CRISBERT I. CUALTEROS, M.D. - Medicine Review Notes
   
DR. CRISBERT I. CUALTEROS
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  Clinical Practice Guidelines

CRISBERT I. CUALTEROS, M.D. (+63919)8586556

 

MEDIASTINUM:

 

  • space between 2 pleural sacs

 

Boundaries:

Superior – Root of the neck, Thoracic inlet

Inferior – Diaphragm

Anterior – Sternum and Costal cartilages

Posterior – Bodies of the 12 Thoracic vertebra

 

Divisible into:

 

  1. Superior:

 

-------------- imaginary plane passing from Sternal angle of Louie anteriorly to the lower border of the body of 4th Thoracic vertebra

 

  1. Inferior:

 

Subdivided into:

 

    1. Anterior

    2. Middle

    3. Posterior

 

CONTENTS:

 

  1. Superior mediastinum: remains of Thymus gland, SVC, Brachiocephalic art/vein, Left CCA, Left Subclavian art, Arch of Aorta, Phrenic and Vagus N, Left Recurrent Laryngeal N, Trachea, Esophagus, Thoracic duct, Lymph nodes, Sympathetic trunk

 

  1. Anterior mediastinum: remains of Thymus gland, Sternopericardial ligament, LN

 

  1. Middle mediastinum: Heart, Pericardium, Roots of great blood vessels, LN, Phrenic N, Bifurcation of Trachea

 

  1. Posterior mediastinum: Descending thoracic aorta, Esophagus, Thoracic duct, Azygous and Hemiazygous veins, Vagus N, Splanchnic N, LN, Sympathetic trunk

 

 

PERICARDIUM:

 

  • double walled fibro-serous sac that encloses the heart and the roots of great blood vessels; located Posteriorly to the body of sternum and 2nd to 6th costal cartilages and Anteriorly to T5 – T8 vertebrae

 

  1. Fibrous Pericardium: tough fibrous tissue, limits unnecessary movements of the heart

 

  1. Serous Pericardium:

    1. Parietal layer closely adherent to fibrous pericardium

 

    1. Visceral layer – closely adherent to heart; equivalent to Epicardium in Histology

 

Pericardial cavity – potential space between Parietal and Visceral layers of Serous Pericardium containing a small amount of fluid (30 ml) to prevent friction

 

PERICARDITIS – inflammation of the pericardium; causes severe Substernal pain and produces Pericardial effusion – if the effusion is extensive, excess fluid may interfere with the action of the heart by compression – results to Cardiac tamponade; inflammation causes the surfaces to become rough and the resulting friction between the 2 layers maybe detected during auscultation – Friction Rub

 

HEART:

 

Normal weight – Males – 280 – 340 gms

Females – 230 – 280 gms

 

  1. Base – formed by Left Atrium

 

  1. Apex – Left Ventricle; Apex beat – 5th ICS LMCL (7 to 9cm from median plane)

 

  1. Surfaces- Sternocostal / Anterior – Right Ventricle

Diaphragmatic / Inferior – Both Ventricles, mainly Left

Pulmonary / Left – Left Ventricle

 

  1. Borders – Right border – Right Atrium

Inferior border – Both ventricles, mainly Right

Left border – Left Ventricle

Superior border – Right / Left Auricles

 

RIGHT ATRIUM:

 

Receives blood from: SVC

IVC

Coronary sinus

Anterior Cardiac vein

Vena cordis minimae

 

Internal wall – Musculi pectinati – rough anterior portion

Sinus venarum – posterior part; presence of oval

Depression – Fossa ovalis (site of Foramen

Ovale); if persists after birth leads to ASD

RIGHT VENTRICLE:

 

- Thicker wall than the R atrium

- Internal surface with irregular muscular ridges called Trabeculae Carnae

where Papillary muscle originates; apices are connected to the valve by

fibrous strands called as Chordae tendinae

  • Moderator Band – modified Trabeculae carnae that crosses the

Interventricular septum

 

LEFT ATRIUM:

 

- Receives the Pulmonary veins

- Thicker wall compared with Right Atrium

 

 

LEFT VENTRICLE:

 

  • Thicker wall than R ventricle

  • Conical cavity longer than Right

  • Trabeculae carnae finer and more numerous than Right

  • Papillary muscles are larger than Right

 

