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1

Blood supply to SA/AV nodes

Right coronary artery (RCA infarct) = nodal dysfunction

2

Dominance in coronary circulation

R-dominant: RCA gives rise to PDA (70%)
L-dominant: LCX gives rise to PDA (20%)
Co-dominant: arises from both (10%)

3

LA can impinge on what 2 structures?

Enlargement of the left atrium can lead to...

- dysphagia: compression of esophagus
- hoarseness: compression of L recurrent laryngeal

4

Adrenal cortex anatomy (also, give stimulation and product of each region)

From the outside in: GFR
G: glomerulosa = stim. by renin-angiotensin system, secretes aldosterone
F: fasciculata = stim. by ACTH/CRH, secretes cortisol
R: reticularis = stim. by ACTH/CRH, secretes DHEA (androgen precursor), DHEA-S (marker for adrenal dysfunction), androstenedione (testosterone precursor)

Increased 17-OHP = congenital adrenal hyperplasia

5

Adrenal medulla derivative, cell type, innervation

neural crest derivative
- chromaffin cells (neural crest), regulated by preganglionic sympathetics
- secretes catecholamines (site of pheochromocytoma)

- neuroblastoma comes from the adrenal medulla

6

Pituitary gland secretory products and embryonic derivative

Anterior: FLAT PiG (FSH, LG, ACTH, TSH, prolactin, GH), derived from oral ectoderm, alpha subunit of hormones is common

Posterior: vasopression and oxytocin (technically made in hypothalamus, then transported by neurophysins), derived from neuroectoderm

7

Pancreatic islet cells organization

Alpha cells: found on periphery of islet (secrete glucagon)
Beta: found in center of islet (secrete insulin)
Delta: found throughout islet (secrete somatostatin)

8

Retroperitoneal structures

SAD PUCKER: Suprarenal (adrenal) glands, Aorta/IVC, Duodenum, Ureters, Colon (asc/desc), Kidneys, Esophagus, Rectum (superior part)

9

GI ligaments to know

Falciform
Hepatoduodenal
Gastrohepatic
Gastrocolic
Gastrosplenic
Splenorenal

Falciform (liver to anterior wall): ligamentum teres hepatis (ventral mesentery)

Hepatoduodenal: portal triad, part of lesser omentum, compression = Pringle maneuver

Gastrohepatic: to lesser curvature of stomach, contains gastric arteries (separates lesser and greater sacs)

Gastrocolic: greater curvature to colon, contains gastroepiploics, part of greater omentum

Gastrosplenic: short gastrics, left gastroepiploics, greater omentum

Splenorenal: splenic artery and vein, tail of pancreas

10

Digestive tract facts

- layers of wall/mucosa
- wave speeds

4 layers in wall: mucosa, submucosa, muscularis, serosa
mucosa = epithelium, lamina propria, muscularis mucosa (site of myenteric plexus)

duodenum: 12/min > ileum: 8-9/min > stomach: 3 waves/min

11

GI tract histology notable features (esophagus, stomach, duodenum, ileum, colon)

Esophagus: non-keratinized stratified squamous

Stomach: gastric glands

Duodenum: villi/microvilli, Brunner glands (HCO3),

Ileum: Peyer's patches,

Colon: no villi! abundant goblet cells

12

Abdominal aorta branch vertebral heights

Celiac T12
SMA L1
Left renal L1
IMA L3
Bifurcation of aorta L4

13

Portosystemic anastomoses

Esophageal: L gastric vein --> esophageal vein (to azygos to SVC)

Umbilical: paraumbilical veins ---> small superficial epigastrics

Rectal: superior rectal --> middle/inferior rectal

Tx: TIPS: portal vein to hepatic vein (bypasses liver entirely)

14

Pectinate line (endoderm meets ectoderm)

Give innervation, blood supply and drainage

Above: internal hemorrhoids (visceral innervation), adenocarcinoma
supplied by IMA, drained to portal vein
Below: external hemorrhoids (somatic = painful!), SCC
supplied by internal pudendal, drains to IVC
anal fissures: posterior due to poor perfusion

15

Liver anatomy (lobule structure, Zones, describe insults)

Apical = bile secretion, basolateral = sinusoids
Blood flow = portal vein (apical) to hepatic vein (basolateral)

Zone 1 (apical, periportal): affected first by viral hepatitis, ingested toxins
Zone 2 (intermediate): location of hepatic infection by yellow fever
Zone 3 (basolateral, centrilobular): affected first by ischemia, location of alcoholic hepatitis/toxic injury and p450 system

16

Femoral triangle (borders and contents)

Superior = inguinal ligament, lateral = sartorius, medial = adductor longus

NAVEL (lateral to medial): Nerve, Artery, Vein, Lymph

femoral sheath: includes artery, vein, lymph (not the nerve!)

