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100 must importantGA conceptions
Dr. Mavrych, MD, PhD, DScProfessor of Gross anatomy, SMU
Understand first, then memorize and apply
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You can use this presentation like a guide during your
preparing for final GA exam.
It does NOT cover all the material of the Gross Anatomycourse.
To complete GA material you have to work with ALL
professors presentations. Good Luck and All the best!
Dr. Mavrych
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1. Lumbar puncture (tap) and
Epidural anesthesia When a lumbar puncture isperformed, the needle enters thesubarachnoid space to extractcerebrospinal fluid (spinal tap) or toinject anesthetic (spinal block) orcontrast material.
The needle is usually insertedbetween L3/L4 or L4/L5. Level ofhorizontal line through upper pointsof iliac crests.
Remember, the spinal cord mayend as low as L2 in adults anddoes end at L3 in young children
and dural sac extends caudally tolevel of S2.
Before the procedure, the patientshould be examined for signs ofincreased intracranial pressurebecause cerebellar tonsils mayherniate through the foramen
magnum.
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Herniated discs usuallyoccur in lumbar (L4/L5 orL5/S1) or cervical regions(C5/C6 orC6/C7) ofindividuals younger than
age 50. Herniations may follow
degenerative changes inthe anulus fibrosus and becaused by suddencompression of the nucleuspulposus.
Herniated lumbar discsusually involve the nerveroot one number below -traversing root (e.g., theherniation L4/L5 willcompress L5 root).
2. Herniated IV disc
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3. Abnormal curvatures of the
spine Kyphosis is an exaggeration of
the thoracic curvature that may
occur in elderly persons as a result
of osteoporosis (multiply
compression fracture of vertebralbodies) or disk degeneration.
Lordosis is an exaggeration of the
lumbar curvature that may be
temporary and occurs as a result
of pregnancy, spondylolisthesisor potbelly.
Scoliosis is a complex lateral
deviation, or torsion, that is
caused by poliomyelitis, a leg-
length discrepancy, or hip disease.
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4. Upper limb fractures:
Humerus fracturesSites of potential injury to major
nerves in fractures of the
humerus:
1. Axillary nerve and posterior
humeral circumflex artery at
the surgical neck.
2. Radial nerve and profunda
brachii artery at midshaft.
3. Brachial artery and median
nerve at the supracondylarregion.
4. Ulnar nerve at the medial
epicondyle.
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Fracture of distal radius: Transverse fracture within the distal 2 cm of
the radius. Most common fracture of the
forearm (after 50).
Smith's fracture results from a fall or a blowon the dorsal aspect of the flexed wrist
and produces a ventral angulation of the
wrist. The distal fragment of the radius is
ANTERIORLY displaced.
Colles' fracture results from forced
extension of the hand, usually as a result oftrying to ease a fall by outstretching the
upper limb. Distal fragment is displaced
DORSALLY - dinner fork deformity.
Often the ulnar styloid process is avulced
(broken off)
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Scaphoid fracture Occurs as a result of a fall onto
the palm when the hand isabducted
Pain occurs primarily on thelateral side of the wrist,especially during wrist extensionand abduction
Scaphoid fracture may not showon X-ray films for 2 to 3 weeks,but a deep tenderness will bepresent in the anatomicalsnuffbox.
The proximal fragment mayundergo avascular necrosisbecause the blood supply isinterrupted.
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Boxers fracture Necks of the metacarpal
bones are frequently
fractured during fistfights.
Typically, fractured 2d
and 3d
metacarpals are seen in
professional boxers, and
fractured 5th and sometimes
4th metacarpals are seen in
unskilled fighters.
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5 Rotator cuff muscles SITS Support the shoulder joint by
forming a musculotendinous
rotator cuff around it
Reinforces joint on all sides
except inferiorly, where
dislocation is most likely
Rotator cuff muscles are
Supraspinatus, Infraspinatus,
Teres minor, Subscapularis:
SITS.
Right humerus
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6. Abduction of the upper limb (0-15) Abduction of the
upper extremity is initiatedby the supraspinatusmuscle (suprascapularnerve).
(15-110) Further abductionto the horizontal position is afunction of the deltoidmuscle (axillary nerve).
(110-180) Raising theextremity above thehorizontal position requiresscapular rotation by actionof the trapezius (accessorynerve CNXI) and serratusanterior (long thoracic
nerve).
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Subacromial bursitis Subacromial bursitis
(influmution of the subacromial
bursa) is often due to calcific
supraspinatus tendinitis,
causing a painful arc of ofabduction.
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7. Medial (golfers elbow) and
lateral (tennis elbow) epicondylitis Medial epicondylitis is inflammation of
the common flexor tendon of the wrist
where it originates on the medial
epicondyle of the humerus.
Lateral epicondylitis: repeated forcefulflexion and extension of the wrist resultingstrain attachment of common extensortendon and inflammation of periosteumof lateral epicondyle. Pain felt overlateral epicondyle and radiates downposterior aspect of forearm. Pain often feltwhen opening a dooror lifting a glass
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8. Arterial anastomoses
around the scapula Blockage of the
Subclavian or Axillaryartery can be bypassedby anastomosesbetween branches ofthe Thyrocervical andSubscapulararteries:
Transverse cervical
Suprascapular
Subscapular Circumflex scapular
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9. Cubital fossa Contents from lateral to medial:
1. Biceps brachii tendon
2. Brachial artery
3. Median nerve
Subcutaneos structures from lateral tomedial:
1. Cephalic vein
2. Median cubital vein: joins cephalicand basilic veins
3. Basilic vein
Sites of venipuncture is usually mediancubital vein because: Overlies bicipital aponeurosis, so deep
structure protected
Not accompanied by nerves
TAN
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10. Carpal Tunnel Syndrome Results from a lesion that
reduces the size of the carpaltunnel (fluid retention, infection,dislocation of lunate bone)
Median nerve most sensitive
structure in the carpal tunneland is the most affected
Clinical manifestations: Pins and needles or anesthesia
of the lateral 3.5 digits
palm sensation is not affectedbecause superficial palmarcutaneous branch passessuperficially to carpal tunnel
Apehand deformity - absentof OPPOSITION
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11. Test of the proximal and
distal interphalangeal joints
PIP FDS
DID - FDP
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12. Lesion of UL nerves
Upper Brachial Palsy Injury of upper roots and trunk
Usually results from excessiveincrease in the angle between theneck and the shoulder stretching or
tearing of the superior parts of thebrachial plexus (C5 and C6 roots orsuperior trunk)
May occur as birth injury fromforceful pulling on infant's headduring difficult delivery
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Upper Brachial Palsy
(Erb-Duchenne palsy) In all cases, paralysis of the muscles of the
shoulder and arm supplied by C5 and C6 spinal
nerves (roots) of the upper trunk.
Combination lesions ofaxillary, suprascapular
and musculocutaneous nerves with loss of the
shoulder mm and anterior arm.
As result patient have waiters tip hand:
adducted shoulder
medially rotated arm
extended elbow
loss of sensation in the lateral aspect of the
upper limb
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Lower Brachial Palsy
(Klumpke paralysis) Injury of lower roots and
trunk
May occur when the upper
limb is suddenly pulled
superiorly: stretching ortearing of the inferior parts
of the brachial plexus (C8
and T1 roots or inferior
trunk)
E.g., grabbing supportduring fall from height or
as a birth injury, orTOS
thoracic outlet syndrome
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Lower Brachial Palsy
(Klumpke paralysis) All intrinsic muscles of the hand
supplied by the C8 and T1 roots ofthe lower trunk affected.
Combination lesions of ulnarnerve (claw hand) and mediannerve (ape hand)
Loss of sensation in the medialaspect of the upper limb andmedial 1,5 fingers.
