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HAD Unit I ReviewTom Eck, ecktw@umdnj.eduCALM Resourceshttp://njms.umdnj.edu/calm

I will email you the link again tonight.

Todays review and a number of other resources should be up by tomorrow afternoon.To activate your clickerPress Ch 52 Ch

Unit I PrioritiesNervous System PrinciplesLymphaticsLungsHeartMediastinumBackUpper LimbSurface AnatomyEmbryologyNervous System Principlesthe second most important content from Chapter 1most important: anatomical terms, but they are rarely tested directlythe structure of peripheral nerves as they exit the spinal cordthe anatomical and functional distinctions between the sympathetic and parasympathetic divisions of the autonomic nervous systemdermatomes (T4 = nipple; T10 = umbilicus)referred pain To which segments does heart pain refer?

10SecondsRemainingC1 C5C3 C5 T1 T4 T3 T8T6 T12

Remember: In referred pain, start by identifying the visceral nerves involved SympatheticsFrom there, identify the spinal segments representedby the nerve(s) T1 T4/T5The pain will refer to the corresponding dermatomes.

Referred PainA high-yield topic; especially important in Unit III, but dont neglect thisWhich of the following, if cut, would block sensory perception in the corresponding dermatome?

10SecondsRemainingventral rootdorsal rootventral ramusdorsal ramusRhizotomyThe dorsal root of spinal nerves can be cut to relieve intractable painAlternately, the ventral root may be cut to treat spastic paralysis

S SensoryD DorsalA AfferentA Afferent M MotorV Ventral E EfferentE Efferent

LymphaticsDont forget to study lymph!You can expect a few lymph questions on every exam (~2-3), often relating to the spread of cancerThese tend to be challenging, detail-oriented questionsMajor TopicsLymph Drainage of the LungLymph Drainage of the Axilla and BreastInto which vessel does lymph from the right arm empty?

Thoracic DuctIVCRight Jugular VeinRight Subclavian Vein:10

Lymph from the right arm drains to the right lymphatic duct, and to the right subclavian vein (at the venous angle) from there. Which of the following correctly stages the path of pulmonary lymphatic flow?

:10Pulmonary Tracheobronchial BronchopulmonaryParatracheal Tracheobronchial Deep CervicalTracheobronchial Paratracheal Deep CervicalPulmonary Paratracheal Aortic Arch

A patient presents with a severe case of pneumonia. When you ask her to lift her arms, you notice that the veins in her upper limbs remain distended. You suspect radical enlargement of which group of lymph nodes:

10Right PulmonaryLeft PulmonaryRight Bronchopulmonary (Hilar)Left Bronchopulmonary (Hilar)Inferior Tracheobronchial (Carinal)SVC SyndromeVeins of head and upper extremities become distended due to constriction of the SVC by a tumor or grossly enlarged lymph nodesThe bronchopulmonary nodes at the right lung hilus are in close proximity to the SVC

SVCHilar NodesThe LungsDifferences between Left and Right LungsLobes, SegmentsPleura, Reflections, RecessesPneumothorax: in tension pneumothorax, mediastinum contralateral sideAspirated Objects Right Main Bronchus

Upon examining a patient with left-sided ptosis, miosis, and anhydrosis, a physician suspects a growing superior lobe tumor. Which of the following segments is most likely involved?

10SecondsRemainingApicalPosteriorApicoposteriorAnteriorSuperior LingularInferior Lingular

Horner SyndromeSympathetic Trunk-Interruption of Sympathetics to Head causes Ipsilateral Ptosis (Lid Lag), Miosis (Pupil Constriction), and Anhydrosis (Lack of Sweating)

-often caused by Pancoast Tumor

-remember to study lung segments; you can expect a few questions testing their locations, both in the written exam and the practical

Which space is entered when a thoracentesis is performed at the MAL in the 9th ICS?

Transverse sinusCardiac notchCostodiaphragmatic recessCostomediastinal recessPericardial sac10SecondsRemaining

The Heartpathway of blood valve pathologiescoronary vessels consequences of blockageauscultation sites pathological heart sounds (continuous machine-like murmer = patent ductus arteriosus)radiographs and CTs especially important

Identify the heart chambers marked B and D:

:10DBRight Ventricle, Left VentricleRight Atrium, Left AtriumRight Ventricle, Left AtriumRight Atrium, Left VentricleCT ScansRight Ventricle is associated with the anterior (sternocostal) surface of the heartLeft Atrium is associated with the posterior surface of the heart, just anterior to the esophagus

CTs and Radiographs show up in the written exam and the practicalBe able to identify major structures Which of the following will result a diastolic murmur at the apex of the heart?

