Poisoning Roop/Jaffe

Question 1

A 48 year old man comes to the ED complaining of trouble seeing and has difficulty swallowing. The patient is not from the area but is visiting friends. Symptoms began three hours ago and the decision to seek medical help was made because of his difficulty in swallowing. The patient is now anxious and easily excited. Vitals show a normal temp, pulse rate= 90/min, resp. rate= 19/min, BP= 145/100 mmHg. Physical exam shows double vision (diplopia) and drooping of the eyelids, slurred speech (dysarthria) and difficulty swallowing (dysphagia), signs of muscle weakness, and deep tendon reflexes are diminished in the legs and arms. CBC & electrolytes appear normal. Brain CT and MRI are normal- what are you trying to rule out here?

Answer 1

Stroke, tumor, brain bleed, etc.

Question 2

A 48 year old man comes to the ED complaining of trouble seeing and has difficulty swallowing. The patient is not from the area but is visiting friends. Symptoms began three hours ago and the decision to seek medical help was made because of his difficulty in swallowing. The patient is now anxious and easily excited. Vitals show a normal temp, pulse rate= 90/min, resp rate= 19/min, BP= 145/100 mmHg. Physical exam shows double vision (diplopia) and drooping of the eyelids, slurred speech (dysarthria) and difficulty swallowing (dysphagia), signs of muscle weakness, and deep tendon reflexes are diminished in the legs and arms. CBC & electrolytes appear normal. Brain CT and MRI are normal. CSF examination was normal. Electromyography showed nerve conduction velocity and amplitude to be normal, however NMJ (neuromuscular junction) impaired. What is an EMG and what is it able to diagnose?

Answer 2

Electromyography

Nerve/muscle conduction and muscle function

Question 3

What can you expect from a nerve conduction study?

Answer 3

Question 4

A 48 year old man comes to the ED complaining of trouble seeing and has difficulty swallowing. The patient is not from the area but is visiting friends. Symptoms began three hours ago and the decision to seek medical help was made because of his difficulty in swallowing. The patient is now anxious and easily excited. Vitals show a normal temp, pulse rate= 90/min, resp rate= 19/min, BP= 145/100 mmHg. Physical exam shows double vision (diplopia) and drooping of the eyelids, slurred speech (dysarthria) and difficulty swallowing (dysphagia), signs of muscle weakness, and deep tendon reflexes are diminished in the legs and arms. CBC & electrolytes appear normal. Brain CT and MRI are normal. CSF examination was normal. Electromyography showed nerve conduction velocity and amplitude to be normal, however NMJ (neuromuscular junction) impaired. The Edrophonium (Tensilon) test appeared normal. What is edrophonium and what do you hope to rule out with this test?

Answer 4

Its a muscle strengthener

Can rule out myasthenia gravis (MG)

Question 5

How is a Tensilon Test given? Why is atropine needed on hand?

Answer 5

Atropine is needed on hand because Ach is apart of the parasympathetic NS → decreases HR and constricts airway/bronchioles
-Ach is a part of the SNS and controls skeletal m.
-Ach is also a part of ANS under the parasympathetic division

Question 6

What happens if muscle strength is improved with a Tensilion Test? What happens if its not improved?

Answer 6

Question 7

A 48 year old man comes to the ED complaining of trouble seeing and has difficulty swallowing. The patient is not from the area but is visiting friends. Symptoms began three hours ago and the decision to seek medical help was made because of his difficulty in swallowing. The patient is now anxious and easily excited. Vitals show a normal temp, pulse rate= 90/min, resp rate= 19/min, BP= 145/100 mmHg. Physical exam shows double vision (diplopia) and drooping of the eyelids, slurred speech (dysarthria) and difficulty swallowing (dysphagia), signs of muscle weakness, and deep tendon reflexes are diminished in the legs and arms. CBC & electrolytes appear normal. Brain CT and MRI are normal. CSF examination was normal. Electromyography showed nerve conduction velocity and amplitude to be normal, however NMJ (neuromuscular junction) impaired. The Edrophonium (Tensilon) test appeared normal. Upon further discussion with the patient, he states that on the day before he ate some green beans that were canned at home by his friends. So what’s the diagnosis?

Answer 7

Botulism

Question 8

A 48 year old man comes to the ED complaining of trouble seeing and has difficulty swallowing. The patient is not from the area but is visiting friends. Symptoms began three hours ago and the decision to seek medical help was made because of his difficulty in swallowing. The patient is now anxious and easily excited. Vitals show a normal temp, pulse rate= 90/min, resp rate= 19/min, BP= 145/100 mmHg. Physical exam shows double vision (diplopia) and drooping of the eyelids, slurred speech (dysarthria) and difficulty swallowing (dysphagia), signs of muscle weakness, and deep tendon reflexes are diminished in the legs and arms. CBC & electrolytes appear normal. Brain CT and MRI are normal. CSF examination was normal. Electromyography showed nerve conduction velocity and amplitude to be normal, however NMJ (neuromuscular junction) impaired. The Edrophonium (Tensilon) test appeared normal. Upon further discussion with the patient, he states that on the day before he ate some green beans that were canned at home by his friends. Doctor now thinks it’s botulism. Stool sample was positive for Clostridium botulinum. What type of organism is C. botulinum? How many different types of Clostridia are there?

