BCS Mini Board

Aortic vestibule

The portion of the ventricle immediately below the aortic orifice is termed the aortic vestibule

What can induce rhabdomyolysis when on a statin?

CYP3A4 inhibitors like grapefruit juice

How does Ca2+ induce ACh vesicle fusion with the pre-synaptic membrane?

Ca2+ binds to Synaptogramin (located on the membrane of the ACh vesicle) which induces vesicle fusion and the release of ACh into the synapse

Rayanodine receptor

Ca2+ induced Ca2+ release channel

Superficial fascia of the abdomin

Camper's (outer fatty layer) Scarpas (inner membranous layer)

Succinylcholine

Depolarizing paralytic agent used during surgery. Works on Nm receptors of skeletal muscle

What gives connective tissue its physical properties?

Extacellular matrix (ECM of bone is mineralized giving it it's rigid structure)

Extensor Pollicis Brevis

Extend MP joint of thumb posterior interosseous nerve

Extensor Pollicis longus

Extend the IP joint of the thumb posterior interosseous nerve

Extensor indicis

Extends the index finger posterior interosseous nerve

ESR and back pain

ESR may be helpful when diagnosing low back pain if there is a strong suspicion of cancer or infection

TNFa decor receptor used in RA

ETANERCEPT

knee joint

A-posterior cruciate ligament B- Anterior Cruciate Ligament C- Medial meniscus- attaches tot he tibial colatteral ligament D- Lateral Meniscus

Essential hypertension

Adipose tissue releases Leptin, which activates the central sympathetic outflow, which could be the primary reason for the genesis of essential HTN

blood supply to middle portion of the esophagus (above the diaphragm)

Esophygeal artery

In what order are muscles effected by Myasthenia Gravis?

First the muscles of the face, neck, and jaw, then the arms and legs are affected later

4 lumbrical muscles

Flex MP joint and Extent IP joint 1/2- Medial nerve 3/4 - Deep ulnar nerve

What causes compression of median nerve resulting in carpal tunnel syndrome?

Flexor retinaculum

Quadratus Lumborum

Floor of the posterior back

Epimysium

a sheath of dense connective tissue that surrounds the whole muscle (collection of fascicles)

Uric acid

a small molecule that is not bound to protein so it is completely filtered 10% of filtered load remains in urine

SLAP lesion

a superior tear where the glenoid labrum meets the tendon of the long head of the biceps muscle

Murphy's sign

a test for gallbladder disease in which the patient is asked to inhale while the examiner's fingers are hooked under the liver border at the bottom of the rib cage. The inspiration causes the gallbladder to descend onto the fingers, producing pain if the gallbladder is inflamed

Compartments of the leg

Anterior, Posterior, and lateral compartments

Anal triangle boundries

Anterior- perineal body lateral wall- obturator internus medial - levator ani posterior- coccyx

How are ACh vesicles moved to the pre-synaptic membrane?

Anterograde transport involving vesicles moving toward the + end using kinesin

Side effects of Cyclobenzaprine

Anti-M (dry mouth, blurry vision) Anti-H1 (Sedation)

Myasthenia Gravis

Antibody produced against Nm receptor and blocking the EPP from being generated

Lambert-Eaton Myasthenic syndrome

Antibody produced against the VGCCa1A (Voltage Gated Calcium Channel) so that ACh vesicles can not fuse and resulting in a loss of EPP Autonomic dysfunction: dry mouth, constipation, erectile dysfunction

Spinal vertebrae/nerve classification

Cervical region has one extra nerve

What muscles form the floor of the pelvis (pelvic diaphragm) ?

Coccygeus (S4) Levator Ani (S3-S4)

Bulbourethral Gland

Cowper's glands (DEEP POUCH) two pea sized glands at the base of the membranous urethra that add fluid to semen during ejaculation

Nm blockers (antagonists)

D-Tubocuranine Cisatracurium Mivacurium Pancuronium Vecuronium

Dopamine

D1/D2 a1 and B1 agonist used for CHF with oliguria dopamine is made in the CNS and proximal tubule cells (local diuretic and natriuretic)

Dopexamine

D2 agonist used for CHF, sepsis, and shock

Syndactyly

Fused digits due to insufficient BMPs (Bone morphogenic factor-apoptotic inducing factor)

Ground substance component that accounts for the compressive nature of bone

GAGs

Leptin

Leptin released by fatty cells can increase sympathetic outflow (stimulating B1) which produces renin which contributes to the development of HTN

Tennis Elbow

Inflammation of superficial extensor muscles originating from the lateral epicondyle of the humerus

Golfers eblbow

Inflammation of superficial flexor muscles originating from the medial epicondyle of the humerus

Lymphatic drainage of upper extremity

Infraclavicular nodes = deltopectoral nodes

M blockers used for Asthma

Ipratropium Tiotropium

Chondromas on the surface

Juxtacortical chondroma

metabolic alkalosis

Loss of H+ (diarrhea/vomiting) leads to an increase in pH and and increase in HCO3-

Popliteus muscle action

Last action of axtension at knee joint is medial roatation of the femur on the tibia. (unlocking: rotation of the femur laterally on the tibia)

Osteopetrosis

Marble bone disease due to decreased osteoclastic bone resorption resulting in defuse, symmetric skeletal sclerosis

Dorsum of the foot

Medial to lateral T-Tibialis anterior H-Extensor hallucis longus A-Dorsalis Pedis artery N- Deep Peroneal Nerve D-Extensor digitorum longus

What lobe of the prostate is associated with Benign Prostatic Hyperplasia?

Median lobe

Most common skeletal malignancy

Metastatic tumor that is most common in adults

Testing for hyperreactive bronchial constriction in asthma patients

Methacholine challenge. Give low dose and see if it evokes an asthma attack

left thoracotomy

Mid axillary line (nipple line or inframamary fold) this is how you get to the heart

What are Ganglia derived from?

Neural crest cells of neural ectoderm

what are all four types of ganglia derived from?

Neural crest cells of the neuroectoderm

Trimethaphan

Nn antagonist used as an antihypertensive drug in aortic dissection

Mecamylamine

Nn antagonist used as an antihypertensive drug in aortic dissection and for tourette syndrome

Hexamethonium

Nn blocker

What happens if a portion of the lower motor neuron is lost (afferent or efferent)

No response

Mitochondrial complex II

No subunits of the ETC complex II are encoded for in the mitochondrial genome, so mitochondrial disease can come from mutations in the nuclear or mitochondiral genomes (if its in the mitochrondrial genome the inheritance will be maternal)

Why is Epinephrine and not norepinephrine used for anaphylaxis?

Norepinephrine does not have a B2 agonist to dilate bronchi (risk of Bronchoconstriction and angeoedema)

joint pain worsens with use of joint

OA

most common joint disease

OA

CN2

Optic

Benign bone forming tumors

Osteoid osteoma, osteoblastomas

OA x-ray characteristics

Osteophytes joint space narrowing Subchondral cysts and sclerosis

M blocker used for overactive bladder

Oxybutinin Propanthelin Fesoterodin

Kidney Proximal/Distal convoluted tubule and pH

PCT reabsorbs HCO3- DCT generates HCO3-

pain and swelling cytokine

PGE2

What structures drain into the portal vein?

PISS in the portal Pancreas intestine stomach spleen

Collections of cell bodies

PNS (Ganglion) CNS (Nucleus/Horn)

normal arterial gasses and pH

PO2= 75-105 mmHG PCO2= 33-45 mmHG pH= 7.35-7.45

What happens if osteophytes in the intervertebral foramen are pinching the Dorsal Rootlets/root?

Pain but no motor defecit (afferent nerves effected)

Dupuytren's Contracture

Palmar aproneurosis- shortening that begins with the ring finger, then little finger, then middle then index

Branches of the ulnar nerve that do not go thru the canal of Guyon

Palmar cutaneous branch Dorsal Cutaneous branch

What branch of the median nerve does not go thru the carpal tunnel?

Palmar cutaneous branch of median nerve (not affected by carpal tunnel syndrome-palm of hand will not be affected)

sympathetic trunk

Paravertebral ganglia (cell bodies of post ganglionic neurons) distribute postgangionic sympathetics to all spinal nerves (this means all spinal nerves carry sympathetic nervous fibers)

tunica vaginalis

Parietal layer on the outside and visceral layer on the inside (derived from peritoneum)

Autonomic Nervous system (Sympathetic/Parasympathetic)

Part of the PNS Ganglia type: Paravertebral, prevertebral, enteric Motor Neuron (Efferent): General Visceral Efferent/Autonomic nerve Sensory Neuron: General visceral Afferent/Autonomic nerve

Somatic nervous system

Part of the PNS Type of ganglia: Dorsal Root Motor neuron (efferent): General Somatic Efferent/Spinal nerve Sensory neuron (afferent): General somatic afferent/Spinal nerve

Triceps Surae

Part of the superficial posterior compartment of the leg 2 heads of the Gastrocnemius and the soleus (attached by the achellies tendon) nerve: tibial action: plantar flexion

What does the internal iliac supply?

Pelvic organs Gluteal region perineum

Adductor canal

Roof- sartorius medial wall- Adductor longus Lateral wall- Vastus medialis

Supinator

Rotates radius into supination origin-ulna insertion-radius Deep radial nerve (potential site for compression)

Brachioradialis

Rotates radius to mid prone position radial nerve

What causes supperative arthritis?

S. aureus Haemophilus influenza (kids 2-5 years) Salmonella (Sickle cell disease patients)

Termination of the dura-arachnoid sleeve

S2 vertebrae

referred pain from pelvic GVAs

S2-S4

Parasympathetic control of the bladder

S2-S4 M3 (contraction of the detrusor)

Somatic control of the bladder

S2-S4 Nm (external urethral sphincter)

Pudendal nerve

S2-S4 (supplies the perineum) branches: dorsal nerve, perineal nerve, inferior rectal nerve Somatic and sympathetic

Parasympathetics to Perineum

S2-S4 Pelvic splanchnics

Parasympathetics to organs supplied by the inferior mesenteric artery

S2-S4 pregnaglionic (pelvic splanchnics) distributed by the inferior mesenteric artery

Levator ani

S3-S4 pubococcygeus: Pubovaginalis/prostate, puborectalis, pubococcygeus Iliococcygeus

Coccygeus

S4

chronotropy

SA node (controlled by B1 and M2) B1 increases HR M2 decreases HR

Brody Syndrome

SERCA1 mutation blunts Ca2+ sequestration

Other treatments for Myasthenia Gravis for when drugs fail

Thymectomy (even when there is no thymoma) Plasmapheresis IVIG

4 dorsal interossei

Tibial Nerve

Tests used for Carpal Tunnel

Tinel's test Phalen's Maneuver Both will elicit pin and needle sensation or pain

Where is CSF located?

Subarachnoid space the cauda Equina in the subarachnoid space is abthed in CSF (the site of a spinal tap)

Innermost intercostals (three groups)

Subcostal Intima Transverse thoracis

Nm agonists

Succinylcholine (depolarizing) Acetylcholine Nicotine

Nm agonists

Succynylcholine, Acetylcholine, Nicotine

Superficial lymph drainage below the umbilicus

Superficial inguinal nodes

common peroneal nerve damage

Superficial peroneal- lose lateral compartment everters Deep peroneal- loose anterior compartment with dorsal flexors results in a foot that is plantar flexed and inverted

How are the 3 Paravertebral cervical ganglia distributed to the 8 cervical spinal nerves?

Superior cervical ganglia (C1-C4) Middle Cervical Ganglia (C5-C6) Inferior Cervical Ganglia (C7-C8)

Lymphatic drainage of organs supplied by the superior mesenteric artery

Superior mesenteric Lymph nodes these go on to drain into the intestinal trunk and finally the thoracic duct

what two veins form the portal vein?

Superior mesenteric and splenic

Inferior mesenteric Artery

Supplies: descending colon Sigmoid colon upper 1/2 rectum

What structures are innervated by sympathetic nerves ONLY?

Sweat glands, blood vessels, hair follicles (no parasympathetic innervation)

Origins of the GVE cell bodies (autonomic nerve)

Sympathetic- Thoracolumbar outflow T1-L2 (lateral horn of spinal chord) Parasympathetic- Craniosacral outflow CNS 3, 7, 9, 10, S2, S3, S4 (brain and lateral horn of spinal chord)

Sympathetics and parasympathetics to structures supplied by the internal iliac and middle rectal artery

Sympathetics= Sacral splanchnics L1-L2 parasympathetics= Pelvic splanchnics S2-S4

Orthostatic Hypotension Physical presentation

Systolic BP> 20 mmHG Less upon standing (N 100-139) Diastolic BP> 10 mmHG less upon standing (N60/89)

At what level is the Esophogeal Hiatus?

T-10

At what level is the Aortic Hiatus?

T-12

At what level does the Inferior vena cava pass thru the diaphragm into the abdominal cavity?

T-8

Internal thoracic artery

a branch of the subclavian artery, gives rise to the anterior intercostal arteries

Pubococcygeus

a component of the levator ani made up of the Pubovaginalis/prostate, puborectalis, pubococcygeus spans from pubic bone to the coccyx

AChE inhibitors used for Alzheimer

Tacrine Donepezil Rivastigmine Galantamine

Axillary view x ray

Taken thru the armpit with patient laying on their back. helps determine if the fracture is anterior or posterior

a1A specific drug used for benign prostatic hyperplasia

Tamsulosin

Holt-Oram syndrome

Tbx 5 associated

Hypocalcemia in Rhabdomyolysis

Tetany and long QT

Iliococcygeus

a component of the levator ani that starts in the fascia of the obturator internus

bones of the wrist

"Some Leopards Try Positions That They Cannot Handle"

Type 2 error

"false negative" when a study finds that there is no difference between two groups being tested when in fact there is a difference

Type 1 error

"false positive" when a study finds there is a difference in effectiveness of two treatments, when in fact there is NO difference

Minor duodenal papilla

#1 Opening of duct of santorini located in the 2nd part of the duodenum

Subcostal nerve

#1 T-12

Subcostal nerve

#1 T12

Iliohypogastric nerve

#2 L-1

Major Duodenal papilla

#2 opening of the duct of Wirsung located in the 2nd part of the duodenum secretes pancreatic juices

Ilioinguinal nerve

#3 L-1

Lateral Femoral Cutaneous nerve

#4 L2-L3

Femoral Nerve

#5 L2-L4

Obturator nerve

#6 L2-L4

Lumbosacral Trunk

#7 L4-L5

Stenosing Synovitis

(DeQuervain's Tenosynovitis) inflammation of the bursa of the Abductor Pollicis Longus and the Extensor Pollicis Brevis due to impingement in the narros osteofiberous tunnel

Iliotibial band

(Fascia Lata)

what do baroreceptors sense?

(MAP) but not actually pressure! they sense stretching in the vessel wall TRPC Channels . more stretch = more firing

Lesser splanchnic nerves

(T10-T11) Superior mesenteric Ganglion

The greater splanchnic nerve

(T5-T9) Celiac Gangion It descends across the vertebral bodies moving in a medial direction, passes into the abdomen through the crus of the diaphragm, and ends in the celiac ganglion

Ductus deferens

(Vas Deferens) transports sperm from the testes

Structures in the tarsal tunnel

(anterior to posterior) Tom- Tibialis Posterior Dick- Flexor Digitorum Longus A-Posterior tibial Artery N-Posterior tibial nerve Harry- Flexor hallucis longus

Mackenrodt's Ligament

(lateral cervical/cardinal ligament) contains the uterine artery

Clonus response (Myotatic reflex)

(repeated jerking) Hyperactive knee jerk response

what lies in the costal groove of a rib?

(superior to inferior) costal vein costal artery castal nerve

Spinal arteries

1 anterior (Artery of Adamkiewicz) and 2 posterior

Dorsal Root Ganglia

A collection of neuron cell bodies in the PNS, located along the dorsal root, just medial to the fusing of the dorsal and ventral roots into the spinal nerve these neurons are pseudounipolar, with sensory receptors in the tissue, and synap in the dorsal horn of the spinal chord. The cell body is only there to support the neuron

Adverse effects of using Succinylcholine to induce paralysis

Anaphylaxis- non-IgE release of histamine from mast cells Malignant hyperthermia

Superficial lymph drainage above umbilicus

Anterior axillary nodes (pectoral nodes)

Lateral Elbow radiograph

Anterior humeral line- line drawn parallel to anterior humerous. Should pass thru the middle third of the capitulum Proximal radial line- line along the longitudinal axis of the radius. Should pass thru the middle of the capitulum

Supercondylar fracture

Anterior humoral line will be abnormal common in children child that presents with a history of falling on an outstretched hand follwed by pain, swelling, and inability to move the affected elbow

Blood, nerve, and lymph supply below pectinate line

Artery= inferior rectal vein= inferior rectal (causes external hemorrhoids) Nerve= Pudendal (somatic S2-S4) Lymphatics= Superficial inguinal

Blood, nerve, and lymph supply above pectinate line

Artery= superior rectal vein= superior rectal (causes internal hemorrhoids) nerves = pelvic splanchnics (S2-S4)and sympathetics Lymphatic = inferior mesenteric nodes

Erector Spinae Muscles

B-Lliocostalis C-Longissimus D- Spinalis Nerve: Dorsal Rami of Spinal Nerves Function: Bilateral extension of the vertebral column and head Unilateral bending of the vertebral column and head

Intertubercular Sulcus

Biceps bracii- long head tendon

Structures drained by the external iliac nodes

Bladder seminal vesicle prostate

HEMICHOLINIUM

Blocks the Na+/Choline cotransporter so that Choline caan not be recycled

Quadrangular space

Boarders: Teres minor Teres major Long head of triceps Shaft of humerus Contents: Axillary nerve Posterior humeral circumflex artery

Corpus cavernosa

Body of the penis (A)

What happens if osteophytes in the intervertebral foramen are pinching the spinal nerve/dorsal or ventral ramus?