17

Inguinal canal layers

Peritoneum, transversalis, transversus abdominus, internal oblique, external oblique, inguinal ligament, superficial inguinal ring

18

Hernias (diaphragmatic, indirect, direct, femoral)

Diaphragmatic: left-sided, hiatal is most common (sliding = upward displacement of GEJ, parasophageal = protrusion of fundus)
Indirect inguinal: processus vaginalis into scrotum, lateral to inferior epigastric (more common in infants!)
Direct inguinal: peritoneum bulges through Hesselbach triangle (older men)
Femoral: below inguinal triangle, lateral to pubic tubercle (more common in females, bowel incarceration)

19

Erythrocyte facts (life span, membrane protein)

life span: 120 days
membrane contains Cl-/HCO3- antiporter (export of HCO3 to allow for CO2 carrying)

20

Thrombocyte facts (life span, granules, receptors)

life span 8-10 days

Dense granules: ADP, Ca2+
Alpha granules: vWF, fibrinogen

vWF receptor: GpIb
fibrinogen receptor: GpIIb, IIIa

21

Neutrophil facts (granules contents, chemotactic factors)

Granules = ALP, collagenase, lysosome, lactoferrin (help with phagocytosis)

chemotactic factors: C5a, IL-8, kallikrein, CTB4

22

Macrophage facts (activation)

activated by IFN-y

septic shock mediator: responds to Lipid A, LPS, CD14

23

Eosinophil (give 5 causes of eosinophilia)

5 causes of increased eos:

neoplasia, asthma, allergies, chronic adrenal insufficiency, parasite

24

Basophil granules

Heparin and histamine
Mediate allergic reactions

25

Mast cell facts

local allergic reaction, bind Fc of IgE in allergic reactions
Type I hypersensitivity reactions
- cromolyn sodium = decreased histamine release (used to prevent asthma attacks)

26

Lymphocyte facts (receptors, site of maturation)

B cell
T cell
Plasma cell

B cell (CD19/20, surface, 21, EBV receptor) - mature in bone marrow, stored in peripheral lymphoid tissue
T cell (CD3, then CD4/8) - matures in thymus (CD4+ = HIV target)
Plasma cell - clock-face chromatin, abundant RER, well-developed Golgi (multiple myeloma is a plasma cell cancer!)

27

Drawer test

ACL/PCL injury (abnormal anterior drawer = ACL injury)
ACL inserts on the anterior aspect of the tibia from the lateral femoral condyle
PCL inserts on posterior aspect of the tibia from the medial femoral condyle

28

McMurray test

click on external rotation = medial meniscus tear
click on internal rotation = lateral meniscus tear

29

Unhappy triad of knee injuries

ACL tear
MCL tear
medial/lateral meniscus

30

Baker cyst

popliteal fluid collection, related to chronic joint disease (knee arthritis or meniscal tear)

31

Most common rotator cuff injury

Supraspinatus

Test with empty can test

32

Pitching injury

Infraspinatus

33

Epicondylitis

Medial = golfer's (repeated flexion)
Lateral = tennis (repeated extension)

34

Wrist bone syndromes (also, give bones of the wrist)

So Long To (Triq) Pinky, Here Comes The (Trapezoid) Thumb (Trapezium)

Scaphoid: avascular necrosis due to retrograde blood supply

Lunate: acute carpal tunnel syndrome

35

Carpal tunnel associations

Pregnancy, rheumatoid arthritis, hypothyroidism

36

Guyon canal syndrome (give association)

Compression of ulnar nerve at the wrist

Often seen in cyclists

37

Humerus surgical neck fracture

Axillary nerve injury
Decreased abduction of arm at shoulder
Decreased sensation over the deltoid

38

Upper trunk of brachial plexus compression

Musculocutaneous nerve injury
Decreased forearm flexion at elbow, supination
Decreased sensation over lateral forearm

39

Midshaft humerus fracture

Radial nerve injury (lies in spiral groove)
Leads to wrist drop (loss of extensors), decreased grip strength
Loss of sensation over posterior arm and dorsal hand