Answer 8

-Gram-positive bacteria
-Anaerobic bacillus
-Spore-forming
-Produces the neurotoxin botulinum
-Theres 12 types
-People can still die from this because of home canning

Question 9

Describe what happens at a motor neuron when an action potential arrives at the presynaptic terminal?

Answer 9

-Calcium influx
-Snare proteins helps vesicles to fuse to the presynaptic membrane
-In the case of botulinum toxin, it destroys Snare proteins → vesicles can’t fuse → no Ach release/exocytosis → cannot bind to receptors → flaccid paralysis

Question 10

At the NMJ, ACh is stored in the vesicles of the presynaptic terminals. After the AP arrives, ________ enters the terminal causing the vesicles to migrate to the membrane.

Answer 10

calcium

Question 11

The SNAP-SNARE proteins allow __________ of the vesicles with the cell membrane, fusion and then exocytosis of the ACh into the synaptic cleft

Answer 11

docking

Question 12

BoNT- botulinum toxin destroys ____ of the family of proteins. ACh is not released and flaccid paralysis occurs

Answer 12

1+

Question 13

Botulinum toxin will result in flaccid paralysis that first occurs in the _______ muscles and is symmetrical, and then will spread to other proximal muscles and then distal muscles

Answer 13

cranial

Question 14

What muscle is paralyzed when a patient has droopy eyelids?

Answer 14

Levator palpebrae superioris m.

Question 15

What muscle is affected that would cause a patient to have dysphasia?

Answer 15

Upper esophageal m. (sphincter)

Question 16

What muscles are affected that would cause a patient to have double vision?

Answer 16

Any of the optic muscles

Question 17

What is the time for symptoms to appear after ingestion of the food-borne toxin?

Answer 17

In foodborne botulism, symptoms generally begin 18 to 36 hours (on average) after eating a contaminated food.

Question 18

How is botulism treated?

Answer 18

-Doctors treat botulism with a drug called an antitoxin, which prevents the toxin from causing any more harm.
-Antitoxin does not heal the damage the toxin has already done
-Fluid intake
-Induce vomiting with medication
-Antibiotics (difficult to treat anaerobic bacteria)
-Maintain airway (depending on how bad it is)

Question 19

What would happen if a patient is not treated for botulism?

Answer 19

The disease may progress and symptoms may worsen to cause full paralysis of some muscles, including those used in breathing and those in the arms, legs, and trunk (part of the body from the neck to the pelvis area/torso)

Will affect the diaphragm muscles, so they are unable to breathe (ventilator may be necessary)

Question 20

How long would a patient have to remain in the hospital when diagnosed with botulism and why? What are you trying to achieve physiologically?

Answer 20

Weeks to months → until all the symptoms disappear

You want the SNARE proteins to restore

Question 21

The use of __________ toxin in the field of oral and maxillofacial surgery has been continuously evolving, for aesthetic and functional indications. There are the dermatological applications of botulinum toxin for cosmetology, as well as its varied therapeutic uses and its application in temporomandibular joint surgery, masseter muscle hypertrophy, bruxism, trismus, maxillofacial traumatology, salivary gland diseases, and facial palsy, among others. This should appeal to head and neck surgeons, oral maxillofacial surgeons, ENT surgeons and dermatologists in particular, and general surgeons and dentists in general.

Answer 21

botulinum

Question 22

What is masseter muscle hypertrophy?

Answer 22

-rare condition
-mostly idiopathic
-enlargement of one or both masseter muscles
-facial asymmetry

Question 23

What is bruxism?

Answer 23

Grinding of the teeth

Question 24

What is Trismus?

Answer 24

Lockjaw, tetanic spasms of the muscles of mastication

Question 25

What is the deadliest toxin in the world?

Answer 25

Botulinum neurotoxin

Question 26

A 26 year old male patient was admitted to the hospital because of recurrent abdominal pain for three months, which has increased tremendously in the past two days. The pain is in the umbilical and hypogastric regions and radiates to the back. The patient visited an urgent care center two months ago. He was diagnosed with kidney stones and sent home with analgesics. Vitals show normal temp. resp= 12/min, pulse= 72/min, BP= 122/74/ Pt appeared to have an anemic appearance and slight tenderness around the umbilicus region. Lab studies showed low RBCs, low hemoglobin (potential anemia), high aspartate aminotransferase, high serum total bilirubin, high serum indirect and direct bilirubin, +1 urobilinogen (should not have this). What do all these lab values mean?