Mitral Valve InsufficiencyMitral Valve StenosisPulmonary Valve InsufficiencyAortic Valve StenosisAortic Valve Insufficiency:10Note: 2 is also correctAortic Valve Insufficiencyblood rushes back into the left ventricle as the ventricle relaxesmurmur is heard at the apex (not at the right upper sternal border) because the blood flow causing the murmur is reversed (APTM 2245 does not always apply)associated with a collapsing pulsecauses left ventricular hypertrophy, as the heart attempts to compensate for decreased pumping efficiency Insufficiency = Backflow of Blooda.k.a. incompetence, regurgitationA patient is diagnosed with left atrial hypertrophy. Which of the following valve defects is most likely to have caused this condition?

:10Tricuspid Valve InsufficiencyMitral Valve StenosisPulmonary Valve InsufficiencyAortic Valve StenosisAortic Valve InsufficiencyMitral Valve StenosisCauses left atrial hypertrophy; the left atrium grows larger to generate the force necessary to push past the obstructionStenosis is often associated with hypertrophy of the preceding chamberFollowing an acute myocardial infarction, necrosis develops at the apex of the heart. Which vessel was likely occluded?

10SecondsRemainingLeft CircumflexCoronary sinus Anterior InterventricularPosterior Interventricular Right coronary

The Anterior Interventricular Artery (LAD) supplies the anterior two-thirds of the interventricular septum, the apex, and the anterior left and right ventricles. It is the most commonly occluded coronary artery.The Mediastinumbe able to trace the course of the major structures that pass through the mediastinumlocalize structures to each mediastinal compartment At which level does the trachea bifurcate?

10T2/T3T3/T4T4/T5T5/T6T6/T7divides the mediastinum into superior and inferior compartmentspasses through the T4/T5 intervertebral disk posteriorly and sternal angle anteriorlybifurcation of the tracheaboundary between cardiopulmonary and abdominopelvic sympathetics (greater, lesser, and least splanchnic nerves)Remember: cardiopulmonary = postsynaptic; abdominopelvic = presynapticTransverse Thoracic PlaneYou see a patient with a hoarse voice and a detectable suprasternal pulse. Which of the following diagnoses might explain these symptoms?

:10Coarctation of the AortaAortic AneurysmTumor Impinging on the Left Subclavian ArteryLung AbscessAortic Aneurysms

Localized dilation of the aortaIf in the vicinity of the aortic arch, it may impinge on the left recurrent laryngeal nerve, causing hoarseness If the aneurysm grows large enough, it may lead to a detectable pulse suprasternallyA patient has been diagnosed with an esophageal hernia, a condition in which part of the stomach passes through an enlarged esophageal hiatus. At which spinal segment has the herniation occurred?

10SecondsRemainingT8T9T10T11T12I Ate Ten Eggs AT NoonI 8 10 E A2T 12T8: IVC (Caval Opening)T10: Esophagus (Vagus too) (Esophageal Hiatus)T12: Aorta, Azygos Vein, Thoracic Duct (Aortic Hiatus)Structures that pass through the DiaphragmIn which compartment of the mediastinum is the IVC located?

10SuperiorAnteriorMiddlePosteriorSuperiorThymus, Phrenic Nerve, Vagus Nerve, Esophagus, Trachea, Thoracic Duct, Azygos Vein, SVC, Aortic Arch, Brachiocephalic Vein, Left Common Carotid Artery, Left Subclavian ArteryAnteriorThymusMiddleHeart, Phrenic Nerve, Ascending Aorta, SVC, IVC, Pulmonary Arteries/VeinsPosteriorDescending Aorta, Esophagus (With Vagus Nerve), Thoracic Duct, Azygos Vein, Splanchnic NervesMediastinal CompartmentsBolded structures are exclusive to that compartment.

The BackMorphological distinctions between cervical, thoracic, lumbar, sacral, and coccygeal vertebraeCurvaturesSpinal Cord StructureVascular Supply: vertebral arteries, segmental medullary arteries (especially the artery of Adamkiewicz)Which of the following prevents posterior displacement of the dens?

10Posterior archAnterior archLateral massesVertebra prominensTransverse ligament

In a case of suspected meningitis where should a lumbar puncture be performed?

10L1/L2L2/L3L3/L4L4/L5L5/S1Lumbar Puncture

Spinal Cord ends at L1/L2What landmarks are used to find the location for a spinal tap?