May include a Hornersyndrome
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Injury to musculocutaneous nerve Usually results from lesions
of lateral cord
Greatly weakens flexion ofelbow (biceps and brachialismuscles) and supination offorearm (biceps muscle)
May be accompanied by
anesthesia over lateralaspect of forearm
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Cutaneous innervation
of the hand
Dorsum: 1,5-U and 3,5 R Palm: 1,5-U and 3,5 M
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13. Avascular necrosis
of femoral head
A common fracture inelderly women withosteoporosis is fracture ofthe femoral neck.
Transcervical fracturedisrupts blood supply tothe head of the femur via
retinacular arteries (frommedial circumflex femoralartery) and may causeavascular necrosis of thefemoral head if bloodsupply through the ligamentto the head is inadequate.
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14. Knee joint injury:
Unhappy triad Because the lateral side of the
knee is struck more often(e.g., in a football tackle), thetibial collateral ligament is
the most frequently tornligament at the knee.
The unhappy triad of athleticknee injuries involves:
1. Tibial collateral ligament
2. Medial meniscus
3. Anterior cruciate ligament
medial
MMA
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Fibular collateral ligament
(lateral collateral ligament)
Rounded cord between
lateral epicondyle of femur
and head of fibula
Does NOT blend with jointcapsule and does NOT
attach to lateral meniscus
Limits extension and
adduction of leg at knee
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Rupture of the
cruciate ligaments
With rupture of theanterior cruciate ligament,the tibia can be pulledforward excessively on the
femur, exhibiting anteriordrawer sign.
In the less common ruptureof the posterior cruciateligament, the tibia can bepulled backward excessivelyon the femur, exhibitingposterior drawer sign.
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Prepatellar bursa
Suprapatellar bursa
Prepatellar bursa: between
superficial surface of patella
and skin. May become
inflamed and swollen
(prepatellar bursitis)
Suprapatellar bursa: superior
extension of synovial cavity
between distal end of femur
and quadriceps muscle and
tendon. Usual place for intra-
articular injections
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Knee jerk reflex
The patellar reflexis tested by tappingthe patellarligament with a
reflex hammer toelicit extension atthe knee joint. Bothafferent andefferent limbs ofthe reflex arch arein the femoral
nerve (L2-L4).
Knee jerk reflex:tests spinal nervesL2-L4.
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15. Ankle joint injury:
Ankle sprains
Sprains are the mostcommon ankle injuries
A sprained ankle is nearlyalways an inversion injury,involving twisting of theweight-bearing plantarflexedfoot.
The lateral ligament (anteriortalofibular ligament) isinjured because it is muchweaker than the medialligament.
In severe sprains, the lateralmalleolus of the fibula may befractured.
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Potts fracture
Fracture-dislocations ofthe ankle (Pott'sfracture):
Forced eversion
(abduction) of the foot The medial ligament
avulses the medialmalleolus or themedial ligamenttears, and fibulafractures at a higher
level Forced inversion
(adduction) avulses thelateral malleolus of fibulaor tears the lateralligament
Pott's fracture
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Ankle jerk reflex
Achilles tendon reflex is
tested by tapping the
calcaneal tendon to elicit
plantar flexion at the anklejoint.
Both afferent and efferent
limbs of the reflex arc are
carried in the tibial nerve
(S1, S2).
Ankle jerk reflex: tests
spinal nerves S1-S2.
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16. Injury of the gluteal region:
Piriformis syndrome
Inflammation or spasm ofthe piriformis muscle mayproduce pain similar to thatcaused by sciatica
("piriformis syndrome").
Piriformis Landmark ofthe gluteal region: provideskey to understandingrelationships in the glutealregion; determines namesof blood vessels and nerves action: supination of hip
joint
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Injury to sciatic nerve
Weakened hipextension and kneeflexion
Footdrop (lack ofdorsiflexion)
Flail foot (lack ofboth dorsiflexion andplantar flexion)
Cause of injury:
caused byimproperly placedgluteal injectionsbut may result fromposterior hipdislocation
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Superior gluteal
nerve injury The superior gluteal nerve may
be injured during surgery,posterior dislocation of thehip or poliomyelitis.
Paralysis of the gluteus
medius and gluteus minimusmuscles occurs so that theability to pull the pelvis upand abduction of the thighare lost.
If the superior gluteal nerve on
the left side is injured, the rightpelvis falls downward when thepatient raises the right foot off theground.
Note that it is the sidecontralateral to the nerve injurythat is affected.
Superior gluteal
nerve injury
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Injury to inferior gluteal nerve
Weakened hip extension(gluteus maximus), mostnoticeable when climbing
stairs or standing from aseated position
Cause of injury: posteriorhip dislocation, surgery inthis region
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Avulsion fractures occurwhere muscles areattached - ischialtuberosities
Hamstrings muscles:
1. Biceps femoris
2. Semitendinosus
3. Semimembranosus
Action: extension of hip
joint and flexion of kneejoint
Nerve supply Tibialnerve (short head ofbiceps femoris is suppliedby the common fibularnerve)
17. Avulsion fractures
of the hip bone and
hamstrings muscles
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18. Femoral sheath & femoral
hernia
Extension oftransversalis fasciaand iliacus fasciathat enters thigh
deep to inguinalligament
Divided into threecompartments fromlateral to medialenclosing:
Femoral artery
Femoral vein
Femoral canal
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Femoral hernia
A femoral hernia passes through the
femoral ring into the femoral canal to
form a swelling in the upper thigh
inferior and lateral to the pubic tubercle
The hernial sac may protrude through
the saphenous hiatus into the
superficial fascia
A femoral hernia occurs more
frequently in females and is dangerous
because the hernial sac may becomestrangulated
An aberrant obturator artery is
vulnerable during surgical repair
Inguinal lig.
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19. Rupture of the Achilles
tendon and Triceps surae muscle
Avulsion or rupture of the calcaneal
(Achilles) tendon disables the triceps
sure muscle (gastrocnemius & soleus)
so that the patient cannot plantar flexthe foot.
Triceps surae muscle:
2 Heads of Gastrocnemius m.
1 Head - Soleus muscle
Plantaris
small fusiform belly with long thintendon; may be absent
sometimes may becomehypertrophy
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Injury to tibial nerve
In popliteal fossa: loss ofplantar flexion of foot (mainlygastrocnernius and soleusmuscles) and weakened
inversion (tibialis posteriormuscle), causingcalcaneovalgus.
Inability to stand on toes
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20. Fracture of the fibular neck May cause an injury to the
common peroneal nerve,which winds laterally aroundthe neck of the fibula.
This injury results inparalysis of all muscles inthe anteriorand lateralcompartments of the leg(dorsiflexors and evertors ofthe foot)
Causing foot drop.
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21. Breast:
Carcinoma of the Breast
Carcinomas of thebreast are malignanttumors, usuallyadenocarcinomasarising from theepithelial cells of thelactiferous ducts in themammary glandlobules
1. It enlarges, attachesto suspensory(Coopers) ligaments,and producesshortening of theligaments, causingdepression or dimplingof the overlying skin.
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Lymphatic drainage
of the breast
It is important becauseof its role in themetastasis of cancercells.
Most lymph (> 75%),especially from thelateral breastquadrants, drains tothe axillary lymphnodes, initially to theanterior (pectoral)nodes for the most
part. Most of the remaining
lymph, particularly fromthe medial breastquadrants, drains to theparasternal lymphnodes or to theopposite breast.
75% 25%
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Mastectomy
Radical mastectomy, a more extensive surgicalprocedure, involves removal of the breast, pectoralmuscles, fat, fascia, and as many lymph nodes aspossible in the axilla and pectoral region.
During a radical mastectomy, the long thoracicnerve may be lesioned during ligation of the lateral
thoracic artery. A few weeks after surgery, the
female may present with a winged scapula and
weakness in abduction of the arm above 90
because serratus anterior m. paralysis.