AUSCULTATORY AREAS FOR HEART VALVES:

 

  • TRICUSPID – Lower end of the sternum

 

  • PULMONARY – 2nd Left ICS

 

  • MITRAL – 5th ICS Left MCL

 

  • AORTIC – 2nd Right ICS

 

HEART SOUNDS:

 

  • 1stproduced by closure of Tricuspid and Mitral valves

  • 2ndproduced by closure of Aortic and Pulmonary valves

 

BLOOD SUPPLY OF THE HEART:

 

  • from ascending aorta

 

  1. Right Coronary

Marginal

Posterior interventricular

 

  1. Left Coronary

Anterior interventricular

Circumplex

 

VENOUS DRAINAGE OF THE HEART:

 

  • mainly by Coronary Sinus which opens into the Right Atrium

 

  • Receives the: Great Cardiac vein

Small Cardiac vein

Middle Cardiac vein

 

  • Anterior cardiac vein and Vena cordis minimae – partly drains blood and directly into the Right atrium

 

  • Branches of Coronary arteries are END arteries – if there is sudden occlusion of a major branch, the region supplied by the occluded branched becomes INFARCTED and soon will undergo NECROSIS – leads to MYOCARDIAL INFARCTION

 

  • 3 MOST COMMON SITES OF CORONARY OCCLUSION

 

    1. Anterion Interventricular artery

    2. Right Coronary

    3. Circumplex artery

 

 

Most common cause of Ischemic heart disease is Coronary Insufficiency resulting from ATHEROSCLEROSIS of Coronary arteries.

 

NERVE SUPPLY OF THE HEART:

 

  • innervated by sympathetic and parasympathetic fibers of the autonomic nervous system via the cardiac plexuses

SKELETAL SYSTEM:

 

Total number of Bones: 206 AXIAL = 80

APPENDICULAR = 126 (64 upper; 62 lower)

 

AXIAL SKELETON:

  1. SKULL – 22

 

PAIRED UNPAIRED

CRANIAL - Parietal Frontal

Temporal Occipital

Sphenoid

Ethmoid

 

FACIAL Palatine Vomer

Lacrimal Mandible

Maxilla

Nasal

Inferior Nasal Concha

Zygomatic

 

  1. OSSICLES – 6

Malleus = Hammer

Incus = Anvil

Stapes = Stirrups

 

  1. HYOID – 1

 

  1. VERTEBRAL COLUMN – 26

 

Cervical = 7

Thoracic = 12

Lumbar = 5

Sacrum = 1

Coccyx = 1

 

  • Primary Curvature – CONCAVE VENTRALLY; Thoracic and Sacral

 

  • Secondary Curvature – CONVEX VENTRALLY; Cervical and Lumbar

 

  1. STERNUM – 1

Manubrium , Body and Xiphoid process

 

  • Sternal angle of Louie = at level T4

= costal cartilage of 2nd rib is attached

 

 

 

 

 

  1. RIBS – 24

TRUE / VERTEBROSTERNAL – 1st to 7th

 

FALSE / VERTEBROCHONDRAL – 8th to 12th

False rib proper – 8th to 10th

Floating rib – 11th and 12th

 

APPENDICULAR SKELETON:

 

  1. Upper extremity – 64

 

    1. Shoulder girdle – Clavicle -2

Scapula -2

    1. Humerus -2

    2. Radius -2

    3. Ulna -2

    4. Carpals – 16

 

PROXIMAL row – Scaphoid / Navicular

Lunate

Triquetral

Pisiform

DISTAL row - Trapezium

Trapezoid

Capitate

Hamate

    1. Metacarpals – 10

    2. Phalanges – 28

 

  1. Lower extremity – 62

 

    1. Hip bone – 2 (Ilium, Ischium, Pubis)

    2. Femur – 2

    3. Patella -2

    4. Tibia – 2

    5. Fibula – 2

    6. Tarsals – 14

 

Calcaneus

Talus

Navicular / Scaphoid

Cuboid

Cuneiform - 3

    1. Metatarsals – 10

    2. Phalanges – 28

 

 

JOINTS:

  • Basis of classification:

  1. Mobility

  2. Medium that connects it

 

Types of Joints:

 

  1. SYNARTHROSIS – united by a Fibrous tissue

 

    1. Suture – Coronal and Sagittal sutures in skull

 

    1. Syndesmosis – Interosseous membranes

 

    1. Gomphosis – articulation between a tooth and alveolar socket of maxilla or mandible

 

  1. AMPHIARTHROSIS – united by a Cartilage

 

    1. Synchondrosis / Primary Cartilagenous joint – Hyaline cartilage

 

    1. Symphysis / Secondary Cartilagenous joint – Fibrocartilage

 

  1. DIARTHROSIS – Synovial

  • characterized by the presence of a joint cavity covered with an articular capsule; synovial membranes lining the capsule secrete fluid to lubricate the joint

 

  • TYPES

 

    1. Plane – flat for gliding / sliding movements ex. Sternoclavicular and Acromioclavicular joints

 

    1. Ball and Socket / Enarthrosis – Multiaxial joint ex. Shoulder and Hip joints

 

    1. Hinge / Ginglymus – for Flexion and Extension movements ex. Knee, Elbow and Ankle joints

 

    1. Pivot / Trochoid – for Rotation ex. Atlantoaxial joint

 

    1. Condyloid – for Flexion / Extension; Adduction / Abduction ex. Metacarpophalangeal / Knuckle joint

 

    1. Saddle – for Flexion / Extension; Adduction / Abduction ex. Carpometacarpal joint

 

MUSCLES OF THE GLUTEAL REGION

 

 

ACTION

 

NERVE SUPPLY

Gluteus Maximus

Extension of Thigh

 

Inferior Gluteal

Gluteus Medius *

Gluteus Minimus

Abduction of Thigh

Medial Rotation

 

Superior Gluteal

Piriformis

Obturator internus

Sup / Inf Gemellus

Quadratus femoris

Lateral Rotation

 

 

  • Waddling gait – as a result of Superior Gluteal nerve injury; weakened abduction of the thigh by Gluteus medius muscle – (+) Trendelenberg sign

 

 

 

 

 

MUSCLES OF THE THIGH

 

 

ACTION

 

NERVE SUPPLY

ANTERIOR GROUP

Iliopsoas

Tensor Fascia Lata

Sartorius

Quadriceps femoris *

 

Flexion of Thigh

Extension of Leg

Femoral

MEDIAL GROUP

Pectineus *

Adductor Longus

Adductor Brevis

Adductor Magnus *

Gracilis

 

 

Adduction of Thigh

 

Obturator

POSTERIOR GROUP

( Hamstring muscles)

Semitendinosus

Semimembranosus

Biceps femoris

 

 

Flexion of Leg

Extension of Thigh

 

Sciatic

 

  • Quadriceps femoris – Rectus femoris, Vastus lateralis, Vastus intermedius and Vastus medialis

  • Pectineus – Adducts and Flexes Thigh, supplied by Femoral nerve

  • Adductor magnus – 2 parts : Adductor and Hamstring

 

FEMORAL TRIANGLE:

- Boundaries: Superiorly – Inguinal ligament

Medially – Adductor longus

Laterally – Sartorius

Base – Inguinal ligament

Apex – Sartorius and Adductor longus

Floor – Adductor longus, Pectineus, Iliopsoas

Roof – Fascia Lata

 

- Contents: 1. Femoral vein

2. Femoral artery

3. Femoral nerve – L2,L3,L4

4. Femoral sheath

5. Lymph nodes

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MUSCLES OF THE LEG

 

 

ACTION

NERVE SUPPLY

ANTERIOR GROUP

Tibialis anterior *

Extensor hallucis longus

Ext. digitorum longus

Peroneus tertius *

 

 

Dorsiflexion of Foot

 

 

Deep Peroneal *

LATERAL GROUP

Peroneus longus

Peroneus brevis

 

Plantarflexion and

Eversion of Foot

 

 

Superficial Peroneal *

POSTERIOR GROUP

Gastrocnemius

Soleus

Plantaris

Popliteus

Flexor hallucis longus

Flexor digitorum longus

Tibialis posterior *

 

 

Plantarflexion of Foot

 

Tibial *

 