10Anterior superior iliac spinesPosterior superior iliac spinesIliac crestsSpinalis parts of erector spinae musclesHigh points of iliac crest correspond to L4 spinous processA patient is suffering from a herniation of the L4/L5 IV disc. Which nerve root is most likely compressed?

10L2L3L4L5In a herniated disc of the lumbar vertebrae the nerve that exits at that level is spared, while the nerve root one segment below is often compressedFor lumbar roots, that means a herniation of IV disc L2/L3 will compress the L3 rootThe rule applies the same for cervical vertebrae: C5/C6 C6 rootFor cervical vertebrae, however, it is the nerve exiting at that level is actually compressed; it is only because there is one extra cervical nerve that the rule still appliesHerniated DiscsThe Upper Limbquestions almost entirely neuromuscular (nerve deficits are BIG)BRACHIAL PLEXUSknow the spinal segments represented by major nerves (e.g. long thoracic, suprascapular, dorsal scapular, radial, axillary, median, ulnar, musculocutaneous, phrenic)know major actions of each muscle (groupings and locations help)memorize the innervation of each muscleInnervation gives clues about action, vice versaattachments

A young man notices that following a stab injury he has difficulty doing push-ups, noting that his right shoulder blade tends to stick out. Which nerve was most likely injured to cause this deficit?

10Dorsal ScapularLong ThoracicSubscapularVagusPhrenicWinged Scapula= Long Thoracic Nerve (C5, C6, C7)

5-6-7, wings to heaven

A patient presents with a medially rotated, adducted arm and extended, adducted forearm. Which spinal segments are represented in the injury?

10C3, C4C4, C5, C6C5, C6C7, C8C8, T1C5, C6 = waiters tip sign

Medially rotated arm due to loss of Infraspinatus (Suprascapular Nerve)Adducted arm due to loss of Deltoid (Axillary Nerve)/ Supraspinatus (Suprascapular Nerve)Extended forearm due to loss of forearm flexors (Musculocutaneous)

Klumpke palsy = C8, T1 (symptoms similar to ulnar nerve palsy) Erb-Duchenne PalsyWhich of the following does not branch off from or derive from the medial cord?MedianLateral PectoralMedial PectoralUlnarMedial Antebrachial

10

Which of the following muscles rotates the glenoid cavity superiorly?Levator ScapulaeTrapeziusSpinalisRhomboid majorRhomboid minor

10Descending fibers elevate the scapula and rotate the glenoid cavity superiorlyCN XI Palsy makes arm abduction more difficult

Which of the following does not insert into the intertubercular groove of the humerus?

10Latissimus dorsiPectoralis majorTeres majorTeres minorlady between two majorsteres major, latissimus dorsi, and pectoralis major insert in the intertubercular groove

attachments are likely to appear in 3 or 4 questionslearn the hotspots: intertubercular groove, greater and lesser tubercles of humerus, supra- and infra-glenoid tubercles, coracoid process, coronoid process, olecranon, medial epicondyle of humerus, lateral epicondyle of the humerus, extensor expansionfor most other attachment sites, a more general idea will suffice (i.e. what bone(s))AttachmentsAfter fracture of the clavicle, which muscle is responsible for the palpable fragment?

10TrapeziusSternocleidomastoidPec MajorPec Minor

SternocleidomastoidWhat nerve may be injured following fracture of the surgical neck of the humerus?

10AxillaryRadialMedianUlnarWhat nerve may be injured following fracture of the medial epicondyle of the humerus?

10AxillaryRadialMedianUlnarWhat nerve may be injured following fracture of the radial groove of the humerus?

10AxillaryRadialMedianUlnarSurgical neck axillaryRadial groove radialDistal end of humerus medianMedial epicondyle - ulnarA man fractures his humerus at the spiral groove. What neurological problem is likely to be observed?

10Claw handSimian handHand of benedictionWrist dropThis would damage the radial nerve leading to loss of extension at the wrist (wrist drop)the radial nerve innervates extensors of the forearm, wrist, and most extensors of the phalangesFollowing a laceration to the palm just medial to the thenar eminence, which of the following intrinsic movements of the thumb is likely to be fully intact?

10OppositionAbductionFlexionAdductionopponens policis, abductor policis brevis, and flexor policis brevis are all innervated by the recurrent branch of the median nerve (which is likely to have been lacerated here)Adductor policis is innervated by the ulnar nerveRecurrent Branch of Median NerveA complete avulsion of the lateral epicondyle would be least likely to disrupt the functioning of which muscle?

10Extensor digitorumSupinatorExtensor carpi ulnarisExtensor pollicis longusExtensor digiti minimiExtensor pollicis longus does not have its origination at the lateral epicondyle; all others listed doWhich of the following resists inferior displacement of the humeral head in the glenoid cavity?

