MRCS 1 Flashcards
(182 cards)
1
Q
NICE guidelines stress vs urge urinary incontinence
A
Initial assessment urinary incontinence should be classified as stress/urge/mixed.
At least 3/7 bladder diary if unable to classify easily.
Start conservative treatment before urodynamic studies if a diagnosis is obvious from the history
Urodynamic studies if plans for surgery.
Stress incontinence: Pelvic floor exercises 3/12, if fails consider surgery.
Urge incontinence: Bladder training >6/52, if fails for oxybutynin (antimuscarinic drugs) then sacral nerve stimulation.
Pelvic floor exercises offered to all women in their 1st pregnancy.
2
Q
What is stress inconcinence
A
50% of cases, especially in females.
Damage (often obstetric) to the supporting structures surrounding the bladder may lead to urethral hypermobility.
Other cases due to sphincter dysfunction, usually from neurological disorders (e.g. Pudendal neuropathy, multiple sclerosis).
Urethral mobility:
Pressure not transmitted appropriately to the urethra resulting in involuntary passage of urine during episodes of raised intra-abdominal pressure.
Sphincter dysfunction:
Sphincter fails to adapt to compress urethra resulting in involuntary passage of urine. When the sphincter completely fails there is often to continuous passage of urine.
3
Q
Urge incontinence
A
In these patients there is sense of urgency followed by incontinence. The detrusor muscle in these patients is unstable and urodynamic investigation will demonstrate overactivity of the detrusor muscle at inappropriate times (e.g. Bladder filling). Urgency may be seen in patients with overt neurological disorders and those without. The pathophysiology is not well understood but poor central and peripheral co-ordination of the events surrounding bladder filling are the main processes.
4
Q
Which of the following is the equivalent of cardiac preload?
A
Preload is the same as end diastolic volume. When it is increased slightly there is an associated increase in cardiac output (Frank Starling principle).
5
Q
Which of the following is responsible for the release and synthesis of calcitonin?
A
Secreted by C cells of thyroid and
Inhibits intestinal calcium absorption
Inhibits osteoclast activity
Inhibits renal tubular absorption of calcium
6
Q
Which of the substances below is derived primarily from the zona reticularis of the adrenal gland?
A
Zona glomerulosa Outer zone Aldosterone
Zona fasiculata Middle zone Glucocorticoids
Zona reticularis Inner zone Androgens
7
Q
Which part of the jugular venous waveform is associated with the closure of the tricuspid valve?
A
JVP: C wave - closure of the tricuspid valve
a’ wave = atrial contraction
‘c’ wave
closure of tricuspid valve
‘v’ wave
due to passive filling of blood into the atrium against a closed tricuspid valve
‘x’ descent = fall in atrial pressure during ventricular systole
‘y’ descent = opening of tricuspid valve
8
Q
PE blood gas?
A
combination of hypoxia and respiratory alkalosis should suggest a pulmonary embolus. The respiratory alkalosis is due to hyperventilation associated with the pulmonary embolism.
9
Q
What decreases the functional residual capacity?
A
Is the volume of air remaining in the lungs at the end of a normal expiration.
FRC = RV + ERV. 2500mls.
Pulmonary fibrosis Laparoscopic surgery Obesity Abdominal swelling Muscle relaxants
10
Q
What increases functional residual capacity?
A
Increased FRC:
Erect position
Emphysema
Asthma
11
Q
Which part of the ECG represents atrial depolarization?
A
The P wave represents atrial depolarization. Note that atrial repolarization is obscured within the QRS complex.
T wave
Represents ventricular repolarization and is longer in duration than depolarization
12
Q
Triad of Wernicke encephalopathy:
A
Acute confusion
Ataxia
Ophthalmoplegia
13
Q
Describe Monroe-Kelly doctrine.
A
considers the skull as a closed box. Increases in mass can be accommodated by loss of CSF. Once a critical point is reached (usually 100- 120ml of CSF lost) there can be no further compensation and ICP rises sharply.
The next step is that pressure will begin to equate with MAP and neuronal death will occur. Herniation will also accompany this process.
14
Q
lumbar puncture performed
A
Samples of CSF are normally obtained by inserting a needle between the third and fourth lumbar vertebrae. The tip of the needle lies in the sub arachnoid space, the spinal cord terminates at L1 and is not at risk of injury. Clinical evidence of raised intracranial pressure is a contraindication to lumbar puncture. Composition Glucose: 50-80mg/dl Protein: 15-40 mg/dl Red blood cells: Nil White blood cells: 0-3 cells/ mm3
15
Q
CPP calculation
A
Cerebral perfusion pressure= Mean arterial pressure - intra cranial pressure
The cerebral perfusion pressure (CPP) is defined as being the net pressure gradient causing blood flow to the brain. The CPP is tightly autoregulated to maximise cerebral perfusion. A sharp rise in CPP may result in a rising ICP, a fall in CPP may result in cerebral ischaemia. It may be calculated by the following equation:
16
Q
MAP
A
1/3 SBP+ 2/3 DBP
17
Q
What is the normal intracranial pressure?
A
The normal intracranial pressure is between 7 and 15 mm Hg. The brain can accommodate increases up to 24 mm Hg, thereafter clinical features will become evident.
18
Q
Which main group of receptors does dobutamine bind to?