Answer 26

Liver dysfunction Bilirubin is the breakdown product of heme and is produced in the spleen then goes to the liver to be a part of bile -All this bilirubin is too much, which means that there's too much breakdown of RBCs and this can result in hemolytic anemia

Question 27

A 26 year old male patient was admitted to the hospital because of recurrent abdominal pain for three months, which has increased tremendously in the past two days. The pain is in the umbilical and hypogastric regions and radiates to the back. The patient visited an urgent care center two months ago. He was diagnosed with kidney stones and sent home with analgesics. Vitals show normal temp. resp= 12/min, pulse= 72/min, BP= 122/74/ Pt appeared to have an anemic appearance and slight tenderness around the umbilicus region. Lab studies showed low RBCs, low hemoglobin (potential anemia), high aspartate aminotransferase, high serum total bilirubin, high serum indirect and direct bilirubin, +1 urobilinogen (should not have this). Total abdominal CT showed bilateral kidney stones and lymph nodes increased in size in abdominal cavity and retroperitoneally. A colposcopy was done and appeared normal. Next a gastroscopy came back with chronic non-atrophic gastritis results. What is chronic superficial non-atrophic gastritis?

Answer 27

-Influx of neutrophils and lymphocytes → still see fundal glands -Epithelium shedding

Question 28

A 26 year old male patient was admitted to the hospital because of recurrent abdominal pain for three months, which has increased tremendously in the past two days. The pain is in the umbilical and hypogastric regions and radiates to the back. The patient visited an urgent care center two months ago. He was diagnosed with kidney stones and sent home with analgesics. Vitals show normal temp. resp= 12/min, pulse= 72/min, BP= 122/74/ Pt appeared to have an anemic appearance and slight tenderness around the umbilicus region. Lab studies showed low RBCs, low hemoglobin (potential anemia), high aspartate aminotransferase, high serum total bilirubin, high serum indirect and direct bilirubin, +1 urobilinogen (should not have this). Total abdominal CT showed bilateral kidney stones and lymph nodes increased in size in abdominal cavity and retroperitoneally. A colposcopy was done and appeared normal. Next a gastroscopy came back with chronic non-atrophic gastritis results. Pt.’s pain began to worsen and doctors delved deeper into his history. They found that his occupation was a warehouse guard. This warehouse stores old books and the building is old. Doctors did a more extensive physical exam and found the patient's gums to have Burton’s lines. What are these lines and what do they indicate? What tests do you do to verify?

Answer 28

-Sign of chronic lead poisoning -Lead levels should be less than 10 micrograms (his blood lead level was found to be 52.8ug/dl- BLOOD TEST) -Burton’s lines is due to precipitation of lead sulfide >>It's a blue-purplish line on the gums >>Caused by reaction between circulating lead with sulfur ions released by oral bacterial activity, which deposits lead sulfide at the junction of the teeth and gums -Hematological smear would show basophilic stippling of RBCs indicative of heavy metal poisoning

Question 29

A 26 year old male patient was admitted to the hospital because of recurrent abdominal pain for three months, which has increased tremendously in the past two days. The pain is in the umbilical and hypogastric regions and radiates to the back. The patient visited an urgent care center two months ago. He was diagnosed with kidney stones and sent home with analgesics. Vitals show normal temp. resp= 12/min, pulse= 72/min, BP= 122/74/ Pt appeared to have an anemic appearance and slight tenderness around the umbilicus region. Lab studies showed low RBCs, low hemoglobin (potential anemia), high aspartate aminotransferase, high serum total bilirubin, high serum indirect and direct bilirubin, +1 urobilinogen (should not have this). Total abdominal CT showed bilateral kidney stones and lymph nodes increased in size in abdominal cavity and retroperitoneally. A colposcopy was done and appeared normal. Next a gastroscopy came back with chronic non-atrophic gastritis results. Pt.’s pain began to worsen and doctors delved deeper into his history. They found that his occupation was a warehouse guard. This warehouse stores old books and the building is old. Doctors did a more extensive physical exam and found the patient's gums to have Burton’s lines, which means chronic lead poisoning. What is the treatment?

Answer 29

Chelating agents -Will be excreted in urine -Examples: >>succimer and penicillamine are given orally >>dimercaprol and edetate (EDTA) calcium disodium (CaNa2 EDTA) are administered parenterally

Question 30

Lead can cross the blood brain barrier and result in what? How?

Answer 30

seizures Edema = increased ICP → encephalopathy Left untreated can result in irreversible brain damage

Question 31

How does lead affect the blood?

Answer 31

-Can block enzymes in heme synthesis pathway → anemia -Basophilic stippling → RNA left back in RBC (not cleared because enzyme is inhibited) -Attaches to RBC = hemolysis is easier

Question 32

The 2 enzymes that are blocked by lead in ________ __________ pathway is aminolevulinate dehydratase and ferrochelatase

Answer 32

heme synthesis

Question 33

Basophilic stipplingIs due to Pb inhibiting the ez 5’-nucleotidase which clears....

Answer 33

clumps of degraded RNA

Question 34

Pb attaches to RBCs membrane making hemolysis much easier– hence the increase in bilirubin levels. Additionally, it reacts with sulfur ions released due to oral bacterial activity. This deposits lead sulfide at the tooth-gum junction as…

Answer 34

Burton’s Lines

Question 35

A 58 year old man came to the ED complaining of bleeding in his mouth. It began 24 hours ago and has been continuous even with compression. He suffered an MI 18 months ago and stopped smoking after the MI. Began exercising moderately after the MI. He started taking warfarin after MI. Vital signs show normal temp., pulse= 85/min, resp.= 18/min, BP=95/65 mmHg. Lab studies show Hct= 35% (low), stool sample test was positive for blood (likely has internal bleeding), PT was 35 seconds and PTT was 48 seconds (both high, indicating clothing dysfunction). What do his blood results indicate?

