Transcript apex syndrome

HAD Unit I Review
Tom Eck, [email protected]
CALM Resources
http://njms.umdnj.edu/calm
I will email you the link again tonight.
Today’s review and a number of other
resources should be up by tomorrow
afternoon.
To activate your “clicker”

Press Ch – 52 – Ch
Unit I Priorities
1)
2)
3)
4)
5)
6)
7)
8)
9)
Nervous System Principles
Lymphatics
Lungs
Heart
Mediastinum
Back
Upper Limb
Surface Anatomy
Embryology
Nervous System Principles
the second most important content from Chapter 1
 most important: anatomical terms, but they are rarely
tested directly
 the structure of peripheral nerves as they exit the spinal
cord
 the anatomical and functional distinctions between the
sympathetic and parasympathetic divisions of the
autonomic nervous system
 dermatomes (T4 = nipple; T10 = umbilicus)
 referred pain

To which segments does heart pain refer?
0%
–
T6
–
T3
T1
–
T4
0%
T1
2
0%
T8
0%
5
0%
–C
5.
C3
4.
5
3.
–C
2.
C1 – C5
C3 – C5
T1 – T4
T3 – T8
T6 – T12
C1
1.
10
Seconds
Remaining
Referred Pain

A high-yield topic;
especially important in
Unit III, but don’t
neglect this
Remember: In referred pain, start by identifying the visceral
nerves involved  Sympathetics
From there, identify the spinal segments represented
by the nerve(s)  T1 – T4/T5
The pain will refer to the
corresponding dermatomes.
Which of the following, if cut, would block sensory
perception in the corresponding dermatome?
ventral root
2. dorsal root
3. ventral ramus
4. dorsal ramus
1.
m
ra
sa
l
lr
am
tra
ve
n
do
r
ot
ro
sa
l
0%
us
0%
us
0%
do
r
ve
n
tra
lr
oo
t
0%
10
Seconds
Remaining
Rhizotomy
S – Sensory
A – Afferent
M – Motor
E – Efferent
D – Dorsal
A – Afferent
V – Ventral
E – Efferent
The dorsal root of
spinal nerves can be
cut to relieve
intractable pain
 Alternately, the ventral
root may be cut to
treat spastic paralysis

Lymphatics
Don‘t forget to study lymph!
 You can expect a few lymph questions on every exam
(~2-3), often relating to the spread of cancer
 These tend to be challenging, detail-oriented questions
 Major Topics

◦ Lymph Drainage of the Lung
◦ Lymph Drainage of the Axilla and Breast
Into which vessel does lymph from the right
arm empty?
Thoracic Duct
2. IVC
3. Right Jugular Vein
4. Right Subclavian Vein
1.
0%
n
Ve
i
tS
ub
cla
vi
an
ar
Ri
gh
tJ
ug
ul
Ri
gh
Th
or
ac
:10
0%
Ve
in
IV
C
0%
ic
Du
c
t
0%
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?
1.
2.
3.
4.
Pulmonary  Tracheobronchial  Bronchopulmonary
Paratracheal  Tracheobronchial  Deep Cervical
Tracheobronchial  Paratracheal  Deep Cervical
Pulmonary  Paratracheal  Aortic Arch
:10
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:
hi
a
.. .
0%
on
ob
ro
nc
ar
y(
. ..
0%
ch
e
ra
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rio
In
fe
Le
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pu
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on
a
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a
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o
Br
gh
t
0%
r. .
.
ry
0%
m
tP
ul
on
ar
y
0%
Le
f
5.
Ri
4.
m
3.
10
tP
ul
2.
Right Pulmonary
Left Pulmonary
Right Bronchopulmonary (Hilar)
Left Bronchopulmonary (Hilar)
Inferior Tracheobronchial (Carinal)
Ri
gh
1.
SVC Syndrome