40

Supracondylar fracture of humerus

Median nerve injury
Loss of wrist flexion, 2nd/3rd finger flexion (ape hand, Pope's blessing)
Loss of sensation over thenar eminence
Tinel sign - tingling on percussion

41

Fracture of medial epicondyle of humerus

Ulnar nerve injury
Loss of wrist flexion, flexion of ulnar fingers, interossei
Loss of sensation over ulnar hand

42

Superficial laceration of palm

recurrent branch of median nerve
Loss of thenar muscle group: opposition, abduction, flexion of thumb
No loss of sensation

43

Tear of upper trunk (lateral pull during dystocia)

Erb's Palsy (tear of C5-C6 nerve roots)
Waiter's tip: arm adducted (deltoid), internally rotated (infraspinatus), extended (biceps)

44

Tear of lower trunk (upward pull during dystocia)

Klumpke's palsy (tear of C8-T1 nerve roots)
Total claw hand: loss of lumbricals, interossei, thenar and hypothenar eminence

45

Compression of lower trunk and subclavian vessels (extra cervical rib, Pancoast tumor)

Thoracic outlet syndrome
Same muscle deficits as Klumpke's, but also ischemia, pain and edema due to vascular compression

46

Winged scapula

lesion of long thoracic nerve (axillary node resection)
Loss of serratus anterior

47

Pope's blessing (first two extended, last two flexed)

If present during extension/rest: distal ulnar lesion (ulnar clawing)
If present during flexion: proximal median lesion

48

Okay sign (first two flexed, last two extended)

If present during extension/rest: distal median lesion (median clawing)
If present during flexion: proximal ulnar lesion

49

Thenar eminence muscles

Opponens pollicus, Abducens pollicus longus, Flexor pollicus longus

Innervated by median nerve

50

Hypothenar eminence muscles

Opponens digiti minimu, Abductor digiti minimi, Flexor digiti minimi

Innervated by ulnar nerve

51

Interossei function and innervation

Dorsal = abduction
Palmar = adduction

DAB, PAD

Innervated by ulnar nerve

52

Pelvic surgery nerve injury (motor and sensory deficits)

Obturator (L2-L4)
decreased thigh sensation
decreased adduction

53

Pelvic fracture nerve injury (motor and sensory deficits)

Femoral (L2-L4)
decreased thigh flexion, leg extension

54

Trauma/compression of lateral leg
Fibular neck fracture

Common peroneal nerve injury (L4-S2)
Foot drop, steppage gait
Loss of eversion and dorsiflexion

PED = peroneal everts and dorsiflexes

55

Knee trauma
Baker cyst
Tarsal tunnel syndrome

Tibial nerve injury (L4-S3)
Loss of sole of feet
Inability to curl toes

TIP: tibial inverts and plantarflexes

56

IM injection nerve injury

Superior gluteal (L4-S1)
trendelenburg gait
Lesion is on the side on which the patient stands (opposite to the hip that drops)

57

Posterior hip dislocation

Inferior gluteal (L5-S2)
difficulty climbing stairs, rising from seated position
Loss of hip extension

58

Nerve block during birth

Pudendal nerve
Innervates perineum
Found near ischial spine

59

Lumbosacral radiculopathy

Nerve is inferior to the disc (L4 nerve is damaged in L3-L4 herniation)

L3-L4: decreased patellar reflex
L4-L5: decreased dorsiflexion, no heel-walking
L5-S1: decreased plantarflexion, difficulty in toe-walking, decreased Achilles reflex

60

Proteins involved in muscle conduction to contraction

Nerve: presynaptic Ca channels, NT release
Muscle cell: DHP receptor (voltage-gated), ryanodine (sarcoplasmic reticulum), troponin C (moves tropomysoin out of the myosin-binding groove)

61

Myosin cycle in muscle contraction

After opening of binding groove by troponin C...
- myosin binds to actin filament
- myosin releases ADP and Pi in the power stroke
- new ATP binds and causes detachment of myosin from actin
- hydrolysis of ATP cocks myosin into high-energy position for next cycle

62

Skeletal muscle microscopic structure

Z-line - borders of the sarcomere (center of light actin chain)
M-line - middle of the sarcomere (center of heavy myosin chain)
A-band - Myosin heavy chain, Always same length!
H-band - distance between light chains (myosin only)
I-band - distance between heavy chains (actin only)

During contraction, H-band and I-band contract, and Z-lines and M-lines move closer together

63

Type 1 vs. Type 2 muscle fibers

Type 1: slow twitch, reddish color due to increased myoglobin concentration and increased mitochondria for sustained contraction (1 slow red ox)