10Long head of the triceps brachiiMedial head of triceps brachiiLateral head of triceps brachiistabilizes the head of the abducted humerus in the glenohumeral joint, resisting inferior displacementattaches to the infraglenoid tubercle

Long Head of the TricepsThe nerve that provides sensory innervation to the posterolateral forearm branches from the

10Posterior cordMedial CordRadial nerveUlnar nerveMusculocutaneous nerveThe posterior antebrachial cutaneous nerve arises from the radial nervemajor nerves of the upper limb often terminate as cutaneous nervesknowing the distribution of these sensory nerves helps to identify the major nerve involved in the deficit

Describe the anatomical location of the long head of the triceps.

10Anterior to both teres major and teres minorPosterior to both teres major and teres minorAnterior to teres major and posterior to teres minorAnterior to teres minor and posterior to teres major

Teres minorTeres majorLong headHumerusQuadrangular SpaceTeres minor wraps around the back to the greater tubercleTeres major passes anteriorly to the intertubercular grooveThe long head of the triceps passes in betweenKnow the quadrangular spaceThe medial humeral circumflex artery and axillary nerve pass through this windowWhich part of the hand would experience paresthesia in carpal tunnel syndrome?

10Thenar eminenceDorsal surfaceHypothenar regionNail bed of middle fingerTip of little finger

The following patient presents with no loss of consciousness, no visible trauma, and no sensory deficits. What is the likely problem?10

Ulnar n. damageMedian n. damageVolkmanns contractureDupuytrens contracture

Not due to nerve damage because no associated sensory lossIn Volkmanns you would expect to see wrist involvement as well and would expect a preceding ischemic event, such as the improper wrapping of a tourniquetIn Dupuytrens, also look for the presence of subcutaneous nodules

Dupuytrens ContractureEmbryologydont neglect; a significant portion of the testquestions are generally straightforward, focusing on the precursors of adult structures as well as abnormalitiesheart embryology is especially important for this examIn which of the following conditions does the body compensate by opening up a collateral pathway for blood flow?

10Tetralogy of FallotPatent Ductus ArteriosusPatent Foramen OvaleCoarctation of the AortaAortic StenosisCoarctation of the AortaDiminished femoral pulses and rib notching due to increased blood flow = classic signs of coarctationCollateral Circulation: Aorta Subclavian Internal Thoracic Anterior Intercostal Posterior IntercostalNote: the Supreme Intercostal Arteries represent an additional pathway Collateral circulations are HUGE; know these

The chest radiograph of a cyanotic newborn is shown below. Immediately suspecting a congenital abnormality, you anticipate four pathological conditions. Which of the following would you NOT expect to find:

Right Ventricular HypertrophyOverriding of the AortaPulmonary StenosisMitral StenosisVentricular Septal Defect10

Boot-Shaped HeartIndicates right ventricular hypertrophy seen in Tetralogy of Fallot. (A similar radiograph is in the lab. Remember to review all of these.)

Pulmonary Artery StenosisRight Ventricular HypertrophyOverriding of the AortaVEntricular Septal DefectWhich aortic arch gives rise to the stapedial artery?

10SecondsRemainingFirst ArchSecond ArchThird ArchFourth Arch Fifth ArchSixth ArchAortic Arch DerivativesRemember MSCARD

MaxillaryStapedialCommon Carotid (External Too)Arch of Aorta (and Right Subclavian)RegressesDuctus Arteriosus (and Pulmonary Arteries)

Which of the following vessels has the highest oxygen saturation?

10Pulmonary VeinsPulmonary ArteriesAscending AortaRight Coronary ArteryAn embryo successfully reaches the blastula stage but fails to implant itself in the endometrium. Which of the following events may have failed to occur?

10CleavageDisappearance of the Zona PellucidaFusion of Male and Female PronucleiFormation of Germ LayersThe blastocyst must hatch by dissolving the zona pellucida before implantation

A newborn suffers from excessive accumulation of saliva and mucous in nose and mouth, gagging, cyanosis after swallowing milk, abdominal distension after crying, and reflux of gastric contents into lungs. Which congenital abnormality may be to blame?

10Pulmonary HypoplasiaTransposition of the Great VesselsCongenital Diaphragmatic HerniaTracheoesophageal FistulaTracheoesophageal Fistula

In most common form (seen at left), esophagus ends in blind pouchTrouble with feeding a prominent symptom at birthThe patient with the herniated disc asks you about the embryological precursor to the substance coming out of the disc (naturally, of course). What should be your response?