Veins of head and upper extremities
become distended due to
constriction of the SVC by a tumor
or grossly enlarged lymph nodes
The bronchopulmonary nodes
at the right lung hilus are in
close proximity to the SVC
Hilar Nodes
SVC
The Lungs
Differences between Left and Right Lungs
 Lobes, Segments
 Pleura, Reflections, Recesses
 Pneumothorax: in tension pneumothorax, mediastinum
 contralateral side
 Aspirated 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?
6.
0%
0%
0%
0%
0%
0%
rio
r
co
po
st
er
io
r
An
te
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In
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lar
5.
Ap
i
4.
Po
st
e
3.
ca
l
2.
Apical
Posterior
Apicoposterior
Anterior
Superior Lingular
Inferior Lingular
Ap
i
1.
10
Seconds
Remaining
Horner Syndrome
Sympathetic 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?
ia
ed
Co
st
om
ap
hr
ag
0%
sa
c
ial
re
c
es
s
0%
ic a
rd
m
at
ic
st
in
al
re
c
es
s
0%
Pe
r
0%
ot
ch
cn
di
a
s in
us
0%
Ca
r
5.
Co
st
od
i
4.
rs
e
3.
sv
e
2.
Transverse sinus
Cardiac notch
Costodiaphragmatic
recess
Costomediastinal
recess
Pericardial sac
Tr
an
1.
10
Seconds
Remaining
The Heart
pathway of blood – valve pathologies
 coronary vessels – consequences of blockage
 auscultation sites – pathological heart sounds
(continuous machine-like murmer = patent
ductus arteriosus)
 radiographs and CTs especially important

Identify the heart chambers marked B and D:
B
,L
ef
tA
tri
u
t. .
.
Ve
n
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t
Ri
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Ri
tri
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en
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:10
0%
0%
0%
m
c le
,L
Ri
ef
gh
tA
tA
tr
tri
iu
um
m
,L
ef
tV
en
tri
c le
0%
D
tri
4.
Ve
n
3.
gh
t
2.
Right Ventricle, Left Ventricle
Right Atrium, Left Atrium
Right Ventricle, Left Atrium
Right Atrium, Left Ventricle
Ri
1.
CT Scans
Right Ventricle is associated with the anterior
(sternocostal) surface of the heart
 Left Atrium is associated with the posterior
surface of the heart, just anterior to the
esophagus

CT’s and Radiographs show up in the written
exam and the practical
 Be able to identify major structures

Which of the following will result a diastolic
murmur at the apex of the heart?
Note: 2 is also correct
ve
Ao
r
Va
l
ry
m
on
a
0%
0%
0%
In
su
ffi
tic
...
Va
Ao
lve
rti
St
cV
en
al
os
ve
is
In
su
ffi
cie
nc
y
St
e
en
c
lve
Pu
l
itr
al
Va
In
su
ffi
ci
:10
0%
no
sis
y
0%
M
5.
lve
4.
Va
3.
al
2.
Mitral Valve Insufficiency
Mitral Valve Stenosis
Pulmonary Valve Insufficiency
Aortic Valve Stenosis
Aortic Valve Insufficiency
M
itr
1.
Aortic Valve Insufficiency
blood rushes back into the left ventricle as the ventricle
relaxes
 murmur 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 pulse
 causes left ventricular hypertrophy, as the heart
attempts to compensate for decreased pumping
efficiency
 Insufficiency = Backflow of Blood
 a.k.a. incompetence, regurgitation

A patient is diagnosed with left atrial hypertrophy. Which
of the following valve defects is most likely to have caused
this condition?
0%
I..
.
Ao
r
tic
Ao
r
tic
Va
Va
lve
lve
v.
..
Va
l
m
on
a
0%
S.
..
0%
ry
lve
Pu
l
Va
:10
0%
S.
..
0%
al
5.
v.
..
4.
Va
l
3.
M
itr
2.
Tricuspid Valve Insufficiency
Mitral Valve Stenosis
Pulmonary Valve Insufficiency
Aortic Valve Stenosis
Aortic Valve Insufficiency
Tr
ic u
sp
id
1.
Mitral Valve Stenosis


Causes left atrial hypertrophy; the left atrium grows
larger to generate the force necessary to push past the
obstruction
Stenosis is often associated with hypertrophy of the
preceding chamber
Following an acute myocardial infarction, necrosis
develops at the apex of the heart. Which vessel was
likely occluded?
3.
4.
5.
0%
0%
0%
0%
0%
tC
ir c
um
fle
Co
x
An
ro
na
te
ry
rio
s in
rI
nt
us
er
Po
v
en
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er
tr
io
icu
rI
la
nt
r
er
ve
nt
r ic
ul
ar
Ri
gh
tc
or
on
ar
y
2.
Left Circumflex
Coronary sinus
Anterior
Interventricular
Posterior
Interventricular
Right coronary
Le
f
1.
10
Seconds
Remaining
The Anterior Interventricular Artery (LAD) supplies the anterior twothirds of the interventricular septum, the apex, and the anterior left
and right ventricles. It is the most commonly occluded coronary
artery.
The Mediastinum
be able to trace the course of the major
structures that pass through the mediastinum
 localize structures to each mediastinal
compartment