Both pain and motor deficits (these compressions are known as ridiculopathies)

Canal of Guyon

Boundaries (Pisiform bone, Palmar carpal ligament, Flexor retinaculum) Contains: Ulnar artery Ulnar nerve

Genu Vara

Bow legged decrease angle of Q or tilt tibia in Q= 10 degrees normally

Coxa Valga

Bow legged (increase the angle or tilt femur out laterally) normal = 125 degrees

Dorsal nerve

Branch of Pudendal (S2-S4) pure sensory to glans penis and clitoris #1

Perineal nerve

Branch of Pudendal (S2-S4) motor to all muscles in the urogenital triangle (deep and superior pouches) and sensory to the posterior area of the scrotum and labia majora #2

Inferior Pancreaticoduodenal artery

Branch of the Superior mesenteric it branches into anterior and posterior branches that run between the head of the pancreas and the lesser curvature of the duodenum

inferior rectal nerve

Branch of the pudendal (S2-S4) motor to the external anal sphincter and sensory to the anal area

Dorsal rami

Branch of the spinal nerve that goes to the back. Since the spinal nerve is a mixed nerve, the Dorsal Rami will also be mixed (containing both sensory and motor neurons). These nerves seperate back out into the dorsal root (sensory neurons) and ventral root (motor neurons) before entering the spinal chord as rootlets

Ventral rami

Branch of the spinal nerve that goes to the front. Since the spinal nerve is a mixed nerve, the ventral Rami will also be mixed (containing both sensory and motor neurons). These nerves seperate back out into the dorsal root (sensory neurons) and ventral root (motor neurons) before entering the spinal chord as rootlets

Middle colic artery

Branch of the superior mesenteric artery that supplies the transverse colon

Blood supply to the head of the pancrease

Branches of Common Hepatic: Superior pancreoduodenal branches of superior mesenteric inferior pancreoduodenal

blood supply to duodenum

Branches off of common hepatic: gastroduodenal (1st part of duodenum) superior pancreaticoduodenal branches off Superior mesenteric: inferior pancreaduodenal

Cancers that are most commonly metastatic to bone

Breast Lung Thyroid Kidney Prostate (BLT with Kosher Pickle)

Conus arteriosus

The infundibulum (also known as conus arteriosus) is a conical pouch formed from the upper and left angle of the right ventricle in the heart, from which the pulmonary trunk arises

Bone

a type of specialized connective tissue

Gq receptors

a1 M3 results in an increase in calcium which is involved in contraction

Phenylephrine

a1 agonist used as a nasal decongestant, mydriatic and for hypotension in operating room

Phenoxybenzamine

a1 antagonist Pheochromocytoma preop

Phentolamine

a1 antagonist Pheochromocytoma preop

Epinephrine

a1/a2 B1/B2/B3 agonist

Norepinephrine

a1/a2 and B1 agonist

Gi receptors

a2 M2 D2 D3 D4

a-methydopa

a2 agonist used for HTN in pregnancy

Clonidine

a2 agonist used for HTN, diabetic autonomic neuopathy diarrhea, opiod/alcohol withdrawl

Tizadine

a2 agonist used for spasticity

Yohimbine

a2 antagonist used to treat erectile dysfunction

Oxymetazoline

a2/a1 agonist used as a nasal decongestant and mydriatic

abductor Pollicis longus

abduct thumb posterior interosseous nerve

4 dorsal interossei

abduction of fingers (away from middle finger) Deep ulnar nerve

4th intercostal space

about where the nipple is located

Superior Epigastric artery and vein

above the umbilicus derived from the subclavian artery and vein

Cleidocranial dysplasia

absence of one or both clavicles patients may have osteopenia and may develop osteoporosis women with this have an increased risk and may require C-section due to a narrow pelvis

Polystotic fiberous dysplasia

accounts for 27%of fiberous dysplasia and include multiple bones somatic mutation in GNAST1 occurs in adulthood and has craniofacial involvement (shoulder and pelvic girdle involvement in severe cases)

Monostotic fiberous dysplasia

accuount for 70% of fiberous dysplasia and only include a single bone somatic mutation in GNAST1 occur in early adolescence before growth plate closes

Contributors to fatigue during high intensity excercise

acidic pH (major cause), Pi accumulation, Ca2+ depletion, Creatine Phosphate depletion

main structural protein of thin filaments

actin

thin filaments

actin

Treatment for Low back pain

activity (NO BED REST) heat therapy NSAIDs Acetominophen Benzodiazapines Muscle relaxers Opiods Spinal manipulation STEROIDS ARE NOT BENEFICIAL

Rhabdomyolysis symptoms

acute myalgia, tenderness, swelling, Tea colored urine, chills, fever, malaise, nausea and vomiting Oliguria- Acute Kidney Failure

metabolic acidosis

add H+ to blood leads to drop in pH and decrease in HCO3- (the base)

palmar interossei

adduct the fingers to the middle finger deep ulnar nerve

Froment's sign

adduction of the thumb, try to hold paper

adductor pollicis

adducts the thumb Deep ulnar nerve

What do the least thoracic splanchnics innervate?

adrenal glands, kidneys, proximal part of ureters

posterio-lateral disk herniation

affects the spinal nerve below the numbered disk that is herniated (EX: disk L3 herniation presses on spinal nerve L4)

Creeping substitution

after bone necrosis, dead bone acts as a scaffold and new bone is produced slowly collapse of old necrotic bone leads to secondary osteoarthritis

Biological drugs

all drugs that are antibodies end in "mab" and "cept"

Hypaxial muscles

all muscles in the body wall except for the deep back muscles (Pax3 gene)

What does the perineal nerve supply?

all of the skeletal muscle in both the deep and superficial pouch

Endochondrial (Intracartilaginous) of appendicular skeleton

all other appendicular bones except for the clavicle

what kinds of muscles have what kinds of muscle fibers?

all three kinds of fibers (red, white, and intermediate) are located in every muscle but may be present in different proportions

centronuclear myopathy

also called myotubular myopathy. characterized by central location of nuclei in skeletal muscle

Pectus Carinatum

an outward bow in the sternum that reduces lung function. Seen with marfans, osteogenesis inperfecta, and trisomy 18 and 21

dystrophin

anchors the actin cytoskeleton to extracellular matrix

Cutting the deep peroneal nerve

antagonist muscles will have the foot plantarflexed and sensory will be lost between the first and second toe

Parasympathetic innervation of organs supplied by the celiac trunk

anterior (left) vagus: liver, stomach, gall bladder posterior (right) vagus: all other abdominal organs except the descending and sigmoid colon

bypassing a blocked aorta

anterior and posterior costal arteries provide a bypass connections from the external illiac to the subclavian also provide a bypass

Extensor digitorum longus

anterior compartemnt of the leg nerve: deep peroneal action: the only dorsiflexors of the ankle

Extensor Hallucis longus

anterior compartemnt of the leg nerve: deep peroneal action: the only dorsiflexors of the ankle. Assists in inversion

Tibialis anterior

anterior compartemnt of the leg nerve: deep peroneal action: the only dorsiflexors of the ankle. Assists in inversion

Compartments of the thigh

anterior compartment is called "Deep Fascia" this is the right leg, so the left leg compartment is the opposite (with the medial compartment towards the midline)

Lachman's test

anterior cruciate ligament tear

obturator nerve

anterior division of this nerves runs along the anterior surface of the adductor brevis L2-L4 ventral rami. Innervates medial thigh muscles and distal medial thigh skin

Bankart Lesion

anterior inferior labral tear associated with dislocation of the shoulder

Urogenital triangle boundries

anterior- Pubic symphysis lateral- ischiopubic ramus posterior- perineal body

Epiplotic foramen boundries

anterior- hepatoduodenal ligament posterior - IVC cranial- caudate lobe of liver caudal- 1st part of duodenum

Endoabdominal fascia

anterior- transversalis fascia posterior- iliacus and psoas fsacia

urogenital triangle

anterior: Pubic Symphysis Lateral: ischiopubic ramus Posterior: perineal body

anal triangle

anterior: perineal body Lateral: Obturator internus Medial: levator ani Posterior: coccyx

ligaments that can be torn during shoulder seperation

any or all of these ligaments can be torn if the shoulder is seperated

What can cause hemorrhage in the thoracic cavity?

aorta, heart, lungs

how do bones increase in thickness?

apositional growth

skeletal muscle cross section

appear as polygons

PHOX2B muation

autonomic dysregulation of ventilatory rhytym hypoventilation during sleep Neural crest tumors (neuroblastoma)/Hirschprung disease (megacolon)

Mutation in ryanodine receptor gene RYR1

autosomal dominant, greatly increases Ca release due to lowered activation and heightened deactivation threshold of RyR1 resulting in malignant hyperthermia

Amyotrophic Lateral Sclerosis (Lou Gehrig's Disease)

average age 40-60 most common neuromuscular disease most die 3-5 years after onset due to respiratory failure kills both upper and lower motor neurons

Pyogenic osteomyelitis

bacterial infection that enters the bone most commonly in children thru the hematogenous route and via extension from contiguous soft tissue site in adults. 80-90% of the time it is staph aureus

Triangle of Calot

area between the cystic duct and common hepatic duct contains the right hepatic artery and the cystic artery

enthesis

area of bone where tendons are inserted

Prevertebral ganglia

around aortic blood vessels Autonomic

pulmonary edema

bats wings appearance

symptoms of lambert eaton syndrome

begins with difficulty walking. ocular symptoms are rare

popliteal artery

behind the knee joint

Inferior Epigastric artery and vein

below the umbilicus derived from the external iliac artery and vein

Hammertoe

bending of the IP joint (excessive flexion)

Osteoblastomas

benign bone forming tumor that appear in the spine with pain that is not alleviated by aspirin

Osteoid osteoma

benign bone forming tumor that presents in teens and early 20s as a <2cm nocturnally painful lesion in cortex of long bone that is relieved by aspirin more common in males

Osteochondroma

benign cartilage capped outgrowth from bone (metaphysis-near the growth plate) attached by a bony stalk more common in males (15-25 years of age)

Reactive arthritis triad

arthritis Non-gonococcal urethritis/cervicitis conjunctivitis

Acetabulum

articulation site for the head of the femur composed of three pelvic bones (ilium, ischium, pubis)

Load velocity graph

as the load increases, the velocity of shortening decreases decreasing the initial length of the muscle decreases the velocity of shortening V max is independent of the initial length

Sarcoidosis

associated with bilateral hilar lymphadenopathy

Posterior shoulder dislocation

associated with seizures and electric shocks looks like a light bulb on both external and internal rotation views

Geographic location of sarcocystis

associated with south east asia

chemosis

associated with trichanosis periorbital edema

stages of gout

asymptomatic hyperuricemia acute gouty arthritis intercritical gout (between flare ups) chronic tophaceous gout

Hemolysis dipstick test

at Hb >100mg/dL (N3-4 mg/dL) is hemoglobinuria which is visible as a pink stain in a serum and urine is positive for heme

aortic bifurcation at L4

at L4, the aorta splits into a right and left common iliac artery

medial arcuate ligament

at the interface between the Psoas and the diaphragm #7

lateral arcuate ligament

at the interface of the quadratus lumborum and the diaphragm #2

Ejaculatory duct

between middle and posterior lobes of the prostate

Lesser omentum

between the liver and stomach 2 layers

Forearm Suppination

biceps brachii musculocutaneous nerve

Flexion at elbow

biceps brachii and brachialis musculocutaneous and radial nerve

calcitonin

binds directly to osteoclast to induce inactivation by altering their morphology (osteoclasts loose their ruffled boarders and decrease lysosomal enzyme secretion)

Haptoglobin

binds hemaglobin at 100mg/dL. This is why we dont normally detect blood in urine Hb-Hp complex is not filtered and is catabolized by hepatocytes to recover iron

Structures drained by the Internal iliac nodes

bladder seminal vesice prostate uterus upper 2/3 of vagina Lower 1/3 of rectum (also drained by inferior mesenteric nodes)

Anti-TNFa drugs used for RA

block access of TNFa to its receptor stopping tissue damage INFLIXIMAB ADALIMUMAB CERTOLIZUMAB

VESAMICOL

blocks the V-Type ATPase on the vesicle so that ACh can not be packaged into them

Pectinate line

bottom of the anal valves this is where the blood and nerve supply changes in the anal canal

medial plantar nerve

branch of the tibial nerve that inervate: flexor digitorum brevis, abductor hallucis, flexor hallucis brevis, 1st lumbrical

lateral plantar nerve

branch of the tibial nerve that innervates the: Quadratus plantae Abductor digiti minimi Flexor Digiti minimi brevis 2-4th lumbricals Adductor Hallucis All dorsal and plantar interossei

Right suprarenal vein

branches from the IVC to the suprarenal gland

Left suprarenal vein

branches from the right renal vein to the right suprarenal gland

Tibial nerve in the foot

branches into the medial plantar and lateral plantar nerve

Common peroneal nerve

branches into the superficial and deep peroneal nerve (they are called fibular in this picture)

Rhabdomyolysis

breakdown of skeletal muscle myoglobin release causes acute kidney failure K+ release = cardiac arrest (peaked T wide QRS) Ca2+ uptake = Hypocalcemia

Lyme Arthritis

caused by Borrelia burgdorferi 3 stages -Erythema chronicus migrans -Early disseminated stage -Late disseminated stage

cancers most notorious for producing bone metastasis

breast, lung, thyroid, kidney, prostate usually appear as multiple lesions (except in thyroid and kidney which usually only have one bone metastasis)

Type 1 OI

brittle bones. least severe form of OI

Myoclonus

broad involuntary muscle jerks

lymphatic drainage of lobar bronchi

bronchopulmonary nodes

Pompe's disease symptoms

buildup of glycogen causes progressive muscle weakness

direct inguinal hernia

bulges anteriorly into the posterior wall of the inguinal canal (hesselbach's triangle) these are medial to the inferior epigastric artery when finger is in the superficial inguinal ring, hernia will come at your finger from the top

Trigger finger

bursa that projects outside of the fiberous sheath and finger gets stuck in a bent position

Osteogenesis type 2

caused by a short pro-a1 resulting in an unstable helix. Death before or shortly after birth

prolapsed uterus

caused by a weak pelvic diaphragm

Primary gout cause

caused by an unknown or known enxyme defect that causes excess of Uric Acid (ex: HGPRT)

Glenoid Labrum Tear

caused by repetative shoulder motion or acute shoulder trauma (falling on outstretched arm) increased pain with overhead activity or elbow flexion. popping or grinding, loss of strength, trouble localizing a specific point of pain

Injury to ribs 1-3

caused by severe force high mortality risk with associated injuries

Subclavian artery compression

causes ischemia with coolness, palor, claudication, paraesthesia and decreased upper limb pulse

Vagus sensory in the lungs

c-fibers (nociceptic) of CN 10 located around the pulmonary capillaries responsible for sensing dyspnea (even when its not really there) senses irritants, edema fluid, and pulmonary embolus

Subclavian vein compression

causes upper limb swelling and pain and may result in venous thrombosis (Paget-Schrotter syndrome)

Prevertebral ganglia Efferent control of Sympathetic Enteric NS from CNS autonomics

celiac superior mesenteric inferior mesenteric

sentinal nodes for the stomach/esophagus below the diaphragm

celiac nodes

blood supply to abdominal portion of esophagus (below the diaphragm)

celiac trunk (esophageal branches of left gastric artery)

symptoms of extrasynovial inflammation in ankylosing spondylitis

calcification of scar tissue Enthesitis = calcaneal or olecranon spurs periarticular periostitis = bony spurs (syndesmophytes)

mixed spicules

calcified cartilage covered in bony tissue

pneumoperitoneum

can be a sign of bowel perforation, or from a recent surgery

Lumbar splanchnic nerves

cell bodies in lateral horn of L1-L2 preganglionic GVE fibers pass thru 5 lumbar paravertebral ganglia

Coracoid process

cen be palpated in the subclavicular depression called the deltopectoral triangle

Sensativity analysis

can be used to determine whether differences across studies may be explained by characteristics of the various populations that were studied

Cremaster muscle reflex

can be used to test injury above L1-L2 (genitofemoral)

Malformed Acromion process

can cause impingement Bursitis

Succinylcholine and Halothane

can cause malignant hyperthermia (increase in CO2 is hallmark)

fibrosis of muscles at the end of an axon

can cause myopathy

Hemivertebrae

can cause scoliosis

posterior duodenal (1st part) ulcer

can erode thru the gastroduodenal artery

posterior stomach ulcer

can erode thru the splenic artery

Chronic spasticity

can lead to contractures

fracture of the surgical neck of the humerus

can lead to damage of the axillary nerve usually result from a minor fall on the hand where the force is transmitted up the extended limb

Inadequate immobilization after fracture

can lead to pseudoarthrosis or the formation of a "false joint"

non-selective B blockers

can not be used for asthma (drugs need to be selective for B1, since B2 blockers will constrict the bronchi

What is the sarcoplasmic creatine phosphate concentration

can reach 20-35mM, enough for 2-7 seconds of intense work. It is depleted during periods of extended contraction and is restored during rest by using excess ATP

Displaced and comminuted fractures

can sometimes leave bone deformity can be succeptible to infection

TB spinal erosion

can track down the psoas muscle (which inserts in the spine) and infect the inguinal canal

Triquetrum fracture

can usually only be visualized on the lateral image soft tissue swelling can be a clue

Where are peripheral chemorecceptors located?

carotid body of glomus and aortic body of glomus

normal MAP for carotid sinus and aortic arch

carotid sinus (50-200 mmHG) aortic arch (110-200 mmHG)

Where are the two baroreceptors of the heart?

carotid sinus, a swelling after the bifurcation of the carotid (CN9 Clossopharyngeal) aortic arch (CN10 Vagus)

Lobster claw deformity

central component of hand or foot is missing due to an overexpression of BMPs

haversian canal

central tunnel in bony tissue where blood vessels and nerves travel nutrients derived thru central blood vessel and spread thru-out tissue via canaliculi

Anterior tibial artery

changes name to dorsal pedis artery below the malleoli

pencil in cup deformation

characteristic of Psoriatic Arthritis

involvement of the sacroiliac joint

characteristic of spondiloarthropathies

Visceral pain in peritoneal pelvic structures

carried by Sacral Splanchnics (L1-L2) fundus and body of uterus uterine tube ovary bladder upper 1/2 rectum

Abdominal efferents

carried by both sympathetics an parasympathetics

Sympathetics to abdominal viscera

carried by splanchnic nerves (preganglionic) synapse in ganglia on a bloodvessel, and then postganglionic fibers travel on the bloodvessel to the organ

Abdominal visceral pain (afferents)

carried by sympathetics only superior mesenteric= T10-T11 Inferior mesenteric L1-L2

Visceral pain in retroperitoneal pelvic structures

carries by Pelvic Splanchnics (S2-S4) cervix vagina prostate gland seminal vesicle lower 1/2 rectum bladder

neuropathic trace Electromyography (EMG)

characterized by low frequency, High amplitude MUAPs on Electromyography (EMG)

myopathic trace Electromyography (EMG)

characterized by short duration, low amplitude, irregular (polyphasic) MUAPs

Physical exam for lower back pain (abdomen)

check for bruits

Anterior drawer test

checks for tears in the anterior and posterior cruciate ligament

Allen's test

checks is the blood flow thru the ulnar artery is good before the ulnar artery is removed and used for a bypass surgery

treatment for massive hemothorax

chest tube inserted in the 5th intercostal space (between 4th and 5th rib)

Nn

cholinergic receptor in ganglia and adrenal medulla

Nm

cholinergic receptors that control skeletal muscle

Endochondrial (Intracartilaginous)

chondrocytes develop cartilage matrix

profunda femoris artery

circumflex arteries branch off of this

what muscle overlays the sacrospinous ligament?

coccygeus muscle (C)

Falx inguinalis (conjoint tendon)

combined fascia of the internal abdominal oblique and transversalis abdominis that inserts into the crest of the pubis directly behind the superficial inguinal ring

Posterior intercostal artery

comes off the descending aorta do not cover the first two intercostal spaces (these are provided by the subclavian)

three branches of the celiac trunk

common hepatic left gastric splenic

Calcium Pyrophosphate Dihydrate disease

common in elderly hyperthyroidism Vitamin D deficiency cortical thinning (subperiosteal resorption and osteopenia) characterized by deposition of calcium pyrophosphate in soft tissue of cartilage psuedogout

Quadriceps tendon

common tendon of the vastus medialis and vastus lateralis

Inspiration on XRay

complete inspiration = 5th-7th ANTERIOR rib at midclavicular line hyperexpanded = >7th rib (airway disease)

duchene muscular dystrophy

complete lack of dystrophin

rectum musculature

composed of circular muscle surrounded by longitudinal muscle

Dromotropy

conduction velocity from SA to Av node, controlled by B1

Troponin C

conformational change upon binding of calcium

Psuedohypertrophy of calf muscle

constant finding in Duchenne and Becker MD due to fat infiltration into the muscle

quadrangular space

contains axillary nerve

Spiral groove

contains radial nerve

Hepatogastric ligament (lesser omentum)

contains right and left gastric arteries

greater omentum

contains right and left gastroepiploic arteries

Gastrolinenal ligament

contains short gastric arteries and splenic artery

Carpal Tunnel

contains the median nerve and 9 tendons: 4 flexor digitorum superficialis 4 flexor digitorum profundus 1 flexor Pollicis longus

neurovascular bundle that runs along the inside of the obturator internus

contains the obturator nerve, artery,and vein, which are in danger of being cut during a hysterectomy

Corpus Spongiosum

contains the urethra (B)

Deltopectoral triangle (boundries and contents)

contents: cephalic vein coricoid process of scapula lateral pectoral nerve thoracoacromial artery

Isotonic contraction

contraction at a constant force (muscle shortens)

Isometric contraction

contraction at a constant length (no shortening of the muscle)

Inotropy

contraction of myocardium, controlled by B1

Eccentric contraction

contraction while lengthening (negative arm curl, walking down stairs) higher force generated with lower metabolic activity susceptible to injury

concentric contraction

contraction while shortening (arm curl, walking up stairs)

Large motor neurons

control large motor units of Type 2b (fast twitch) fibers

small motor neurons

control small motor units of Type 1 (slow twitch) fibers

Flexion at the shoulder

coracobrachialis and bicheps brachii musculocutaneous nerve

Dorsal rootlets of spinal nerve

covered by pia mater only

Spinal nerve roots

covered in all three meningeal layers

inferior surface of diaphragm

covered in parietal peritoneum that is also supplied by the phrenic nerve (referred pain to C3-C5)

1st and 4th part of the duodenum

covered in visceral peritoneum

Dorsal and ventral roots of lumbar and sacral spinal nerves

covered with all three menengral layers

Pia mater

covers spinal chord

Bulbospongiosus muscle

covers the bulb of the penis

Ischiocavernosus muscle

covers the crus of the penis

visceral pleura

covers the organs

Pathologic findings in OA

cracking and fibrillation of articular cartilage loss of articular cartilage bone eburnation bone sclerosis small fractures (loose bodies and subchondral cysts) bony outgrowths (osteophytes)

Where is creatine phosphate synthesized

creatine is synthesized in the liver from Arg, Gly, and Met then transported to muscle cells where it is phosphorylated by creatine kinase to form CP in the mitochondria

major storage fuel of Type IIa muscle fibers

creatine phosphate, glycogen or intracellular glucose stores

alpha actinin

crosslink neighboring actin filaments

Osteoblasts

cuboidal cells that reside on the surface of bone and secrete matrix (know as osteoid or uncalcified matrix) osteoid is not stained in H&E

Baker's cyst

cystic herniation of synovium of posterior knee seen in RA

Z disk

dark line in the middle of the I band

OPG (osteoprotegarin)

decoy receptor for RANKL that stops bone reabsorption

Parasympathetic functions

decrease HR increase peristalsis constrict pupils release urine erection

Gli-3

decreases expression of Shh

Endothoracic fascia

deep fascia of the muscles lining the thoracic cavity (below the visceral and parietal pleura)

dorsal interossei

deep ulnar nerve

scurvy

deficiency in Vit. C coefactor that is needed for proline and lysine hydroxylation or crosslinking post-translational modifications

osteopetrosis

deficiency in bone remodeling due to mutation in osteoclast proton pump

Characteristics of Osteoarthritis

degenerative articular cartilage Bone changes are secondary Not an inflammatory process

ACh Esterase

degrades ACh in the synapse to Choline and Acetate. Choline is recycles back to the pre-synaptic side thru a Na+/Choline cotransporter.