A
Inotrope Cardiovascular receptor action Adrenaline α-1, α-2, β-1, β-2 Noradrenaline α-1,( α-2), (β-1), (β-2) Dobutamine β-1, (β 2) Dopamine (α-1), (α-2), (β-1), D-1,D-2
19
Q
Effects of adrenergig receptor binding
A
α-1, α-2 vasoconstriction β-1 increased cardiac contractility and HR β-2 vasodilatation D-1 renal and spleen vasodilatation D-2 inhibits release of noradrenaline
20
Q
Factors stimulating renin secretion
A
Hypotension causing reduced renal perfusion Hyponatraemia Sympathetic nerve stimulation Catecholamines Erect posture
21
Q
Factors reducing renin secretion
A
Drugs: beta-blockers, NSAIDs
22
Q
What do parietal cells secrete
what to chief cells secrete
what to mucosal cells secrete
A
Chief of Pepsi cola = Chief cells secrete PEPSInogen
Parietal cells: secrete HCl, Ca, Na, Mg and intrinsic factor
Chief cells: secrete pepsinogen
Surface mucosal cells: secrete mucus and bicarbonate
23
Q
IV Pamidronate
A
Calcium > 3.5 mmol/l
24
Q
Urgent management of hyperCa is indicated if:
A
Calcium > 3.5 mmol/l
Reduced consciousness
Severe abdominal pain
Pre renal failure
25
At what site is most dietary iron absorbed?
Iron is best absorbed from the proximal small bowel (duodenum and jejunum) in the Fe 2+ state.
26
Felty's syndrome
heumatoid arthritis (RA), an enlarged spleen (splenomegaly) and a decreased white blood cell count (neutropenia)
27
Stimulation of insulin release:
```
Glucose
Amino acid
Vagal cholinergic
Secretin/Gastrin/CCK
Fatty acids
Beta adrenergic drugs
```
28
Which of factors are sensitive to temperature
Factors V and VIII are sensitive to temperature which is the reason why FFP is frozen soon after collection.
29
Where does spironolactone act in the kidney?
Spironolactone is an aldosterone antagonist which acts at in the distal convoluted tubule.
30
The acute phase response includes:
```
acute phase proteins
Reduction of transport proteins (albumin, transferrin)
Hepatic sequestration cations
Pyrexia
Neutrophil leucocytosis
Increased muscle proteolysis
Changes in vascular permeability
```
31
Relative Glucocorticoid activity:
hydrocortisone
prednisolone
dexamethasone
Relative Glucocorticoid activity:
```
Hydrocortisone = 1
Prednisolone = 4
Dexamethasone = 25
```
32
excess glucocorticoids side effects
```
Thinning of the skin, osteonecrosis and osteoporosis are all common. Steroids are associated with retention of sodium and water. Potassium loss may occur and hypokalaemic alkalosis has been reported.
ctions
Glycogenolysis
Gluconeogenesis
Protein catabolism
Lipolysis
Stress response
Anti-inflammatory
Decrease protein in bones
Increase gastric acid
Increases neutrophils/platelets/red blood cells
Inhibits fibroblastic activity
```
33
Causes of scapula winging
Winging of Scapula occurs in
- long thoracic nerve injury (most common)
- or from spinal accessory nerve injury (which denervates the trapezius)
- or a dorsal scapular nerve injury
34
Long thoracic nerve
Derived from ventral rami of C5, C6, and C7 (close to their emergence from intervertebral foramina)
It runs downward and passes either anterior or posterior to the middle scalene muscle
It reaches upper tip of serratus anterior muscle and descends on outer surface of this muscle, giving branches into it
35
Extra peritoneal rectum
Posterior upper third
Posterior and lateral middle third
Whole lower third
36
Arterial supply to rectum
Superior rectal artery
Middle rectal artery (from the internal iliac)
Inferior rectal artery (from the pudendal vessels)
37
Venous drainage of rectum
Superior rectal vein
Inferior rectal vein
Note the venous drainage is a site of portosystemic anastomosis.
38
Lymphatic drainage rectum
```
Mesorectal lymph nodes (superior to dentate line)
Inguinal nodes (inferior to dentate line)
```
39
Inferior vena cava tributaries
```
Mnemonic for these: : I Like To Rise So High
Iliacs
Lumbar
Testicular
Renal
Suprarenal
Hepatic vein
```
40
Pathway of the IVC
Left and right common iliac veins merge to form the IVC. (L5)
Passes right of midline
Paired segmental lumbar veins drain into the IVC throughout its length
The right gonadal vein empties directly into the cava and the left gonadal vein generally empties into the left renal vein.
The next major veins are the renal veins and the hepatic veins
Pierces the central tendon of diaphragm at T8
Right atrium
41
Relations of IVC
Anteriorly:
small bowel, first and third part of duodenum, head of pancreas, liver and bile duct, right common iliac artery, right gonadal artery
Posteriorly:
Right renal artery, right psoas, right sympathetic chain, coeliac ganglion
42
Inferior vena cava tributaries and their levels
```
T8 Hepatic vein, inferior phrenic vein, pierces diaphragm
L1 Right suprarenal vein, renal vein
L2 Gonadal vein
L1-5 Lumbar veins
L5 Common iliac vein, formation of IVC
```
43
radial nerve course
The radial nerve runs in its groove on between the two heads (lateral and medial head of triceps muscle)
44
The ulnar nerve lies
anterior to the medial head of triceps
45
axillary nerve
The axillary nerve passes through the quadrangular space. This lies superior to lateral head of the triceps muscle and thus the lateral border of the quadrangular space is the humerus.
46
Triceps muscle - Origin
Has 3 heads - long, lateral and medial.
Origins of each
Long head- infraglenoid tubercle of the scapula.
Lateral head- dorsal surface of the humerus, lateral and proximal to the groove of the radial nerve
Medial head- posterior surface of the humerus on the inferomedial side of the radial groove and both of the intermuscular septae
47
Triceps- insertion
Olecranon process of the ulna.
Here the olecranon bursa is between the triceps tendon and olecranon.
Some fibres insert to the deep fascia of the forearm, posterior capsule of the elbow (preventing the capsule from being trapped between olecranon and olecranon fossa during extension)
48
Triceps muscle inntervation
Innervation - radial nerve
49
Triceps blood supply
Blood supply - profunda brachii artery
50
triceps action
Action
| Elbow extension. The long head can adduct the humerus and extend it from a flexed position
51
Triceps Relations
The radial nerve and profunda brachii vessels lie between the lateral and medial heads
52
Vertebral column. how many at each level
```
There are
7 cervical,
12 thoracic,
5 lumbar, and
5 sacral vertebrae.