At which level does the trachea bifurcate?
7
0%
T6
/T
0%
6
0%
T5
/T
0%
5
0%
T4
/T
5.
4
4.
T3
/T
3.
3
2.
T2/T3
T3/T4
T4/T5
T5/T6
T6/T7
T2
/T
1.
10
Transverse Thoracic Plane





divides the mediastinum into superior and
inferior compartments
passes through the T4/T5 intervertebral disk
posteriorly and sternal angle anteriorly
bifurcation of the trachea
boundary between cardiopulmonary and
abdominopelvic sympathetics (greater, lesser,
and least splanchnic nerves)
Remember: cardiopulmonary = postsynaptic;
abdominopelvic = presynaptic
You see a patient with a hoarse voice and a detectable
suprasternal pulse. Which of the following diagnoses might
explain these symptoms?
ng
ng
i
Im
pi
or
ss
0%
gA
bs
ce
Lu
n
..
e.
on
An
tic
Ao
r
Tu
m
0%
th
eu
ry
Ao
rta
he
of
t
:10
0%
sm
0%
n
4.
at
io
3.
rc
t
2.
Coarctation of the Aorta
Aortic Aneurysm
Tumor Impinging on the Left
Subclavian Artery
Lung Abscess
Co
a
1.
Aortic Aneurysms



Localized dilation of the aorta
If 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 suprasternally
A 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?
10
Seconds
Remaining
0%
0%
0%
0%
0%
T1
2
5.
T1
1
4.
T1
0
3.
T9
2.
T8
T9
T10
T11
T12
T8
1.
Structures that pass through the Diaphragm
I Ate Ten Eggs AT Noon
 I8
10 E A2T 12
 T8: IVC (“Caval Opening”)
 T10: Esophagus (Vagus too) (“Esophageal Hiatus”)
 T12: Aorta, Azygos Vein, Thoracic Duct (“Aortic
Hiatus”)

In which compartment of the mediastinum
is the IVC located?
r
rio
id
dl
M
0%
Po
st
e
0%
e
0%
r
0%
An
te
rio
4.
r
3.
10
io
2.
Superior
Anterior
Middle
Posterior
Su
pe
r
1.
Mediastinal Compartments
Superior
Thymus, Phrenic Nerve, Vagus Nerve, Esophagus, Trachea,
Thoracic Duct, Azygos Vein, SVC, Aortic Arch,
Brachiocephalic Vein, Left Common Carotid Artery, Left
Subclavian Artery
Anterior
Thymus
Middle
Heart, Phrenic Nerve, Ascending Aorta, SVC, IVC,
Pulmonary Arteries/Veins
Posterior
Descending Aorta, Esophagus (With Vagus Nerve), Thoracic
Duct, Azygos Vein, Splanchnic Nerves
Bolded structures are exclusive to that compartment.
The Back
Morphological distinctions between cervical,
thoracic, lumbar, sacral, and coccygeal vertebrae
 Curvatures
 Spinal Cord Structure
 Vascular Supply: vertebral arteries, segmental
medullary arteries (especially the artery of
Adamkiewicz)

Which of the following prevents
posterior displacement of the dens?
am
en
s
lig
in
sv
er
se
Tr
an
te
b
ra
er
0%
en
t
0%
pr
om
al
m
rc
h
La
t
ra
0%
as
se
s
0%
Ve
r
0%
h
5.
rc
4.
An
te
rio
3.
ra
2.
Posterior arch
Anterior arch
Lateral masses
Vertebra prominens
Transverse ligament
Po
st
er
io
1.
10
In a case of suspected meningitis where should
a lumbar puncture be performed?
0%
0%
0%
0%
0%
L5
/S
1
5.
L4
/L
5
4.
L3
/L
4
3.
L2
/L
3
2.
L1/L2
L2/L3
L3/L4
L4/L5
L5/S1
L1
/L
2
1.
10
Lumbar Puncture
Spinal Cord ends at L1/L2
What landmarks are used to find the
location for a spinal tap?
Anterior superior iliac
spines
2. Posterior superior iliac
spines
3. Iliac crests
4. Spinalis parts of
erector spinae muscles
1.
ct
or
pa
rt
so
fe
re
Ili
a
cc
...
cs
lia
0%
.. .
0%
re
st
s
0%
Sp
i
na
l
is
rs
rio
Po
st
e
An
te
rio
rs
up
er
io
ri
up
er
io
ri
lia
cs
p.
..
0%
10