Type 2: fast twitch, white fibers from decreased mitochondria, increased anaerobic glycolysis (weight-training = increased fast-twitch muscle)

64

Smooth muscle contraction

mediated by calcium, regulated by calmodulin
L-type voltage gated channel allows Ca influx, increases myosin-light-chain kinase activity (MLCK), increased myosin-P + actin, contraction via cross-bridging

65

Smooth muscle relaxation

mediated by NO
Increases intracellular guanylate cyclase, increased cGMP, increased myosin-light-chain phosphorylase (MLCP)

66

Endochondral bone formation

Axial/appendicular skeleton
Chondrocytes make cartilaginous model, which is later replaced by osteoclasts/blasts to remodel into lamellar bone
Woven bone is formed later after fractures and in Paget disease

67

Membranous ossification

Bones of calvarium/skull, facial bones
Woven bone formed without cartilage first, later remodeled to lamellar bone

68

Effect of PTH on bone

low levels = anabolic effects (building bone)
high levels = catabolic effects (osteitis fibrosa cystica)

69

Estrogen effects on bone

Induces apoptosis in bone-resorbing osteoclasts

Decreased estrogen leads to excess remodeling/resorption --> osteoporosis

70

Ureter course

The ureters pass under the uterine artery (or under the vas deferens) prior to entering the bladder

71

Venous drainage of the gonads

Left gonadal veins drain into the L renal vein at a 90 degree angle, thus have less laminar flow, therefore increased risk of varicocele on the left (dilation of pampiniform plexus)
Right gonadal vein drains directly into the IVC

72

Lymphatic drainage of the gonads

ovaries/testes --> paraaortic
Distal vagina/scrotum --> superficial inguinal
Proximal vagina --> obturator/hypogastric nodes

73

Infundibulopelvic ligament

Suspensory ligament
ovaries --> lateral pelvic wall
contains *ovarian* vessels!
When operating, there is risk of ligating the ureter

74

Cardinal ligament

cervix --> pelvic side wall
contains *uterine* vessels

75

Round ligament

Uterine fundus --> labia majora
contains artery of Sampson
(remnant of gubernaculum)

76

Broad ligament

uterus/ovaries --> side pelvic wall

77

Ovarian ligament

ovary --> uterus
(remnant of gubernaculum)

78

Histology of female repro tract
(stratified squamous, simple columnar, simple cuboidal)

Stratified squamous: vagina, ectocervix
Simple columnar: endocervix, uterus (glands are tubular in follicular phase, coiled in luteal phase), fallopian tube (ciliated)
Simple cuboidal: outer surface of ovary

79

SEVEN-UP

Seminiferous tubules
Epididymis
Vas deferens
Ejaculatory duct
(nothing)
Urethra
Penis

80

Urethra segments

Posterior: membranous (pelvis fractures), bulbar (blunt force)
Anterior: penile (perineal straddle - leads to urine Buck's fascia)

81

Erection mechanisms (nerves: pelvic, hypogastric, pudendal)

NO --> increased cGMP --> smooth muscle relaxation --> vasodilation

Norepinephrine --> increased [Ca]i --> smooth muscle contraction --> vasconstriction

Emission: sympathetic
Ejaculation: visceral/somatic

82

Sertoli cell functions

- located in tubule wall
- secrete inhibin B (responds to FSH) = decreased FSH
- forms blood-sperm barrier (tight junctions)
- temperature sensitive (increased temp = decreased inhibin, decreased sperm)

83

Leydig cell functions

increased LH = increased testosterone

unaffected by temperature

84

Conducting zone of lungs

no gas exchange!
anatomic dead space
Cartilage/goblet cells - until the end of bronchi
Pseudostratified ciliated columnar cells - until end of terminal bronchioles (therefore, mucociliary clearance happens until end of terminal bronchioles)

85

Respiratory zone

lung parenchyma: respiratory bronchioles, alveolar ducts, alveoli

Mostly cuboidal until alveoli, then simple squamous

86

Pneumocytes (Type I, Type II, Clara)

Type I: line alveoli, squamous, gas diffusion
Type II: pulmonary surfactant, cuboidal/clustered
- precursors to Type I and other Type II
- proliferate during lung damage

Clara cells: non-ciliated, secretory granules
- secrete part of surfactant, degrade toxins

87

Bifurcations to know: (all at 4!)

Common carotid: C4
Trachea: T4
Abdominal aorta: L4