```
53
Spinal cord relative levels in respect to the vertebrae
The spinal cord segmental levels do not necessarily correspond to the vertebral segments.
C1 cord is located at the C1 vertebra
C8 cord is situated at the C7 vertebra
T1 cord is situated at the T1 vertebra
T12 cord is situated at the T8 vertebra.
The lumbar cord is situated between T9 and T11
The sacral cord is situated between the T12 to L2 vertebrae.
The spinal cord is approximately 45cm in men and 43cm in women. The denticulate ligament is a continuation of the pia mater (innermost covering of the spinal cord) which has intermittent lateral projections attaching the spinal cord to the dura mater
54
Cervical vertebrae
The interface between C1-2 atlanto-axis junction.
| The C3 cord contains the phrenic nucleus.
55
Muscles and nerve root values of C spine
```
Muscle Nerve root value
Deltoid C5,6
Biceps C5,6
Wrist extensors C6-8
Triceps C6-8
Wrist flexors C6-T1
Hand muscles C8-T1
```
56
Thoracic vertebrae
The thoracic vertebral segments are defined by those that have a rib. The spinal roots form the intercostal nerves that run on the bottom side of the ribs and these nerves control the intercostal muscles and associated dermatomes.
57
Lumbosacral vertebrae
Form the remainder of the segments below the vertebrae of the thorax. The lumbosacral spinal cord, however, starts at about T9 and continues only to L2. It contains most of the segments that innervate the hip and legs, as well as the buttocks and anal regions.
58
Cauda Equina
The spinal cord ends at L1-L2 vertebral level. The tip of the spinal cord is called the conus. Below the conus, there is a spray of spinal roots that is called the cauda equina. Injuries below L2 represent injuries to spinal roots rather than the spinal cord proper.
59
Structures within the right atrium
Musculi pectinati
Crista terminalis
Opening of the coronary sinus
Fossa ovalis
60
Cranial nerves carrying parasympathetic fibres
X IX VII III (1973)
III (oculomotor) Pupillary constriction and accommodation
VII (facial) Lacrimal gland, submandibular and sublingual glands
IX (glossopharyngeal) Parotid
X (vagus) Heart and abdominal viscera
61
Oesophagus
how long?
start and end?
covering?
25cm long
Starts at C6 vertebra, pierces diaphragm at T10 and ends at T11
Squamous epithelium
62
What are the constrictions of the oesophagus and how far are they from the incisors?
```
Structure Distance from incisors
Cricoid cartilage 15cm
Arch of the Aorta 22.5cm
Left principal bronchus 27cm
Diaphragmatic hiatus 40cm
```
63
Arterial supply to the oesophagus
Arteriarl supplies to oesophagus
Upper third Inferior thyroid
Mid third Aortic branches
Lower third Left gastric
64
venous drainage oesophagus
Veins
Upper third Inferior thyroid
Mid third Azygos branches
Lower third Left gastric
65
oesophagus lymphatic drainage
Upper third - deep cervical
Middle third - mediastinal
Lower third - gastric
66
Oesophagus nerv. supply
Upper half is supplied by the recurrent laryngeal nerve
| Lower half by oesophageal plexus (vagus)
67
Histology oesophagus
Mucosa :Non-keratinized stratified squamous epithelium
Submucosa: glandular tissue
Muscularis externa (muscularis): composition varies. upper third - striated muscle, middle third - striated and smooth, lower third - smooth muscle
Adventitia
68
Superior mesenteric artery
| start and how far does it supply
Branches off aorta at L1
Supplies small bowel from duodenum (distal to ampulla of vater) through to mid transverse colon
Takes more oblique angle from aorta and thus more likely to recieve emboli than coeliac axis
69
Relations of superior mesenteric artery
Superiorly: Neck of pancreas
Postero-inferiorly: Third part of duodenum Uncinate process
Posteriorly: Left renal vein
Right: Superior mesenteric vein
70
Branches of the superior mesenteric artery
```
Inferior pancreatico-duodenal artery (SMA passes under the neck of the pancreas prior to giving its first branch the inferior pancreatico-duodenal artery)
Jejunal and ileal arcades
Ileo-colic artery
Right colic artery
Middle colic artery
```
71
The structures passing behind the medial malleolus
from anterior to posterior include: tibialis posterior, flexor digitorum longus, posterior tibial vein, posterior tibial artery, nerve, flexor hallucis longus.
72
Ankle joint
```
The ankle joint is a synovial joint composed of the tibia and fibula superiorly and the talus inferiorly.
Movements at the ankle joint
Plantar flexion (55 degrees)
Dorsiflexion (35 degrees)
Inversion and eversion movements occur at the level of the sub talar joint
```
73
Ligaments of the ankle joint
```
Deltoid ligament (medially)
Lateral collateral ligament
Talofibular ligaments (both anteriorly and posteriorly)
The calcaneofibular ligament is separate from the fibrous capsule of the joint. The two talofibular ligaments are fused with it.
```
74
The components of the syndesmosis are
Antero-inferior tibiofibular ligament
Postero-inferior tibiofibular ligament
Inferior transverse tibiofibular ligament
Interosseous ligament
75
Nerve supply to ankle joint
Nerve supply
| Branches of deep peroneal and tibial nerves.
76
which muscles does median nerve innervate in the hand?
```
Hand (Motor):
Lateral 2 lumbricals
Opponens pollicis
Abductor pollicis brevis
Flexor pollicis brevis
```
77
Forearm median nerve branches and innervates which of the muscles?