High points of iliac crest correspond to
L4 spinous process
0%
0%
0%
0%
L5
4.
L4
3.
L3
2.
L2
1.
A patient is suffering from a herniation of the
L4/L5 IV disc. Which nerve root is most likely
compressed?
L2
L3
L4
L5
10
Herniated Discs
In 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 compressed
 For lumbar roots, that means a herniation of IV disc
L2/L3 will compress the L3 root
 The rule applies the same for cervical vertebrae: C5/C6
 C6 root
 For 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 applies

The Upper Limb






questions almost entirely neuromuscular (nerve deficits
are BIG)
BRACHIAL PLEXUS
know 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 muscle
◦ Innervation gives clues about action, vice versa
attachments
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?
ic
0%
Ph
re
n
us
r
0%
Va
g
ho
r
gT
0%
ul
a
ac
ic
0%
Su
bs
ca
p
0%
r
5.
Lo
n
4.
pu
la
3.
Sc
a
2.
Dorsal Scapular
Long Thoracic
Subscapular
Vagus
Phrenic
Do
rs
al
1.
10
Winged 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?
0%
0%
0%
1
0%
C8
,T
0%
C7
,C
8
5.
C5
,C
6
4.
C6
3.
C4
,C
5,
2.
C3, C4
C4, C5, C6
C5, C6
C7, C8
C8, T1
C3
,C
4
1.
10
Erb-Duchenne Palsy

C5, C6 = “waiter’s 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)
Which of the following does not branch off
from or derive from the medial cord?
to
r
lP
ec
0%
Ul
n
ed
ia
M
M
ed
ia
ec
to
ra
0%
ar
lA
nt
eb
ra
ch
ia
l
0%
al
0%
l
0%
n
5.
er
al
P
4.
ed
ia
3.
La
t
2.
Median
Lateral Pectoral
Medial Pectoral
Ulnar
Medial Antebrachial
M
1.
10
Which of the following muscles rotates the
glenoid cavity superiorly?
d
bo
i
Rh
om
or
0%
d
m
aj
or
is
na
l
Sp
i
ez
iu
Tr
ap
0%
m
in
0%
Rh
om
bo
i
0%
s
0%
ae
5.
ap
ul
4.
Sc
3.
at
or
2.
Levator Scapulae
Trapezius
Spinalis
Rhomboid major
Rhomboid minor
Le
v
1.
10
Descending fibers
elevate the scapula
and rotate the
glenoid cavity
superiorly
 CN XI Palsy makes
arm abduction more
difficult

Which of the following does not insert into the
intertubercular groove of the humerus?
0%
or
m
in
re
s
Te
re
sm
ajo
r
m
is
al
Pe
ct
or
0%
aj
or
0%
Te
0%
do
rs
i
4.
im
us
3.
iss
2.
Latissimus dorsi
Pectoralis major
Teres major
Teres minor
La
t
1.
10
Attachments
“lady between two majors”
 teres major, latissimus dorsi, and pectoralis major insert
in the intertubercular groove




attachments are likely to appear in 3 or 4 questions
learn 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 expansion
for most other attachment sites, a more general idea
will suffice (i.e. what bone(s))
After fracture of the clavicle, which muscle is
responsible for the palpable fragment?
Trapezius
2. Sternocleidomastoid
3. Pec Major
4. Pec Minor
1.
M
in
o
Pe
c
Pe
c
M
d
0%
r
0%
ajo
r
0%
om
as
to
i
St
er
no
cle
id
Tr
ap
ez
iu
s
0%
10
Sternocleidomastoid
What nerve may be injured following fracture of the
surgical neck of the humerus?
n
ed
ia
0%
ar
0%
Ul
n
0%
M
0%
l
4.
Ra
di
a
3.
lla
ry
2.
Axillary
Radial
Median
Ulnar
Ax
i
1.
10
What nerve may be injured following fracture of the
medial epicondyle of the humerus?
n
ed
ia
0%
ar
0%
Ul
n
0%
M
0%
l
4.
Ra
di
a
3.
lla
ry
2.
Axillary
Radial
Median
Ulnar
Ax
i
1.
10
What nerve may be injured following fracture of
the radial groove of the humerus?
n
ed
ia
0%
ar
0%
Ul
n
0%
M
0%
l
4.
Ra
di
a
3.
lla
ry
2.
Axillary
Radial
Median
Ulnar
Ax
i
1.
10
Surgical neck – axillary
 Radial groove – radial
 Distal end of humerus – median
 Medial epicondyle - ulnar

