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)