```
Pronator teres
Pronator quadratus
Flexor carpi radialis
Palmaris longus
Flexor digitorum superficialis
Flexor pollicis longus
Flexor digitorum profundus (only the radial half)
```
78
There are 3 patterns of damage of median nerve.
| how this would clinically present if the injury is at the level of the wrist
Patterns of damage
Damage at wrist
e.g. carpal tunnel syndrome
paralysis and wasting of thenar eminence muscles and opponens pollicis (ape hand deformity)
sensory loss to palmar aspect of lateral (radial) 2 ½ fingers
79
There are 3 patterns of damage of median nerve.
| how this would clinically present if the injury is at elbow
unable to pronate forearm
weak wrist flexion
ulnar deviation of wrist
80
There are 3 patterns of damage of median nerve.
| how this would clinically present if the injury is just below elbow?
would present as anterior interosseous nerve (branch of median nerve) damage:
leaves just below the elbow
results in loss of pronation of forearm and weakness of long flexors of thumb and index finger
81
Describe McEvedy incision
traditionally used to approach incarcerated femoral hernias.
| Groin incision e.g. Emergency repair strangulated femoral hernia
82
```
Waldeyers fascia- ?
Sibsons fascia- ?
Bucks fascia- ?
Gerotas fascia- ?
Denonvilliers fascia- ?
```
```
Waldeyers fascia- Posterior ano-rectum
Sibsons fascia- Lung apex
Bucks fascia- Base of penis
Gerotas fascia- Surrounding kidney
Denonvilliers fascia- Between rectum and prostate
```
83
Renal anatomy
approx 11cm long, 5cm wide and 3cm thick.
located in a deep gutter alongside the projecting vertebral bodies, on the anterior surface of psoas major.
In most cases the left kidney lies approximately 1.5cm higher than the right.
The upper pole of both kidneys approximates with the 11th rib (beware pneumothorax during nephrectomy).
On the left hand side the hilum is located at the L1 vertebral level and the right kidney at level L1-2. The lower border of the kidneys is usually alongside L3.
84
Hilium of kidneys lt and right
left hand side the hilum is located at the L1 vertebral level and the right kidney at level L1-2.
85
anatomical relations of the right kidney
Posterior Quadratus lumborum, diaphragm, psoas major, transversus abdominis
Anterior Hepatic flexure of colon
Superior Liver, adrenal gland
86
anatomical relations of left kidney
Posterior Quadratus lumborum, diaphragm, psoas major, transversus abdominis
anterior - Stomach, Pancreatic tail
superior - Spleen, adrenal gland
87
Structures at the renal hilum
The renal vein lies most anteriorly, then renal artery (it is an end artery) and the ureter lies most posterior.
88
Fascial covering of kidneys.
Each kidney and suprarenal gland is enclosed within a common layer of investing fascia, derived from the transversalis fascia. It is divided into anterior and posterior layers (Gerotas fascia).
89
Renal structure
Kidneys are surrounded by an outer cortex and an inner medulla which usually contains between 6 and 10 pyramidal structures. The papilla marks the innermost apex of these. They terminate at the renal pelvis, into the ureter.
Lying in a hollow within the kidney is the renal sinus. This contains:
1. Branches of the renal artery
2. Tributaries of the renal vein
3. Major and minor calyces's
4. Fat
90
Where does the middle colic vein drain to ?
middle colonic vein drains into the SMV
91
Pudendal canal
pudendal canal is located along the lateral wall of the ischioanal fossa at the inferior margin of the obturator internus muscle. It extends from the lesser sciatic foramen to the posterior margin of the urogenital diaphragm. It conveys the internal pudendal vessels and nerve.
92
intrinsic hand muscles
```
Mnemonic for intrinsic hand muscles
'A OF A OF A'
A bductor pollicis brevis
O pponens pollicis
F lexor pollicis brevis
A dductor pollicis (thenar muscles)
O pponens digiti minimi
F lexor digiti minimi brevis
A bductor digiti minimi (hypothenar muscles)
```
93
Structures transmitted through Superior orbital fissure
```
Recurrent meningeal artery*
Lacrimal nerve
Trochlear nerve
Abducens nerve
Superior opthalmic vein
Superior division of the oculomotor nerve
```
94
Inferior orbital fissure
Maxillary nerve
Inferior opthalmic vein
Zygomatic nerve
95
Optic foramen
Optic nerve
| Opthalmic artery
96
How many collateral circulations exist as alternative pathways of venous return?
```
There are 4 collateral venous systems:
There are 4 collateral venous systems:
Azygos venous system
Internal mammary venous pathway
Long thoracic venous system with connections to the femoral and vertebral veins (2 pathways)
```
97
right adrenalectomy - brisk bleeding. Supply?
It drains directly via a very short vessel. If the sutures are not carefully tied then it may be avulsed off the IVC. An injury best managed using a Satinsky clamp and a 6/0 prolene suture.
98
Transpyloric plane
| Level of the body of L1
```
Pylorus stomach
Left kidney hilum (L1- left one!)
Fundus of the gallbladder
Neck of pancreas
Duodenojejunal flexure
Superior mesenteric artery
Portal vein
Left and right colic flexure
Root of the transverse mesocolon
2nd part of the duodenum
Upper part of conus medullaris
Spleen
```
99
What level does IMA leave aorta?
The inferior mesenteric artery leaves the aorta at L3.
100
The vertebral artery traverses all of the following except?
The vertebral artery passes through the foramina which are located in the transverse processes of the cervical vertebra, it does not traverse the intervertebral foramen.
101
Lung anatomy
The right lung is composed of 3 lobes divided by the oblique and transverse fissures.
The left lung has two lobes divided by the oblique fissure.
The apex of both lungs is approximately 4cm superior to the sterno-costal joint of the first rib. Immediately below this is a sulcus created by the subclavian artery.
102
Peripheral contact points of the lung
Base: diaphragm
Costal surface: corresponds to the cavity of the chest
Mediastinal surface: Contacts the mediastinal pleura. Has the cardiac impression. Above and behind this concavity is a triangular depression named the hilum, where the structures which form the root of the lung enter and leave the viscus. These structures are invested by pleura, which, below the hilum and behind the pericardial impression, forms the pulmonary ligament
103
Right lung anatomy and relations around it
Above the hilum is the azygos vein;
Superior to this is the groove for the superior vena cava and right innominate vein; behind this, and nearer the apex, is a furrow for the innominate artery.