  • SCIATIC NERVE – L4 to S3 ; 2 terminal branches – TIBIAL

COMMON PERONEAL

 

  • FOOT DROP – due to injury to Common Peroneal nerve

 

  • Peroneus muscles ( tertius, longus & brevis ) – Eversion of Foot

 

  • Tibialis anterior and posterior – Inversion of Foot

 

 

 

INTRINSIC MUSCLES OF THE SHOULDER

 

 

ACTION

 

NERVE SUPPLY

Supraspinatus*

Abduction of arm

 

Suprascapular

Infraspinatus*

Lateral rotation of arm

 

Suprascapular

Teres minor*

Lateral rotation of arm

 

Axillary

Subscapularis*

Medial rotation of arm

 

Upper Subscapular

Deltoid

Abduction

 

Axillary

 

  • ROTATOR CUFF MUSCLES – stabilizes the shoulder joint on it’s anterior, posterior and superior parts. WEAKEST on the inferior portion – common dislocation of shoulder joint

 

 

 

 

MUSCLES OF THE ARM

 

 

ACTION

 

NERVE SUPPLY

Biceps Brachii

Flexor of Elbow joint

Supinator of Forearm

 

Musculocutaneous

Coracobrachialis

Flexion and Adduction of arm

 

Musculocutaneous

Brachialis

Main Flexor of Elbow joint

 

Musculocutaneous

Triceps Brachii

Main Extensor of Elbow joint

 

Radial

 

 

MUSCLES OF THE FOREARM

 

 

ACTION

NERVE SUPPLY

 

ANTERIOR GROUP *

Pronator teres

Flexor carpi radialis

Palmaris longus

Flexor carpi ulnaris *

Flexor digitorum superficialis

Flexor digitorum profundus *

Flexor pollicis longus

Pronator quadratus

 

 

FLEXION

 

Median

POSTERIOR GROUP *

Brachioradialis *

Ext. carpi radialis longus

Ext. carpi radialis brevis

Ext. digitorum

Ext. digiti minimi

Ext. carpi ulnaris

Anconeus

Supinator

Abductor pollicis longus

Ext. pollicis brevis

Ext. pollicis longus

Ext. indicis

 

 

EXTENSION

 

 

Radial

 

  • All muscles of Anterior aspect of Forearm supplied by Median nerve EXCEPT Flexor carpi ulnaris and medial half of Flexor digitorum profundus – supplied by Ulnar nerve

 

  • All muscles of Posterior aspect of Forearm are Extensors EXCEPT Brachioradialis which is a Flexor

 

  • LATERAL EPICONDYLITIS / ELBOW TENDONITIS – inflammation of the lateral epicondyle ( common origin of extensor muscles ); repetitive forceful Pronation - Supination of the forearm leads to “TENNIS ELBOW”

 

  • ANATOMICAL SNUFF BOX:

Boundaries – Anteriorly: tendons of APL and EPB

Posteriorly: tendon of EPL

Floor: Scaphoid and Trapezium

BRACHIAL PLEXUS – formed by union of ventral rami of C5 to T1

 

  1. Branches from roots

    1. Dorsal scapular – Rhomboids

    2. Long thoracic – Serratus anterior

 

  1. Branches from upper trunk

    1. Suprascapular – Supraspinatus and Infraspinatus

    2. Nerve to Subclavius

 

  1. Branches from lateral cord

    1. Lateral pectoral – Pectoralis major

    2. Musculocutaneous – Coracobrachialis, Brachialis, Biceps brachii

    3. Lateral half of Median – Flexor muscles of forearm

 

  1. Branches from medial cord

    1. Medial pectoral – Pectoralis minor

    2. Medial brachial cutaneous nerve

    3. Medial antebrachial cutaneous nerve

    4. Ulnar – Intrinsic muscles of hand

    5. Medial half of Median – Flexor muscles of forearm

 

  1. Branches from posterior cord

    1. Upper subscapular – Subscapularis

    2. Thoracodorsal – Latissimus dorsi

    3. Lower subscapular – Teres major

    4. Axillary – Deltoid and Teres minor

    5. Radial – Extensor muscles of upper limb

 

UPPER BRACHIAL PLEXUS INJURY:

 