Answer 35

Something is wrong with clotting cascade

Question 36

What are the 2 major components of hemostasis?

Answer 36

Platelet plug formation and clotting cascade

Question 37

Bleeding of the oral mucous membranes could also indicate internal bleeding, e.g. GI system. Would this be indicated in vital signs? How?

Answer 37

Low BP, pulse/respiration are high because body is compensating

Question 38

What are platelets also known as? What are they derived from?

Answer 38

Thrombocytes, derived from megakaryocytes

Question 39

What is the platelet lifespan?

Answer 39

7-10 days

Question 40

Platelet formation is regulated by the hormone ___________

Answer 40

Thrombopoietin

Question 41

Platelets have three different types of granules. What are they and what do they contain?

Answer 41

Alpha -Contains adhesion proteins like fibrinogen and vWF Dense -Contains bioactive amines like serotonin and histamine, and also contains nucleotides like ADP/ATP Lysosomes -Contains degenerative enzymes

Question 42

What is the mechanism of action of warfarin?

Answer 42

Inhibits vitamin K clotting factors Clotting factor II = prothrombin

Question 43

A 58 year old man came to the ED complaining of bleeding in his mouth. It began 24 hours ago and has been continuous even with compression. He suffered an MI 18 months ago and stopped smoking after the MI. Began exercising moderately after the MI. He started taking warfarin after MI. Vital signs show normal temp., pulse= 85/min, resp.= 18/min, BP=95/65 mmHg. Lab studies show Hct= 35% (low), stool sample test was positive for blood (likely has internal bleeding), PT was 35 seconds and PTT was 48 seconds (both high, indicating clothing dysfunction). Upon further examination and workup, the patient is found to be on the best dose of warfarin. Medical personnel again begin to question further into his history and ask about anything additional he might be taking including any supplements. Pt reveals that he began to take garlic and ginkgo biloba supplements one month ago. What are the effects of these herbal extracts?

Answer 43

Garlic inhibits platelet adhesion Ginkgo biloba -Potentiates warfarin effects (increases activity of warfarin) -Vasodilator (for peripheral vascular disease) Side effects: massive headaches

Question 44

Most metals that cause poisoning are in a microscopic (molecular) form when they enter your body. Heavy metals can enter your body by three different systemic routes. What are they?

Answer 44

1) Absorbing through your skin (subcutaneous/topical) 2) Inhaling into your lungs 3) Ingesting into your digestive tract organs (orally)

Question 45

What makes intact skin a good barrier?

Answer 45

Has layers, and the top layer sheds off (desquamates) Normal skin should have a neutral pH (approx 7.35) -Moderately acidic (5.5) acid mantle Contains sweat glands and sebaceous glands Secretions can kill bacteria The pigment melanin provides a chemical pigment defense against UV light

Question 46

What are the regions of the integument?

Answer 46

Epidermis, dermis, and subcutaneous tissue

Question 47

What are the layers of the epidermis of thick and thin skin?

Answer 47

Thick skin is only on palmar and plantar regions and contains 5 skin layers The 5 layers are: (“come lets get sun burnt”) -stratum basale (deep) -stratum spinosum -stratum granulosum -stratum lucidum -stratum corneum (superficial) Thin skin does not contain the stratum lucidum layer

Question 48

Classify the epidermis as a specific tissue type

Answer 48

Keratinized stratified squamous epithelium

Question 49

What are the layers of the dermis?

Answer 49

Thin upper layer called the papillary dermis, and a thick lower layer called the reticular dermis -Deep reticular layer is the “leathery part” and is about 80% of the dermis -Papillary layer makes up about 20% of dermis -Basement membrane separates the basal layer of epidermis from the papillary layer of dermis Contains connective tissue, blood vessels, oil and sweat glands, nerves, and hair follicles

Question 50

Classify the dermis as a specific tissue type

Answer 50

Dense irregular connective tissue (contains reticular, collagen, and elastin fibers)

Question 51

What are the accessory organs of the integument?

Answer 51

Hair Nails Sweat glands -Eccrine sweat glands (also called sudoriferous or sudoriparous glands, and they secrete salt water) -Apocrine sweat glands (open on hair follicle and secretes amino acids that can cause BO) Sebaceous glands (secretes sebum/oil)

Question 52

What structures are found in the hypodermis/subcutaneous tissue?

Answer 52

-Adipose tissue -Blood vessels -Superficial fascia (areolar connective tissue, adipose tissue, arteries and nerves)

Question 53

Cells are born in the basal layer of the ________ and migrate up. This process takes about a month. What happens if they migrate too quickly to the top? Or are too slow?

Answer 53

epidermis If it happens too quickly then its most likely psoriasis (about 10 days) If it takes longer than 4-5 weeks then its most likely an occlusion

Question 54

The papillary layer houses small projections called the __________ ___________. They contain small and large blood vessels and nerve endings. They give us our fingerprints and footprints and it causes the dermis to twist and turn to give us our print morphology

Answer 54

dermal papilla

Question 55

The breast started off embryologically as a....