A man fractures his humerus at the spiral groove. What
neurological problem is likely to be observed?
0%
Ha
nd
of
Sim
be
n
ia
n
ed
ic t
ha
io
n
nd
0%
ro
p
0%
W
r is
td
0%
nd
4.
ha
3.
w
2.
Claw hand
Simian hand
Hand of benediction
Wrist drop
Cl
a
1.
10
This 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 phalanges

Following 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?
0%
n
tio
Ad
du
c
n
tio
0%
n
0%
Fle
xio
0%
Ab
du
c
4.
n
3.
os
iti
o
2.
Opposition
Abduction
Flexion
Adduction
Op
p
1.
10
Recurrent Branch of Median Nerve
opponens 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
nerve

A complete avulsion of the lateral epicondyle would be least
likely to disrupt the functioning of which muscle?
i
im
git
i
m
lo
is
so
r
di
llic
Ex
te
n
po
so
r
0%
in
ar
is
rp
iu
ln
Ex
te
n
so
r
0%
ng
us
0%
ca
Su
pi
n
at
or
0%
Ex
te
n
ru
m
5.
0%
git
o
4.
di
3.
so
r
2.
Extensor digitorum
Supinator
Extensor carpi
ulnaris
Extensor pollicis
longus
Extensor digiti
minimi
Ex
te
n
1.
10

Extensor pollicis longus does not have its
origination at the lateral epicondyle; all
others listed do
Which of the following resists inferior displacement
of the humeral head in the glenoid cavity?
b.
..
ric
e
ps
ep
sb
of
t
tri
c
ea
d
er
al
h
ed
ia
M
La
t
lh
ea
d
of
0%
...
0%
of
th
e
tri
ce
ps
. ..
0%
d
3.
gh
ea
2.
Long head of the
triceps brachii
Medial head of
triceps brachii
Lateral head of
triceps brachii
Lo
n
1.
10
Long Head of the Triceps
stabilizes the head of the abducted humerus in
the glenohumeral joint, resisting inferior
displacement
 attaches to the infraglenoid tubercle

The nerve that provides sensory innervation to the
posterolateral forearm branches from the…
0%
M
us
cu
l
oc
u
ta
n
eo
. ..
e
0%
ar
ne
rv
ve
er
ln
di
a
Ra
ed
ia
0%
Ul
n
0%
lC
or
d
0%
M
5.
or
d
4.
rc
3.
rio
2.
Posterior cord
Medial Cord
Radial nerve
Ulnar nerve
Musculocutaneous
nerve
Po
st
e
1.
10
The posterior antebrachial cutaneous
nerve arises from the radial nerve
 major nerves of the upper limb often
terminate as cutaneous nerves
 knowing 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.
..
in
aj
or
m
m
te
re
s
te
re
s
o
rt
An
te
rio
An
te
rio
rt
o
o
rt
rio
0%
or
a
..
re
s.
bo
th
te
r
h
Po
st
e
0%
.. .
0%
te
es
m
.. .
0%
bo
t
4.
o
3.
rt
2.
Anterior to both teres
major and teres minor
Posterior to both teres
major and teres minor
Anterior to teres major
and posterior to teres
minor
Anterior to teres minor
and posterior to teres
major
An
te
rio
1.
10
Quadrangular Space
Teres
minor
Teres
major

Teres minor wraps
around the back to the
greater tubercle

Teres major passes
anteriorly to the
intertubercular groove

The long head of the
triceps passes in
between

Know the
quadrangular space

The medial humeral
circumflex artery and
axillary nerve pass
through this window
Humerus
Long
head
Which part of the hand would experience
paresthesia in carpal tunnel syndrome?
0%
fin
ge
r
ge
r
p
of
l
itt
le
ef
in
m
id
dl
of
0%
Ti
re
gio
en
ar
lb
ed
Na
i
Hy
po
th
Do
rs
al
0%
n
0%
su
rf a
ce
0%
en
ce
5.
in
4.
em
3.
ar
2.
Thenar eminence
Dorsal surface
Hypothenar region
Nail bed of middle
finger
Tip of little finger
Th
en
1.
10
The following patient presents with no loss of
consciousness, no visible trauma, and no sensory deficits.
What is the likely problem?
0%
0%
re
n’
sc
on
tr
Du
pu
yt
n’
sc
km
an
Vo
l
on
tra
ac
t
da
m
n.
n
ed
ia
0%
ct
ur
e
ur
e
ag
ag
e
e
0%
M
4.
am
3.
ar
n.
d
2.
Ulnar n. damage
Median n. damage
Volkmann’s
contracture
Dupuytren’s
contracture
Ul
n
1.
10
Dupuytren’s Contracture
Not due to nerve damage because no
associated sensory loss
 In Volkmann’s you would expect to see wrist
involvement as well and would expect a
preceding ischemic event, such as the improper
wrapping of a tourniquet
 In Dupuytren’s, also look for the presence of
subcutaneous nodules