Behind the hilum and the attachment of the pulmonary ligament is a vertical groove for the oesophagus;
In front and to the right of the lower part of the oesophageal groove is a deep concavity for the extrapericardiac portion of the inferior vena cava.
The root of the right lung lies behind the superior vena cava and the right atrium, and below the azygos vein.
The right main bronchus is shorter, wider and more vertical than the left main bronchus and therefore the route taken by most foreign bodies.
104
Left lung and relations to it
Above the hilum is the furrow produced by the aortic arch, and then superiorly the groove accommodating the left subclavian artery; Behind the hilum and pulmonary ligament is a vertical groove produced by the descending aorta, and in front of this, near the base of the lung, is the lower part of the oesophagus.
The root of the left lung passes under the aortic arch and in front of the descending aorta.
105
Inferior borders of both lungs
6th rib in mid clavicular line
8th rib in mid axillary line
10th rib posteriorly
106
Diaphragmatic hernia types and symptoms.
protrussion of abdominal contents into the thoracic cavity through small defects in the diaphragm.
Usually left-sided, and cause significant respiratory issues due to lung compression (lung and pulmonary vasculature become underdeveloped). This can lead to pulmonary HTN.
Symptoms:
The finding of a scaphoid abdomen and respiratory distress suggests extensive intra thoracic herniation of the abdominal contents. Bowel sounds in thorax, no breath sounds.
This is seen most frequently with Bochdalek hernias. Morgagni hernias seldom present in such a dramatic fashion. The other options do not typically present with the symptoms and signs described.
Workup: CXR - intestine protruding into the chest. Sometimes can be diagnosed prenatally with ultrasound.
Treatment: surgical repair.
Morgagni - failure of fusion between septum transversum and lateral body wall
Diaphragmatic hernia types
Morgagni Anteriorly located, Minimal compromise on lung development, Minimal signs on antenatal ultrasound, Usually present later, Usually good prognosis
Bochdalek hernia Posteriorly located, Larger defect, Often diagnosed antenatally, Associated with pulmonary hypoplasia, Poor prognosis
107
quadrangular space borders
quadrangular space is bordered by the humerus laterally, subscapularis and teres minor superiorly, teres major inferiorly and the long head of triceps medially. It lies lateral to the triangular space. It transmits the axillary nerve and posterior circumflex humeral artery.
108
Structures passing through the parotid gland
Facial nerve and branches
External carotid artery (and its branches; the maxillary and superficial temporal)
Retromandibular vein
Auriculotemporal nerve
109
What forms retromandibular vein
The maxillary vein joins to the superficial temporal vein and they form the retromandibular vein which then runs through the parotid gland.
110
Describe Freys Syndrome
The auriculotemporal nerve runs through the gland. Following a parotidectomy this nerve may be damaged and during neuronal regrowth may then attach to sweat glands in this region. This can then cause gustatory sweating (Freys Syndrome).
111
Parotid gland - Location
Overlying the mandibular ramus; anterior and inferior to the ear.
112
Parotid gland salivary duct
Salivary duct - Crosses the masseter, pierces the buccinator and drains adjacent to the 2nd upper molar tooth (Stensen's duct).
113
Facial nerve
Mnemonic:
The Zebra Buggered My Cat;
Temporal Zygomatic, Buccal, Mandibular, Cervical
114
Relations of parotid gland
Anterior: masseter, medial pterygoid, superficial temporal and maxillary artery, facial nerve, stylomandibular ligament
Posterior: posterior belly digastric muscle, sternocleidomastoid, stylohyoid, internal carotid artery, mastoid process, styloid process
115
Lymphatic drainage of parotid gland
Deep cervical nodes
116
Nerve innervation - parotid gland
Parasympathetic-Secretomotor
Sympathetic-Superior cervical ganglion
Sensory- Greater auricular nerve
Parasympathetic stimulation produces a water rich, serous saliva. Sympathetic stimulation leads to the production of a low volume, enzyme-rich saliva.
117
Prosthetic heart valves on Chest X-rays
The aortic and mitral valves are most commonly replaced and when a metallic valve is used, can be most readily identified on plain x-rays.
Aortic Usually located medial to the 3rd interspace on the right.
Mitral Usually located medial to the 4th interspace on the left.
Tricuspid Usually located medial to the 5th interspace on the right.
118
Phrenic nerve origin and supply
Origin C3,4,5
| Supplies Diaphragm, sensation central diaphragm and pericardium
119
Phrenic nerve course
Path
The phrenic nerve passes with the internal jugular vein across scalenus anterior. It passes deep to prevertebral fascia of deep cervical fascia.
Left: crosses anterior to the 1st part of the subclavian artery.
Right: Anterior to scalenus anterior and crosses anterior to the 2nd part of the subclavian artery.
On both sides, the phrenic nerve runs posterior to the subclavian vein and posterior to the internal thoracic artery as it enters the thorax.
Right phrenic nerve
In the superior mediastinum: anterior to right vagus and laterally to superior vena cava
Middle mediastinum: right of pericardium
It passes over the right atrium to exit the diaphragm at T8
Left phrenic nerve
Passes lateral to the left subclavian artery, aortic arch and left ventricle
Passes anterior to the root of the lung
Pierces the diaphragm alone
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Which nerve innervates Stylohyoid?
Stylohyoid is innervated by the facial nerve.
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Trigeminal nerve
| branches
The trigeminal nerve is the main sensory nerve of the head. In addition to its major sensory role, it also innervates the muscles of mastication.
V1 Ophthalmic nerve Sensory only
V2 Maxillary nerve Sensory only
V3 Mandibular nerve Sensory and motor
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Pathway of trigeminal nerve
Originates at the pons
Sensory root forms the large, crescentic trigeminal ganglion within Meckel's cave, and contains the cell bodies of incoming sensory nerve fibres. Here the 3 branches exit.