Botulinum toxin

degrades SNAP-25 and Syntaxin so that ACh can not dock to the pre-synaptic membrane. Degradation of pre-synaptic membrane proteins so that vesicles can not dock and ACh is not released into the synapse

Tetanus toxin

degrades synaptobrevin (a vesicle protein) which prevents the release of Glycine and GABA into the Spinal Chord

Uricolytic drugs for chronic gout

degrades uric acid PEGLOTICASE

what factors expedite fatigue?

dehydration and vitamin deficiency (vit. D)

alpha level

denotes the likelyhood of a type 1 error. when the difference between two groups is not a real difference but is due to chance .05% is the risk of making a type 1 error

beta level

deontes the likelyhood of a type 2 error .2 (one in five chance of missing a true difference)

Simple vs compound fracture

depends on if the skin is intact

Pseudogout (Chondrocalcinosis)

deposition of calcium pyrophosphate dihydrate crystals (CPPD) in cartilage inflammatory reaction that perpetuates joint injury

Pec minor

depress scapula when scapula is not fixed, elevate ribs when scapula is fixed Medial pectoral nerve

Osteoprogenitor cells

derived from mesemchymal stem cells flattened cells that reside on the surface of bone and undergo mitotic division and differentiate into osteoblasts

Appendicular skeleton

derived from somatic lateral plate mesoderm

innervation of parietal pleura

derived from somatic mesoderm (so its innervated by spinal nerves) parietal pleura that is connected to thoracic wall (intercostal nerves) parietal pleura in mediastinal region (phrenic nerve)

What do Lumbar (inferior mesenteric ganglion) innervate?

descening and sigmoid colon, upper portion of rectum, distal ureter

Golgi tendon organs

detect force (lb afferent) feedback reduces intensity of contracction (inverse myotactic reflex)

muscle spindles

detect length (la afferent) stretch elicits contraction of extrafusal and intrafusal fibers via alpha and gamma motor neurons respectively (myotatic reflex)

Best way to detect Rhabdomyolysis

detection of myoglobin in blood or urine (most specific but impossible to do) Creatine Kinase-MM detection (actually used and MOST SENSITIVE) total CK>5000 is diagnostic

Stress fracture

develop over a long period of time and are usually associated with repetitive stress on a bone

axial skeleton

developed from scleratome in paraxial mesoderm

swan neck deformity

diagnostic for RA

ulnar deviation and nodules

diagnostic for RA

What part of the bone do ewing sarcoma usually involve

diaphysis (middle part of long bone)

Diffuse Tenosynovial giant cell tumor

diffuse giant cell tumor of tendon sheath pigmented villonodular synovitis 80% occur in the knee (hip and ankle also)

Varicocele

dilated pampiniform plexus usually occurs on the left side

Dopamine

dilates renal vasculature

Cytosolic Creatine Kinase

dimer of two subunits of two different types (B-brain and M-muscle) Three different iso enzymes - CK-BB, CK-BM, CK-MM

Clinical Trial

direct comparison of two or more treatment modalities in human groups purpose of a clinical trial is to provide information that will help in the selection of appropriate, timely, and effective treatments

What type of hernia can be pushed back into the abdominal cavity?

direct hernia

intramembranous ossification

direct mineralization of the matrix. appositional bone growth

What happens when ACh filled vesicles reach the pre-synaptic membrane?

docking proteins on the vesicle (Synaptobrevin) interact with docking proteins on the membrane (SNAP-25 and Syntaxin)

Wnt-7

dorsal muscle signaling in limbs extensors and abductors of limbs

What structure contains the cell bodies for the peripheral sensory nerve fibers?

dorsal root ganglia

Lateral Axillary nodes

drain the cubital nodes, superficial and deep arm

Popliteal lymph nodes

drain the superficial lateral leg, superficial lateral food, and ALL of the deep leg and foot

Cubital nodes

drain the superficial medial hand, superficial medial forearm, deep hand, and deep forearm

thoracic duct

drains LEFT subclavian, jugular, and mediastinal trunks on the left

right lymphatic duct

drains the RIGHT subclavian trunk, jugular trunk, mediastinal trunk

BACLOFEN

drug that stops spastic movement. Agonist for GABAb receptor in the inhibitory pathway

TIZANIDINE

drug that stops spastic movement. alpha2 agonist for inhibitory pathway

BENZODIAZEPINES

drug that stops spastic movment. Agonist for GABAa receptor in the inhibitory pathway

DMARDs

drugs that can modify disease Methotrexate (for RA, SLE, Crohns) -side effects are hepatotoxicity and hermaturia -monitor with liver function test and urinalysis

causes of orthostatic HTN

drugs: diuretics, anti-HTN, antidepressants, ethanol, insulin, dopamine, narcotics, barbituates, CCBs Diseases: Diabetes, parkinsons, CHF, Hypovolemia

popcorn calcified lung mass

due to hamartoma

x-linked recessive centronuclear myopathy

due to mutations in the myotubularin gene (MTM1) encoding lipid phosphatase

Nemaline Myopathy

due to rod shaped intracytoplasmic inclusions congenital myopathy characterized by weakness and hypotonia at birth "floppy baby" syndrome

Pain over the lateral epicondyle of the tibia

due to rubbing of the IT band

Divarication of the Recti Abdominis

due to weak muscles hernia sac bulges between the medial margins of the recti

When are calcitonin levels high?

during gestation and lactation to protect maternal bones

When are most life threatening thoracic injuries identified?

during the primary survey

automaticity of ventillation

generated by groups of neurons in the medulla (Pre-Botzinger Complex) regulated by autonomic nervous system, but can also be controlled voluntarily

Contents of spermatic chord

genital branch of genitofemoral nerve (L1-L2) testicular artery and lymphatics Pampiniform venous plexus Ductus (vas) deferens Epididymis testes

Grey Ramus COmmunication

get postganglionic nerve fibers from the sympathetic trunk to the spinal nerve (these can only synapse in the region they are located in )

White Ramus Communication

get pre ganglionic nerve fibers from the spinal nerve to the sympathetic trunk (only located in T1-L2) this means they can travel up and down the sympathetic trunk to send sympathetics to other regions of the spine

localized Tenosynovial giant cell tumor

giant cell tumor of tendon sheath Nodular tenosynovitis solitary, slow growing, painless mass

somites

give rise to the axial skeleton

Major fuel source for type IIb/x muscle fibers

glucose- imported from the outside using the GLUT-4 transporter

Most important prognostic feature of bone tumors

grade!

pulmonary mass

greater than 3 cm

how do bones increase in length?

growth at the epiphyseal plate stimulated by IGF growth hormone

Cardiac tamponade

heart can not contract normally hypotension distended neck veins muffled heart sounds

routes of infectious arthritis

hematogenous spread direct innoculation spread from osteomyelitis or soft tissue abcess

types of swellings upon palpation

hernias- mobile and soft lymph nodes- teathered and hard

Synovial cyst

herniation of synovium cyst with a synovial linink Baker cyst (popliteal fossa)

baker cyst

herniation of the knee joint synovial membrane into the popliteal fossa

Mycobacterial osteomyelitis histology

highly destructive necrotizing granulomata

Joints commonly involved in Osteoarthritis

hips, knee, lower lumbar/cervical spine, PIP and DIP of fingers, first tarsometatarsal joint

Mitochondrial Creatine Kinase

homo-octamers are the predominant form. Ubiquitous and sarcomeric forms of the enzyme

Skene's glands

homologous with prostate gland

labia majora

homologous with scrotum

Labia minora

homologous with the skin of the penis (lack hair folicles)

forced internal rotation test

how to check for a tear or weakness in the subscapularis

Westphal's sign

hypoactive knee jerk response useful in indicating neural/neuromotor deficit

Cavernous nerve

hypogastric plexus parasympathetics to the perineum

Ice Pack test

ice recovers the eye drooping seen in Myasthenia gravis used for diagnosis

Imaging for back pain

imaging not indicated for back pain with duration less than 4 weeks unless red flags are present Plain films should include AP, Lateral, and oblique views

What type of bone tissue appears first?

immature bone that can be remodeled into mature bone

treatment for Tension Pneumothorax

immediate decompression (needle or chest tube)

skeletal muscle nuclei location

immediately under the plasma membrane or "sarcolemma"

METHOTREXATE

in RA it increases adenosine outside the cell which helps stop cells releasing cytokines that are responsible for RA main MOA is folic acid metabolism

What artery supplies the AV node?

in a right dominant heart- right coronary artery in a left dominant heart- circumflex artery

Sphinctor urethra

in males, the urethra passes thru in females, both the urethra and the vagina pass thru

Bi-cuspid valve

in the left ventricle

where are blood vesicles and nerves found in muscle?

in the perimysium along with inflammatory cells

Tri-cuspid valve

in the right ventricle

Enteric ganglia

in the wall of the viscera Autonomic

Metabolic complications leading to decreased rate of healing in bone fracture

inadequate calcium, phosphorus, and Vit. D vascular insufficiency diabetes

Giant cell tumor of bone histology

include giant multinucleated cells (but the neoplastic cells are the mononuclear cells that produce rank lignad which recruits giant cells)

atelectasis

incomplete expansion of the lung or part of the lung right upper lobe is common (due to endobronchus lesion)

Sympathetic functions

increase HR decrease peristalsis vasoconstriction stimulates arrector pilli Dilate pupils retention of urine Ejaculation

peripheral chemoreceptor sensing Hypercapnia

increase firing when PCO2 > 40mmHG

peripheral chemoreceptor sensing peripheral hypoxemia

increase firing when PO2 < 100mmHG

peripheral chemoreceptor sensing Acidemia

increase firing when pH < 7.35

fatigue

increase in muscle and blood lactate leads to muscle fatigue as well as increased respiration and heart rate and depletion of skeletal muscle glycogen stores

Osteopetrosis characterisitcs

increased hardness of bone and increased occurrence of bone fracturing compression of nerves in the skull leads to vision and hearing loss as well as paralysis of facial muscles crowding of bone marrow can lead to anemia and leukemia

Osgood-Schlatter's disease

inflammation at the tibial tuberosity (tibial tuberosity is enlarged) can lead to patellar sleeve fracture

dermatomyositis

inflammatory disorder of the skin (rash) followed by a myositis (muscle weakness) Perifasicular atrophy Highly associated with a new cancer in adults (perineoplastic syndrome)

sarcocystis

ingested via undercooked meats. grainy appearing bradyzoites that infect enterocytes

Myoclonic epilepsy and Ragged red fiber disease (MERRF) inheritance

inherited maternally due to mutation in mitochondrial gene mutation A8344G (tRNA-Lys)

FGFR3

inhibits the proliferation of chondrocytes. When it is mutated it is always on and inhibits bone elongation

Bankart lesion

injury of the anterior (inferior) glenoid associated with anterior shoulder dislocations

Splanchnic lateral plate mesoderm

innervated by autonomic nerves organs

innervation of skeletal muscle

innervated by motor neurons of spinal chord and brain stem. Axons branch into twigs and end on individual fibers

Somatic lateral plate mesoderm

innervated by spinal nerves body wall

ventral ramus

innervates all muscles except the deep back muscles

radial nerve

innervates the brachialis, brachioradialis, and extensor carpi radialis longus before dividing into the deep and superficial radial nerves

Dorsal ramus

innervates the deep back muscles

Median recurrent nerve

innervates the opponens pollicis, flexor pollicis brevis, abductor pollicis brevis

Needle decompression

insert needle in the midclavicular line over the third rib

Physical exam for lower back pain (back)

inspect for deformity, redness, or swelling palpate for tenderness check range of motion

clear zones

integrins that anchor the osteoclast to the bone so that the acid can not escape the compartment in which it is being secreted

Valsalva meneuver

initial increase in BP due to rise in stroke volume as blood is forced out by pressure in the chest venous return to the heart is decreased due to pressure in the chest causing the stoke volume to fall (BP decreases) which then causes vessels to constrict (BP rises slightly) when pressure is released, allowing vessels to re-expand causing another slight fall in stroke volume

What happens if osteophytes in the intervertebral foramen are pinching the Venteral Rootlet/Root?

efferent nerves effected. no pain or sensory component

ventral root

efferent/motor

what happens when nerves become disconnected from muscle fibers?

either the muscle fibers will become reinnervated by a different nerve (become the type of fiber that the new nerve innervates) or they will die

If you get your spleen removed what vaccines do you need?

encapsulated bacteria! hemaphilus strep pneumo menengitis

B blockers

end in OLOL

B1 blockers that can be used in patients with asthma

end in OLOL (B1/B2 blockers can not be used because it will cause bronchoconstriction and exacerbate asthma)

Conus Medullaris

end of the spinal chord (L2 vertebra) after the spinal chord tappers out, the spinal nerves continue to branch out in a structure called the Cauda Equina

what is the femoral sheath formed by?

endoabdominal fascia

Gerota fascia

endoabdominal fascia that covers the kidney

medial and lateral nerve of the foot

enter the foot between the first and second layers of plantar muscles

Characterisitcs of pasasitic myositis

eosinophilia and travel history to endemic area

What artery and nerve are in the deep pouch?

internal pudendal artery and dorsal nerve

Horner syndrome

interruption of sympathetics to the eye at any level produces myosis and ptosis (pinpoint pupil and drooping eyelid) and facial anyhdrosis enophthalmos (posterior displacement of eyeball)

Where do lateral rotators of the hip insert?

intertrochanteric crest

fossa ovale

intra-atrial septum

symptoms of sarcocystis

episodic muscle swelling and pain that last two weeks, muscle fasiculations may cause diarrhea, chills, fever, vomiting

Somatopleure

epithelial lining of the body coelom produced by the Somatic lateral plate mesodrem parietal layers

Splanchnopleure

epithelial lining of the body coelom produced by the Splanchnic lateral plate mesodrem visceral layers

Chronic Tophaceous arthritis

eventually occurs with chronic gout hyperplastic synovium pannus Bone erosion leading to ankylosis

Anaerobic threshold

excercise intensity at which lactate production exceeds release

McArdle disease symptoms

excercise intolerence, myalgia, early fatigue, painful cramps, weakness of excercised muscles, and myoglobinuria patients may exhibit second wind phenomenon

Lordosis

excessice sacral curvature "hollow back" "sway back"

Scoliosis

excessive lateral curvature

Kyphosis

excessive thoracic curvature of the spine "hunchback" "Dowager's hump"

What can induce symptoms of Carnitine palmitoyltransferase II deficiency

exercise, fasting, high-fat diets, cold temperatures, and infection

Pudendal nerve and artery/ Nerve to obturator internus

exit greater sciatic foramen and enter the lesser sciatic foramen

inguinal hernia

exits the superficial inguinal ring medial and superficial to the pubic tubercle

contracture

extended contraction due to the inability of the muscle to relax (ATP depletion, impaired Ca2+ handling)

Latissimus dorsi

extension of arm Thoracodorsal nerve

Anatomical Snuffbox

extensor pollicis longus (medially) abductor pollicis longus and extensor pollicis brevis (laterally)

3 muscle layers of the abdomin

external abdominal oblique internal abdominal oblique transversus abdominis

contents of anal triangle

external anal sphincter anus Inferior rectal artery, nerve, and vein

Anal triangle contents

external anal sphincter anus inferior rectal artery/nerve/vein

Urogenital triangle contents

external genitalia deep pouch and superficial pouch

contents of urogenital triangle

external genitalia, deep pouch, superficial pouch

Intramembranous ossification gives rise to what bones in the skull?

facial bones

Prune belly

failure of anterior abdominal muscles to form due to a mutation in Pax-3 that interferes with ventral/lateral signaling by BMP-4

Marfan syndrome

failure of fibrillin results in failure of elastin to form

Type IIb/IIx fibers

fast glycolytic equivalent to white fibers, fatigue prone

type IIa muscle fibers

fast oxidative glycolytic equivalent to intermediate fibers, fatigue resistant

Appendicis Epiploica

fat tags on large intestine

femoral triangle contents

femoral artery and vein are covered in a femoral sheath femoral nerve runs along the msucle empty space/femoral canal is the site of the deep inguinal node and is where femoral hernias occur

What happens when venous blood backs up because of blockage in the liver?

it backs up into portal-systemic anastomoses

What is the function of creatine phosphotase

it donates a phosphate to turn ADP to ATP in the Cytosol

how is a simple pneumothorax different than a tension pnemothorax?

it i much smaller and will not cause a mediastinal shift

follow the femoral artery down

femoral artery comes down the anterior side of the thigh and exits thru the haitus to the back of the knee where it becomes the popliteal artery. It continues down the back of the leg until branching into an anterior and posterior tibial artery. The posterior tibial artery has a branch called the fibular artery that gets the lateral posterior side of the lower leg

femoral nerve compression

femoral nerve can be compressed if the hip is flexed for a prolonged period of time during surgery or child birth

fascia surrounding heart

fiberous pericardium (external) serous parietal pericardium serous visceral pericardium (internal) two outermost layers have afferents supplied by the phrenic nerve (C3-5)

what cells are responsible for muscle repair when the external lamina has been damaged?

fibroblasts

flexor digitorum brevis

first layer of plantar muscles nerve: medial plantar nerve action:Flex MP and proximal IP joints of digits 2-5

Greg Turner sign

flank bruising

COPD Xray

flattened diaphragm, hyper extended lungs (past the 7th rib) increases retrosternal clear space on lateral view

bone lining cells

flattened osteoblasts that are no longer secreting matrix (osteoid) can revert back to cuboidal cells when there is a demand

Palmaris Longus

flex wrist Median nerve

Flexor Carpi Radialis

flexation of the wrist Median Nerve

Flexor Carpi Ulnaris

flexation of the wrist (has two heads: humoral and ulnar) ulnar nerve

perineal membrane

floor of the deep pouch and roof of the superficial pouch

pleural effusion

fluid in the pleural space. Gathers at the costophrenic angle when the pt is standing will have a meniscus sign

pectinate muscle

folds in cardiac muscle only located in the right atrium (making it rough) while the left atrium is smooth

spongey, trabecular, or cancellous bone

form the marrow cavity and do not for haversian systems

formation of skeletal muscle

formed by fusion of myoblasts

fundiform ligament

formed by scarpa's fascia

Inguinal ligament

formed by the EAO Aponeurosis and has an opening called the superficial inguinal ring

external spermatic fascia

formed by the EAO aponeurosis

glans clitoris

formed by the bulb of the vestibule

Parietal pleura of the lungs

formed by the somatopleure

serous visceral pericardium (epicardium)

formed by the splanchnopleure

visceral pleura of the lungs

formed by the splanchnopleure

pericardial sac

formed by two layers: parietal pleura and serous parietal pericardium, which both arise from the Somatopleure