Answer 55

modified sweat gland

Question 56

What is the preferred cavity for breathing?

Answer 56

nose

Question 57

What tissue type is the nose lined with? What does this do?

Answer 57

ciliated pseudostratified columnar epithelium that moistens and sanitizes air

Question 58

How many tonsils are there along the breathing route?

Answer 58

3

Question 59

What makes the respiratory tract a good barrier?

Answer 59

The ciliated pseudostratified columnar epithelium has mucus that can capture and trap foreign entities Foreign entities stick to the mucus membrane (mucus pathways: respiratory, GI, reproductive, urinary tracts) the 3 tonsils in breathing pathway (palatine, pharyngeal/adenoids, and lingual tonsils)

Question 60

Where can you find the palatine tonsils?

Answer 60

Under the palatoglossal arches Say “ahh” and you can see them Located in oropharynx

Question 61

What is the histology of palatine tonsils?

Answer 61

nonkeratinized stratified squamous epithelium

Question 62

Where can you find the pharyngeal/ adenoid tonsils?

Answer 62

Superior to the palatine tonsils, and located in the nasopharynx

Question 63

What is the histology of the pharyngeal/ adenoid tonsils?

Answer 63

ciliated pseudostratified columnar epithelium

Question 64

Where can you find the lingual tonsils?

Answer 64

at the root of tongue and in laryngopharynx

Question 65

What is the histology of the lingual tonsils?

Answer 65

nonkeratinized stratified squamous epithelium

Question 66

What are the 2 clinical divisions of the respiratory tract?

Answer 66

Upper and lower respiratory tracts upper= go to ENT lower= go see pulmonologist

Question 67

Which part of the throat is common to air & foods?

Answer 67

Oropharynx and laryngopharynx Laryngopharynx openings -Anterior opening →Larynx (glottis: opening into our voice box) → Trachea. >>Intubation tube goes here -Posterior opening → esophagus.

Question 68

Follow the air from your nose into your lungs through the respiratory tract identifying the organs and tubes a molecule of air passes across until it reaches the lungs starting with the external nares and ending with the alveoli

Answer 68

Air enters through the nostrils (external nares) → nasal septum separates the nasal cavities → turbinates (nasal conchae) runs through nasal cavities; superior, inferior, middle concha → internal nares (choanae) is an opening that separates the posterior nasal cavity from the nasopharynx → pharyngeal tonsil/adenoids → opening that goes to middle ear (auditory tube) which equalizes air pressure when you change altitude → palatine tonsil → lingual tonsil → vestibular fold (false vocal cord) → true vocal cord → larynx → trachea → primary bronchi (lobes) → secondary bronchi (lobules) → tertiary bronchi → bronchiopulmonary segment → terminal bronchioles → respiratory bronchioles → alveolar duct → alveolar sacs → alveoli.

Question 69

What is the function of nasal conchae?

Answer 69

-prepare air for going deeper -agitation of airflow to redirect it up & improve sense of smell -humidify the air

Question 70

Which nasal concha is considered true individual bone (of our 206 bones)?

Answer 70

inferior concha

Question 71

The superior and middle conchae belongs to which bone and what plates are involved here?

Answer 71

ethmoid bone Perpendicular plate and cribriform plate as also a part of ethmoid bone Olfactory n. (CN I) passes through the ventral surface of the cerebrum to the cribriform plate

Question 72

What epithelia line the different regions of the respiratory tract (nasopharynx, laryngopharynx, oropharynx, bronchi, bronchioles, alveoli)

Answer 72

Nasopharynx= ciliated pseudostratified columnar epithelium Largyngeopharynx= nonkeratinized stratified squamous epithelium Oropharynx= nonkeratinized stratified squamous epithelium From the nasal cavity to the bronchi, it is lined by pseudostratified columnar ciliated epithelium Bronchioles are lined by simple columnar to the cuboidal epithelium Alveoli possess a lining of thin squamous epithelium that allows for gas exchange

Question 73

What are the cartilages of the larynx?

Answer 73

Nine Cartilages 3 unpaired (6) - Anteriorly located -Epiglottis -Thyroid cartilage -Cricoid cartilage - Landmark for artificial airway placement 3 paired (3) - Posteriorly located -Cuneiform cartilage -Corniculate cartilage -Arytenoid cartilage

Question 74

Describe the anatomy of the trachea and name its point of bifurcation and relate that bifurcation to bony landmarks

Answer 74

Trachea is the tube that connects the larynx to the chest Angle of louis is found here and is a palpable bony landmark (sternal angle) At the Carina the trachea bifurcates at T-4 vertebrae (posteriorly) & 2nd intercostal space (anteriorly). The bifurcation forms R/L primary bronchus The R primary bronchus is straighter and has 3 lobes (R upper, middle, and lower) The left primary bronchus is more angled than right side because the mass of the heart takes up space -has 2 lobes (left upper and lower) The hilum of lung contains the primary bronchus and per lung, there are 2 pulmonary veins (superior and inferior), 1 pulmonary artery (blood is blue in artery), and bronchial arteries Primary bronchus leads to 5 total secondary bronchi Lung lobules will have tertiary bronchi (gives off 14-16 bronchial divisions)