The intercostobrachial nerve may also be
damaged during mastectomy, resulting in
numbness of the skin of the medial arm.
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Breast infection
Mastitis is an infection of the tissue
of the breast that occurs most
frequently during the time of
breastfeeding (1 to 3months after the
delivery of a baby).
This infection causes pain, swelling,
redness, and increased temperature
of the breast.
It can occur when bacteria, often from
the baby's mouth, enter a milk ductthrough a crack in the nipple.
It can occur in women who have not
recently delivered as well as in women
after menopause.
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22. Diaphragm:
Paralysis of Half and ruptures
Paralysis of the halfof the Diaphragmmay result from injuryor operative division of
the phrenic nerve ofsame side
It can be detectedradiologically.
Paradoxicalmovement: dome ofdiaphragm of injuredside pushed superiorlyby abdominal visceraduring inspirationinstead of descending
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Diaphragmatic ruptures
Diaphragmatic injuries are
relatively rare and result from
either blunt trauma or
penetrating trauma.
Presently, 80-90% of blunt
diaphragmatic ruptures resultfrom motor vehicle crashes.
The majority (80-90%) of blunt
diaphragmatic ruptures have
occurred on the left side.
Blunt trauma typically produceslarge radial tears measuring 5-15
cm, most often at the
posterolateral aspect of the
diaphragm.
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23. Cardiac hypertrophy Left atrial enlargement
(hypertrophy) secondary to
mitral valve failure may
compress on theesophagus and manifest
as dysphagia (difficulty in
swallowing).
It may be observed as a
filling defect in the
esophagus by barium
swallow on the lateral
thoracic X-Ray
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Cardiac Shadow
Right borderis formed by:
1. SVC,2. Right atrium
Left borderis formed by:
1. Aortic arch2. Pulmonary trunk
3. Left auricle
4. Left ventricle
P-A projection
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24. Auscultation of Heart
Valves
Right 2 ICS
PSL
Left 5 ICS
MCL
Left 4 ICS
PSL
Left 2 ICS
PSL
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Auscultation sites for
mitral and aortic murmurs
A heart murmur is heard downstream from the valve: stenosis is orthograde direction from valve
insufficiency is retrograde direction from valve
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25. Blood supply of the Heart:
Right coronary artery (RCA) It supplies major parts of the right
atrium and the right ventricle.
It anastomoses with the marginalbranch of the left coronary artery
posteriorlyBranches:
1. Anterior cardiac branchessupplies the right atrium
2. Nodal branch supplies the (1) SAnode, (2) AV node
3. Marginal artery supplies the right
ventricle4. Posterior interventricular arterysupplies (1) diafragmatic (inferior)surface of both ventricles and (2)posterior 1/3 of the IV septum
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Left coronary artery
(LCA)Branches:
1. Anterior interventricular artery
descends in the anterior
interventricular sulcus and provides
branches to the (1) anterior heard
wall, (2) anterior 2/3 of IV septum,
(3) bundle of His, and (4) apex of the
heart.
2. Circumflex artery winds around the
left margin of the heart in the
atrioventricular groove to anastomosewith the right coronary artery
posteriorly; supplies the left atrium
and left ventricle
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Blood supply of the conducting
system SA node RCA
AV node RCA
AV bundle (andmoderator band)- LCA
AV Bundle of His
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26. Aspiration of Foreign
Bodies & Bronchopulmonary
segmentsAspiration of Foreign Bodies:
Inhalation of FBs (e.g. pins,parts of teeth, screws, nuts,
bolts, toys) into the lowerrespiratory tract is common,especially in children
More likely to enter the rightprimary bronchus and pass intothe middle or lower lobebronchi
If the vertical position of thebody, the foreign body usuallyfalls into the posterior basalsegment of the right inferiorlobe.
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Right lung:
10 bronchopulmonary segments
Superior lobe:
1. Apical2. Anterior
3. PosteriorMiddle lobe:
4. Lateral5. MedialInferior lobe:
6. Superior7. Anterior basal8. Posterior basal9. Lateral basal10.Medial basal
1
8
97
6 4
5
2
3
10
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Left lung:
9 bronchopulmonary segments
Superior lobe:
1. Apicoposterior2. Anterior3. Superior lingular4. Inferior lingularInferior lobe:
5. Superior6. Anterior basal
7. Posterior basal8. Lateral basal9. Medial basal
1
3 5
7
89
6
2
4
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27. Lung diseases:
Pneumonia Pneumonia is an inflammation
of the lung, caused by an
infection or chemical injury to the
lungs.
Three common causes are
bacteria, viruses and fungi.
Symptoms: cough, chest pain,
fever, and difficulty in breathing.
Chest x-rays: areas of opacity
(seen as white) of the lungparenchyma and enlargement of
bronchomediastinal lymph
nodes (mediastinal widening).
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Bronchogenic Carcinoma
Arises in the mucosa of thelarge bronchi
Produces as persistent,
productive cough orhemoptysis
Early metastasis to thoracic(bronchomediatinal) lymphnodes
Hematogenous spread to thebrain, bones, lungs,
suprarenal glands A tumor at the apex of the
lung (Pancoast tumor) mayresult in thoracic outletsyndrome
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Qs about Auscultation
and penetrated wounds To listen to breath sounds of the
superior lobes of the right and left
lungs, the stethoscope is placed on
the superior area of the anteriorchest wall (above the 4th rib for the
right lung & above 6th for the left
one).
For breath sounds from the
middle lobe of the right lung, the
stethoscope is placed on theanterior chest wall between the 4th
and 6th ribs
For the inferior lobes of both
lungs, breath sounds are primarily
heard on the posterior chest wall.
4
6
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28. Open pneumothorax It is entry of airinto a pleural cavity
causing lung collapse.
Open pneumothorax due to stabwounds of the thoracic wall which
pierce the parietal pleura so thatthe pleural cavity is open to theoutside air via the lung or throughthe chest wall.
Air moves freely through thewound during inspiration andexpiration. During inspiration, airenters the chest wall and the
mediastinum will shift toward otherside and compress the oppositelung. During expiration, air exitsthe wound and the mediastinummoves back toward the affectedside.
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Nerve supply of the pleuraParietal Pleura sensitive to general
sensibilities (pain, temperature,touch, and pressure) - somaticsensory innervation:
costal pleura intercostal nerves
mediastinal pleura phrenicnerve
diaphragmatic pleura phrenicnerve over the domes and lower 6intercostal nerves around theperiphery
Visceral Pleura sensitive to stretchbut insensitive to generalsensibilities; autonomic nervesupply from the pulmonary plexus
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29. Anterior abdominal wall
The liverand gallbladderare in the right upperquadrant;
The stomach and spleen
are in the left upperquadrant;
The cecum and appendixare in the right lowerquadrant;
The end of the descendingcolon and sigmoid colonare in the left lowerquadrant.
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Referred abdominal pain
Pain arising out of theforegut derived structuresis referred to the
epigastric region.
Pain arising out of themidgut derived structuresis referred to theumbilical region.
Pain arising out of thehindgut derivedstructures is referred tothe hypogastric region.
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Transversalis fascia is the FIRST
STRUCTURE which is crossed by
any abdominal hernia
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Indirect Inguinal Hernia
Indirect inguinal hernia is the mostcommon form of hernia and is believedto be congenital in origin (boys 0-3years).
It passes through the deep inguinal ring
lateral to the inferior epigastricvessels, inguinal canal, superficialinguinal ring and descend into thescrotum.
An indirect inguinal hernia is about 20times more common in males than infemales, and nearly 1/3 are bilateral.
It is more common on the right(normally, the right processus vaginalisbecomes obliterated after the left; theright testis descends later than the left).
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Direct Inguinal Hernia
Direct inguinal hernia composesabout 15% of all inguinal hernias.