Esophageal hiatus

formed completely by the right crus

crus of the clitoris

forms the body of the clitoris

Popliteus muscle

forms the floor of the popliteal fossa attaches to the lateral femoral epicondyle and the medial tibia Nerve: Tibial nerve Action: unlocks knee joint prior to flexion

saphenous nerve

found between the tendons of the sartorius and gracilis

superficial inguinal ring

found within external oblique aponeurosis (houses the spermatic chord and round ligament)

Hill Sac's Lesion

fracture of the posterior lateral head of the humerous associated with dislocation of the shoulder

Achondroplasia

gain of function mutation on FGFR3 whose function is to stop chondrocyte proliferation at the epiphyseal plate lethal is homozygous

parasympathetic to the perineum

ganglia= enteric ganglia in pelvic viscera S2-S4

Flexor Digitorum Longus

second layer of plantar muscles

external lamina

secreted by myocytes. consists of collagen IV, laminin, perlecan

Heberden nodes vs. Bouchard nodes

seen in OA Heberden - DIP ostephytes Bouchard- PIP osteophytes

rice bodies

seen in RA

Negative birefringent crystals

seen in gout Blue crystals- perpendicular to plane of polarized light yellow crystals- parallel to plane of polarized light

carotid body glomus cells and aortic body glomus cells

sense oxygen (chemoreceptors) vagus and glossopharygeal convey this info to the NTS and N Ambiguous

skeletal muscle spindle

sensory innervation of skeletal muscle nuclear chain fibers and nuclear bag fibers wrapped in nerves

Pleuropericardial fold

seperates the primative thoracic cavity into pleural and pericardial cavities somatic lateral plate mesoderm

Kerley B lines

septal lines due to fluid accumulating between the secondary lobles of the lungs, almost always caused by pulmonary edema (especially in pts with cardiac history)

muscle structure

muscle > fascicles > muscle fibers (cells) > myofibrils > myofilaments

largest glycogen store of the body

muscle contains 1-2% glycogen by weight

winged scapula

seratus anterior innervated by long thoracic nerve

Salter-Harris fracture

serious because it goes thru the growth plate

Muscular Dystrophy biopsy

muscle fibers are slowly replaced with fibrosis and adipose tissue -proliferation of endomysial connective tissue -ROUND muscle fibers of various sizes with regeneration and degeneration

length of muscle fibers compared to the entire muscle

muscle fibers are typically shorter than the entire muscle because the tendon at the end takes up some of the length of the muscle

Ligation of gonadal artery and vein

must be careful not to ligate the ureter or you will loose that kidney

Amelia

mutation in any of the AER (FGF-8/FGF-10/Shh) signaling molecules can result in defects in early limb bud development

GNAST1

mutation in this G proteincauses permanent cellular proliferation

Nemaline Myopathy genetics

mutations in proteins of contractile apparatus Nebulin (50%) ACTA1 (15-25%) tropomodulins 2 and 3 troponin T

Genetic succeptibility to autoantigen production in Rheumatoid arthritis (failure of tolerence)

mutations in the following can lead to suceptibility to RA: MHC II HLA-DRB1 PTPN22 (protein tyrosine phosphatase) CTLA4

thick filaments

myosin

Myosine heads

myosin chain has two heads, each with two light chains- an Alkali light chain (stabilizes molecule during contraction) and a Regulatory light chain

Osteosarcoma treatment

neoadjuvant chemo and surgery 60-70% 5 Year survival with no metastasis at diagnosis <20% 5 year survival with lung metastasis at diagnosis

Tenosynovial giant cell tumor

neoplastic proliferation that can be either the localized variant or diffuse variant

Anterior compartment of the leg

nerve: Deep peroneal Action at the ankle: ONLY dorsiflexors in the leg. Also assist in inversion

lateral compartment of the leg

nerve: Superficial peroneal/fibular nerve Action: Plantar flexion. the ONLY everters (pronators) of the foot come down behind the lateral mallelous

Peroneus brevis/Fibularis brevis

nerve: Superficial peroneal/fibular nerve Action: Plantar flexion. the ONLY everters (pronators) of the foot inserts on 5th metatarsal

Peroneus longus/ Fibularis longus

nerve: Superficial peroneal/fibular nerve Action: Plantar flexion. the ONLY everters (pronators) of the foot inserts on the first metatarsal

Sartorius

nerve: femoral nerve action: flex, laterally rotate, and abduct thigh. flex and medially rotate leg reffered to as the tailors muscle. and it is responsible for crossing your leg while sittin g

Pectineus

nerve: femoral nerve action: hip flexion

Vastus medialis

nerve: femoral nerve action: knee extension has oblique fibers that are responsible for holding the patella medially for proper tracking over the distal end of the femur

Obturator internus

nerve: nerve to obturator internus function: lateral rotation

Superior gemellus

nerve: nerve to obturator internus function: lateral rotation

Inferior gemellus

nerve: nerve to quadratus femoris function: lateral rotation

Quadratus femoris

nerve: nerve to quadratus femoris function: lateral rotator

reflex arc

neural circuit at the level of the spinal chord providing automatic link between sensory input and specific motor output (alpha motor neurons)

Involucrum

new bone that surrounds necrotic bone in osteomyelitis

appositional growth

new layer is added onto an existing layer (Ex: osteoid added on top of preexisting bone)

late-onset Pompe disease

occurs after the first year of life and is characterized by slow progression and less adverse outcomes

Termination of the Dura-Arachnoid Sleeve

occurs at S2 vertebrae after this, the pia mater coninues until it attaches to the coccyx in a structure called the filum terminale which stabilizes the spinal chord.

epigastric hernia

occurs at the widest part of the linea alba from the xyphoid to the umbilicus

Ewing Sarcoma

occurs before the age of 20 small round blue cell tumor 2nd most common bone tumor in children

Giant cell tumor of bone

occurs between 20-40 years. occur in knee and distal radius appear as large lytic lesions

femoral hernia

occurs in the femoral canal

Spondyloarthropathies

seronegative (no Rheumatoid factor)

Felty syndrome

severe RA + splenomegaly + neutropenia very high RF levels

Treacher Collins Syndrome

severe craniofacial defects due to defect in patterning gene TCOF1 that encodes TREACLE

Midshaft fracture of the humerus

often associated with injury to the radial nerve as it runs along the radial groove

Where is RANKL located

on stromal cells, Osteoblasts and in a soluble form released by T-lymphocytes during inflammation

Na+/Choline cotransporter

once ACh is decraded by ACh esterase, choline is transported back into the pre-snyapse via a Na+/Choline cotransporter

alpha motor neuron

one alpha motor neuron can innervate multiple muscle fibers, but each muscle fiber will only be innervated by a single motor neuron

Lunate

one of the only two bones that articulates with the radius most commonly dislocated bone

non-classical Pompe's disease

onest between first and second year of life, characterized by variable prognosis

Retinacular arteries

only blood supply to the head and neck of the femur in an adult (penetrate the joint capsule)

External spermatic fascia

only on the spermatic cord once it exits the inguinal ring

Zone of Polarizing Activity (ZPA)

organizing center for the anterior-posterior (cranial-caudal) growth of limbs

Hamstring muscles

origin: Ischial tuberosity nerve: Tibial nerve Action: hip extension and knee flexion

riglers sign

shows outline of the bowl because of free air in the abdomen

Y-view

shows true lateral view of scapula and oblique view of humerous shows dislocations and fractures in the shoulder

Statins

side effects of Myopathy, hepatitis, and Rhabdomyolysis Except Pravastatin, all are metabolized by CYP3A4

Mallet finger

sidtal phalynx pulled into flexion by flexor digitorum because the lateral slip is evulsed

Obturator sign

sign of appendicitis

Psoas sign

sign of appendicitis

M-CSF

signal that induced osteoclast progenitor cells to start producing RANK receptor. When RANK is bound to RANKL the cell differentiates into a mature osteoclas

Notocord

signals differentiation of neural ectoderm to neural plate/ neuroectoderm that becomes the brain and spinal chord

Non-gonococcal supperative arthritis

single joint affected (knee> hip> shoulder)

Lumbar triangle

site of potential bowl herniation right above the illiac crest

Coronary sulcus

site of the AV septum anteriorly contains the right and left coronary artery, the circumflex artery, and the right marginal vein posteriorly contains the coronary sinus and great cardiac vein

Interventricular sulcus

site of the ventricular septum anteriorly contains the anterior interventricular artery and the great cardiac vein posteriorly contains the posterior interventricular artery and middle cardiac vein

Heart on AP view

size of the heart is magnified on an AP view Xray

cuboidal osteoblasts

osteoblasts appear cuboidal when they are actively secreting matrix. When they are no longer secreting osteoid they become flattened bone lining cells

cytoplasmic extensions of osteoblasts

osteoblasts put out projections that secrete matrix and can eventually be encased in the matrix that they have secreted once they are engulfed they become osteocytes

how is osteoid calcified?

osteoblasts secrete osteocalcin and sialiproteins that sequester calcium from the blood and also secrets alkaline phosphatase an increase in these substances initiate the formation og calcium phosphate crystals which in turn promote the formation of hydroxyapatite crystals which grow until they co-allesce with neighboring crystals

cutting zone (reabsorption canal)

osteoclasts invade tissue and remove bony tissue and capillary loop follows with osteoprogenitor cells which differentiate into osteoblasts on this new surface so that the cavity is closed up

Striated muscle subtypes

skeletal muscle visceral striated muscle cardiac muscle

Insulin dependent GLUT2

skeletal muscle and fat require insulin to take up glucose from blood

Symptoms of Spinal Muscular Atrophy (SMA)

skeletal muscle cells become atrophic no sensory loss to face, arms, or legs normal intelligence -problems holding head up, talking, and breathing

What covers the Ulnar nerve as it passes under the medial epicondyle and thru the two heads of the Flexor carpi Ulnaris?

skin and fascia

Endochondrial Ossification of axial skeleton

skull bones not associated with the face, vertebral column, sternum, ribs

what germ layers do smooth muscle arise from?

slanchnic mesoderm and somatic lateral plate mesoderm only two muscles do not arise from mersoderm (they are found in the eye)

NaDC1

sodium dicarboxylate cotransporter pumps sodium into the cell, down its concentration gradient, along with DC2 dicarboxylate (oxalate and succinate) NaKATPase generates the Na gradient by pumping sodium out of the cell

Compartment Syndrome

soft tissue damage with edema

Comminuted Distal radius and Displaced Ulnar styloid

soft tissue swelling and dorsal displacement of the distal fracture fragment

paracellular urate transport

some urate can also be transported back into the cell via a paracellular route

Spiral groove fracture

spares the long and medial head of the triceps affects the lateral head of the triceps

What happens if the upper motor neuron is damaged?

spastic response

compact bone

osteonal bone systems

closing zone

osteoprogenitors follow capillary loop into cutting zone osteoblasts deposit lamella and enclose blood vessels and nerves in the new bone tissue

ACTA1 gene

specific for skeletal muscle

kerley lines

specific sign of pulmonary edema

Rachischisis

spinal dysraphism where the neurotube and vertebral arch fail to fuse dorsally. Spinal chord will be exposed

Blood supply to the body and tail of the pancrease

splenic artery

Intervertebral disks

outer fiberous capsule (anulus fibrosus) Inner gelatinous body (nucleus pulposus)

Smooth muscle layers of the stomach

outer longitudinal middle circular inner oblique

Subtrochanteric fracture

outside the capsule. Does not disrupt the blood supply to the head of the femur

Pectus excavatum

over growth of costal carilage that can impair cardiac and respiratory function

Presentation of Myasthenia Gravis

painless muscle weakness ptosis increased weakness with activity rapid restoration with rest improvement with AChE inhibitors

Erb Deuchenne (Erb Palsy)

paralysis of the arm caused by injury to the C5-C6 nerves that comprise the upper trunk (musculocutaneous, suprascapular, axillary nerves) due to dystocia (difficult child birth)

renal fascia

pararenal fat endoabdominal fascia (Gerota fascia) perirenal fat (also in the sinus) renal capsule

Thoracic outlet syndrome

parasthesia due to nerve compression or pain due to muscle anoxia caused by nerve or artery entrapment between scalene muscles (under the clavicle or under the pec minor)

lymphatic drainage of trachea

paratracheal nodes

Osteocalcin

part of the ground substance that sequesters calcium

Plantaris

part of the superficial posterior compartment of the leg nerve: Tibial (S1-S2) Action: plantar flexion

Muscles of the deep posterior compartment of the leg

pass behind the medial malleolus

femoral hernia

passes posterior to the inguinal ligament and lateral to the pubic tubercle into the femoral canal more common in women

femoral artery

passes thru the adductor haitus into the back of the knee (a portion of the adductor magnus)

high riding patella

patellar ligament is too long

Tophi

pathognomonic for gout they are composed of urate crystals and FB giant cell reactions found in joints, ligaments, and tendons

important information to obtain regarding bone tumors

patient age, tumor location (bone type and portion of bone), X-ray appearance, biopsy types of bone tumor tend to have very diagnostic growth patterns (appear in the same place in the same age group)

Pyogenic osteomyelitis due to salmonella

patients with sickle cell disease

FAST exam

pericardial tamponade RUQ LUQ Free fluid in the pelvis

What does the internal pudendal artery supply?

perineum

where is the only place long bones have lymphatics?

periosteum

cuboid bone

peroneus longus tendon runs in a groove on the cuboid bone

Paget's disease

persistence of woven bone leading to mechanical weakness and deformity (no lamellar or secondary bone) mutation in osteoprotegrin (OPG)

How is succinylcholine used to achieve paralysis

phase 1-muscle fasiculations Phase 2- overstimulation and desensitization (flacid paralysis)

cushing reflex

physiological responce to increased intracranial pressure that results in: Hypertension Bradycardia Irregular bradypnea RX: hyperventilation (CSF alkylosis that will lead to cerebral vasoconstriction and a decrease in ICP)

pain involving abdominal parietal peritoneum

pin point pain via thoracic spinal nerves C7-11

smooth ER in skeletal muscle fibers

plays an important role in contraction and surrounds muscle fibers individually (myofibrils)

osteosarcoma histology

plieomorphic neoplastic cells that are producing osteoid

McCune Albright syndrome

polystotic fiberous dysplasia with cafe au lait skin and endocrine abnormality (PP) accounts for 3% of fiberous dysplasia somatic mutation in GNAST1

Contents of popliteal fossa

popliteal lymph nodes tibial nerve (lateral to the vein) popliteal vein (most seperficial and lateral to artery) popliteal artery' (deep and medial) popliteus muscle

Varices of Caput Medusa (portal/systemic anastomosis)

portal- Paraumbilical vein systemic- superficial epigastric vein

varices causing internal hemorrhoids (portal/systemic anatstomosis)

portal- Superior rectal vein systemic- inferior rectal vein

Esophogeal varices (portal/systemic anastomosis)

portal= left gastric vein systemic- azygous and esophogeal veins

What arteries supply costal spaces 3-11

posterior intercostals (branches off of the aorta)

What lobe of the prostate is most associated with cancer?

posterior lobe (felt during a rectal exam)

muscular boundry of the pelvis

posterior= Piriformis lateral= obturator internus floor= pelvic diaphragm (coccygeus and levator ani)

bony boundries of the pelvis

posterior= sacrum anterior= pubic bone Pelvic inlet= iliopectineal line

Hill-Sachs lesion

posterolateral humoral head compression secondary to reccurent anterior shoulder dislocation. As the humoral head comes to rest against the anterioinferior part of the glenoid. Often associated with a bankart lesion of the glenoid

Splanchnic nerves

postganglionic

Inferior hypogastric plexus

postganglionics innervate the organs of the pelvis

Parasympathetics to organs supplied by the Superior mesenteric artery

preganglionic parasympathetics from RIGHT VAGUS, distributed by the superior mesenteric artery

Achondroplasia

premature ossification of epiphyseal plates in long bones mutation in FGFR3 on 4q16

Mitochondrial myopathy

present in young adulats and presents with muscle weakness -maternal inheritence -ragged red fibers due to aggregates of mitochondria -EM shows mitochondrial "parking lot inclusions"

Pseudogout (CPPD Deposition disease)

presents like gout Calcium Pyrophosphate dihydrate crystals that are positivly birefringent (yellow when perpendicular/blue when parallel) polyarticular NON-INFLAMMATORY arthritis

Gi/o receptor

presynaptic self inhibitory receptor that stops the release of the neurotransmitter when the concentration is high (negative feedback)

Pre-Botzinger Complex

primary generator of automaticity of ventilation

transporters active in urate reabsorption

primary- NaK ATPase secondary-NaDC1 tertiary- URAT1

diffusely calcified lung mass

probably due to granulomatous disease and is benigne

silhouette sign

probably pneumonia

Cystocele

prolapsed bladder

pronator teres

pronate forearm Median nerve

Hepatoduodenal ligament

proper hepatic artery common bile duct portal vein

bone metastasis that is classically blastic (induces bone to make more bone)

prostate cancer bone metastasis

divisions of the male urethra as they exit the bladder

prostatic urethra- inside the prostate membranous urethra- passes thru the UG diaphragm Spongy/penile urethra- in the perineum

function of muscle spindles

protects against over extension and provides posture and balance control

Etrogen

protects bony tissue by inhibiting the expression of M-CSF thus stopping osteoclast progenitors from maturing into osteoclasts

Calcium gluconate

protects cardiotoxicity of hyperkalemia

Ground substance of bone matrix

proteoglycans, glycosaminoglycans, an multiadhesive glycoproteins

superior and inferior epigastric vessels

provide a bypass for blockage of the aorta or the IVC

Superfiial branch of ulnar artery

provides dermatome innervation on pinkey and ring finger?

phalanges

proximal, middle, and distal portions

What three muscles make up the Pubococcygeus portion of the levator ani?

pubovaginalis/puboprostate puborectalis pubococcygeus

lower 1/2 of rectum

pudendal nerve (somatic S2-S4)

root of the lung

pulmonary artery (blue) pulmonary veins lobar bronchi

injury to ribs 4-9

pulmonary contusion and pneumothorax

Bat wing appearance on X ray

pulmonary edema

lymphatic drainage of tertiary bronchi

pulmonary nodes

URAT1 antiporter

pumps CD2 dicarboxylate (oxalate and succinate) out of the cell and urate back into the cell

Increased ICP

puts pressure on medullary vessels and leads to medullary ischemia increased ICP directly activates RVLM and sinals CML to activate the sympathetic cascade. activates B1 in heart and a1 in vessels leading to hypertension Hypertension causes baroreceptors to signal NTS and activate parasympathetic M2 in the heart NTS and RVLM become dissociated in cushings reflex RVLM will stay activated because ICP will stay elevated

Fasciculations

quick involuntary muscle twitch

When is the long thoracic nerve usually damaged?

radical mastectomy

Gold standard that determines the usefulness of a treatment

randomized, controlled clinical trial of one treatment verses another

Traumatic aortic distension

rapid acceleration/deceleration injury aortic disruption at the ligamentum arteriosum

Laryngeotacheal injury

rare airway obstruction hoarsness subcutaneous emphysema (air under skin)

Sympathetic Efferent Outflow (GVE)

reaches all areas of the body Thoracolumbar outflow (T1-L2) innervates: cardiac muscle- heart glands- sweat snooth muscle- oragns, BVs, Hair follicles

Linea alba

rectus sheaths from each side converge at the midline. Avascular

Gout

recurrent episodes of acute arthritis 50% of first attacks occur at the metatarsophalangeal joint

pain in visceral peritoneum

referred pain via phrenic nerve (C3-C5) visceral afferents (sympathetics)

Pre-and Post ganglionic neurons

refers to general visceral efferent (GVE) neurons before and after the ganglion (can be paravertebral, prevertebral, or enteric)

what can cause hemorrhage in retroperitoneum?

