor Neurons4. Melanocytes

Neural Crest CellsNeural Crest Cells“the fourth germ layer”know the derivatives and

consequences of failed migration

Surface AnatomySurface AnatomyGenerally come in the form, “A

stab wound to the _______ will lacerate which of the following structures:”

Be able to associate surface structures with the viscera underneath

Don’t forget the posterior thorax

A stab wound through the manubrium A stab wound through the manubrium damages a vessel coursing almost damages a vessel coursing almost horizontally. Which of the following was horizontally. Which of the following was most likely lacerated?most likely lacerated?

Left Brach

iocephalic

Vein

Right B

rachioce

phalic Vein SV

C

Left Common Caro

tid

0% 0%0%0%

:10

1. Left Brachiocephalic Vein

2. Right Brachiocephalic Vein

3. SVC4. Left Common

Carotid

MAL MCL PS Median PS MCL MAL

1st ICS

Posterior Segment

of Superior

Anterior Segmentof Superior

Axillary Vessels

Anterior Segment

of Superior

SVC

Aortic Arch,Left

Brachiocephalic

V.

Anterior Segment

of SuperiorAortic Knob

Anterior Segment

of SuperiorAxillary Vessels

AP Segment of

Superior

1st

ICS

2nd ICS

Posterior Segment

of Superior

Anterior Segmentof Superior

Anterior Segment

of Superior

SVC

Ascend-ing

Aorta

Anterior Segment

of SuperiorPulmonary

Trunk

Anterior Segmentof Superior

AP Segment of

Superior

2nd

ICS

3rd ICS

PS of S

LS ofMiddle

MS ofMiddle

Anterior Segment

of Superior

RA

RV

Anterior Segment

of SuperiorConus

Arteriosus

Superior Lingular of

Superior

Superior Lingular of

Superior

3rd

ICSLateral

Segment of Middle

4th ICS

LS of Middle LS of

Middle

*Nipple

MS of Middle

Medial Segment of Middle

RA

RV RV

Inferior Lingular of

SuperiorLV

*Nipple

Superior Lingular of

Superior

4th

ICSAnterior Basal of Inferior

5th ICS

Anterior Basal of Inferior

LS ofMiddle

MS of Middle

Medial Segment of MiddleRA/IVC

RVRV

*No pleura

IL of SLV (apex)

Antero- medial

Basal of Inferior

5th

ICSAMB of Inferior

6th ICS

Anterior Basal ofInferior

DIAPHRAGM AMB of I

LB of I

6th

ICS

Which heart chamber is at greatest Which heart chamber is at greatest risk from a thoracic stab wound?risk from a thoracic stab wound?

Left Atri

um

Left Ventri

cle

Right A

trium

Right V

entricle

0% 0%0%0%

1. Left Atrium2. Left Ventricle3. Right Atrium4. Right Ventricle

:10

MAL MCL PS Median PS MCL MAL

1st ICS

Posterior Segment

of Superior

Anterior Segmentof Superior

Axillary Vessels

Anterior Segment

of Superior

SVC

Aortic Arch,Left

Brachiocephalic

V.

Anterior Segment

of SuperiorAortic Knob

Anterior Segment

of SuperiorAxillary Vessels

AP Segment of

Superior

1st

ICS

2nd ICS

Posterior Segment

of Superior

Anterior Segmentof Superior

Anterior Segment

of Superior

SVC

Ascend-ing

Aorta

Anterior Segment

of SuperiorPulmonary

Trunk

Anterior Segmentof Superior

AP Segment of

Superior

2nd

ICS

3rd ICS

PS of S

LS ofMiddle

MS ofMiddle

Anterior Segment

of Superior

RA

RV

Anterior Segment

of SuperiorConus

Arteriosus

Superior Lingular of

Superior

Superior Lingular of

Superior

3rd

ICSLateral

Segment of Middle

4th ICS

LS of Middle LS of

Middle

*Nipple

MS of Middle

Medial Segment of Middle

RA

RV RV

Inferior Lingular of

SuperiorLV

*Nipple

Superior Lingular of

Superior

4th

ICSAnterior Basal of Inferior

5th ICS

Anterior Basal of Inferior

LS ofMiddle

MS of Middle

Medial Segment of MiddleRA/IVC

RVRV

*No pleura

IL of SLV (apex)

Antero- medial

Basal of Inferior

5th

ICSAMB of Inferior

6th ICS

Anterior Basal ofInferior

DIAPHRAGM AMB of I

LB of I

6th

ICS

Which rib does the horizontal Which rib does the horizontal fissure approximate most closely?fissure approximate most closely?

Third

Fourth

Fifth

Sixth

Seventh

0% 0% 0%0%0%

101. Third2. Fourth3. Fifth4. Sixth5. Seventh

Study TipsStudy TipsStudy the TBL’s! Use them to

guide your review.Learn the Blue Boxes, especially

the Chapter 1 ones (summary online)

Don’t forget lymph and embryo!Review as many bodies as

possible

Mock PracticalMock PracticalSaturday morning: 10 am – 4 pmThere will be bodies tagged in the lab, as

well as radiographsComplete on your own, giving yourself a

minute for the A and B questionsTags will be left on until Saturday

afternoonAnswers will be posted in the lab

Good Luck!Good Luck!

ecktw@umdnj.eduecktw@umdnj.edu