During a direct inguinal hernia,the abdominal contents willprotrude through the weak area of
the posterior wall of the inguinalcanal medial to the inferiorepigastric vessels in the inguinal[Hesselbach's] triangle and afterthat through superficial inguinalring. It never descends into thescrotum.
It is a disease of old men withweak abdominal muscles. Directinguinal hernias are rare in women,and most are bilateral.
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30. Peritoneal structure:
Lesser omentumConsist of 2 ligaments:
hepatogastric
hepatoduodenal
Contents : Right & Left gastric
vessels
Connective and fattytissue
and Portal triad:
Bile duct Portal vein
Proper hepatic artery
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Epiploic (winslows) foramen
Anteriorly: The freeborder of thehepatoduodenal
ligament, containingportal triad (DVA).
Posteriorly: IVC
Superiorly: Caudate
lobe of the liver.
Inferiorly: The 1st
part of theduodenum.
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Douglas (rectouterine) pouch
Rectouterine pouch(pouch of Douglas):deeper point of
peritoneal space invertical position of thefemale body between therectum and the uterus. Itis space of the pelvicabscess location.
Vesicouterine pouch: it isdeepness between theuterus and the urinarybladder.
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Culdocentesis
Culdocentesis isaspiration of fluid fromthe cul-de-sac ofDouglas (rectouterinepouch) by a needle
puncture of theposterior vaginalfornix near the midlinebetween the uterosacralligaments
Because therectouterine pouch is
the lowest portion ofthe female peritonealcavity, it can collectinflammatory fluid(pelvic abscess).
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31. Everything about Foregut, Midgut
& Hindgut
FOREGUT MIDGUT HINDGUT
Esophagus
Stomach
Duodenum (1st
and2nd parts)
Liver
Pancreas
Biliary apparatus
Gallbladder
Duodenum (2nd, 3rd,
4th
parts)Jejunum
Ileum
Cecum (with
Appendix)
Ascending colon
Transverse colon(proximal 2/3)
Transverse colon
(distal 1/3)
Descending colonSigmoid colon
Rectum (anal canal
above pectinate line)
spleen
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FOREGUT MIDGUT HINDGUT
Artery: CA Artery: SMA Artery: IMA
Parasympathetic
innervation: vagus
nerves, CNX
Parasympathetic
innervation: vagus
nerves, CNX
Parasympathetic
innervation: pelvic
splanchnic nerves, S2-S4
Sympathetic
innervation:
Preganglionics: greatersplanchnic nerves, T5-T9
Postganglionics:
celiac ganglion
Sympathetic
innervation:
Preganglionics: lessersplanchnic nerves, T10-
T11
Postganglionics:
superior mesenteric
ganglion
Sympathetic
innervation:
Preganglionics: lumbarsplanchnic nerves, L1-L2
Postganglionics: inferior
mesenteric ganglion
Sensory Innervation:DRG T5-T9
Sensory Innervation:DRG T10-T11
Sensory Innervation:DRG L1-L2
Referred Pain:
Epigastrium
Referred Pain:
Umbilical
Referred Pain:
Hypogastrium
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32. Posterior gastric ulcer
1. Posterior gastric ulcermayerode through the posteriorwall of the stomach into the
pancreas resulting inreferred pain to the back.
2. Erosion of splenic artery isvery common in posteriorgastric ulcers because of
the proximity of the artery tothis wall.
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33. Congenital diaphragmatic
hernia
Hernia of stomach orintestines through aposterolateral defect
in diaphragm(foramen ofBochadalek).
It is seen in infantsand the mortality rate ishigh because of leftlung hypoplasia.
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34. Sliding hiatal hernia
A sliding hiatal hernia which
occurs in individuals past
middle age is caused by
the hernia of cardia of thestomach into the thorax
through the esophageal
hiatus of the diaphragm.
This can damage the vagal
trunks as they pass through
the hiatus and resulting in
hyposecretion of gastric
juice.
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35. Meckel's diverticulum
Meckel's diverticulum is a congenitalanomaly representing a persistent portion ofthe vitellointestinal duct.
This condition is often asymptomatic but
occasionally becomes inflamed if it containsectopic gastric, pancreatic, or endometrialtissue, which may produce ulceration.
It occurs in 2% of patients, is located about 2feet (61 cm) before the ileocecal junction,and is about 2 inches (5 cm) long.
The diverticulum is clinically importantbecause diverticulitis, liberation, bleeding,perforation, and obstruction arecomplications requiring surgical interventionand frequently mimicking the symptoms ofacute appendicitis.
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36. Features of the large
intestine
Features of the large intestine:
1. Appendices epiploic
2.
Sacculations(haustrations)
3. Taeniae coli
The taeniae coli meettogether at the base ofthe appendix where theyform a complete
longitudinal muscle coatfor the appendix.
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37. Pain of Appendicitis
In appendicitis, first pain isreferred around the umbilicus.Visceral pain in the appendix isproduced by distention of itslumen or spasm of its muscle.
The afferent pain fibers enterthe spinal cord at the level ofT10 segment, and a vaguereferred pain is felt in the regionof the umbilicus.
Later if parietal peritoneumgets involved, and then the painis shifted laterally to the McBurneys point. Here the painis precise, severe, and localized(second pain)
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Mc Burney's point
This point indicatesthe surface markingof the base of theappendix.
It is a point at thejunction between thelateral 1/3 andmedial 2/3 of a line
joining the rightanterior superior iliacspine with theumbilicus.
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38. Volvulus
Because of its extrememobility, the small intestine
and sigmoid colonsometimes rotates aroundits mesentery.
This may correct itselfspontaneously, or the rotationmay continue until the blood
supply of the gut is cut offcompletely.
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39. Hirschsprung's Disease
It is a rare congenital abnormality thatresults in obstruction because theintestines do not work normally.
It is commonly found in Down Syndromechildren.
The inadequate motility is a result of anaganglionic section (congenital absentsof postganglionic parasympatheticneuronsinside of the intestinal wall) of theintestines resulting in megacolon.
In a newborn, the main signs andsymptoms are failure to pass a
meconium stool within 1-2 days afterbirth, reluctance to eat, bile-stained(green) vomiting, and abdominaldistension.
Treatment is removal of the aganglionicportion of the colon.
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40. Branches of Abdominal aorta
Celiac trunk (CA) originatesfrom the aorta at the lowerborder of T12 vertebra
Superior mesenteric arteryoriginates at the lowerborder of L1 vertebra
Renal arteries originate atapproximately L2 vertebra
Inferior mesenteric arteryoriginates at L3 vertebra
Two terminal branches are
common iliac arteries atthe level of L4 vertebra
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CELIAC ARTERY (TRUNK)
Origin: T12-L1, just below
the aortic opening of the
diaphragm.
The CA passes above the
superior border of the
pancreas and then divides
into three retroperitoneal
branches:
Left gastric artery (1)
Common hepatic artery (2) Splenic artery (3)
2
3
1
L gastric - cardia portion
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Left gastric artery
The left gastric artery (1)
courses upward to the left to
reach the lesser curvature of
the stomach and may be
subject to erosion by a
penetrating ulcer of thelesser curvature of the
stomach.
Branches:
Esophageal branches (2) - tothe abdominal part of theesophagus
Gastric branches (3) supply
the left side of the lesser
curvature of the stomach and
make anastomosis with right
gastric artery.
2
3
1
L gastric cardia portion
R gastric - fundal portion
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Common hepatic artery
The common hepatic artery
(1) passes to the right to
reach the superior surface of
the first part of the duodenum,
where it divides into its twoterminal branches:
Proper hepatic artery (2)
Gastroduodenal artery (3)
1
2
3
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Proper hepatic artery Proper hepatic artery (1) gives
offright gastric artery (2) and
then ascends within the
hepatoduodenal ligament of the
lesser omentum to reach the
porta hepatis, where it divides
into the right (4) and left (3)
hepatic arteries.