kidneys and veins

Coxa Vara

knocked knee (decrease angle or tilt femur in) normal = 125degrees

Osteomalacia

known as rickets in children (bowing of long bones) caused by a deficiency in Vit. D which is important for absorption of calcium and phosphate

What accounts for muscle stiffness in cramping and rigor mortis?

lack of ATP leaves actin and myosin in the bound state (muscle stiffness)

Nemaline Myopathy symptoms

lack of sponataneous movement at birth, difficulty swallowing and with speech

Batson's plexus

lacks valves so that blood can flow in either direction (depending on gravity) these veins are draining body organs. If there is a tumor in one of these organs it can be disseminated via the vertebral column

lung cancer X ray

large mass with spiculations

osteoclasts

large multinucleated cells derived from hematopoietic stem cells (same progenitor as granulocyte/monocyte) that is responsible for bone reabsorption

joint mice

large pieces of articular cartilage that become loose in the joint

white muscle fibers

large, fast twitch (appear light on histological stain)

Lateral branch of T1

lateral antibrachial cutaneous or intercostal brachial

Superficial inguinal ring boundries

lateral crural fibers internal crural fibers medial crural fibers

Linea semilunaris

lateral edge of rectus sheath

Which of the femoral condyles is the longest?

lateral femoral condyle is longer than the medial femoral condyle

ACL

lateral femoral condyle to anterior tibia Anterior Drawr sign

hesselbach's Triangle boundries

lateral wall = inferior epigastric vessels medial wall= EAO apon floor of triange= inguinal ligament

what nerve is the kidney supplied by?

least thoracic splanchnic (T12) renal ganglia

sympathetics to organs supplied by the renal arteries

least thoracic splanchnics (T12) aorticorenal ganglia = prevertebral ganglia

renal veins

left renal vein crosses anterior to the abdominal aorta (superior mesenteric artery coming off of the aorta crosses over the left renal vein, causing higher pressure in the left kidney)

Myotatic reflex (knee jerk reflex)

reflex circut at the level of L3-L4 striking the patellas ligament stretches the muscle spindle in the quadriceps eliciting a reflex contraction 0= no response 4+ = hyperactive response

Pax gene

related to muscle

Rate Ratio

relative difference measure used to compare the incidence rates of event occuring at any given time

What determines the direction of the reaction in anaerobic glycolysis?

relative intracellular concentrations of lactate, pyruvate, and NADH/NAD+ ratio

thickness of epiphyseal plate

remains constant

water under the bridge

remember that uterine arteries pass OVER the ureters

SERCA

removes Ca2+ from the sarcomere and back into the sarcoplasmic reticulum

long term McArdle disease

renal failure due to myoglobinuria, increasing muscle weakness, and rhabdomyolysis may present to ED with contractures and need to be tested for rhabdomyolosis

Endochondral ossification

replacement of hyaline cartilage model. Bone formation within cartilage that occurs in the short and long bones

Osteocytes

reside within the matrix occupying the lacunae they put out cytoplasmic extensions located in tunnels called canaliculi allowing adjacent osteocytes to connect via gap junctions

Tension Pneumothorax

respiratory distress shock distended neck veins absent breath sounds Hyperresonance Elevated hemithorax Cyanosis (late sign)

Meromelia

results from improper Hox gene signaling (Ex: insufficient Shh being produced)

Brachial plexus compression

results in pain, paraesthesia and or numbness of upper limb

Endomysium

reticular fibers that surround individual muscle fibers

2nd and 3rd part of duodenum

retroperitoneal

NADH stain

reveals 50/50 ratio of slow and fast twitch muscle. at pH 4.3 dark muscles will stain dark if the ratio is not 50/50 then it is pathalogic

hypoventilation

less CO2 exhaled = increase PCO2 = decrease pH (respiratory acidosis)

Baroreceptor function when BP is too low

less firing, signal is conveyed to NTS via CN9/10 NTS inhibits N ambiguous (turns off M2) and CVLM (dis-inhibits RVLM) non inhibited RVLM stimulates IML (which increases postganglionic ACh to B1 in the heart and a1 in the bloodvessels) this will increase the heart and vasoconstrict = increasing the BP

Sympathetics to organs supplied by the superior mesenteric artery

lesser thoracic splanchnics (T10-T11) superior mesenteric ganglia = preverterbral ganglia

Amish Nemaline Myopathy

lethal in early childhood

A band

stains dark

I band

stains light

Trendelenburg test

stand on one leg, hip tilts into raised side problem with the gluteus medius (Superior gluteal nerve) the leg you are standing on is the leg with the problem (picture = problem with the left superior gluteal nerve)

what muscles form the perineum

levator ani and coccygeus

Carnitine palmitoyltransferase II deficiency symptoms

rhabdomyolysis, myoglobinemia and myoglobinuria, recurrent myalgias, weakness

Anatomical Snuffbox tenderness

scaphoid fracture BAD!!!!! complain of pain behind thumb or with grip

Triangle of auscultation

listening to the lower lobe located lateral the the trapezius and superior to the latissimus dorsi along the inferior angle of the scapula

what can cause hemorrhage in the abdomen?

liver and speen

What do the greater splanchnic nerves innervate?

liver, gall bladder, stomach, spleen, pancrease, proximal part of the duodenum

Mycobacterial osteomyelitis symptoms

localized mild pain, low grade fever, usually only one lesion (monototic)

Intersphincteric Groove (Hiltons White Line)

located at the lower 1/3 or the anal canal this is where longutudinal outer muscles interface with part of the external sphincter

cardiac muscle nuclei

located centrally

Right coronary artery

located in coronary sulcus

utricle

located in the Seminal colliculus and above the openings of the ejaculatory duct. This structure is a homolog of the vagina

Anterior interventricular artery

located in the coronary sulcus

Circumflex artery

located in the coronary sulcus

Right marginal vein

located in the coronary sulcus

Flexor Digitorum Profundus

located in the deep ceompartment of the anterior arm responsible for flexing the wrist and the distal IP joints of the fingers (2-5) Lateral half- tendons to index and middle fingers (anterior interosseous nerve) Medial half- tendons to ring and little fingers (ulnar nerve)

Flexor Pollicis Longus

located in the deep compartment of the anterior forearm responsible for flexing the wrist and the distal IP joint of the thumb anterior interosseous nerve

Pronator Quadratus

located in the deep compartment of the anterior forearm responsible for pronating the arm anterior interosseous nerve

plicae circularis

located in the duodenum (except for the 1st part which is smooth)

Automaticity of the heart

located in the heart (SA node)

Inguinal canal boundries

roof= IAO, transversus abdominis posterior wall= transversalis fascia, conjoined tendon at the superficial inguinal ring anterior wall= EAO Floor= inguinal ligament (laterally)

urogenital triangle deep pouch

roof= superior fascia of UG diaphragm contents:UG diaphragm (Sphincter urethra muscle) floor: inferior fascia of UG diaphragm (perineal membrane)

Trabeculae carneae

rough cardiac muscle located in both left and right ventricles

Flexor Digitorum Superficialis

located in the intermediate compartment of the anterior forearm responsible for flexing the wrist, MP joints, and proximal IP joints (does not act of the distal IP joint) Median nerve

Anterior interventricular artery

located in the interventricular sulcus

Great cardiac vein

located in the interventricular sulcus alongside the anterior interventricular artery

Extensor Digitorum

located in the superficial posterior compartment of the forearm wrist extension and digital extension deep radial nerve

Extensor Digiti Minimum

located in the superficial posterior compartment of the forearm wrist extension and digital extension (#7) deep radial nerve

Extensor Carpi radialis longus

located in the superficial posterior compartment of the forearm wrist extension and radial deviation radial nerve

Extensor carpi radialis brevis

located in the superficial posterior compartment of the forearm wrist extension and radial deviation Deep radial nerve

Extensor carpi Ulnaris

located in the superficial posterior compartment of the forearm wrist extension and ulnar deviation Deep radial nerve

Meckel's Diverticulum

located on ilium. May give similar symptoms to appendicitis

Biceps Brachii

long head on the left, short head on the right

Psoriatic arthritis characterisitcs

long standing phsoriasis and arthritis that involves small joints of hands and feet asymmetric arthritis HLA-B27 and HLA-Cw6 30-50years old less severe than RA

Flail chest and pulmonary contusion

loose piece of chest wall (2 or more ribs broken in two or more spots) moves opposite to the rest of the chest wall treatment: intubate as needed and give oxygen

lose deep peronial nerve

lose dorsiflexion

sarcopenia

loss of muscle mass and function associated with aging preferential thinning and loss of type II fibers (type 1/2 ratio increases)

Ankylosing spondylitis symptoms

lower back pain and stiffness for more than 3 months that improves with excercise limited lumbar movement restriction of chest expansion Bamboo spine and Sacroiliitis on x-ray

Celiac lymphnodes receive drainage from what organs?

lower esophagus stomach spleen liver gall bladder duodenum pancreas

what does the external iliac supply?

lower extremity

Tbx4

lower limbs

what makes up a motor unit?

lower motor neuron and multiple muscle fibers

Erb's Palsy presentation

lower motor neuron syndrome associates with sensibility disturbance and vegetative phenomena. Loss of sensation in the arm and paralysis/atrophy of the deltoid, biceps, and brachialis muscles "waiter tip" sign

Arcuate line

lowest extent of the rectus sheath ( 3 fingers below the umbilicus)

sympathetics to organs supplied by the Inferior mesenteric artery

lumbar splanchnics (L1-L2) inferior mesenteric ganglia = prevertebral ganglia

testicular lymphatics

lymphatic drainage follows testicular vessels to para-aortic nodes

Fibrous component of bone matrix

made up of collagens (mostly type 1) accounts for 90% of the bone matrix sheets of collagen are laid down in a very ordered arrangement in mature bone

Skeletal muscle

made up of multi-nucleated cells that are responsible for movement of axial/appendicular skeleton and maintaining body position and posture

Polymyositis

mainly seen in adults and is not associated with skin involvement or perifasicular atrophy

glycogen

major storage form of glucose in cytoplasmic granules muscles quickly break glycogen don to G-6-P to provide energy for high intensity aerobic work

inheritance of mitochondiral diseases

maternally inherited

What bones undergo intramembranous ossification?

maxilla, mandible, zygomatic bone, temporal bone flat bones of the skull clavicle

Physical exam for lower back pain (extremities)

measure leg length from ASIS to medial malleous check distal pulses, strength, and sensation If there is pain in the buttocks or leg check hip range of motion and SLR (also FABERE sign)

Electromyography (EMG)

measures muscle potential (motor unit action potentials) and is used to identify myopathy, neuropathy, or impaired neuromuscular communication

Cuneiform bones

medial intermediate and lateral to the side of it

PCL

medial femoral condyle to posterior tibia Posterior drawr sign

What are you looking for on an X ray if you suspect aortic injury?

mediastinal widening obliteration of aortic knob right tracheal deviation left hemothorax left bronchus depression fractures of ribs 1-3 or scapula

Intramembranous Ossification

membranous sheath develops in the mesechyme

function of Golgi tendon organs

modifies recruitment, preventing damage and promoting smooth movements

hyperventilation

more CO2 exhaled (pH increases)

Reactive arthritis characterisitcs

more common in males 20-30year olds 80% due to HLA-B27 asymmetric joint stiffness and lower back pain occuring several weeks after an infection

Fibromyalgia

more prominent in females ultiple trigger point tenderness with mild digital pressure persistent pain urresponsive to NSAIDs morning fatigability

classical Pompe's disease

more severe and manifests shortly after birth usually causing death after the first year of life

Diagnostic features of RA (4 or more to make a diagnosis)

morning stiffness 3 or more joint arthritis involvement of hand joints symmetrical rheumatoid nodules cyclic citrulinated peptide antibody rheumatoid factor x-ray changes duration of symptoms lasting 6 weeks or more

causes of acute low back pain

most cases are idiopathic and presumed to be due to lumbar strain. Less than 1% are due to non mechanical causes (cancer, osteomyelitis, ect.)

indirect inguinal hernia

most common type enters the inguinal canal via the deep inguinal ring (lateral to the inferior epigastric artery) when finger is in the superficial inguinal ring, hernia will come at your finger from the side

Scaphoid

most commonly fractured carpal bone nutrient artery enters at the proximal side of this. on of the only two carpal bones that articulates with the radius

Fiberous cortical defect symptoms

mostly asymptomatic most have limited growth and resolve spontaneously a small percentage will present with a pathologic fracture

Neuromuscular junction

motor end plate

superficial peroneal nerve

motor nerve of the lateral compartment of the leg sensory nerve of the dorsum of the foot

deep peroneal nerve

motor nerve to the anterior compartment of the leg, and sensory to the dorsum of the foot between the first and second toes

motor unit

motor neuron and the muscle fiber that it innervates

size principle of motor units

motor units are recruited from small to large as intensity of work load increases

Extra articular features of ankylosing spondylitis

mucosal inflammation (uveitis, conjuncticitis, urethritis) cardiovascular involvement (aortic/mitral incompetance and pericarditis)

Peyer's patches

mucosal lymphoid tissue associated with the ilium

plica circularis

mucosal ridges inside the intestins (only present on the small intestines NOT the large)

Osteopontin

multiadhesive glycoprotein comprising the ground substance of the bone matrix attaches cells to bone matrix

Sialoproteins

multiadhesive glycoprotein comprising the ground substance of the bone matrix facilitate the calcification of the matrix by initiating the formation of calcium phosphate crystals

Osteonectin

multiadhesive glycoprotein comprising the ground substance of the bone matrix holds collagen to hydroxyapatite crystals

Superior mesenteric vein and artery

run anterior to the 3rd part of the duodenum and can create "nutcracker syndrome" where the 3rd part of the duodenum gets pinched

femoral artery, nerve, and vein

run just beneath the Pectineus

radial nerve

runs between the groove of the origins of the lateral and medial head of the triceps bracii this nerve can be damaged when the arm is fractured

profunda brachii artery

runs between the groove of the origins of the lateral and medial head of the triceps bracii along with the radial nerve

Genitofemoral nerve

runs thru the Psoas muscle L1-L2

Characteristics of Ankylosing spondylitis

sacroiliac joint and vertebra involvement 20-30 yr old more males than females affected presents with lower back pain 90% due to HLA-B27

meta analysis

statistical integration of the results from several independent studies

satellite cells

stem cells for the muscles located external lamina and sarcolemma. responsible for repair when extrenal lamina is intact

Parathyroid hormone (PTH)

stimulates osteoblasts to secrete M-CSF and promotes expression of RANKL inhibits synthesis of OPG promotes osteoclast activity

Uricostatic drugs used for Chronic gout

stops the production of uric acid (inhibits xanthine oxidase) ALLOPURINOL FEBUXOSTAT

Straight leg raise test (for lower back pain)

straighten leg, dorsiflex toes, gently raise leg to 70 degrees positive test will produce radiating pain in leg between 30-70 degrees

myofibrils

stretch from end to end of a muscle with mitochondria and glycogen in between

Where does lymph from the scrotum drain?

superficial inguinal, however lymph from the testes drains into the para-aortic nodes

cullens sign

superficial oedema and bruising in the subcutaneous fatty tissue around the umbilicus.

injury to ribs 10-12

suspect intra-abdominal injury

ligament of Treitz

suspensory muscle of the duodenum which is derived from the right crus of the diaphragm

Mortons Neuroma

swelling in the sheath of a nerve. usually between 3rd and 4th digits

Paravertebral ganglia

sympathetic trunk of ganlia Autonomic

how is pain carried in the abdominal region?

sympathetics (associated with a spinal nerve) this creates referred pain to a dermatome

RA

systemic chronic inflammatory autoimmune disease that targets the joints (non-suppurative synovitis)

Bursa of the hand

tells us how infections will spread (along the bursa)

Rectus Abdominis

tendinous intersections seperate muscles laterally

reabsorption of urate

tertiary transporter URAT1 mostly responsible for the reabsorption of urate

forced external rotation

test for a tear or decreased strength in the Infraspinatus

Horn Blowers test

tests the strength of the teres minor (tests for a teres minor tear) arm up at 90 degrees while medial rotation pressure is applied. patient resists

When does limb formation occur?

the 4th week of gestation

Statistical power

the ability of a study to detect a true difference between groups being compared 1-beta (usually 80%)

what covers the aorta as it passes thru the diaphragm?

the aorta passes behind the diaphragm thru the median arcuate ligament

codman triangle

the area in which bone formation extends into soft tissue in an osteosarcoma resulting in the lifting of the periosteum

what state is resting muscle in?

the cocked state, waiting for calcium to bind and expose the actin binding site

most common place to damage the common peroneal nerve

the head or neck of the fibula

Kehr's sign

the occurrence of acute pain in the tip of the shoulder due to the presence of blood or other irritants in the peritoneal cavity when a person is lying down and the legs are elevated. Kehr's sign in the left shoulder is considered a classic symptom of a ruptured spleen

what part of the bladder (and uterus) is covered in peritoneum?

the superior aspect, so everything below it will be retroperitoneal

how are bone tumors classified?

the type of matrix that the neoplastic cells make (bone, cartilage, ect. ) and also by the cell of origin

Spinal nerve to ganglia ratio

there are 8 cervical spinal nerves and only 3 cervical ganglia (all other regions have comparable numbers of spinal nerves to ganglia)

Myoclonic epilepsy and Ragged red fiber disease (MERRF) therapy

there is no cure but supportive therapy includes coenzyme Q10, L-caritine, vitamins, anticonvulsants

Para-aortic nodes

these are associated with the lumbar trunks (which drain into the thoracic duct) and drain the following retroperatoneal structures: Lower extremities pelvic organs kidney and suprarenal gland testes body wall

Chordae tendineae

these chords come off of the heart valves and are contracted by papillary muscles to contract the heart during ventricular systole

cremaster muscle

these muscle fibers surround the spermatic chord and go into the scrotum, and are derived from Internal Abdominal Oblique muscle innervated by the lumbar plexus (genitofemoral nerve)

uterus, uterine tube, and ovaries

these structures are mesenteric and are surrounded by peritoneum called the Broad Ligament

What organs do mitochondrial diseases normally affect?

they affect multiple organs, but most frequently organs with high energy demands sch as skeletal and cardiac muscles, brain, liver and kidney

How do acetyl choline filled vesicles fuse with the pre synaptic membrane?

they dock to the membrane by forming a SNARE-synaptotagmin complex (synaptobrevin, SNAP-25, Syntaxin) the actual vesicle is opened when Ca interacts

How to osteoclasts promote bone reabsorption?

they secrete acid to promote release of Ca2+ and PO4 from calcified bone tissue (Osteolysis) results in a ruffled boarder, matrix acidification, digestive enzymes, and howships lacunae

myofilaments

thick and thin

Apical Ectodermal Ridge (AER)

thickened area of ectoderm organizing center for the proximal-distal growth of the limb

Perimysium

thicker layer that surrounds a group of fibers to form a fascicle

Carnitine palmitoyltransferase II deficiency

three forms, (mild adult, severe infantile, and lethal neonatal) but the adult form is exclusively myopathic, the most prevalent and least severe.