Question 75

Describe the 3 divisions of the bronchi and relate them to the anatomical division of the lungs

Answer 75

Primary (first) bronchi are the left and right main bronchi in the upper portion of your lungs Secondary bronchi near the middle of your lungs, also called lobar bronchi Tertiary (third) bronchi at the edge of your lungs (also called segmental bronchi), just before the bronchioles

Question 76

Describe a bronchopulmonary segment

Answer 76

A portion of lung supplied by a specific segmental bronchus and its vessels These arteries branch from the pulmonary and bronchial arteries, and run together through the center of the segment There are 10 bronchopulmonary segments in the right lung (3 in superior lobe, 2 in middle lobe, 5 in inferior lobe) and 9 segments on the left (4 in upper lobe, 5 in lower lobe)

Question 77

Discuss the pleural cavities and serous membranes

Answer 77

2 pleural cavities on right and left side Mediastinum separates the cavities and they do not communicate Serous membranes associated with lungs = visceral and parietal pleura Attached to wall of thoracic cavity= parietal Attached to surface of lungs= visceral Space between them= pleural cavity

Question 78

Describe the gross anatomy of the lungs (apex, base, surfaces, structures entering and leaving at the hilum)

Answer 78

lung general shape = Pyramidal shape Apex - pointy end Base - flat end; sitting on the diaphragm Surfaces Mediastinal surface → hilum costal surface → against the ribcage Diaphragmatic surface (base) Both left and right hilum contain a pulmonary artery, pulmonary veins (superior and inferior), and bronchial arteries

Question 79

Outline systemic and pulmonary circulations

Answer 79

Pulmonary circulation moves blood between the heart and the lungs. It transports deoxygenated blood to the lungs to absorb oxygen and release carbon dioxide. The oxygenated blood then flows back to the heart. Systemic circulation moves blood between the heart and the rest of the body. Portal caval system= type of anastomoses which occurs between the veins of portal circulation and veins of systemic circulation Systemic is pumped at higher pressure compared to pulmonary circulation -If not, could cause pulmonary edema Hilum of the lungs -Systemic circulation branches: bronchial vessels → feed pleura Systemic begins: Left ventricle → ascending aorta → Aortic Arch → Brachiocephalic → Common carotid → Subclavian Left → Descending Aorta → Thoracic Aorta → Abdominal Aorta → Lower extremity via caval system → Superior/ Inferior Vena Cava → Right Atrium. Upper Extremity via the superior caval system Pulmonary Circulation: Right Ventricle → Pulmonary Artery → Lungs → Pulmonary Veins → Left Atrium

Question 80

T/F: At the same time there are equal amount of blood flow in pulmonary and systemic circulation

Answer 80

True!

Question 81

T/F: Pulmonary and Systemic is pumped at the same pressure Explain why

Answer 81

False! If you pumped right ventricle into the lungs at the same pressure -Causes systemic insufficiency -Causes excessive pulmonary Results in Pulmonary Edema → Lack of blood flow to extremities and go into shock

Question 82

What makes the digestive tract a good barrier?

Answer 82

GI mucosa acts as a semipermeable barrier that allows the absorption of nutrients, while limiting the transport of potentially harmful antigens/microorganisms

Question 83

What are the clinical divisions of the digestive tract?

Answer 83

Upper GI (esophagus, stomach, and duodenum of small intestine) and lower GI (large intestine and anus)

Question 84

Follow the food or liquid from your lips to your anus identifying the organs a drop of food or liquid passes across

Answer 84

Start at oral cavity, the labia guards the entrance (superior and inferior labia) and vestibules (space between teeth and outer lip) > jaw > pharynx > esophagus > lower esophageal sphincter > stomach > small intestine > large intestine > colon > rectum > anus

Question 85

What epithelia line the different regions of the GI tract?

Answer 85

Nonkeratinized stratified squamous epithelium from the oral cavity through the upper esophagus, then changes to simple columnar epithelium until the rectum Intestines are lined with simple columnar epithelium and contain goblet cells that make mucus

Question 86

Ingestion begins in the oral cavity. Review the structure of the oral cavity related to mastication and deglutition.

Answer 86

The muscles of mastication move the mandible during mastication and speech. They are the masseter, temporalis, lateral pterygoid, and medial pterygoid muscles TMJ also helps with mastication Muscles of deglutition= omohyoid, sternohyoid, and sternothyroid muscles (ansa cervicalis), and the thyrohyoid muscle (CN XII). Structures involved in deglutition = tongue, hard and soft palate, pharyngeal muscles, esophagus, and gastroesophageal junction The tongue has both intrinsic and extrinsic musculature Cranial nerves involved in oral cavity: trigeminal nerve (CN V, both) facial nerve (CN VII, both) glossopharyngeal nerve (CN IX, both) vagus nerve (CN X, both) hypoglossal nerve (CN XII, motor)

Question 87

What are the muscles of mastication?

Answer 87

The muscles of mastication move the mandible during mastication and speech. They are the masseter, temporalis, lateral pterygoid, and medial pterygoid muscles

Question 88

What are the muscles of deglutition?