The motor root cell bodies are in the pons and the motor fibres are distributed via the mandibular nerve. The motor root is not part of the trigeminal ganglion.
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Trigeminal sensory - Ophthalmic
Exits skull via the superior orbital fissure
Sensation of: scalp and forehead, the upper eyelid, the conjunctiva and cornea of the eye, the nose (including the tip of the nose, except alae nasi), the nasal mucosa, the frontal sinuses, and parts of the meninges (the dura and blood vessels).
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Trigeminal sensory - Maxillary nerve
Exit skull via the foramen rotundum
Sensation: lower eyelid and cheek, the nares and upper lip, the upper teeth and gums, the nasal mucosa, the palate and roof of the pharynx, the maxillary, ethmoid and sphenoid sinuses, and parts of the meninges.
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Trigeminal sensory -
| Mandibular nerve
Exit skull via the foramen ovale
Sensation: lower lip, the lower teeth and gums, the chin and jaw (except the angle of the jaw), parts of the external ear, and parts of the meninges.
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Trigeminal motor innervation
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Distributed via the mandibular nerve.
The following muscles of mastication are innervated:
Masseter
Temporalis
Medial pterygoid
Lateral pterygoid
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Other muscles innervated include:
Tensor veli palatini
Mylohyoid
Anterior belly of digastric
Tensor tympani
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127
prostate lymphatic drainage
The prostate lymphatic drainage is primarily to the internal iliac nodes and also the sacral nodes. Although internal iliac is the first site.
128
Which of the structures listed below accompanies the aorta as it traverses the aortic hiatus?
The aorta is accompanied by the thoracic duct as it traverses the aortic hiatus. The vagal trunks accompany the oesophagus which passes through the muscular part of the diaphragm on the right. The right phrenic nerve accompanies the IVC as it passes through the caval opening. The left phrenic nerve passes through the muscular part of the diaphragm anterior to the central tendon on the left.
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Submandibular gland structures
| Relations of the submandibular gland
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Superficial
Platysma, deep fascia and mandible
Submandibular lymph nodes
Facial vein (facial artery near mandible)
Marginal mandibular nerve
Cervical branch of the facial nerve
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Deep
Facial artery (inferior to the mandible)
Mylohyoid muscle
Sub mandibular duct
Hyoglossus muscle
Lingual nerve
Submandibular ganglion
Hypoglossal nerve
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Innervation to submandibular gland
Sympathetic innervation- Derived from superior cervical ganglion
Parasympathetic innervation- Submandibular ganglion via lingual nerve
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Venous drainage of submandibular gland
Anterior facial vein (lies deep to the Marginal Mandibular nerve)
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Lymphatic drainage of submandibular gland
Deep cervical and jugular chains of nodes
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Submandibular duct (Wharton's duct) opening. What nerve is associated with Whartons duct?
Opens lateral to the lingual frenulum on the anterior floor of mouth.
5 cm length
Lingual nerve wraps around Wharton's duct. As the duct passes forwards it crosses medial to the nerve to lie above it and then crosses back, lateral to it, to reach a position below the nerve.
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External carotid artery branches
Some Angry Lady Figured Out PMS'
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Superior thyroid (superior laryngeal artery branch)
Ascending pharyngeal
Lingual
Facial (tonsillar and labial artery)
Occipital
Posterior auricular
Maxillary (inferior alveolar artery, middle meningeal artery)
Superficial temporal
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135
Contents of carotid sheath
Common carotid artery
Internal carotid artery
Internal jugular vein
Vagus nerve
136
Which of the nerves listed below will usually be anaesthetised to allow the episiotomy?
The pudendal nerve innervates the posterior vulval area and is routinely blocked in procedures such as episiotomy.
arises from nerve roots S2, S3 and S4 and exits the pelvis through the greater sciatic foramen
re-enters the perineum through the lesser sciatic foramen.
It travels inferior to give innervation to the anal sphincters and external urethral sphincter. It also provides cutaneous innervation to the region of perineum surrounding the anus and posterior vulva.
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Muscles of the deep posterior compartment of lower leg
Tibialis posterior
Flexor hallucis longus
Flexor digitorum longus
Popliteus
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Pharyngeal arches
These develop during the fourth week of embryonic growth from a series of mesodermal outpouchings of the developing pharynx.
They develop and fuse in the ventral midline. Pharyngeal pouches form on the endodermal side between the arches.
There are 6 pharyngeal arches, the fifth does not contribute any useful structures and often fuses with the sixth arch.
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Pharyngeal arches - First
First
- Muscular contributions (Muscles of mastication; Anterior belly of digastric ; Mylohyoid; Tensor tympanic; Tensor veli palatini)
- Skeletal contributions (Maxilla, Meckels cartilage, Incus, Malleus)
- Endocrine - nil
- Artery (Maxillary, External carotid)
- nerve - mandibular
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Pharyngeal arches - Second
Second
- Muscular contributions: Buccinator, Platysma, Muscles of facial expression, Stylohyoid, Posterior belly of digastric
Stapedius
- skeletal contributions: Stapes, Styloid process, Lesser horn and upper body of hyoid
- Endocrine - nil
- Artery Inferior branch of superior thyroid artery, Stapedial artery
- nerve Facial
141
Pharyngeal arches - Third
Third:
- Muscular contributions: Stylopharyngeus;
- Skeletal: Greater horn and lower part of hyoid
- endocrine: Thymus; Inferior parathyroids
- arteries: Common and internal carotid
- nerves Glossopharyngeal
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Pharyngeal arches - Fourth
Fourth:
- muscular contributions: Cricothyroid, All intrinsic muscles of the soft palate
- Skeletal: Thyroid and epiglottic cartilages
- Endocrine: Superior parathyroids
- Arteries: Right- subclavian artery, Left-aortic arch
- Nerves Vagus
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Pharyngeal pouch - sixth
Sixth
- muscular contributions: All intrinsic muscles of the larynx (except cricothyroid)
- Skeletal: Cricoid, arytenoid and corniculate cartilages
- endocrine: nil
- arteries: Right -Pulmonary artery, Left- Pulmonary artery and ductus arteriosus
- nerves: Vagus and recurrent laryngeal nerve
144
Which structure lies deepest in the popliteal fossa?