  • due to excessive separation of neck and shoulder or may result from violent stretching of an infant’s neck during a difficult delivery

  • ERB – DUCHENES PARALYSIS

  • Characteristic position – WAITER”S TIP ; limb hangs by the side in medial position and forearm is pronated

 

LOWER BRACHIAL PLEXUS INJURY:

 

  • due to traction injury as in excessive abduction of arm; ex. Forceful pull of the infants upper limb during delivery

  • ULNAR NERVE INJURY

  • Impairment of wrist flexion and movements of intrinsic muscles of the hand – CLAW HAND DEFORMITY

 

LONG THORACIC NERVE INJURY:

 

  • caused by blows or surgical injury to the nerve in axilla; ex. Weight lifting or carrying a heavy object on the shoulder for a long time

  • paralysis of Serratus anterior muscle

  • medial border and inferior angle of scapula to become unusually prominent – WINGED SCAPULA

 

AXILLARY NERVE INJURY:

 

  • due to inferior dislocation of the shoulder joint or fracture of the surgical neck of the humerus

  • wasting and atrophy of Deltoid muscle; results to weakened abduction of the shoulder

 

RADIAL NERVE INJURY:

 

  • due to fracture of the midshaft of the humerus

  • inability to extend wrist and fingers

  • WRIST – DROP

 

MEDIAN NERVE INJURY:

 

  • due to supracondylar fracture of the humerus

  • compression of median nerve at Carpal tunnel

  • Muscles of the Thenar eminence are paralyzed and wasted; thumb is laterally rotated

  • APE – LIKE HAND

 

ULNAR NERVE INJURY:

 

  • due to fracture of the medial epicondyle of the humerus

  • inability to adduct and abduct the fingers

  • CLAW – HAND

 

LATERAL EPICONDYLITIS / TENNIS ELBOW:

 

  • inflammation of the common extensor tendon – lateral epicondyle

 

MEDIAL EPICONDYLITIS / GOLFER’S ELBOW:

 

  • inflammation of the common flexor tendon – medial epicondyle

 

 

PLEURA: 2 parts:

 

  1. PARIETAL LAYER – lines the thoracic wall

  2. VISCERAL LAYER – covers the outer surfaces of the lungs

 

  • 2 layers are separated from one another by a slit-like space called as Pleural cavity which normally contains a small amount of fluid

 

  • Nerve supply:

 

  • Parietal layer is sensitive to Pain, Temperature, Pressure and Touch

 

    1. Costal part – Intercostal nerve

    2. Mediastinal part – Phrenic nerve

    3. Diaphragmatic part – Phrenic and Lower intercostals nerve

 

  • Visceral layer is sensitive to Stretch; from pulmonary plexus

COSTAL LINE of Pleural reflection passes obliquely across the:

 

  • 8th rib in MCL

  • 10th rib in MAL

  • 12th rib in sides of vertebral column

 

LOWER MARGIN of Lungs cross the:

 

  • 6th rib in MCL

  • 8th rib in MAL

  • 10th rib in sides of vertebral column

 

PLEURISY /PLEURITIS:

  • inflammation of pleura secondary to inflammation of lung ex. Pneumonia

  • results in the pleural surfaces becoming coated with exudates causing the surface to be rough – produces friction – PLEURAL RUB

 

LUNGS:

 

 

RIGHT

 

LEFT

 

Larger,heavier,shorter,wider

Smaller,lightier,longer,narrower

 

Lobes

Superior,Middle & Inferior

 

Superior & Inferior

Fissures

Horizontal and Oblique

Oblique

 

 

 

BRONCHOPULMONARY SEGMENTS:

  • anatomical, functional and surgical unit of lung

  • subdivision of lung lobe

  • pyramidal in shaped; apex directed towards the lung root

  • surrounded by connective tissue

  • supplied by it’s own bronchus, receives an artery, vein, lymph vessels

 

 

RIGHT LUNG

 

LEFT LUNG

Superior lobe

Apical

Posterior

Anterior

 

Apical

Posterior

Anterior

Superior Lingular

Inferior Lingular

 

Middle lobe

Lateral

Medial

 

 

Inferior lobe

Superior / Apical

Anterior Basal

Medial Basal

Lateral Basal

Posterior Basal

 

Superior / Apical

Anterior Basal

Medial Basal

Lateral Basal

Posterior Basal

 

Blood supply of Lungs:

 

  1. Bronchial artery – from descending aorta

  2. Pulmonary artery

 

Venous drainage:

 

  1. Bronchial vein – drains into Azygous and Hemiazygous veins

  2. Pulmonary vein

 

Nerve Supply:

 

  1. From pulmonary plexus which is formed from branches of the sympathetic trunk and receives parasympathetic fibers from Vagus nerve.