Answer 88

omohyoid, sternohyoid, and sternothyroid muscles (ansa cervicalis), and the thyrohyoid muscle (CN XII).

Question 89

What structures are involved in deglutition?

Answer 89

Tongue, hard and soft palate, pharyngeal muscles, esophagus, and gastroesophageal junction

Question 90

Does the tongue have intrinsic or extrinsic musculature, or both?

Answer 90

both

Question 91

What cranial nerves are involved in the oral cavity?

Answer 91

trigeminal nerve (CN V, both) facial nerve (CN VII, both) glossopharyngeal nerve (CN IX, both) vagus nerve (CN X, both) hypoglossal nerve (CN XII, motor)

Question 92

Review the regions of the pharynx specific to digestion

Answer 92

Oropharynx and laryngopharynx = specific to digestion

Question 93

Describe the anatomy of the esophagus

Answer 93

Upper esophagus has some skeletal muscles that are related to deglutition/chewing Mastication is voluntary Deglutition is both voluntary and involuntary (peristalsis) Salivation is both controlled and uncontrolled The esophagus has a dentate line which is embryologically separating the non-keratinized stratified tissues behind the cords from the simple columnar

Question 94

Describe the anatomy of the diaphragm and name the hiatuses it contains and what passes through them

Answer 94

I Eat Apples at 8, 10 and 12 IVC - T8 Esophagus - T10 Aorta - T12

Question 95

Describe the anatomy of the stomach, its regions, and layers

Answer 95

Regions: -Cardia (top portion of stomach) -Fundus -Body (corpus) is the largest section of stomach -Pylorus (bottom portion of stomach) Curvatures -Greater and lesser omentum Layers (from outside to inside) -Mucosa, submucosa, muscularis externa (smooth muscle bands in this layer) , and the serosa Contains rugae Stomach contains 3 directional bands of smooth muscle: -Circulatory: Inner Band - Does Peristalsis -Longitudinal Band: Outer Band -Deep Oblique Band: Responsible for churning -Esophagus, Small and Large Intestine: >>Only has two directional bands Histological Feature: Mucosa → Gastric Pits: Gastric cells like chief cells & parietal cells are here. -Mucosa @ the small intestines have intestinal “crypts” where tissues are folded into finger-like projections called villi. -Cells of the fingers have microvilli. -Mucosa of the stomach when empty has folds called → Rugae: Folds that allow the stomach to stretch when we eat.

Question 96

Describe the anatomy of the small intestine, its regions, and layers

Answer 96

Right and left hypochondriac regions and epigastric region do NOT contain the small intestine Regions: duodenum, jejunum, and ileum The pancreas creates natural juices called pancreatic enzymes to break down foods. These juices travel through the pancreas via ducts. They empty into the upper part of the small intestine called the duodenum. The common hepatic duct then joins with the cystic duct from the gallbladder to form the common bile duct. This runs from the liver to the duodenum (the first section of the small intestine). Special movement that the small intestine can do is called segmentation, it is where primary absorption occurs (unique movement like windshield wiper) Duodenum → goes from pH from 1 (stomach) to pH of 8 -Shortest Region -Bile duct from gallbladder -Pyloric sphincter from stomach -Pancreatic Duct -How do we not suffer from going to such extreme pH? >>Sodium Bicarbonate & Mucus >>Bile = pH 8 >>Pancreatic Juice = pH 8 -By the time we reach the ileum the pH goes down to 7.5 pH. Layers (from outside to inside) -Mucosa, submucosa, muscularis externa, and the serosa Has intestinal crypts that involve villi and microvilli -The crypts are pleated like circular folds Valves involved with the small intestine -Upper esophageal sphincter, lower esophageal sphincter (cardiac) and ileocecal valve Pyloric Sphincter → Small Intestines → Duodenum → Jejunum → Ileum → Ileocecal Valve

Question 97

Describe the anatomy of the large intestine, its regions, and layers

Answer 97

Regions -cecum, colon, rectum, and anal canal Layers (from outside to inside) -Mucosa, submucosa, muscularis externa, and the serosa The cecum and colon have 3 longitudinal muscular bands -Outer bands: longitudinal -Deeper bands: circular -Stomach has deeper oblique bands to do churning, the stomach also has gastric pits Haustra are saccules in the colon that give it its segmented appearance Teniae coli are three longitudinal smooth muscle bands in the colon wall Vermiform appendix is found near the cecum and ilium The appendix position is normally retrocecal Ileocecal Valve → Cecum → Ascending Colon → Transverse Colon → Descending Colon → Sigmoid Colon → Rectum → Anal Canal.