The right and left arteries enter the
two lobes of the liver, with the
right hepatic artery first giving rise
to the cystic artery (5) to the
gallbladder. Right gastric artery (2) supplies
the right side of the lesser
curvature of the stomach where it
anastomoses the left gastric
artery.
54
3
21
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Gastroduodenal artery
Gastroduodenal artery (1)
descends posteriorto the first
part of the duodenum (may be
subject to erosion by a
penetrating ulcer in this place)
and divides into two branches: Right gastroepiploic artery (2)
(supplies the right side of the
greater curvature of the
stomach where it anastomoses
the left gastroepiploic)
Superior pancreaticoduodenalarteries (3) (supplies the head
of the pancreas, where it
anastomoses the inferior
pancreaticoduodenal
branches of the SMA).
1
2
3
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Ligature of the hepatic artery:
The hepatic artery may beligated proximal to the originof its gastroduodenal branch,a collateral circulation to theliver is established throughthe left and right gastricarteries, left and rightgastroepiploic andgastroduodenal arteries.
The right hepatic arterymay be mistakenly ligatedduring holecystectomy inCalot triangle together withthe cystic artery, right lobehepatic necrosis commonlyoccurs.
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Splenic artery
Splenic artery (1) runs a
tortuous horizontal course to
the left along the upper border
of the pancreas, behind the
peritoneum of the posterior
wall of the lesser sac, forming a
part of the stomach bed.
The splenic artery may be
subject to erosion by a
penetrating ulcer of the
posterior wall of the stomach
into the lesser sac.
N.B. The splenic vein runs amore straight course below theartery and behind of thepancreas.
1
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Splenic artery
Splenic (1) a. is retroperitoneal
until it reaches the tail of the
pancreas, where it enters the
splenorenal ligament to enter
the hilum of the spleen.
Branches: Branches to the spleen (2)
Branches to the neck, body, and
tail of pancreas (3)
Left gastroepiploic (4) artery that
supplies the left side of the
greatercurvature of the stomachwhere it anastomoses the right
gastroepiploic
Short gastric (5) branches that
supply to the fundus of the
stomach
5
43
1 2
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SMA Branches:
(1) Inferiorpancreaticoduodenalarteries
(2)Jejunal and (3)Ileal branches
(4) Ileocolic artery
Ascending branch
Anterior cecal artery
Posterior cecal artery
(5) Appendicularartery
(6) Right colic artery
(7) Middle colic artery
17
6
5
4
3
2
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IMA Branches:
(1) Left colic artery
(2) Sigmoid arteries
(3) Superior rectal artery
3
2
1
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41. Mesenteric ischemia
Ischemia occurs when your blood cannotflow through arteries as well as it should,and intestines do not receive thenecessary oxygen to perform normally.Mesenteric ischemia usually involves thesmall intestine.
Mesenteric ischemia usually occurs inpeople older than age 60. You may bemore likely to experience mesentericischemia if you are a smokeror have ahigh cholesterollevel.
Atherosclerosis, which slows theamount blood flowing through arteries, is
a frequent cause of chronic mesentericischemia.
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42. Abdominal aortic aneurysm
It is a localized dilatation of the
aorta. It is typically happened
just above of the bifurcation at
level of L4 and crossed by 3rd
part of duodenum.
Pulsations of a large aneurysmcan be detected to the left of
the midline at the umbilical
region.
Acute rupture of an abdominal
aortic aneurysm is associated
with severe pain in theabdomen or back (mortality rate
is nearly 90%).
Surgeons can repair an
aneurysm by opening it and
inserting a prosthetic graft.
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43. Biliary system
Bile is secreted by the livercells,stored, and concentrated in thegallbladder and later it isdelivered to the duodenum.
The gallbladderlies in a fossa
on the visceral surface of theliver to the right of the quadratelobe.
It stores and concentrates bile,which enters and leavesthrough the cystic duct.
The cystic duct joins thecommon hepatic (from leftand right hepatic)due to formthe common bile duct.
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Biliary system
The common bile ductdescends in thehepatoduodenal ligament,then passes posteriorto thefirst part of the duodenum
It penetrates the head of thepancreas where itjoins the
main pancreatic duct andforms the hepatopancreaticampulla (sphincter of Oddi),which drains into the secondpart of the duodenum at themajorduodenal papilla.
posteromedial
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44. Cholelithiasis (gallstones)
The distal end of the hepatopancreatic
ampulla is the narrowest part of the
biliary passages and is the common
site for impaction of gallstones. As
result of common hepatic (1), bile
duct (2), or hepatopancreatic ampulla(3) obstruction patient will have yellow
eyes andjaundice
Gallstones may also lodge in the cystic
duct. A stone lodged in the cystic duct
(4) causes biliary colic (intense,spasmodic pain in the gallbladder ) but
doesn't produce jaundice.
1
2
3
4
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Gallstones
The fundus (1) of the gallbladderisin contact with the transverse colonand thus gallstones erode through theposterior wall of the gallbladder andenter the transverse colon. They arepassed naturally to the rectumthrough the descending colon andsigmoid colon.
Gallstones lodged in the body (2) ofthe gallbladdermay ulcerate throughthe posterior wall of the body of thegallbladder into the duodenum
(because the gallbladder body is incontact with the duodenum) and maybe held up at the ileocecal junction,producing an intestinal obstruction.
2
1
45 Nerve supply of the liver
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45. Nerve supply of the liver
and gallbladder
Sensory innervation of the liver is done by theright phrenic nerve (C3-C5). Pain may radiate tothe right shoulder.
The liverreceives parasympathetic innervationfrom the vagi nerves (CNX), reaching it throughthe celiac plexuses around the supplying arteries.The preganglionic fibers synapse on the cells ofthe uxtaramural plexuses in hilum of the liver andshot postganglionic fibers supply organs.
Sympathetic fibers of preganglionic neurons
T5-T9 segments (IML) come through thesympathetic trunk and form greater splanchnicnerves. They contribute to the celiac plexus,where postganglionic neurons are located.Branches of celiac plexus reach the liver wrappingaround the branches of the celiac artery.
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46. Portal Hypertension
Portal hypertension is acommon clinical condition,and for this reason the list ofportal-systemic anastomosesshould be remembered.
Enlargement of the portal-systemic connections isfrequently accompanied bycongestive enlargement of thespleen.
Portacaval shunt for thetreatment of portalhypertension: the splenicvein may be anastomoses tothe left renal vein afterremoving the spleen.
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Portocaval anastomosis
If there is an obstruction to flow
through the portal system (portal
hypertension), blood can flow in
a retrograde direction (because
of the absence of valves in the
portal system) and pass throughanastomoses to reach the caval
system.
Sites for these anastomoses
include the (1) esophageal
veins, (2) thoracoepigastric
veins, and (3) rectal veins. Enlargement of these veins may
result in (1) esophageal varices,
(2) a caput medusae and (3)
internal hemorrhoids.
1
3
2
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Esophageal anastomosis
Anastomosis between thetributaries of the left gastricvein (portal vein) and thetributaries of the azygous
vein (SVC) in the wall of thelower end of the esophagus.
In portal hypertension theseanastomoses veins enlarge inthe wall of the esophagus andlater burst into the lumen of
the esophagus (esophagealvarices) resulting inhematemesis (vomiting redblood).
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Umbilical anastomosis
Anastomosis between theparaumbilical vein (portalvein) and the superiorandinferior epigastric veins(SVC and IVC) of the anterior
abdominal wall around theumbilicus.
In portal hypertension, thisanastomosis gets enlargedand dilated veins form caputMedussae around the
umbilicus.