Where does the needle pass during an epidural?

thru the epidural space (between two spinus processes) through the dura-arachnoid sleeve, into the Subarachnoid space of the Cauda Equina (located inferior to the conus medularus-or the end of the spinal chord)

O'brian test

thumb down and adduct extremity 10 derees across the body. you press down and patient resists (pain =SLAP) thumb up and repeat the process (NO pain= SLAP) pain for both positions= labral tear

Adductor Magnus (Hamstring portion)

tibial nerve

Tommy John surgery

torn ulnar collateral ligament

lymphatic drainage of primary bronchi

tracheobronchial nodes

Action potential

transmission of depolarization of the presynapse that invilves Ca2+ influx thru VGCCa1A (P/Q) that allows the ACh vessicle to fuse with the pre-synaptic membrane

how do you open the pericardial sac?

transversely to the phrenic nerve so you dont cut the phrenic nerve

Cyclobenzaprine

treatment for acute local muscle spasm caused by local tissue trauma or muscle strains stimulates descending analgesic pathway works for fibromyalgia

nurse cell complex

trichanella DNA incorporates into muscle fiber. muscle cell then dedifferentiates and redifferentiates

bilateral periorbital edema

trichonosis begins in the extraocular muscles, followed by the masseters, and muscles of the diaphragm, neck, and larynx

Chondroma

tumors formed only of cartilage

canaliculi

tunnels that allow adjacent osteocytes to communicate and transfer nutrients

Iliopsoas

two muscles come together to form this Nerve: lumbar spinal nerves Action: hip flexion

skeletal muscle triad

two terminal cystenri and a t tubule

Type 1/2 ratio in sarcopenia

type 1/2 fiber ratio increases

Pompe's disease

type 2 glycogen storage disease caused by accumulation of glycogen in lysosomes due to a mutation in acid alpha-glucosidase which breaks down glycogen in lysosomes (lysosomes are NOT a normal storage site for glycogen)

McArdle disease

type 5 glycogen storage disease caused by a deficiency in glycogen phosphorylase

muscle fiber type grouping

type of muscle fiber (red/white) depends on what type of axon innervates it. If a muscle is traumatically denervated and reinnervated by a different axon, types of fibers can appear in cluters because they are all innervated by the same axon (converted to the same type red or white)

Greater omentum

under the stomach 4 layers

FENTANYL

used during surgery for analgesia

ISOFLURANE

used during surgery to induce loss of consciousness to prevent Awareness, anxiety, and perception of pain

CISATRACURIUM

used during surgery to induce myorelaxation and stop motor reflexes after surgery, paralysis is reversed using neostigmine

ATROPINE

used during surgery to promote autonomic stabilization

Colchicine

used for acute gout microtubule disruptor that inhibits neutrophil migration side effect: Diarrhea

Saphenous vein

used for coronary transplants. This vessel runs posterior to the medial side of the knee joint and anterior to the medial malleous (inside heel bone)

Probenecid

used for gout. Blocks the tertiary urate transporter URAT1 and blocks the reentry of urate into the cell (more urate is excreted in the urine)

Corticosteroids for Acute gout

used is the patient is intolerent to Colchicine or if the patient has poor renal function

Houndsfield units

used to describe the relative brightness of a substance on CT (corresponds to density) White = 1000 (bone) grey = 0 (water) Black = -1000 (air)

Tinel's test

used to diagnose carpal tunnel Tapping over the flexor retinaculum

trachea and broncheal innervation

vagus (CN10) provides both afferents and efferents cough reflex

Metabolic and Mitochondrial Myopathies

variety of protein or enzyme anomalies causing impaired energy production

What does stretching of the vessel wall lead to?

vasodilation and bradycardia

Spacticity

velocity-dependent increase in resistance to passive movement sign of upper motor neuron Lesion

Paget-SChrotter syndrome

venous thrombosis due to subclavian vein compression

En-1 (engrailed-1)

ventral muscle signaling in limbs flexors and adductors in limbs

Lower limb rotation at 8 weeks

ventromedial with big toe in the midline

Where are bone metastasis more common?

vertebral column > pelvis > proximal femur > humerous

Visceral pain in abdomen

visceral pain is carried (afferents) by whatever sypmathetics innervate that tissue

neuromuscular junction

voltage gated calcium channels on pre synaptic knob allow calcium to flow in. Calcium induces the fusion of acetyl choline filled vesicles to the pre synaptig membrane releasing acetyl choline into the synaptic cleft Acetyl choline (the ligand) binds to Nicotinic ACh receptors allowing them to open and let ions like sodium and potassium flow thru increasing the concentration of Na Na will bind to voltage gated Na fast channels allowing massive sodium influx and a rapid action potential

Rhomboid crystals

weak positive birefringent crystals found in joint fluid of patients with pseudogout

Hyperkalemia in Rhabdomyolysis

weakness (Peaked T and wide QRS) can cause heart problems push K+ back into cells with insulin and glucose remove K+ with hemodialysis

centronuclear myopathy presentation

weakness and hypotonia, macrosomia, large head circumference, external ophthalmoplegia, and respiratory failure (eventually fatal)

MuSK sybtype Myasthenia Gravis

weakness in bulbar (medullary), facial, and neck muscles. No eye involvement

tractotomy

wedging out a piece of lung when there is traumatic lung injury

pulmonary nodule

well circumscribed and less than 3 cm

Pro-IL-1B

when TLR4 (PAMPs), TLR9 (DAMPs), or TLR2 (Lipoteichoic acid PAMP) are bound, they activate NFkB wich produces inflammatory cytokines IL-6 and TNKa. It also produces Pro-IL-1B which is a precursor molecule that needs to be cleaved by caspase 1 to initiate inflammation

Active length tension curve

when a muscle is stretched, it can generate more force until it reaches the optimal length (peak on graph) which is related to the end to end overlapping of thick and thin filaments

Calcium dependent thin filament regulation

when calcium binds troponin C there is a conformational change in the troponin complex which removes tropomyosin and troponin from the binding site of actin, allowing the myosin heads to bind to actin

When do you preform a CT without contrast?

when looking for calcifications or stones (these will appear white, and can be obscured by the contrast)

aerobic glyolysis

when oxygen is abundant, pyruvate is converted to Acetyl-CoA by pyruvate dehydrogenase complex in the mitochondria No ATP is made directly

anaerobic glycolysis

when oxygen is limited, pyruvate is converted to lactate by lactate dehydrogenase

Centeral chemoreception of Hypercapnia

when pH in CSF/interstitium decreases (PCO2> 40mmHg)

Perifasicular atrophy

when the outside of the muscle fiber is being attacked. Fibers on the outside will be small. Seen in Dermatomyositis

Diaphragmatic parietal pleura

where the diaphragm is attached to the ribs

Perineal body

where the superficial transverse perineal muscles meet in the middle

sliding filament model of muscle contraction

whole sarcomere shortens (Z lines get closer together)

Diagnosis of Myathenia Gravis with electromyography

with each repeated motor nerve stimulation, there is progressive decrease in evoked compound muscle action potential

Diagnosis of Lambert Eaton Syndrome with Electromyography

with each repeated motor nerve stimulation, there is progressive increase in evoked compound muscle action potential

Woven bone vs lamellar bone

woven bone = juvenile lamellar bone= organized via osteoclast activity

Fenoldopam

D1 agonist used for HTN in emergency situations

what supplies blood to the diaphragm?

Inferior phrenic artery

What kind of tissue covers the anal canal?

Stratified squamous

Anterior interosseous nerve

a branch of the median nerve

Sinding-Larsen-Johansson syndrome

inflammation at the patella

Epaxial musles

smooth muscles of the body wall deep back muscles Pax3 gene

bypassing blockage of the IVC

Azygous and hemiazygous, which are continuous all the way down to the common iliac

Tibiofibular ligament

B "high ankle sprain" from forces that drive the fibula down to the ground = over inversion

Adductor Pollicis

Adducts the thumb (Froment's Sign) Innervated by the Deep radial nerve

M blockers used for Parkinson rigidity and spasticity

Benztropine mesylate Trihexphenidyl Procyclidine

Axonal degeneration (Neurogenic Myopathy)

1) leads to angular atrophic muscle fibers 2) reinnervation leads to muscle fiber type grouping 3) if nerve damage continues then fiber type grouping atrophy may occur

Bursa of gluteus maximus

1. Ischial Tuberosity 2. Greater trochanter 3. Gluteal tubercle inflammation can cause pin point pain

5 steps of fracture repair

1. fibrocartilage callus forms around fracture 2. boney callus replaces fibrocartilage callus 3.endosteal repair 4. woven bone is replaced by secondary bone 5. osteaclast remove remnants of callus

zones of the epiphyseal plate

1. zone of reserved cartilage (resting zone) no active matrix production 2.Zone of proliferation- rapidly dividing chondrocytes secreting matrix 3.Zone of hypertrophy- enlarged chondrocytes in rows secreting matrix 4.Zone of calcified cartilage- matrix is calcified 5. Zone of ossification-mixed spicules-woven bone

Symptoms of trichanosis

2-7 days post ingestion -nausea, cramps, anorexia, vomiting, diarrhea 4-5 weeks post ingestion -petechial hemorrhage of the brain, myocraditis, Bilateral periorbital edema, splinter hemorrhages

Mesenchymal chondrosarcoma

10-20 years of age

Clear cell chondrosarcoma

10-20 years of age occur in the epiphyses of long bones (usually the head of the femur)

Prostate gland

20% of ejaculate contains prostaglandins and citric acid (pH=6.4) phosphatases and proteases (liquifaction of semen)

Characterisitcs of Lyme Arthritis late disseminated stage

2-3 years after infection chronic arthritis affecting large joints chronic papillary synovitis with arterial thickening

dorsal interossei

1= index 2/3= middle finger 4= ring finger

Abductor digiti minimi

1st layer of plantar muscles nerve: lateral plantar nerve action: abducts 5th digit

Abductor Hallucis

1st layer of plantar muscles nerve: medial plantar nerve action: abducts 1st digit

layers of the spermatic chord

1st= external spermatic fascia derived from EAO Apon. 2nd= cremaster muscle derived from IAO 3rd= internal spermatic fascia derived from Transversalis fascia transversis abdominis does not contribute anything to the spermatic chord, because this muscle arches over the inguinal canal

components of thick filament myosin

2 myosin heavy chains (222kDa) 2 essential light chains (18kDa) 2 regulatory light chains (22kDa)

Tenia Coli

3 strips of outer longitudinal muscle that converge at the appendix sites of diverticuli

What cranial nerves are also Parasympathetic?

3- Occulomotor 7-Facial 9- Glossopharyngeal 10- Vagus

how much ATP and pyruvate are generated during glycolysis?

2ATP, 2NADH, 2 pyruvate

Aortic valve

2nd intercostal space

Flexor Hallucis longus insertion

2nd layer of plantar muscles

Quadratus Plantae

2nd layer of plantar muscles nerve: lateral plantar action: straightens the pull of the FLD tendons

1-4 lumbricals of the foot

2nd layer of plantar muscles nerves: 2-4= lateral plantar 1= medial plantar action: flex Mp joints and extend IP joints of digits 2-5

Spinal distribution of ganglia

3 cervical (superior, middle, inferior) 12 thoracic 5 lumbar 5 sacral 1 ganglion impar

Krebs cycle energy balance

3NADH = 3 ATP 1 GTP 1 FADH2 = 2 ATP

Deep plantar arch

3rd layer of plantar muscles

Adductor Hallucis

3rd layer of plantar muscles nerve: lateral plantar nerve action: adducts big toe

Flexor Digiti Minimi Brevis

3rd layer of plantar muscles nerve: lateral plantar nerve action: flex MP joint of digit 5

Flexor Hallucis Brevis

3rd layer of plantar muscles nerve: medial plantar nerve action: flex MP joint of the big toe

How is mean Arterial pressure maintianed?

Heartrate (sympathetic/para) Vesicular resistance/ dilation (sympathetic) Cardiac output (sympathetic)

Mycobacterial osteomyelitis

5% of TB patients have bone involvement (Pott disease = vertebral bone involvement resulting in scoliosis and neurological defects) caused by hematogenous spread of mycobacterium from the lungs to the bone

Secondary osteoarthritis

5% of cases occurs in younger patients can be caused by predisposing condition like trauma or developmental deformity can be caused by systemic disease (diabetes, ochronosis, hemachromatosis, Marked obesity)

inner circumferential lamella

4= inner circumferential lamella of compact bone 7= outer circumferential lamella of compact bone 8= periosteum 5= endosteum

3 plantar interossei

4th layer of plantar muscles nerve: lateral plantar action: adduct digits 3,4,5 flex MP joints and extend IP joints of digits 3-5

4 Dorsal interossei of the foot

4th layer of plantar muscles nerve: lateral plantar nerve Action: Abduct digits 2, 3, 4 flex MP joints and extend IP joints of digits 2-4

Pseudogout characterisitcs

50 year olds acute arthritis chronic arthritis (symmetrical synovitis affecting knees>wrists>elbows>shoulders and ankles)

Seminal vesicle

50% of ejaculate gelatinous and contains fructose (alkaline pH=7.4)

how many thin filaments surround each thick fillament?

6

tropomyosin

64kDa double helix

Ewing Sarcoma genetics

85% due to t(11;22) rearrangement of EWS gene

CN12

Hypoglossal

Autoantibodies detected in RA

80% will be positive for Rheumatoid factor (anti-IgG-Fc IgM) 20% seronegative

Primary osteoarthritis

95% of cases associated with aging Oligoarticular (hands, knee, hip, spine)

At what concentration do monosodium urate crystals form in gout?

>6.8mg/dL

anterior tibiofibular ligament

A

Organophosphate Pesticides and Nerve Gas

ACh Esterase inhibitor

PHYSOSTIGMINE

ACh Esterase inhibitor Glaucoma, Atropineoverdose toxicity- crosses BBB

PYRIDOSTIGMINE

ACh Esterase inhibitor (PO) Best drug for Myasthenia Gravis, Nerve Gas prophylaxis

NEOSTIGMINE

ACh Esterase inhibitor (SC or IM) Myasthenia gravis

EDROPHONIUM

ACh Esterase inhibitor (short acting) used to diagnose Myasthenia Gravis

Neostigmine

AChE inhibitor used for Ileus, diagnosis and treatment of Myasthenia Gravis

Pyridostigmine

AChE inhibitor used for Myasthenia gravis and prophylaxis for nerve gas

Edrophonoium

AChE inhibitor used to diagnose Myasthenia Gravis

Physostigmine

AChE inhibitor used to treat glaucoma and atropine toxicity (it crosses the BBB)

How are our digits separated during development?

AER is only maintained at the tips of digits Bone Morphogenic Protein is responsible for apoptosis of tissue in between digits

Anti -IL1 drug used for RA

ANAKINRA

IL-1 antagonists for acute gout

ANAKINRA CANAKINUMAB RILONACEPT

Standard radiological views of the shoulder

AP external rotation (anatomical position) AP internal rotation Y-view (trans-scapular) Axillary

Pec Major

Adduction of arm, Medial rotation of arm, flexion of arm Medial and lateral pectoral nerves

3 palmar interossei

Adduction of the fingers (except the middle finger and thumb) Deep ulnar nerve

MCL tear

Abdnormal passice ABduction medial space widening of tibia with lateral valgus force (push knee in)

LCL tear

Abdnormal passice ADDuction medial varus force gives lateral space widening of the tibia

Advese effects of AChE inhibitors used to treat Myasthenia Gravis

Abdominal cramps and diarrhea

CN6

Abducens

Deltoid

Abduction of arm to 90 degrees Axillary nerve (C5-C6)

Hypothenar eminence muscles

Abductor Digiti minimi Flexor digiti minimi brevis opponens digiti minimi innervated by the Deep Ulnar nerve

Thenar Eminence muscles

Abductor Pollicis Brevis Flexor Pollicis Brevis Opponens Pollicis Innervated by the Recurrent (Motor) branch of the median nerve

CN11

Accessory

Congenital myasthenia

Acetylcholine receptors interact with Dok7 and rapsyn. Mutant Doc7 and rapsyn are important in the development of congenital myasthenia

Posterior compartment of the leg

Action at the ankle: Plantar flexion (lifting feel off of ground) and inversion (raise the medial side of the foot off the ground) Nerve: Tibial

Medial compartment of the thigh

Action: Adductors Nerve: obturator Artery: Profunda femoris

Posterior compartment of the thigh

Action: Hip extension and knee flexion Nerve: Tibial and common peroneal Artery: perforating arteries of profunda femoris

Anterior compartment of the thigh

Action: hip flexion and knee extension Nerve: femoral L2, 3, 4 Artery: femoral artery

Dorsal root

Afferent/sensory

Cauda Equina

After the spinal chord ends, the Cauda Equina continues to branch out. It is made of Dorsal and ventral rootlets of spinal nerves (each covered ONLY in pia mater)

Diaphragm injury

Air under the diaphragm (hole in diaphragm or bowl perforation) that does not allow the lung to expand like normal

Treatment of Chronic Gout

Allopurinol, Probenecid, Pegloticase

Gi signaling

Alpha subunit can inhibit adenylate cyclase Beta bubunit opens K+ channel (hyperpolarization) receptor is also coupled to a Ca2+ channel and activation of Gi closes this calcium channel

tendons

At the end of muscle, connective tissue continues as a tendon to attach muscle to the skeleton

Gerdy's Tubercle

Attachment if IT band

Myasthenia gravis

Autoimmune disorder resulting in loss of ACh receptor and muted end plate potentials

Lambert eaton Syndrome

Autoimmune disorder resulting in loss of neuronal Voltage gated calcium channels and impaired ACh release into synaptic cleft

Polymyalgia Rheumatica

Autoimmune pain in the shoulder and hip that is worse in the morning (temporal arteritis and osteomyelitis) Very high ESR (>100mm/hr) strong association with temporal arteries (headaches) with a risk of blindness

How are osteogenesis imperfecta Type 1/4 and Achondroplasia inherited?

Autosomal Dominant

Osteogenesis Imperfecta Type 1

Autosomal Dominant Brittle bone disease caused by defective Tyle 1 collagen synthesis due to a mutation in a1/a2 chains (low pro-a1)

Achondroplasia

Autosomal dominant Dysplasia that is a growth plate disease caused by a point mutation on FGFR3 activating mutation. 90% due to new mutations

How is osteogenesis imperfecta type 2 inherited?

Autosomal recessive

Spinal Muscular Atrophy (SMA)

Autosomal recessive Group of diseases that affect lower motor neurons or the spinal chord and brainstem due to a chromosome 5 gene mutation

Troponins (troponin complex)

I (30kDa) C (18kDa) T (30kDa)

Dobutamine

B1 agonist used for septic shock

Isoproterenol

B1/B2 agonist used for refractory Torsade de Pointes

Terbutaline

B2 agonist used for asthma and COPD

Albuterol

B2 agonist used for asthma, COPD, Hyperkalemia

What signals mesemchymal stem cells to differentiate into osteoprogenitors?

BMP (Bone morphogenic proteins)

Triangular Space

Barders: Teres minor Teres major Long head of triceps Contents: Scapular Circumflex artery

Greater Vestibular glands

Bartholin's glands responsible for lubricating the vagina Superficial pouch of female UG triangle

What muscle covers the bulb of the penis/vestibule?

Bulbospongiosum muscle

Posterior tibiofibular ligament

C

Superficial transverse perineal muscle

C

Bulb and crus of penis

C and D both are covered in skeletal muscle (these muscles stop at the ischiopubic rami and do not extend the length of the penis)

What spinal nerve does not have a dermatome?

C1 (no efferent neurons that go to the skin)

C3-C5

C3-5 ventral rami efferents to the diaphragm Afferent innervation of mediastinal and diaphragmatic parietal pleura, fiberous and serous parietal pericardium, T7-11 afferents to costal portions of diaphragmatic parietal pleura)

Phrenic nerve

C3-5 ventral rami efferents to the diaphragm Afferent innervation of mediastinal and diaphragmatic parietal pleura, fiberous and serous parietal pericardium, T7-11 afferents to costal portions of diaphragmatic parietal pleura)

Cricopharyngeus muscle

C6

anti PGE2 drug used for RA

CELECOXIB

Baroreceptors of the aortic arch

CN 10 vagus

Cranial nerve responsible for cough reflex

CN10

Baroreceptors of the carotid sinus

CN9 glossopharyngeal

Lipohemearthrosis

Can only be seen on a cross table lateral view indicates interarticular fracture

What transporter is used to move Acyl-CoA from the cytosol to the mitochondrial matrix since CoA is not membrane permeable?

Carnitine

Choline Acetyl-Transferase

Catelizes the reaction that surnes Acetyl CoA and Choline into Acetyl-choline

Drop test

Checks for a tear in the Supraspinatus arm is abducted as high as it will go and patient is asked to slowly lower the arm. When the arm gets to about 90 degrees it will drop if there is a tear in the supraspinatus

Nm

Cholinergic Synapse at the SKELETAL neruromuscular junction (not smooth or cardiac muscle)

Guanidine HCl

Cholinergic agonist used to treat Lambert Eaton Syndrome

What drugs can be used to test for Myathenia Gravis?