From superficial to deep:
The common peroneal nerve exits the popliteal fossa along the medial border of the biceps tendon. Then the tibial nerve lies lateral to the popliteal vessels to pass posteriorly and then medially to them. The popliteal vein lies superficial to the popliteal artery, which is the deepest structure in the fossa.
145
Rectus abdominis - insertion and start. innervation. blood supply.
Arises from the pubis.
Inserts into 5th, 6th, 7th costal cartilages.
The muscle lies in the rectal sheath, which also contains the superior and inferior epigastric artery and vein.
Action: flexion of thoracic and lumbar spine.
Nerve supply: anterior primary rami of T7-12.
The aponeurosis is deficient below the arcuate line.
146
Mediastinum
Region between the pulmonary cavities.
It is covered by the mediastinal pleura. It does not contain the lungs.
It extends from the thoracic inlet superiorly to the diaphragm inferiorly.
Mediastinal regions
Superior mediastinum (between manubriosternal angle and T4/5)
Middle mediastinum
Posterior mediastinum
Anterior mediastinum
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Superior mediastinum contents
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Superior vena cava
Brachiocephalic veins
Arch of aorta
Thoracic duct
Trachea
Oesophagus
Thymus
Vagus nerve
Left recurrent laryngeal nerve
Phrenic nerve
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148
Anterior mediastinum contents
Thymic remnants
Lymph nodes
Fat
149
Middle mediastinum contents
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Pericardium
Heart
Aortic root
Arch of azygos vein
Main bronchi
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150
Posterior mediastinum
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Oesophagus
Thoracic aorta
Azygos vein
Thoracic duct
Vagus nerve
Sympathetic nerve trunks
Splanchnic nerves
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151
The features of a LMN lesion include:
Flaccid paralysis of muscles supplied
Atrophy of muscles supplied.
Loss of reflexes of muscles supplied.
Muscles fasciculation
152
Pectoral muscles
- Pectoralis major
origin, insertion, nerve supply and actions.
Origin From the medial two thirds of the clavicle; manubrium and sternocostal angle
Insertion Lateral edge of the bicipital groove of the humerus
Nerve supply Medial and lateral pectoral nerves
Actions Adductor and medial rotator of the humerus
153
Pectoral muscles
- Pectoralis minor
origin, insertion, nerve supply and actions.
Origin Upper margins of third to fifth ribs and intercostal fascia
Insertion Medial border and upper surface of the coracoid process
Nerve supply Medial pectoral nerve
Actions Assists serratus anterior in drawing scapula forwards and depresses the point of the shoulder
154
thyroidea ima vessel origins?
brachiocephalic artery or the arch of the aorta.
155
what is juxtarenal aaa
Abdominal aortic aneurysms (AAAs) are classified as juxtarenal if their proximal extent is next to the origin of the renal arteries but does not involve them.
156
Internal jugular vein - where does it begin and terminate ?
Each jugular vein begins in the jugular foramen, where they are the continuation of the sigmoid sinus.
They terminate at the medial end of the clavicle where they unite with the subclavian vein.
157
Internal jugular vein - course?
The vein lies within the carotid sheath throughout its course. Below the skull the internal carotid artery and last four cranial nerves are anteromedial to the vein. Thereafter it is in contact medially with the internal (then common) carotid artery. The vagus lies posteromedially.
At its superior aspect, the vein is overlapped by sternocleidomastoid and covered by it at the inferior aspect of the vein.
Below the transverse process of the atlas it is crossed on its lateral side by the accessory nerve. At its mid point it is crossed by the inferior root of the ansa cervicalis.
Posterior to the vein are the transverse processes of the cervical vertebrae, the phenic nerve as it descends on the scalenus anterior, and the first part of the subclavian artery.
On the left side its also related to the thoracic duct.
158
Branches of subclavian artery
Mnemonic for the branches of the subclavian artery: VIT C & D
V ertebral artery
I nternal thoracic
T hyrocervical trunk
C ostalcervical trunk
D orsal scapular
159
Subclavian artery pathway
Path
The left subclavian comes directly off the arch of aorta
The right subclavian arises from the brachiocephalic artery (trunk) when it bifurcates into the subclavian and the right common carotid artery.
From its origin, the subclavian artery travels laterally, passing between anterior and middle scalene muscles, deep to scalenus anterior and anterior to scalenus medius. As the subclavian artery crosses the lateral border of the first rib, it becomes the axillary artery. At this point it is superficial and within the subclavian triangle.
160
Where does axillary artery staart?
As the subclavian artery crosses the lateral border of the first rib, it becomes the axillary artery.
161
Arterial supply to femoral head?
Medial circumflex femoral and lateral circumflex femoral arteries (Branches of profunda femoris). Also from the inferior gluteal artery. These form an anastomosis and travel to up the femoral neck to supply the head.
The vessels which form the anastomoses around the femoral head are derived from the medial and lateral circumflex femoral arteries. These are usually derived from the profunda femoris artery.
162
deep external pudendal artery
The deep external pudendal artery runs under the long saphenous vein close to its origin and may be injured. It is at greatest risk of injury during the flush ligation of the saphenofemoral junction.
163
Lateral cutaneous nerve of the thigh
Cutaneous nerve arising from posterior surface of the second and third lumbar ventral rami
Emerges from the lateral border of psoas major anterior to the iliac crest, and passes between iliacus and iliac fascia
Enters thigh posterior to the lateral end of the inguinal ligament, medial to the anterior superior iliac spine
It pierces the fascia lata 10cm inferior to the anterior superior iliac spine and divides into 2 branches
Anterior branch supplies skin and fascia of the anterolateral surface of the knee
Smaller posterior branch supplies the skin and fascia on the lateral part of the upper leg between the greater trochanter and distal third of the thigh
164
A 53 year old man is admitted to the vascular ward for a carotid endarterectomy. His CT head report confirms a left parietal lobe infarct. What type of visual field defect might be noted?