Question 98

Describe the anatomy of the abdominal accessory organ, the spleen

Answer 98

Found in left hypochondriac region Contains a splenic vein that forms into the hepatic portal vein

Question 99

Describe the anatomy of the abdominal accessory organ, the liver

Answer 99

Found in the right upper quadrant Has 4 lobes

Question 100

Describe the anatomy of the abdominal accessory organ, the gallbladder

Answer 100

Found in the right upper quadrant of the abdomen, or right hypochondriac region 3 regions from lateral to medial= fundus, body and neck (infundibulum) Attached to the ventral surface of the liver

Question 101

Describe the anatomy of the abdominal accessory organ, the pancreas

Answer 101

Found in the upper left quadrant Retroperitoneal & behind greater omentum Contains the Islets of langerhans cells -Alpha = glucagon (storage of glucose) -Beta = insulin (breaks down glucose, also allows glucose to enter the cells)

Question 102

Discuss the vascularity of the foregut, midgut, and hindgut structures

Answer 102

foregut = celiac trunk (gives off the left gastric & hepatic proper artery) midgut= superior mesenteric artery hindgut= inferior mesenteric artery

Question 103

Describe the membrane, proper or “true” mesentery

Answer 103

-Largest mesnetary -Connects small intestine to abdominal wall -Binds the loops of the small intestine together -Allows for the small intestines to fold and not get tangled

Question 104

What is the largest mesentery?

Answer 104

proper/true mesentery

Question 105

Describe the membrane, mesocolon of large intestine

Answer 105

-Unlike the small intestine that is completely enclosed, the mesocolon of large intestine only segments or a small portion is bound -Usually non movable parts get a mesencolon - regionalized -Mesocolon attaches the colon to the abdominal wall

Question 106

Describe the membrane, greater omentum - "Greasy Apron" (curvature of stomach)- where does it hang?

Answer 106

Hangs from the stomach and closes over the transverse colon

Question 107

Describe the membrane, lesser omentum (curvature of stomach)- what region does it lie in and what does it connect?

Answer 107

-In the epigastric region -Connects parts of the lower esophagus, gallbladder, and liver to the cardia region of the stomach.

Question 108

Which digestive or accessory digestive organs are intraperitoneal?

Answer 108

-stomach -spleen -liver -gallbladder -1st and 4th part of the duodenum -jejunum -ileum -transverse colon -sigmoid colon

Question 109

Which digestive or accessory digestive organs are retroperitoneal?

Answer 109

-adrenal glands -aorta -kidneys -esophagus -ureters -pancreas -rectum -parts of the stomach and colon

Question 110

Which digestive or accessory digestive organs are secondary peritoneal?

Answer 110

-pancreas -ascending and descending colon -distal part of the duodenum

Question 111

Compare the hepatic portal venous system to the caval venous system

Answer 111

Caval Venous System -Restores most of the blood from the lower limbs and from kidneys and organs that do not need to be processed Hepatic Portal Venous System -Everything in the GI tract needs to go to the liver first -Liver is unique in that it has two named veins. >>The Hepatic Portal is entering like an artery >>The Hepatic Vein is leaving to join the inferior vena cava just below the diaphragm

Question 112

What are the 9 abdominal regions?

Answer 112

Question 113

What are the sphincters and valves related to the GI tract?

Answer 113

Upper Esophageal Sphincter - Throat region Lower Esophageal Sphincter aka cardiac notch -Separates lower esophageal from cardiac region of stomach Pyloric Valve Ileocecal Valve Internal anal sphincter → smooth muscle External anal sphincter → skeletal muscle (gets myelinated last) -Explains why babies are incontinence

Question 114

A 48 y/o man comes to the ED complaining of trouble seeing, and he has difficulty swallowing. Symptoms began 3 hours ago and are increasing in severity. He is visiting friends and indicates that approximately 24 hours ago he ate green beans that were canned at home. Physical examination reveals double vision, drooping eyelids, slurred speech, and difficulty swallowing. There is also muscle weakness. What abnormality would be present at the NMJ?

Answer 114

docking and fusion of the ACh vesicles would be impaired

Question 115

The surface of the lung that contains the hilum is the....

Answer 115

medial surface

Question 116

The mainstay of treatment for lead toxicity is....

Answer 116

chelation therapy

Question 117

The left gastric, splenic, and common hepatic arteries are branches of the....

Answer 117

celiac trunk

Question 118

A 58 y/o man comes to the ED complaining of bleeding in his mouth. He has multiple small bleeding sites on the mucosal membranes of the nose and mouth. He has suffered from an MI 18 months ago and has been on low dose warfarin. One month ago, he started taking herbal supplements containing ginkgo biloba. HCt= 35% and PT and PTT levels are high. Plasma analysis should dhow decrease in....

Answer 118

thrombin

Question 119

This is not one of the muscles of mastication that moves the mandible: A) tongue B) medial pterygoid C) temporalis D) masseter E) lateral pterygoid

Answer 119

A) tongue

Question 120

Lead toxicity can result in anemia because.... A) it can cross the BBB B) hemolysis occurs C) it inhibits a number of enzymes necessary for heme synthesis D) both B and C are correct

Answer 120

D) both B and C are correct

Question 121

The layer of the epidermis deep to the papillary dermis is the? A) stratum basale B) reticular layer C) stratum corneum D) stratum spinosum E) none of the above

Answer 121

E) none of the above

Question 122

An edrophonium test shows an improvement in muscle strength. There is a high probability that the diagnosis is....

Answer 122

myasthenia gravis

Question 123

The region of the pharynx used for both respiration and digestion is the....

Answer 123

oropharynx and laryngopharynx