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Rectal anastomosis
Anastomosis between thesuperior rectal vein (inferiormesenteric vein and then intoportal vein) and inferiorrectal vein which drains intothe internal iliac vein (from
IVC system). In portal hypertension this
anastomoses gets dilatedresulting in internalhemorrhoids and bleedingper anus.
47 Pancreas:
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47. Pancreas:
Head and uncinate process
The head of the pancreasrests within the C-shapedarea formed by theduodenum and is
traversed by the commonbile duct.
It includes the uncinateprocess which is crossedby the superior
mesenteric vessels.
Cancer of the head
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Cancer of the head
of the pancreas
Cancerof the head of thepancreas compresses thebile duct and it results inOBSTRUCTIVE TYPE OF
JAUNDICE. This type of jaundice is NOT
usually associated with painor fever.
Hepatitis also causes jaundice
but is associated with thefever.
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Neck of the pancreas
Posteriorto theneck of thepancreas is the siteof formation of thePORTAL VEIN.
(1)Splenic veinjoins with (2)superiormesenteric vein toform (3) portal vein.
3
2
1
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Body of the pancreas
The body passes to theleft and passes anteriortothe (1) aorta and the (2)
left kidney.
The (3) splenic arteryundulates along thesuperior border of thebody of the pancreas with
the splenic vein coursingposterior to the body.
3
2
1
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Tail of the pancreas
The tail of the pancreasenters the splenorenalligament to reach thehilum of the spleen.
It is the only part of thepancreas that isintraperitoneal.
Tail of the pancreas maybe mistakenly removedduring spleenectomy andresulting in sugardiabetes because itcontains a lot endocrinecells.
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Ducts of the pancreas
Main pancreatic ductruns along the long axis ofthe pancreas from the tailto the head.
Accessory pancreaticduct which is runshorizontally opens onto
the top of the minorduodenal papilla which isabout 2 cm proximal tothe major duodenalpapilla on theposteromedial wall of theduodenum.
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Annular Pancreas
Annular pancreas is caused by
malformation during the development of
the pancreas, before birth.
Occurs when the ventral and dorsal
pancreatic buds form a ring around the
duodenum, thereby causing anobstruction of the duodenum and
polyhydramnios
Symptoms:
1. Feeding intolerance in newborns
2. Fullness after eating
3. Nausea and vomiting
Half of cases are not diagnosed until
symptoms occur in adulthood.
48. Spleen:
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48. Spleen:
Two borders
The spleen is a peritonealorgan in the upper leftquadrant that is deep to theleft 9th, 10th, and 11th ribs.
The spleen follows the contourof rib 10 (axis of the spleen).
Because the spleen liesabove the costal margin, anormal-sized spleen is not
palpable. The spleen may be lacerated
with a fracture of the 9th and10th ribs.
Relations of the Spleen and
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Relations of the Spleen and
Left Kidney
The spleen followsthe contour of 10th riband extends from thesuperior pole of theleft kidney to justposterior to themidaxillary line.
The border betweenspleen and upperpole of the left kidneyis 11th rib.
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Peritoneal connections
Gastrosplenic ligament (1)connects the spleen with theupper end of the greatercurvature of the stomach. Itcontains the short gastricvessels, left gastroepiploic
(gastroomental) vessels andaccompanying lymph vessels
Splenorenal (lienorenal)ligament (2) connects thespleen with the left kidney. Itcontains the tail of thepancreas, splenic vessels,accompanying lymph vesselsand nerves.
1
2
49 Kidney:
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49. Kidney:
Dimensions and position
During life, the kidneysare reddish brown andmeasure approximately11-12 cm in length, 5-6cm in width, and 2.5-3cm in thickness.
They are extending fromthe level of T12 to thelevel of L3, the rightkidney lying about 2-3 cmlowerthan the left one.
The lateral border of the
kidney is convex. Itsmedial border is convex atboth ends but concave inthe middle where there isthe hilum of the kidney.
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Position of the kidneys
The upperend of the left kidney(XI rib) is a little higher than theright one (XII rib).
The lowerends of the kidneysoccur around the level of the IVdisc L3/L4.
N.B. The border between leftkidney and spleen is XI rib
The hila of the kidneys and thebeginnings of the ureters are atapproximately the L1 vertebra.
The ureters descend verticallyanterior to the tips of thetransverse processes of thelower lumbar vertebrae and enterthe pelvis and lies on the psoasmajormuscle.
Anterior relations
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of the right kidney
1. Right suprarenal gland
2. 2nd part of theduodenum
3. Right lobe of the liver4. Right colic flexure
5. Small intestine
Anterior relations
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of the left kidney
1. Left suprarenal gland
2. Stomach
3. Spleen
4. Body of pancreas andsplenic vessels
5. Descending colon
6. Small intestine
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Renal (Gerota) fascia
Enclosing the perinephric fat is
a membranous condensation
of the extraperitoneal fascia -
the renal fascia (3).
The suprarenal glands (4) arealso enclosed in this fascial
compartment, usually
separated from the kidneys by
a thin septum.
N.B. The renal fascia must
be incised in any surgicalapproach to this organ.
3
4
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50. Nephrolithiasis
Renal calculi are solid concretions
(crystal aggregations) formed in the
kidneys from dissolved urinary minerals.
There are several types of kidney
stones. The majority are calciumoxalate stones, followed by calcium
phosphate stones.
Kidney stones typically leave the body
by passage in the urine stream, and
many stones are formed and passed
without causing symptoms. If stones grow to sufficient size before
passage (at least 2-3 mm), they can
cause obstruction of the ureter (renal
colic).
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Staghorn calculi
Renal stone that develops in the
pelvicaliceal system, and in
advanced cases has a branching
configuration which resembles the
antlers of a stag.
Staghorn calculi are composed of
magnesium ammonium
phosphate, which forms in urine
that has an abnormally high pH
(above 7.2).
This high pH usually developsbecause of recurrent urinary tract
infection with microorganisms
such as Proteus mirabilis.
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51. Renal veins
The right renal (1) vein ismuch shorterthan the left.Both veins lie anterior to thecorresponding artery in
hilum of kidneys. The long left renal vein (2)
is joined by the leftsuprarenal (3) and leftgonadal (4) (testicular orovarian) veins before itreached IVC.
The left renal vein crossesanterior to the aorta, justinferior to the origin of theSMA.
1
2
3
4
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52. Varicocele It is engorgement of the
pampiniform plexus thatproduces a wormlikescrotal mass and
enlargement of thespermatic cord.
Formation is usually onthe left side.
Varicocele on either sidemay indicate kidneydisease or may signal a
retro peritonealmalignancy obstructingthe testicular vein.
Pampiniform plexus
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p p
Each testicular or ovarian vein isformed by coalescence of apampiniform plexus: thetesticular at the deep inguinalring, the ovarian at the margin ofthe superior aperture of thepelvis.
The veins run accompany thecorresponding arteries. The leftpampiniform plexus enters theleft renal vein; the right oneenters directly the IVC inferiorto the renal vein.
That is why varicocely(engorgement of the pampiniformplexus that produces a scrotalmass) is more often located onthe left.
53. Hemorrhoids:
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53. Hemorrhoids:
Venous drainage from rectum
Above pectinate line: superior
rectal vein [1] into portal
system [2].
Below pectinate line: inferiorrectal vein [3] into inferior
vena cava [4].
1
2
3
4
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External hemorrhoids
Hemorrhoids are masses that
typically protrude from anus
during defecation.
Hemorrhoids are commonly
associated with constipation,extended sitting and straining at
the toilet, pregnancy, and
disorders that hinder venous return.
1. External hemorrhoids are
dilated tributaries of the inferior
rectal veins (IRV) below thepectinate line and are painful
because the mucosa is supplied by
somatic afferent fibers of the
inferior rectal nerves.
1
1
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Internal hemorrhoids 2. Internal hemorrhoids
are dilated tributaries of thesuperior rectal veins(SRV) above the pectinate
line and are not painfulbecause the mucosa issupplied by visceral afferentfibers.