Superior quadranopia = temporal lobe lesion
| Inferior quadranopia = parietal lobe lesion
165
Features of Klumpkes Paralysis
A C8, T1 root lesion is called Klumpke's paralysis and is caused by delivery with the arm extended.
Claw hand (MCP joints extended and IP joints flexed)
Loss of sensation over medial aspect of forearm and hand
Horner's syndrome
Loss of flexors of the wrist
166
What type of epithelium is present on the external aspect of the tympanic membrane?
The external aspect of the tympanic membrane is lined by stratified squamous epithelium.
167
Quadratus lumborum
| origins, insertion, innervation, function
Origin: Medial aspect of iliac crest and iliolumbar ligament
Insertion: 12th rib
Action: Pulls the rib cage inferiorly. Lateral flexion.
Nerve supply: Anterior primary rami of T12 and L1-3
168
Sciatic nerve
| root values. How it is formed?
L4 to S3 (ventral rami continuation)
| The sciatic nerve is formed from the sacral plexus
169
Sciatic nerve - ? branches
- Articular Branches: Hip joint
- Muscular branches in upper leg: Semitendinosus, Semimembranosus, Biceps femoris, Part of adductor magnus
- Cutaneous sensation: Posterior aspect of thigh (via cutaneous nerves), Gluteal region, Entire lower leg (except the medial aspect))
170
sciatic nerve - Terminates?
At the upper part of the popliteal fossa by dividing into the tibial and peroneal nerves
171
Sciatic nerve course
L4-S3 ventral rami converge at the inferior border of piriformis to form the nerve itself.
passes through the inferior part of the greater sciatic foramen and emerges beneath piriformis.
Medially, lie the inferior gluteal nerve and vessels and the pudendal nerve and vessels. It runs inferolaterally under the cover of gluteus maximus midway between the greater trochanter and ischial tuberosity. It receives its blood supply from the inferior gluteal artery. The nerve provides cutaneous sensation to the skin of the foot and the leg. It also innervates the posterior thigh muscles and the lower leg and foot muscles. The nerve splits into the tibial and common peroneal nerves approximately half way down the posterior thigh. The tibial nerve supplies the flexor muscles and the common peroneal nerve supplies the extensor muscles and the evertor muscles of the foot.
172
Which structures pass through the foramen ovale?
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Mnemonic: OVALE
O tic ganglion
V3 (Mandibular nerve:3rd branch of trigeminal)
A ccessory meningeal artery
L esser petrosal nerve
E missary veins
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173
external urethral sphincter innervation?
The external urethral sphincter is innervated by branches of the pudendal nerve, therefore the root values are S2, S3, S4.
174
Describe femoral nerve injury possible examination findings
weak hip flexion, weak knee extension, and impaired quadriceps tendon reflex, as well as sensory deficit in the anteromedial aspect of the thigh.
175
The epiploic foramen boundaries
Anteriorly (in the free edge of the lesser omentum): Bile duct to the right, portal vein behind and hepatic artery to the left.
Posteriorly Inferior vena cava
Inferiorly 1st part of the duodenum
Superiorly Caudate process of the liver
176
Zollinger Ellison syndrome
1. Non beta islet cell tumours of the pancreas
2. Hypergastrinaemia
3. Severe ulcer disease
Zollinger-Ellison syndrome (ZES) is characterized by the development of a tumor (gastrinoma) or tumors that secrete excessive levels of gastrin, a hormone that stimulates production of acid by the stomach. Many affected individuals develop multiple gastrinomas, which are thought to have the potential to be cancerous (malignant). In most patients, the tumors arise within the pancreas and/or the upper region of the small intestine (duodenum). Due to excessive acid production (gastric acid hypersecretion), individuals with ZES may develop peptic ulcers of the stomach, the duodenum, and/or other regions of the digestive tract.
177
Clinical features related to peptic ulcer disease.
Diagnosis is based on 3 criteria:
1. Fasting hypergastrinaemia
2. Increased basal acid output
3. Secretin stimulation test positive
178
Dumping syndrome,
can be divided into early and late,
may occur following gastric surgery.
It occurs as a result of a hyperosmolar load rapidly entering the proximal jejunum. Osmosis drags water into the lumen, this results in lumen distension (pain) and then diarrhoea. Excessive insulin release also occurs and results in hypoglycaemic symptoms.
179
Post gastrectomy syndromes
Post gastrectomy syndromes may vary slightly depending upon whether a total or partial gastrectomy is performed. A Roux en Y reconstruction generally gives the best functional outcomes. Where a gastrojejunostomy is performed as reconstruction following a distal gastrectomy the gastric emptying is generally better if the jejunal limbs are tunneled in the retrocolic plane.
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The following may occur following gastrectomy:
Small capacity (early satiety)
Dumping syndrome
Bile gastritis
Afferent loop syndrome
Efferent loop syndrome
Anaemia (B12 deficiency)
Metabolic bone disease
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180
Mirizzi syndrome
as common hepatic duct obstruction caused by extrinsic compression from an impacted stone in the cystic duct or infundibulum of the gallbladder.
181
Why ileal resection would increase chance of gallstone formation
Bile salt reabsorption occurs at the ileum. Therefore cholesterol gallstones form as a result of ileal resection.
Bile salt absorption can be affected in CD as well and lead to GB stone formation.
182
Crigler–Najjar syndrome
rare inherited disorder affecting the metabolism of bilirubin.
It is caused by abnormalities in the gene coding for uridine diphosphoglucuronate glucuronosyltransferase (UGT1A1). UGT1A1 normally catalyzes the conjugation of bilirubin and glucuronic acid within hepatocytes. Conjugated bilirubin is more water-soluble and is excreted in bile.