Cholinesterace inhibitors: EDROPHONIUM NEOSTIGMINE PYRIDOSTIGMINE

Pseudogout X ray

Chondrocalcinosis

Chondrocyte injury in OA

Chondrocytes release MMP leading to degredation of collagen and proteoglycans IL-1, TNFa, IL-6, IL-8 released release of NO and prostoglandins all of these things trigger chondrocyte activation and apoptosis

How do infection and smoking promote the generation of autoantigens in Rheumatoid arthritis?

Citrullination of proteins can turn them into autoantigens -fibrinogen -Type 2 collagen (cartilage) -alpha enolase -Vimentin

Shoulder

Clavicle, scapula, and humerus

a2 agonists that work on the presynaptic a2 autoreceptor

Clonidine and a-methyldopa

Suboccipital triangle

Contains the vertebral artery and vein and suboccipital nerve (dorsal ramus C1) Boundries: Rectus Capitus posterior major Obliquus capitus superior Obliquus capitis inferior

Haddad syndrome

Congenital central hypoventilation syndrome + Hirschsprung RX= nocturnal ventilation via tracheostomy, diaphragm pacing

GSE nerve migration signals

Connective tissue is responsible for GSE nerve migration signals

Gs receptors

D1 B1 B2 B3

Neck of femur fracture

DISRUPTS BLOOD SUPPLY TO THE HEAD OF THE FEMUR CAUSING AVASCULAR NECROSIS

RA drug treatment

DMARDs (methotrexate) TNFa inhibitors (Infliximab, Adalimumab) NSAIDs and Steroids used for flare ups

Antidote for Malignant hyperthermia

Dantrolene

treatment for malignant hyperthermia

Dantrolene

Chondrosarcoma

Dedifferentiated associated with high grade non cartilaginous sarcoma

Extensor Hallucis Brevis

Deep Peroneal nerve

Extensor Digitorum Brevis

Deep peroneal nerve

Flexor Digitorum Longus

Deep posterior compartment of the leg nerve: tibial action: Plantar flexion

Flexor Hallucis Longus

Deep posterior compartment of the leg nerve: tibial action: Plantar flexion and inversion

Tibialis Posterior

Deep posterior compartment of the leg nerve: tibial action: Plantar flexion and inversion

Articular Genus

Deep to the vastus intermedius inserts on the suprapatellar bursa. contracts to pull bursa out of joint during knee extension

Smooth muscle of the bladder

Detrusor B3- (relaxes it) M3+ (contracts it)

ALS Symptoms caused by upper motor neuron damage

Dysphagia- difficulty swallowing Dysarthria- difficulty speaking Babinski sign- muscle spasticity and hyperreflexia

Lumbar disc syndrome L4

Disk: L3-L4 Refles: Patellar Motor: Knee extension Sensory: Anterior thigh

Lumbar disc syndrome L5

Disk: L4-L5 Reflex: none Motor: Big toe dorsiflexion Sensory: Big toe

Lumbar disk syndrome S1

Disk: L5-S1 Reflex: Ankle Motor: Foot plantar flexion Sensory: Lateral boarder of foot

Chronic demyelination and remyelination

Distal axonal degeneration appear as "onion bulbs" due to damages schwan cells in the PN. Multiple schwann cells per axon will be present

orthostatic hypotension

Dizziness/ fainting upon standing (hypovolemia), postprandial (splanchnic pooling), Ambiant warming (vasodilation), or with excercise (Skeletal muscle vasodilation)

Parasympathetic nerves

Do not go into the periphery

Spinal nerve

Dorsal and ventral roots fuse to form a spinal nerve

Autonomic Ganglia of the PNS

Dorsal root Paravertebral Prevertebral Enteric

Pseudounipolar neuron

Dorsal root ganglia cells are pseudounipolar, and no actual synapse happens in the dorsal root ganglia.

Signaling that induces epaxial muscle formation

Dorsalizing signal (Wnt) Pax-3 gene

Upper limb rotation at 8 weeks

Dorsolateral rotation with thumb pointing up

Infraclavicular Nodes

Drain superficial lateral hand, superficial Lateral forearm and superficial lateral arm

Inferior phrenic vein

Drains the diaphragm splits into left and right right ends at the IVC left enters the left suprarenal vein

Forms an interface between the intracellular contractile apparatus (sarcomere) and the extracellular connective tissue matrix

Dystrophin and the dystrophin-associated protein complex

Drugs used to treat fibromyalgia

Duloxetine, Venlafaxine, Milnacipran (SNRI) - upregulation of desending analgesic system Pregabalin (inhibits presynaptic release of glutamate) Tramadol (weak opiod agonist + SNRI in dorsal horn)

Parasympathetic control of the pupil

Edinger Westphal nerve (CN3-occulomotor) stimulates M3 ciliary muscles resulting in contraction of the pupil

Dorsal rootlets

Emerge from the dorsal horn of the spinal chord. These rootlets only carry afferent neuron fibers to the spinal chord Near the intervertebral foramen, multiple dorsal rootlets coalesce into a dorsal root

ventral rootlets

Emerge from the ventral horn of the spinal chord. These rootlets only carry efferent neuron fibers away from the spinal chord. Near the intervertebral foramen, multiple ventral rootlets coalesce into a ventral root

Chondromas of the medullary cavity

Enchondroma (usually solitary- only one) most common intasaosseous cartilage tumor found in 20-50 year olds found in TUBULAR BONES OF HANDS AND FEET

Maffucci syndrome

Enchondromatosis + soft tissue hemangiomas

connective tissue layers of Nerve

Endomeurium Perineurium Epineurium

three connective tissue types of muscle fibers

Endomysium Perimysium Epipysium

V-Type H+ ATPase

Energy is generated via a proton gradient set up by V-type H+ ATPase in the membrane of the vesicle that pumps protons into the vesicle

ZPA signaling molecules

FGF-10 (derived from mesenchymal cells and acts of extoderm to stimulate FGF-8 production) FGF-8 (acts on mesoderm to stimulate the production of Shh) Shh (acts on hox genes in a anterior to posterior fashion)

AER signaling molecules

FGF-10 (derived from mesenchymal cells and acts of extoderm to stimulate FGF-8 production) FGF-8 (acts on mesoderm to stimulate the production of Shh) Shh (acts on hox genes in a proximal to distal fashion)

CN7

Facial

No osteoblastic rim on a C shaped bony trabeculae

Fiberous dysplasia histologic finding

GSA nerves

GSA nerves are the last thing to enter the muscle masses

other antispastic drugs

Gabapentin Pregabalin Glycine (inhibitory neurotransmitter) Riluzole (ALS drug) Dantrolene Dronabinol Botulinum toxin

Peripheral Nervous seystem

Ganglion (collection of cell bodies outside the CNS) -4 types including Dorsal Root Motor Neurons (Efferent) -General somatic Efferent-Spinal nerve Sensory Neurons (Afferent) -General somatic afferent (spinal nerve)

Afferent Sensory Neurons of the PNS

General Visceral Afferent Autonomic Nerve

Efferent Motor neurons of the PNS

General Visceral Efferent (GVE) Autonomic nerve

Muscular Dystrophy

Genetic deletion/Mutation of membrane tethering proteins resulting in muscle damage

M2

Gi type cholinergic receptor that functions in the heart (SA node) agonism slows down the heart

Polydactyly

Gli-3 is underexpressed resulting in increased expression of Shh and the production of a secondary AER site can also be due to an abnormal wave of BMP that induces a duplication of the middle digit

Hemimelia

Gli-3 overexpression results in lower expression of Shh and failure of radius and thumb (distal phalynx) to develop

CN9

Glossopharyngeal

Contributors to fatigue during endurance excercise

Glycogen depletion (during first hour), Triglyceride depletion, Dehydration (reduced cardiac output/temp)

AP external rotation

Goof for looking at the greater tubercle (lesser tuberosity will be superimosed beneath) looks like a hockey stick

Clinical features of Lesch-Nyhan

Gout, Mental retardation, self mutilation, orange colored crystals in urine

M3

Gq type cholinergic receptor Glandular secretion Visceral Smooth Muscle Contraction Endothelium

CYP3A4 Inhibitors

Grapefruit Juice Cimetidine Erythromycin Ciprofloxacin Ketoconazole

Sympathetics to organs supplied by the Celiac Trunk

Greater thoracic splanchnics (T5-T9) celiac ganglia = paravertebral ganglion

4 Hamstring muscles

Hamstring portion of adductor magnus Semimembranous Semitendinous Long head of Biceps femoris

Intrinsic muscles

Have an origin and insertion on a bone of the back

Fracture repair

Hematoma + organization = soft callus Subperiosteal woven bone + chondroblastic differentiation + endochondral ossification = bony callus weight bearing that leads to remodeling and normal bone shape

How does Myoglobin induce acute kidney failure?

Heme is released from myoglobin, and Fe2+ creates ROS which causes Proximal tubular necrosis Heme in acidic urine reacts with Tamm-Horsefall protein (Uromodulin) which forms a gel that obstructs the distal tubule Distal tubule obstruction increases the Proximal tubule myoglobin uptake which upregulates this whole cycle!

superficial inguinal lymph nodes

Horazontal group:superficial gluteal region, anterior abdominal wall below umbilicus, external genitalia, and anal triangle Vertical group:lower extremity (all of the superficial thigh, medial superficial leg and medial superficial foot)

Malignant Hyperthermia

Hypersensative RyR allow uncontrolled Ca2+ release

Acute phage protein cytokine

IL-1

Angiogenesis cytokine

IL-6

Sympathetic control of the pupil

IML (C8-T1) stimulates a1 in the radial eye muscles resulting in dilation of the pupil

NSAIDs used for acute gout

Ibuprofen and other NSAIDs are used Aspirin is NOT used because it causes renal retention of uric acid at low doses

Median nerve position in comparison to the Pronator Teres

If only the humoral head is present, the median nerve lies posterior to the pronator teres. If both heads are present the median nerve lies between both heads

Secondary Gout cause

Increased nucleic acid turnover (leukemia) chronic renal disease Inborn errors in metabolism

What is the principle adverse effect of immunosuppressive drugs (including glucocorticoids)?

Infection (bacterial, fungal, viral)

Filum Terminal

Internal Filume- pia mater only external Filum- pia, arachnoid, and dura mater

what muscle covers the crus of the penis/clitoris?

Ischiocavernosus muscle

Infraspinatus

Nerve: Suprascapular nerve (C5-C6) Function: lateral rotation of the arm

Genu Valga

Knocked knee increase angle of Q or tilt tibia out Q= 10 degrees normally

Dihydropyridine receptor

L-type voltage gated Ca2+ channel

Ilioinguinal nerve

L1 fibers located in the inguinal canal, anterior to the spermatic chord (not inside the fascial layers of the spermatic chord) travels all the way down into the scrotum, so one of the dermatomes for the anterior scrotum is L1 (this is also the dermatome for the medial thigh)

Iliohypogastric nerve

L1 fibers not actually in the inguinal canal with the spermatic chord (located above that area)

Sympathetics to perineum

L1-L2

Sympathetics to the Perineum

L1-L2

Lumbar ganglion

L1-L2 Inferior Mesenteric ganglion

Umbilicus location

L3-L4

What dermatome is over the patella?

L4

Illiac crest

L4 vertebrae

Sciatic nerve

L4-S3 Tibial nerve (lower half lateral posterior leg, plantar surface of foot, knee joint) Common peroneal (upper half lateral posterior leg, lateral anterior leg, dorsum of foot, knee joint)

Neutrophil infiltration cytokine

LTB4

Autosomal recessive osteopetrosis

Lack of medullary canal and Erlenmyere flask deformity Nerve compression due to narrowed foramena No room for hemopoietic tissue in the bone so extra medullary hematopoeisis in the liver and spleen are elevated (hepatosplenomegaly)

mutations in a, B, y, Sarcoglycans

Limb girdle muscular dystrophy

Dysostoses

Localized abnormality due to abnormal migration of mesenchymal cells. Examples: extra finger, missing an entire bone, fusion of bones ect.

Vastus intermedius

Located deep to the rectus femoris nerve: femoral nerve action: hip flexion and extension

lumbricals of the hand

Located on the palmar side index =1 middle finger = 2 ring finger = 3 little finger = 4 finger 1 and 2- common palmar digital branches of median nerve 3 and 4th finger- Deep branch of the ulnar nerve

Sympathetics to organs supplied by the inferior mesenteric artery

Lumbar splanchnics L1-L2

what systemic vein anastomoses with the Colic vein?

Lumbar vein

Diphenylhydramine

M antagonist used as an antihistamine and anticholinergic

Scopolamine

M antagonist used for motion sickness and antiemetic

Glycopyrrolate

M antagonist used to prevent bradycardia in surgery

Atropine

M antagonist used for mushroom poisoning, dilation of eyes for exam, and to reduce saliva and bronchial mucus for surgery

Bethanechol

M3 agonist that is used for lleus and atonic bladder

Methacholine

M3 agonist that is used to test for hyperreactivity in asthma

Carbachol

M3 agonist used for glaucoma (stimulates circular muscle/cilliary muscle in the eye increasing aqueous outflow and lowering interocular pressure)

Pilocarpine

M3 agonist used for xerostomia in Sjogren syndrome

MRI and back pain

MRI may be indicated in presence of red flags and negative plain films

How to MSU crystals produce inflammation in gout?

MSU crystal binds the NLRP3 inflammasome which activates caspase 1 caspase 1 cleaves Pro-IL-1B to produce IL-1B whcih produces inflammation

Type IIx muscle fiber myosin head chain gene

MYH1

Type II1 muscle fiber myosin head chain gene

MYH2

Type 1 muscle fiber myosin head chain gene

MYH7

Chronic gout

Monosodium urade deposition in tophi (fingers and ears) joint destruction recurrent bouts of gout due to high uric acid Chronic polyarticular gout (joint swelling) takes years to develop

Anal columns

Morgagni's Columns formed by blood vessels under the mucosa

Supraspinatus

Nerve: Suprascapular nerve (C5-C6) function: initiates arm abduction to 15 degrees

Latissimus Dorsi

Nerve: Thoracodorsal nerve Function: Extends the arm Blood Supply: Thoracodorsal artery Arm Extension test

Multipolar neuron

Motor = efferent multiple dendrites

Serratus Posterior Inferior

Nerve: Ventral rami of lumbar spinal nerves (T9-T12) Function: accessory muscle of respiration that depresses the rib cage

Osteogenesis Imperfecta

Mutation in gene for type 1 collagen 7q22

Dysplasia

Mutations in regulators of organogenesis that affect cartilage and bone. More diffuse effects

swelling in the femoral triangle

Mycobacterium tuberculosis and Staph aureus can create an abcess that tracks into the psoas fascia and present as a swelling in the femoral triangle

Myoclonic epilepsy and Ragged red fiber disease (MERRF)

Myoclonus (breief sudden twitching), epileptic seizures, ataxia, ragged-red fibers caused by hyper proliferation of mitochondria

main structural component of thick filament

Myosin II (510kDa)

Inhibition of N ambiguous

N Ambiguous normally stimulates M2 inthe heart causing Hear Rate to decrease. If N Ambiguous is inhibited, M2 will not be stimulated and Heart rate will increase

Short head of Biceps femoris

NOT A HAMSTRING origin: femur nerve: common Peroneal (fibular) nerve action: knee flexion the only flexor at the knee joint that is not innervated by the tibial nerve

Treatment for acute gout (first attack)

NSAIDS, Colchacine, Glucocorticoids, Anakinra

treatment for acute gout

NSAIDs colchicine

Treatment for pseudogout

NSAIDs and Colchicine

Serratus Posterior Superior

Nerve: Ventral rami of thoracic spinal nerves (T1-T4) Function: Accessory muscle of respiration that elevates the rib cage

External Abdominal oblique

Nerve: intercostal nerves (iliohypogastric nerve and ilioinguinal nerve) function: rotates trunk to the opposite side and bends trunk to the same side

Subscapularis

Nerve: upper and lower Subscapular nerve (C5-C6) Function: adductor and internal rotator of the arm

Impingement Bursitis tests

Neers Impingment sign Jobe's Test Hawkins Sign

Trapezius

Nerve supply: CN6 (sensations travel via ventral rami of C3/C4) Function: elevates and rotates the shoulder Blood Supply: Transverse cervical artery Shoulder shrug test

Adductor canal contents

Nerve to vastus medialis (femoral nerve) Saphenous nerve (femoral nerve) femoral artery femoral vein

Teres Minor

Nerve: Axillary Nerve (C5-C6) Function: Lateral rotator of the arm

Deltoid

Nerve: Axillary nerve (C5-C6) Function: abducts are to 90 degrees

Splenius Capitis

Nerve: Dorsal Rami of spinal nerves (C2-C6)

Semispinalis Capitis

Nerve: Dorsal rami of spinal nerves (C3-T6)

Rhomboid Minor/Major

Nerve: Dorsal scapular n (C5) Function: retracts scapula and elevates its medial boarder Blood Supply: Dorsal Scapular Artery

Levator scapulae

Nerve: Dorsal scapular n (C5) Function: retracts scapula and elevates its medial boarder Blood supply: Transverse cervical artery and ascending cervical artery

Rectus femoris

Nerve: Femoral nerve Action: hip flexion and knee extension only muscle that crosses the hip joint (assists in flexion of the hip)

Vastus Lateralis

Nerve: Femoral nerve Action: knee extension

Gluteus maximus

Nerve: Inferior Gluteal nerve (L5, S1, S2) Function:extension at the hip joint

Serratus Anterior

Nerve: Long Thoracic Nerve (C5-7) Function: protracts the scapula and elevates the glenoid fossa upward, allowing the head of the humerus to clear the acromion process of the scapula when raising the arm over the head

Teres major

Nerve: Lower Subscapular Nerve (C5-C6) Function: Extensor and adductor of the arm

Obturator externus

Nerve: Obturator nerve Action: Adduction

Adductor brevis

Nerve: Obturator nerve action: Adduction

Gracilis

Nerve: Obturator nerve action: adduction

Adductor longus

Nerve: Obturator nerve action: adduction of the leg

Adductor Magnus (adductor portion)

Nerve: Osturator nerve action: Adduction hamstring portion inserts on adductor tubercle of the medial epicondyle of the femur

Tensor Fascia Lata

Nerve: Superior gluteal nerve Funtion: Assists in extension at the knee joint (requires less energy to stand for long periods than is you used the quadriceps)

Gluteus Minimus

Nerve: Superior gluteal nerve (L4, L5, S1) Function: Medial rotator of the thigh

Acute Kidney Failure Labs

Normal BUN/creatine ration = 10-20/1 Proximal tubular necrosis BUN/Creatine ratio = <10/1 (intrarenal azotemia) less BUN is absorbed by the proximal tubule

How do you treat Rhabdomyolysis

Normal saline and Mannitol (to increase Myoglobin clearence and replace fluid volume) Protect the Distal Tubule by Alkalinizing Urine (and preventing Tamm-Horsefall cast formation) by using sodium Bicarb If pH remains lower then 6.5 after adding sodium bicarb, use Acetazolamide

Parasympathetic Efferent Outflow (GVE)

Not found in the body wall, extremities, or skin Craniosacral outflow (brain and S2-S4/Pelvic Splanchnic nerves) Innervates: Glands Cardiac muscle- heart smooth muscle- organs

Strutures exiting the lesser sciatic foramen

Obturator internus muscle tendon

CN3

Oculomotor

CN1

Olfactory

Enchondromatosis

Ollier disease characterized by multiple Enchondromas

sensory innervation of the pericardial sac (fiberous and serous parietal pericardium)

Phrenic nerve (C3-5)

Afferent innervation to diaphragmatic parietal pleura

Phrenic nerve (C3-5) T7-11 intercostals to the costal portion of the diaphragmatic parietal pleura

What drug do you use for Atropine overdose?

Physostigmine because it crosses the blood brain barrier

fat pad sign

Posterior fat pad is always Abnormal! indicates fracture

a1 antagonists used for benign prostatic hyperplasia

Prazocin Doxazocin Terazocin Tamsulosin (a1A specific in prostate)

treatment for polymyalgia rheumatica

Prednisone (glucocorticoids)

Rectocele

Prolapsed rectum

Advantages of using Succinylcholine to induce paralysis

Rapid sequence induction anesthesia and short duration (begins working in 1 minute and ends working in 8 minutes)

Treatment for Advese effects of AChE inhibitors used to treat Myasthenia Gravis

Propantheline bromide and Scopolamine (both are M blockers, where MG drugs work at Nm receptors)

B1/B2 blockers to avoid in asthma pts

Propranolol Pindolol Timolol Sotalol

Psoriatic Arthritis

Psoriasis imflammatory peripheral arthritis with DIP involvemnt SAUSAGE digits (dactylitis)

Pubovesicular ligament

Pubocervical

What two muscles make up the levator ani?