 

  1. Sympathetic efferent fibers produce Bronchodilatation and Vasoconstriction

 

  1. Parasympathetic efferent fibers produce Bronchoconstriction and Vasodilatation; and increase glandular secretion.

 

AORTA:

 

  1. Ascending Aorta

  • R / L Coronary

 

  1. Arch of Aorta

  • Brachiocephalic

  • Left CommonCarotid

  • Left Subclavian

 

  1. Descending / Thoracic Aorta

  • Posterior intercostals

  • Subcostal

  • Pericardial

  • Esophageal

  • Bronchial

  • Mediastinal

 

  1. Abdominal Aorta

 

  • Descending / Thoracic Aorta enters the Aortic Hiatus at level T-12 to become Abdominal aorta

 

COMMON CAROTID: Right from Brachiocephalic; Left from Arch of Aorta

 

  1. External Carotid

  • Superior Thyroid

  • Ascending Pharyngeal

  • Lingual

  • Facial

  • Occipital

  • Posterior Auricular

  • Superficial Temporal

  • Maxillary

 

  1. Internal Carotid

  • Opthalmic

  • Posterior communicating

  • Anterior cerebral

  • Middle cerebral

SUBCLAVIAN ARTERY: Right from Brachiocephalic; Left from Arch of Aorta

  • divided into three / 3 parts by Scalenous anterior muscle

 

  • 1. First part – Vertebral

Thyrocervical

Internal thoracic

 

  • 2. Second part – Costocervical trunk

 

  • 3. Third part

 

AXILLARY ARTERY:

  • begins at the lateral border of 1st rib as a continuation of the subclavian artery; and at the lower border of Teres major muscle it becomes the Brachial artery

 

  • divided into three / 3 parts by Pectoralis Minor muscle

 

  • 1. First part – Highest Thoracic

 

  • 2. Second part – Thoraco-acromial

Lateral thoracic

 

  • 3. Third part – Subscapular

Anterior Circumplex humeral

Posterior Circumplex humeral

 

ABDOMINAL AORTA:

  • Branches:

  • 1. Anterior Visceral ( Unpaired) – Celiac

Superior mesenteric

Inferior mesenteric

 

  • 2. Lateral Visceral ( Paired) – Suprarenal

Renal

Testicular / Ovarian

 

  • 3. Lateral Parietal ( Paired) – Inferior Phrenic

Lumbar

 

  • 4. Terminal branches – R / L Common Iliac

Median Sacral

 

INTERNAL JUGULAR VEIN:

 

  • drains blood from brain, face and neck regions

 

  • continuation of Sigmoid sinus

 

  • Receives the – Facial

Pharyngeal

Lingual

Superior Thyroid

Middle Thyroid

 

 

 

BRACHIOCEPHALIC / INNOMINATE VEIN:

 

  • union of Internal jugular and Subclavian veins

 

  • at the level of the inferior border of the 1st Right costal cartilage, the 2 Brachiocephalic veins unite to form the Superior vena cava

 

  • Receives the – Internal thoracic

Vertebral

Inferior thyroid

Superior intercostals

 

SUPERIOR VENA CAVA:

 

  • union of R and L Brachiocephalic veins

 

  • ends at the level of the 3rd costal cartilage to enter the Right Atrium

 

AZYGOUS VEIN:

 

  • connects SVC from IVC

  •  

  • Receives the – Lower intercostals veins

Mediastinal

Esophageal

Bronchial

Hemiazygous

Accessory Hemiazygous

 

  • Azygous, Hemiazygous and Accessory Hemiazygous system offers an alternate means of venous drainage from the thoracic, abdominal and back regions when there is obstruction to IVC

 

 

 

   

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