Internal hemorrhoids
frequently develop duringpregnancy because ofpressure on the superiorrectal veins.
2
2
2
54. Perineal pouches:
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Contents of the deep pouch
The deep perineal pouch is
formed by the fasciae and
muscles of the urogenital
diaphragm.
It contains:1. Sphincter urethrae
muscle
2. Deep transverse
perineal muscle
3. Bulbourethral
(Cowper) glands (inthe male only) - ducts
perforate perineal
membrane and enters
bulbar urethra.
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55. Superficial perineal pouch1. Ischiocavernosus muscle
2. Bulbospongiosus muscle
3. Superficial transverse perinealmuscle
1
2
3
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Urine leaks
After a crushing blow or a
penetrating injury, the spongy
urethra commonly ruptures
within the bulb of the penis, and
urine leaks into the superficialperineal pouch.
The superficial perineal fascia
keeps urine from passing into the
thigh or the anal triangle, but after
distending the scrotum and penis,
urine can pass over the pubis intothe anterior abdominal wall deep
to the deep layer of superficial
abdominal fascia.
56 Cystocele
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56. Cystocele
(hernia of bladder) Loss of bladder support in
females by damage to the
pelvic floor during childbirth
(e.g., laceration of perineal
muscles or a lesion of thenerves supply) can result in
protrusion of the bladder onto
the anterior vaginal wall.
When intrabdominal pressure
increases (as when bearing
down during defecation), the
anterior wall of the vagina may
protrude through the vaginal
orifice into the vestibule
1
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57. Ureter
Ureter [1] crosses pelvic brimnear bifurcation of common iliacartery
In male, crossed superiorly byductus deferens [2] nearbladder
In female, crossed anteriorlyand superiorly by uterine artery[3] in base of broad ligament
N.B. The ureter can be
damaged during ahysterectomy or surgical repairof a prolapsed uterus because itlies posterior and inferior to theuterine artery.
1
2
1
3
58 Nerve supply of pelvic
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58. Nerve supply of pelvic
visceraParasympathetic innervation:
Preganglionic neurons are located in sacral parasympathetic n.(S2-S4) in the spinal cord.
Their processes run into pelvic splanchnic nerves and relay withpostganglionic neurons located inside of pelvic organs in the
intramural plexus.Sympathetic innervation:
Sympathetic fibers of preganglionic neurons T12-L2 segments (IML)come through the sympathetic trunk and form sacral splanchnicnerves.
They contribute to the inferior hypogastric plexus, wherepostganglionic neurons are located. Branches of inferior hypogastric
plexus reach organs wrapping around the branches of the internal iliacartery.
Sensory innervation:
The sensory fibers from S2-S4 dorsal root ganglions comes togetherwith parasympathetic and carry pain sensations from the organs.
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Micturition reflex
Facilitating emptying:
Parasympathetic fibers (pelvicsplanchnic nn.) stimulatedetrusormuscle [1] contractionand involuntary relax internal
sphincter [2]. Somatic motorfibers (pudendal
nerve) cause voluntaryrelaxation of external [3] urethralsphincter.
Inhibiting emptying: Sympathetic fibers (sacral
splanchnic nn.) inhibit detrusormuscle [1] and stimulateinternal sphincter [2].
1
2
3
59. Paracentesis of urinary
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59. Paracentesis of urinary
bladder
Suprapubic aspiration:
Urine can be removed fromthe bladder without penetrating
the peritoneum by inserting aneedle JUST ABOVE thepubic symphysis.
The needle passessuccessively through skin,superficial and deep layers ofsuperficial fascia, linea alba,
transversalis fascia,extraperitoneal connectivetissue, and wall of the bladder.
60. Prostate tumors
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Prostate cancer
It usually begins in theposterior lobe of the gland, andearly stages are oftenasymptomatic.
Later malignant enlargement ofthe prostate can narrow orocclude the prostatic urethra.
N.B. Prostatic malignanciestend to metastasize tovertebrae and the brain
because the prostatic venousplexus has numerousconnections with the vertebralvenous plexus via sacralveins.
Benign hypertrophy of the
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Benign hypertrophy of the
prostate (BHP) BHP is common in men after
middle age.
Prostate adenoma (benignhypertrophy) usually involves
median lobe. BHP is a common cause of
urethral obstruction, leadingto nocturia (need to voidduring the night), dysuria(difficulty and/or pain duringurination), and urgency
(sudden desire to void). The prostate is examined for
enlargement and tumors byDIGITAL RECTALexamination.
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Prostatectomy
A prostatectomy maybe performed through asuprapubic [1] orperineal [2] incision ortransurethrally.
Because damage tonerves in the capsuleof the prostate andaround the urethra(cavernous nerves)can cause impotenceand/or urinaryincontinence.
12
3
transurethral resection of the
prostate = TURP
61. Male urethra
P i
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Prostatic part
It is the widest and the mostdilatable part.
It is spindle shaped (middle part isdilated)
Its posterior wall presents thefollowing features:
Urethral crest - vertical ridge in themidline
Seminal colliculus- a sphericalswelling in the middle of theurethral crest
Openings of the 2 ejaculatoryducts are seen on each side onthe seminal colliculus
Ducts of the prostate gland openinto the male urethra
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Membranous part Passes through the
urogenitaldiaphragm to enterthe bulb of the penis
It is the shortest,
narrowest and theleast dilatable part
It is surrounded by theexternal sphincterurethra
Bulbourethralglands lieposterolateral to thispart inside ofurogenital diaphragm(deep perinealpouch)
S t
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Spongy part
Average 15 cm in length.
Passes through the bulband corpus spongiosumof the penis to open at theexternal urethral orifice on
the tip of the glans penis. There are two dilatations
bulbar fossa (in thebeginning) and navicularfossa (in the glans penis)
Ducts of the bulbourethralglands open into the floor
of the spongy part in itsbeginning
S hi t f th th
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Sphincters of the urethra
1. Internal urethralsphincter is made ofsmooth muscles in theneck of the bladderand has sympathetic
innervation
2. External urethralsphincter has skeletalmuscle fibers andsurrounds themembranous part ofurethra, supplied bythe perineal branch ofthe pudendal nerve
1
2
62. Hydrocele &
h t l
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hematocele
The tunica vaginalis testisor other remnants of theprocessus vaginalis mayform a hydrocele orhematocele.
With transillumination, ahydrocele produces areddish glow, whereaslight will not penetrateother scrotal masses suchas a hematocele, solidtumor, or herniated bowel.
63 C t hi
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63. Cryptorchism
Undescended testes
(cryptorchism) occurs when the
testes fail to descend into the
scrotum. This normally occurs
within 3 months after birth. The undescended testes may be
found in the abdominal cavity orin the inguinal canal.
If neglected, malignanttransformation may occur in theundescended testis.
N.B. In case of cryptorchism,spermatogenesis is arrestedand the spermatogenic tissue isdamaged leading to permanentsterility in bilateral cases.