Pubococcygeus and iliococcygeus

Structures entering the lesser sciatic foramen

Pudendal Nerve nerve to obturator internus internal pudendal artery

blood supply for the perineum

Pudendal artery and Pudendal nerve (S2-S4) exits the greater sciatic foramen and enters the lesser foramen

Type 2 OI

Pulmonary hypoplasia that is lethal in utero. Most sever type of OI

Joint pain that improves with use of the joint

Rheumatoid arthritis

DENOSUMAB

RA antibody that binds to RANKL and prevents osteoclastic activity

ABATACEPT

RA blocks costimulation of antigen presenting cell by blocking CD80/86

denosumab

RANKL inhibitor used to treat Giant cell tumor of bone

Vasculitis in RA

Raynaud Phenomenon chronic leg ulcers

Disseminated gonococcal migratory monoarthritis (with no ocular symptoms)

Reactive arthritis

Pouch of Douglas

Rectouterine pouch

Reactive Arthritis

Reiter Syndrome asymetric inflammation seen with urethritis, salmonella, shigella, or campylobacter "cant see, cant pee, cant climb a tree"

Scapula on AP view

Scapula overlay the lung field on an AP view, but are retracted to the sides on a PA view

Structures exiting the greater sciatic foramen

Sciatic nerve Superior gluteal nerve inferior gluteal nerve Pudendal nerve internal pudendal artery superior gluteal artery inferior gluteal artery

Unipolar Neuron

Sensory = Afferent

Rhabdomyolysis dipstick test

Serum Not pink, Urine is positive for heme

Klippel-Feil Syndrome/Brevicollis

Short neck with reduced number of cervical vertebrae

Achondroplasia characteristics

Shortened proximal extremities with relatively normal trunk length. Frontal bossing, Midface deficiencies. Not associated with decrease life expectancy, IQ, or reproductive status

AP internal rotation

Shows the lesser tuberosity in profile at the medial aspect of the humerus. shows the posterior aspect of the humoral head (looks like a lightbulb) back of hand against thigh

Rovsing's sign

Sign of appendicitis palpation of the LLQ generates pain in the RLQ

Difference in Skeletal muscle and visceral striated muscle

Skeletal muscle has both ends attached to bone and visceral striated muscle may only have one end attached to bone or may be completely detached from bone

Cranial nerve action rhyme

Some Say Marry Mary But My Brother Says Bettys Better My My (S-Sensory, M-Motor, B-Both)

Ampulla of vas Deferens

Sperm storage

contents of the inguinal canal

Spermatic chord and ilioinguinal nerve

What veins branch from the portal vein?

Splenic and Superior mesenteric veins

CYP3A4 Inducers

St. Johns Wart Rifampin Griseofulvin

reffered pain from heart muscle

T1-4 (upper thoracic region and medial arm) pain can also be projected posteriorly (since the dermatome wraps all the way around)

Where are White Rami Communicans located?

T1-L2 ONLY

Sympathetics to the heart

T1-T4 (incudes the medial arm)

Inferior esophygeal contrictor/Esophygeal hiatus

T10

Umbilicus dermatome

T10

Xyphoid process location

T10

Least thoracic splanchnics

T12 Aorticorenal ganglion

Sympathetic control of the bladder

T12-L2 a1 (contraction of the sphincter vesicae and prostate) B3 (relaxation of the detrusor)

Suprasternal notch

T2, above the manubrium (where the first rib attaches)

Arch of aorta and left pulmonary bronchus

T4-5

Sternal angle

T4-T5

important cytokine in RA

TNF

Tissue damage cytokine

TNF-alpha

Anti-IL6 drug used for RA

TOCILIZUMAB

Osteogenesis Imperfecta Type 1 characteristics

Too little bone, cortical thinning, Extreme skeletal fragility Blue sclerae, hearing loss, dental abnormality,

Raynaud's Disease

Too m uch sympathetic input resulting in vasoconstriction that can make the digits numb or painful. Gets worse in cold weather Treatment- Sympathectomy between T1 and T2 sympathetic chain ganglia

Popeye sign

Torn tendon of long head of biceps

Shoulder shrug test

Trapezius

CN5

Trigeminal

major storage fuel of Type 1 muscle fibers

Triglycerides (fat)

CN4

Trochlear

Tensilon Test

Use of Edrophonium to test for Myasthenia Gravis. Recrires the availability of resuscitation facility and Atropine. Test dose of 2mg is given via IV. If no adverse reactions occur 6 to 8 mg can be given 45 seconds later. full dose after 5 min

Finkelsteins Test

Used to check for (DeQuervain's Tenosynovitis)/Stenosing Synovitis

Phalens Maneuver

Used to diagnose carpal tunnel fingers pointed downward with back of both hands against eachother

Broad ligament

Uterus, uterine tubes, and ovaries are mesenteric and are surrounded by peritoneum called the Broad ligament

3,4-diaminopyridine

VGKC blocker. primary drug used to treat Lambert Eaton Syndrome

Prevertebral ganglia Efferent control of Parasympathetic Enteric NS from CNS autonomics

Vagal

CN10

Vagus

causes of osteonecrosis

Vascular interruption corticosteroids Embolism (dysbarism) Vasculitis Radiation therapy Sickle cell disease Infection

Pathologic findings in RA

Vasculitis (small or larger arteries, acute and necrotizing) serosal involvement progressive interstitial lung disease ocular changes

Signaling that brings about Hypaxial muscles

Ventral/lateral signaling (BMP-4) Pax-3 gene

CN8

Vesticulocochlear

Retinoic Acid

Vit. A = a signaling molecule that causes a cranial shift if taken early in development. more thoracic and less cervical vertebra. It will cause a caudal shift if taken later in pregnancy. more thoracic and less lumbar vertabrae

Acute flare ups of gout

We are only treating the inflammation. NOT the uric acid levels If the patient is already taking urate lowering drugs, continue them, if they are not DO NOT START

ALS Symptoms caused by lower motor neuron damage

Weakness and atrophy Cramping Fasciculations

Tibial nerve damage

Weakness in plantar flexion and inversion, but these functions will not be knocked out completely because they are assisted by plantar flexors and invertors of the anterior compartment

Lesch-Nyhan Syndrome

X-linked recessive mutation of HGPRT (hypoxanthine-guanine phosphoribosyltransferase) of the purine salvage pathway hyperuricemia and hyperuricosuria

Iliofemoral ligament

Y ligament of Bigelow limits extension at the hip

Where is Shh produced?

ZPA

treatment for trichanosis

albendazole (first choice) and mebendazole (alternative) drugs do not affect encysted larvae

what induces myasthenia gravis?

antibodies against Acetylcholine receptors, muscle-specific kinase (MuSK) and Lipoprotein receptor-related peptide 4 (LRP4)

What can be used as biomarkers in some patients with Myasthenia Gravis?

antibodies against intramuscular proteins titin and ryanodine receptor

inflammation in Endomysium

any inflammation in this layer is pathologic (neutrophils and lymphocytes) CD45 stain will show these

Inflammatory Neuropathy

blue = inflammatory response chronic neuropathy- one nerve involved, polyneuropathy= more than one nerve involved

Pathologic fracture

bone altered by disease process that makes bone susceptible to fracture (usually caused by a tumor) Think of people with history of cancer who got a fracture from something very minor

what types of cells can be augmented into muscular satellite cells?

bone marrow HSCs, mesangioblasts, pericytes,

Osteonecrosis (Avascular necrosis)

bone necrosis caused by ischemia most commonly seen in medullary bone empty lacuna and fat necrosis

SCFE

capital femoral epiphysis has slipped off the femoral neck thru the weekend growth plate. Common in overweight teenage males Use a frogleg view

Nemaline Myopathy ACTA1 mutation

cardiac isoform ACTC can replace mutant ACTA1

How do you manage Laryngeotacheal injury?

careful intubation tracheostomy (or cricothyrodomy above the cricoid bone)

lymphatic drainage of bifurcation of trachea

carinal nodes/ inferior tracheobronchial nodes

Control of ventilation

carotid and aortic glomus bodies signal to NTS, which signals the Pre-Botzinger complex, that sends signals to C3-C5 phrenic (controls the diaphragm)

Intramembranous ossification of appendicular skeleton

clavicle

Pectoral girdle

clavicle and scapula

sacrotuberous and sacrospinous ligaments

close off the foramen to create the greater and lesser sciatic foramen

Pleuralperitoneal folds

close off the rest of the diaphragm

Suprascapular notch

closed into a tunnel by the Transverse scapular ligament This tunnel contains the Suprascapular nerve, artery, and vein

Transverse Scapular Ligament

closes great scapular notch into a foramen which encloses the Suprascapular nerve (Suprascapular artery goes over the ligament

saturday night palsy

compression of radial nerve that supplies the extensors (symptom = wrist drop)

mutations in Lamin 2

congenital muscular dystrophy

Epiplotic foramen (Winslow)

connects the greater and lesser sacs. It is an opening under the hepatoduodenal ligament If you put your finger behind this ligament, your finger would be behind the lesser omentum

Marginal artery

connects the inferior mesenteric artery with the superior mesenteric artery

myoblasts that migrate into the limb buds forming dorsal muscle masses

consist of extensors, abductors, and supinators innervated by posterior divisions of nerve plexuses

myoblasts that migrate into limb buds and form ventral muscles masses

consist of flexors, adductors, and pronators innervated by anterior divisions of nerve plexuses

ALS Symptoms (General)

early symptoms include twitching, cramping, weakness and stiffness of muscles, slurred speech

Pes Anserine

from anterior to posterior ("Say Grace before Tea"= Sartorius, Gracilis, Semitendinous)

sarcomere

from one Z disk to another

Extrinsic muscles

have an origin or insertion in a bone of the back

Fine control muscles

have higher neuron to fiber ratio

intermediate muscle fibers

have properties intermediate to red and white fibers

What do the lesser splanchnic nerves innervate?

head of the pancreas, distal part of duodenum, jejunum, ilium, cecum, ascending and transverse colon

humans are what kind of host in sarcocystis?

human can be both intermediate or defenitive (preditor is the defenitive host)

Posterior shoulder dislocation

humerus dislocates posterior to the glenoid

Anterior shoulder dislocation

humoral head ends up inferior to the coracoid process 95% of cases (usually from trauma)

osteoporosis

increased reabsorption that leads to loss of bone mass in both compact and trabecular bone

Gli-1

increases expression of Shh

Temporal (Frequency) summation

increasing muscle force by increasing the frequency of motor neuron action potentials

Spatial (Multi-Fiber) Summation

increasing muscle force by recruiting additional motor units

Bilateral Quadriceps tendon tear

indicates potential underlying condition: renal failure hyperparathyroidism gout SLE long term statin use anabolic steroids

Presence of creatine kinase in the blood

indicates tissue damage and is used to diagnose acute mycocardial infarction, Rhabdomyolysis, muscular dystrophy, and acute renal failure

Open pneumothorax

ineffective ventilation treatment: 3-sided cover over defect chest tube definitive operation

Lymphatic drainage of organs supplied by the inferior mesenteric artery

inferior mesenteric nodes these go on to drain into the intestinal trunk and finally the thoracic duct

Luxatio Erecta

inferior shoulder dislocation patient will present with the arm fixed in an upright position, usually with the elbow flexed

blood supply to the superior portion of the esophagus

inferior thyroid artery

jejunum vs ilium

jejunum= thicker walled with more plicae circularis less mesenteric fat less archades (arteriae rectae instead) ilium= thinner walls with less plicae circularis more mesenteric fat more archades Peyer's patches

How do you diagnose suppurative arthritis?

joint fluid collection and culture

Ankylosing spondylitits

joints are fused from outside the joint HLA-B27 absence of granulomas (nodules) and RF extensive extrasynovial inflammation (joint fusion)

uterosacral ligament

just medial to the ureter

intercostal nerves and blood vessels

lie between the innermost and internal costal muscles

intercostal nerves

lie between the innerost and internal intercostal muscles

femoral hernia

lies lateral and inferior to the pubic tubercle

Small saphenous vein

lies posterior to the lateral malleolus

End Plate Potential

ligand gated channel. binding of ACh to and ACh recceptor induces a conformational change and allows Na+ to flow into Post synpatic knob and K+ to flow out of the post synaptic knob depending on the sodium ion difference inside and out When EPP>50mV NaV gate opens and allows massive influx of sodium (ACTION POTENTIAL)

Volkmans Ischemia

ligation of brachial artery should be done distal to the superior ulnar collateral artery. If not the patient can lose blood flow to the forearm muscle compartments causing volkmans ischemia

H band

lighter region in the middle of the a band

Hazard ratio

like rate ratio but are cumulative over the entire study, not just at a given time

Pubofemoral ligament

limits extension and abduction at the hip joint

M line

line that bisects the H band and the A band

How can you distinguish between Tension pneumothorax, massive hemothorax, and cardiac tamponade?

make a pericardial window and preform a needle decompression

Uricosuric drugs for chronic gout

makes patient excrete more uric acid in urine (do not use in overproducers becasue it will cause stones) PROBENECID Nephrolithiasis (radiolucent stones)-in urate overproducers, reduces the excretion of NSAIDs and Antibiotics (thiazide drugs are anti-uricosuric)

Scaphoid fracture

makes the proximal aspect of the hand susceptible to avascular necrosis since the lateral and distal radial artery that runs over it is a nutrient carrying artery

who is affected most by centronuclear myopathy?

males

osteosarcoma

malignant bone forming disease that typically occurs in long bones (around the knee) and occurs in both children and older adults

result of malignant hyperthermia

metabolic and respiratory acidosis

Massive hemothorax

no breath sounds dull percussion flat neck veins shock

Osteoarthritis (OA)

no inflammation. degeneration due to overuse crepitus, limitation in joint movement, nerve root compression

sarcocystis treatment

no treatment

Fibrous cortical defect

non-ossifying fibroma that occurs at the metaphyses (usually surrounded by a ring of sclerotic bone-bright white) Eccentrically located (involves one cortex but grows off to the side) common sites = distal femur and distal tibia

Appendicitis

non-specific pain in the umbilical region pain moves to the RLQ when the parietal peritoneum becomes infected (McBurney's Point)

cardiothoracic ratio

normally less than 50% (heart should be less than 50 % the diameter of the thoracic cavity)

esophogeal injury

not covered in psorosa like the rest of the GI so food will spill into the abdomen if there is injury

Trichinosis

nurse cell complexes in skeletal muscle that when ingested break open, and release larvae into the lacteals of the small intestine, travel thru the blood stream and get deposited in skeletal muscle

causes of muscle cramps

overuse, dehydration, Low Na+ Ca2+ Mg2+ K+, injury or disease and medications

Pulmonary contusion

oxygenate and ventilate, pain control pretty much just wait for it to heal

ACh/H+ Antiporter

packages ACh into vesicles in the presynaptic knob in an energy dependent manner. Energy is generated via a proton gradient set up by V-type H+ ATPase in the membrane of the vesicle that pumps protons into the vesicle

tibial tuberosity

pain here is due to the patellar ligament

McMurray Test

pain/popping on external rotation= medial Miniscal Tear pain/popping on internal rotation = Lateral meniscal tear

Where do the ribs originate?

ribs arise from the vertebrae and eventually separate

What artery supplies the SA node?

right coronary artery

What side can pelvic fluid reach the diaphragm?

right side causes inflammation of the diaphragm (Kers sign )

reverse S sign of golden

right upper lobe atelectasis

Parasympathetics to organs supplied by the superior mesenteric artery

right vagus

Risk Ratio (relative risk)

risk group1/ risk group 2 (event/total group 1)/(event/Total group 2)

Nemaline myopathy

rod like inclusion myopathythat primarily effects proximal muscle (respiratory, trunk, neck)

popliteal fossa

roof- skin and fascia floor- Popliteus muscle Medial wall- semimembranous /Head of Gastrocnemius lateral wall- biceps femoris, Plantaris, lateral head of gastrocnemius

femoral triangle

roof: skin and fascia superior boarder: inguinal ligament floor lateral: Iliopsoas floor medial: Pectineus Lateral wall: Sartorius medial wall: adductor longus

type I muscle fibers

slow oxidative equivalent to red fibers, fatigue resistant

Ganglion cyst

small cyst (1.5cm) found near a joint like the writs occur in fluid filled spaces with no epithelial lining on the cyst

red muscle fibers

small, slow twitch (appear dark on histological stain) have higher myoglobin and mitochondrial content

How is information form the aortic/carotic sinus baroreceptors conveyed?

stretch sensing is conveyed by neurons (CN9/10) to the NTS (primary autonomic sensory information collector) from the NTS information can either go to the Nucleus Ambiguous (efferent vagus-M2= slows HR) or to the CVLM, which releases GABA which inhibits RVLM, fails to stimulate IML (pre-ganglionic ACh decreases, which decreases stimualtion of cardiac B1 and vaso a1 = heart rate decreases and BVs dilate

classifications of muscle

striated and smooth

parietal pleura

stuck to the body wall. lines inside of ribs and diaphragm. DOES NOT CROSS THE MIDLINE

gonococcal supperative arthritis

subacute presentation oligoarticular

How do you determine if there is cardiac injury (tamponade)

subxiphoid pericardial window

what stains do you use to distinguish red from white muscle fibers

succinate dehydrogenase (SDH) and NADH- tetrasolium stain

Supperative arthritis

sudden onset of pain and swelling limited range of motion fever, high WBC, high ESR can be non-gonococcal or gonococcal

varicose veins

superficial veins are low pressure and are connected to deeper veins that are higher pressure. when the valves that connect these two veins become incompetent, the high pressure blood flows into the thin superficial veins and ruptures them

posterior cutaneous innervation of thoracic wall

supplied by the dorsal ramus of spinal nerves

Superior Mesenteric Artery

supplies blood to the: Duodenum Small intestine Pancreas Cecum Appendix Acending colon Transverse colon

Lateral and anterior cutaneous nerves of the thoracic wall

supplies by the ventral ramus of spinal nerves

external iliac artery

supplies lower extremities

internal iliac artery

supplies pelvic organs

What arteries supply the first two intercostal space?

supreme intercostal arteries (a branch off of the costocervical trunk, which is a branch off of the subclavian artery)

rectum

upper half of rectum is mesenteric, lower half is not

Tbx5

upper limbs

What quadrant do you give hip injections?

upper outer quadrant to avoid injecting into the sciatic nerve

Prevention of repeat gout attack

urate lowering therapies Probenecid- increases urinary excretion Allopurinol- decreases uric acid production

URAT1

urate transporter responsible for reuptake of uric acid. urate is reabsorbed in exchange for lactate, pyruvate, acetoacetate, and B-hydroxybutyrate

what supplies blood to the ureter?

ureter recieves blood supply from numerous different vessels as it travels from the bladder dont (renal artery, gonadal artery, internal iliac artery)

Strenuous exercise (>60% Max)

uses Type 1 and 2 fibers and increases muscle size and strength creatine phosphate depleted in seconds and then glycogen /glucose is used thereafter

Endurance exercise

uses type 1 fibers and increases oxidative capacity of muscles (more mitochondria and oxidative enzymes) fatty acid, glucose, and glycogen (depleted in the first hour)

First Gout attack

usually affects the ankle, mid foot, small joints of hand, wrist and elbow (axial and large joints rarely involved and never in the primary attack) extremely rapid onset worst pain ever/extreme tenderness self limiting (lasts 5-14 days) (will look like septic arthritis, except septic arthritis involves large joints)

Pyogenic osteomyelitis due to Mixed bacterial infection

usually due to open fracture or surgery

Malignant Myperthermia

usually induced by exposure to anesthetics like halothane or muscle relaxants like succinylcholine

Pyogenic osteomyelitis due to Gram negative bacteria

usually stems from genitourinary infection and IV drug abuse

contents of the vestibule

vagina urethra paraurethral glands (Skenes) greater vestibular glands (Bartholins)