10NeuroectodermNotochordIntermediate MesodermLateral Plate MesodermNucleus Pulposus is the only remnant of the notochord in the adult humanRemember your germ layersWhich of the following is not derived from neural crest cells?

10Dorsal Root GangliaEnteric GangliaMotor NeuronsMelanocytesNeural Crest Cellsthe fourth germ layerknow the derivatives and consequences of failed migrationSurface AnatomyGenerally come in the form, A stab wound to the _______ will lacerate which of the following structures:Be able to associate surface structures with the viscera underneathDont forget the posterior thoraxA stab wound through the manubrium damages a vessel coursing almost horizontally. Which of the following was most likely lacerated?

:10Left Brachiocephalic VeinRight Brachiocephalic VeinSVCLeft Common CarotidMALMCLPSMedianPSMCLMAL1st ICSPosterior Segmentof SuperiorAnterior Segmentof SuperiorAxillary VesselsAnterior Segmentof SuperiorSVCAortic Arch,Left Brachiocephalic V.Anterior Segmentof SuperiorAortic KnobAnterior Segmentof SuperiorAxillary VesselsAP Segment of Superior1stICS2nd ICSPosterior Segmentof SuperiorAnterior Segmentof SuperiorAnterior Segmentof SuperiorSVCAscend-ing AortaAnterior Segmentof SuperiorPulmonary TrunkAnterior Segmentof SuperiorAP Segment of Superior2ndICS3rd ICSPS of SLS ofMiddleMS ofMiddleAnterior Segment of SuperiorRARVAnterior Segmentof SuperiorConus ArteriosusSuperior Lingular of SuperiorSuperior Lingular of Superior3rdICSLateralSegment of Middle4th ICSLS of MiddleLS ofMiddle

*NippleMS of MiddleMedial Segment of MiddleRARVRVInferior Lingular of SuperiorLV*NippleSuperior Lingular of Superior4thICSAnterior Basal of Inferior5th ICSAnterior Basal of InferiorLS ofMiddleMS of MiddleMedial Segment of MiddleRA/IVCRVRV*No pleuraIL of SLV (apex)Antero- medial Basal of Inferior5thICSAMB of Inferior6th ICSAnterior Basal ofInferiorDIAPHRAGMAMB of ILB of I6thICSWhich heart chamber is at greatest risk from a thoracic stab wound?

Left AtriumLeft VentricleRight AtriumRight Ventricle:10MALMCLPSMedianPSMCLMAL1st ICSPosterior Segmentof SuperiorAnterior Segmentof SuperiorAxillary VesselsAnterior Segmentof SuperiorSVCAortic Arch,Left Brachiocephalic V.Anterior Segmentof SuperiorAortic KnobAnterior Segmentof SuperiorAxillary VesselsAP Segment of Superior1stICS2nd ICSPosterior Segmentof SuperiorAnterior Segmentof SuperiorAnterior Segmentof SuperiorSVCAscend-ing AortaAnterior Segmentof SuperiorPulmonary TrunkAnterior Segmentof SuperiorAP Segment of Superior2ndICS3rd ICSPS of SLS ofMiddleMS ofMiddleAnterior Segment of SuperiorRARVAnterior Segmentof SuperiorConus ArteriosusSuperior Lingular of SuperiorSuperior Lingular of Superior3rdICSLateralSegment of Middle4th ICSLS of MiddleLS ofMiddle

*NippleMS of MiddleMedial Segment of MiddleRARVRVInferior Lingular of SuperiorLV*NippleSuperior Lingular of Superior4thICSAnterior Basal of Inferior5th ICSAnterior Basal of InferiorLS ofMiddleMS of MiddleMedial Segment of MiddleRA/IVCRVRV*No pleuraIL of SLV (apex)Antero- medial Basal of Inferior5thICSAMB of Inferior6th ICSAnterior Basal ofInferiorDIAPHRAGMAMB of ILB of I6thICSWhich rib does the horizontal fissure approximate most closely?

10ThirdFourthFifthSixthSeventhStudy TipsStudy the TBLs! Use them to guide your review.Learn the Blue Boxes, especially the Chapter 1 ones (summary online)Dont forget lymph and embryo!Review as many bodies as possible

Mock PracticalSaturday morning: 10 am 4 pmThere will be bodies tagged in the lab, as well as radiographsComplete on your own, giving yourself a minute for the A and B questionsTags will be left on until Saturday afternoonAnswers will be posted in the lab

Good Luck!

ecktw@umdnj.edu