64. Lymphatic drainage of the
male viscera
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male viscera
Testis & epididymis lumbarlymph nodes
Scrotum superficial inguinal
nodes
Penis:
skin - superficial inguinal nodes
glans deep inguinal nodes
body and roots internal iliac
nodes
Prostate gland & bladder- internal
iliac nodes
Anal canal: above pectinate line - internal iliac
below pectinate line - superficial
inguinal nodes
65. Lymphatic drainage from
the female viscera
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the female viscera
Ovary and uterine tubes to lumbarlymph nodes
Uterus:
lateral angle and teres ligament superficial inguinal lymph nodes
fundus and upperpart of the body- lumbarlymph nodes
lowerpart of the body - externaliliac lymph nodes
cervix - external & internal iliac
Vagina:
Superior to hymen - to external &internal iliac
Inferior to hymen - to superficial
inguinal nodes
All external genitalia (with exception -glans clitoris) - superficial inguinallymph nodes
Glans clitoris deep inguinal
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66. Arterial supply of the uterusThe uterus is almost exclusively
supplied by the uterinearteries [1] (from internaliliac artery):
Crosses pelvic floor in
transverse cervicalligament on the base ofbroad ligament [2]
Near uterus, passes superiorand anterior to ureter[3]
Ascends along lateral wall[4] of uterus within broadligament
Vaginal branch anastomoseswith vaginal artery [5]
Ovarian branch anastomoseswith ovarian artery [6]
4
3
2
1
5
6
67 P t f th t i t b
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67. Parts of the uterine tube
Uterine part Pierces uterine wall to
open into uterine cavity
Isthmus Narrowest part of tube
just lateral to uterus Ampulla
Medial continuation ofinfundibulum comprisingabout half of uterine tube
Usual site of fertilization
Infundibulum
Funnel-shaped expansionof lateral end, fringed withfimbriae
Overlies ovary andreceives oocyte atovulation
uterus is amped w fun!
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Hysterosalpingography
The instillation of
viscous iodine
through the
external os of the
uterine cervix
allows the lumen of
the cervical canal,
the uterine cavity,
and the different
parts of the
uterine tubes tobe visualized on X-
ray.
68. Foramina of the base
of the skull
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of the skull
Exit of cranial nerves
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Exit of cranial nerves
69. Fracture of the
anterior cranial fossa
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anterior cranial fossa
Fracture of the anterior cranial
fossa (cribriform plate of the
Ethmoid bone) is suggested by
anosmia, periorbital bruising
(raccoon eyes), and CSF leakage
from the nose (rhinorrhea).
70. Development of skull
Sutures of neurocranium
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Sutures of neurocranium
Coronal suture: lies
between the frontal bone
and the two parietal
bones.
Sagittal suture: lies
between the two parietal
bones.
Squamous suture: lies
between the parietal bone
and the squamous part of
the temporal bone. Lambdoid suture: lies
between the two parietal
bones and the occipital
bone.
Cranial Malformations
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Cranial Malformations
[A] Scaphocephaly: premature
closure of the sagittal suture, in
which the anterior fontanelle is small
or absent, results in a long, narrow,
wedge-shaped cranium.
[C] Oxycephaly: premature closureof the coronal suture results in a
high, tower-like cranium.
When premature closure of the
coronal or the lambdoid suture occurs
on one side only, the cranium istwisted and asymmetrical, a condition
known as plagiocephaly [B].
Fontanelles
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Fontanelles
Anterior fontanelle
present at birth; closes
at age 9 to 18 months
diminished size or
absence at birth may
indicatecraniosynostosis or
microcephaly.
Posterior fontanelle
present at birth; usually
closes by age 2 months
Persistence suggests
underlying
hydrocephalus or
congenital
hypothyroidism.
74 Epidural hematoma
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74. Epidural hematoma
Skull fracture near pterion often
causes epidural hematoma from
torn middle meningeal artery.
Unconsciousness and death are
rapid because the bleeding
dissects a wide space as it stripsthe dura from the inner surface of
the skull, which puts pressure on
the brain.
An epidural hematoma forms a
characteristic biconvex pattern on
computed tomography images.
75. Infection of the Cavernous
sinus
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sinus
Lateral to body ofsphenoid bone and sellaturcica, forming lateralwall of hypophyseal fossa
Related structures:
Structures that passthrough sinus:
1. Internal carotid artery andinternal carotid plexus
2. Abducens nerve (CN VI)
Structures on lateral wall ofsinus:
1. Oculomotor nerve (CN III)
2. Trochlear nerve (CN IV)
Ophthalmic Veins
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Ophthalmic Veins
Superior ophthalmic vein
communicates anteriorly with
the facial (angular) vein
Inferior ophthalmic vein
communicates through the
inferior orbital fissure with thepterygoid plexus of veins
Both veins pass posteriorly
through the superior orbital
fissure and drain into theCavernous sinus
76. Layers of the scalp
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1. Skin - contains numerous sweatglands, sebaceous glands, andhair follicles
2. Connective tissue- Densesuperficial fascia containing nervesand blood vessels
3. Aponeurosis (Epicranial) -Fibrousepicranial aponeurosis connectingfrontalis and occipitalis parts ofoccipitofrontalis muscle
4. Loose areolar tissue -Allows 3more superficial layers to moveover skull surface; somewhat like asponge because it contains
innumerable potential spacescapable of being distended withfluid resulting from injury orinfection
5. Pericranium -periosteum coveringthe outer surface of the skull bones
77. Innervation skin of the face
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Skin of face suppliedby branches of thethree divisions of the[1] TRIGEMINAL
NERVE (CN V)
Except for a smallarea over the angleof the mandiblewhich is supplied bythe [2] great
auricular nerve(C2-C3) cervicalplexus
2
1
78 Facial nerve (CN VII)
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78. Facial nerve (CN VII)
FACIAL NERVE (CN VII) -sole motor supply to themuscles of facialexpression and certainother muscles derivedfrom the embryonic 2nd
pharyngeal arch Sensory to the taste buds
in anterior 2/3 of thetongue through thechorda tympani
Secretomotor(parasympathetic) to the
submandibular,sublingual, palatinesalivary glands, glands ofnasal cavity and lacrimalgland
Bell's palsy
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Bell s palsy
It is idiopathic unilateral facial
paralysis (constitutes 75% of
all facial nerve lesions)
Terminal branches of CN VII
may be injured by parotid
canceror by surgery toremove a parotid tumor.
An infant's facial nerve may be
injured during a forceps
delivery because the mastoid
process has not yet developedand the stylomastoid foramen is
relatively superficial.
Lesions of CN VII
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Lesions of CN VII
Symptoms associated with lesions of CN VII are determined by the
location of the lesion in the nerve.
Bels Manifestations:
unable to close lips and eyelids on affected side
eye on affected side is not lubricated (dry eye)
unable to whistle, blow a wind instrument, or chew effectively
facial distortion due to contractions of unopposed contralateral facial
muscles
A lesion within the facial canal will also affect taste from the anterior 2/3
of the tongue carried by the chorda tympani and loss of secretion
from submandibularand sublingual glands ipsilateral to the lesion
79. Communication of the
paranasal sinuses
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paranasal sinuses
Sphenoethmoidal recess
receives the opening of the
sphenoidal air sinus
Superior meatus
Receives opening of
posteriorethmoidal air cells
Middle meatus
Infundibulum, ethmoidal bulla
and semilunar hiatus
Receives openings of frontal
and maxillary sinuses and
anteriorand middleethmoidal air cells
Inferior meatus
Receives opening of
nasolacrimal duct
80. Epistaxis
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p
Epistaxis (nosebleed)most often occurs fromthe anterior nasal septum(Kiesselbach's area),where branches of the
sphenopalatine,anterior ethmoidal,greater palatine, andsuperior labial (fromfacial) arteries converge.
81 Sphenoiditis
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81. Sphenoiditis
Relationships of the
sphenoidal sinus are clinically
important ; because of potential
injury during pituitary
surgery and the possible
spread of infection. Infection can reach the sinuses
through their ostia from the
nasal cavity or through their
floor from the nasopharynx.
Infection may erode the walls toreach the cavernous sinuses,
pituitary gland, optic nerves,
or optic chiasma
82 Cheeks
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82. Cheeks
Form the lateral, movable
walls of the oral cavity and
the zygomatic prominences
of the cheeks over the
zygomatic bones
Buccinator principalmuscle of the cheek
Buccal pad of fat
encapsulated collection of fat
superficial to buccinator
Parotid duct opens in innersurface of the cheek right
opposite 2nd upper molar
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