Embryology
don’t neglect; a significant portion of the test
 questions are generally straightforward, focusing on the
precursors of adult structures as well as abnormalities
 heart embryology is especially important for this exam

In which of the following conditions does the body
compensate by opening up a collateral pathway for blood
flow?
0%
en
os
i..
.
of
. ..
St
tic
Ao
r
rc
t
at
io
m
Co
a
or
a
0%
n
en
...
tu
s
Pa
t
en
tD
uc
0%
...
0%
en
tF
F.
..
0%
of
5.
Pa
t
4.
lo
gy
3.
10
tra
2.
Tetralogy of Fallot
Patent Ductus Arteriosus
Patent Foramen Ovale
Coarctation of the Aorta
Aortic Stenosis
Te
1.
Coarctation of the Aorta




Diminished femoral pulses and
rib notching due to increased
blood flow = classic signs of
coarctation
Collateral Circulation: Aorta
 Subclavian  Internal
Thoracic  Anterior
Intercostal  Posterior
Intercostal
Note: 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:
0%
lD
ef
ec
t
os
is
rS
ep
ta
St
en
ul
a
tri
c
Ve
n
St
e
0%
al
no
sis
0%
M
itr
m
on
a
ry
he
Pu
l
di
Ao
r
r. .
.
ng
of
t
rH
yp
e
rri
0%
ta
0%
cu
la
5.
Ov
e
4.
tri
3.
10
tV
en
2.
Right Ventricular
Hypertrophy
Overriding of the Aorta
Pulmonary Stenosis
Mitral Stenosis
Ventricular Septal
Defect
Ri
gh
1.
Boot-Shaped
Heart
Indicates right ventricular hypertrophy seen in Tetralogy of Fallot.
(A similar radiograph is in the lab. Remember to review all of
these.)
Pulmonary Artery Stenosis
Right Ventricular Hypertrophy
Overriding of the Aorta
VEntricular Septal Defect
Which aortic arch gives rise to the stapedial artery?
0%
Six
th
Ar
Ar
c
ch
h
0%
h
Ar
c
h
0%
Fif
t
0%
Ar
ch
ch
0%
Fo
ur
th
0%
Th
ir d
6.
Ar
5.
nd
4.
rc
h
3.
Se
co
2.
First Arch
Second Arch
Third Arch
Fourth Arch
Fifth Arch
Sixth Arch
Fir
st
A
1.
10
Seconds
Remaining
Aortic Arch Derivatives

Remember MSCARD

Maxillary
Stapedial
Common Carotid (External Too)
Arch of Aorta (and Right Subclavian)
Regresses
Ductus Arteriosus (and Pulmonary Arteries)





Which of the following vessels has the
highest oxygen saturation?
0%
er
y
Ar
t
ry
ng
A
on
a
di
er
ie
Co
r
gh
t
Ri
ry
on
a
m
As
ce
n
Ar
t
Ve
i
ry
0%
or
ta
0%
s
ns
0%
Pu
l
4.
on
a
3.
10
m
2.
Pulmonary Veins
Pulmonary Arteries
Ascending Aorta
Right Coronary Artery
Pu
l
1.
An embryo successfully reaches the blastula stage but fails
to implant itself in the endometrium. Which of the
following events may have failed to occur?
0%
0%
rs
0%
ye
m
La
Fe
m
io
n
at
of
M
al
of
ea
Ge
r
nd
th
e
of
an
ce
Fu
sio
n
Fo
rm
av
Z..
.
a.
.
ag
e
0%
Cl
e
4.
ar
3.
10
pp
e
2.
Cleavage
Disappearance of the Zona Pellucida
Fusion of Male and Female Pronuclei
Formation of Germ Layers
Di
sa
1.

The 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?
op
ha
g
ea
lF
gm
ph
ra
Tr
ac
he
o
es
lD
ia
ni
ta
ist
ul
..
Gr
e
th
e
of
Co
ng
e
sp
os
iti
o
0%
a
0%
at
..
0%
n
ry
Hy
po
pl
as
ia
0%
on
a
4.
Tr
an
3.
10
m
2.
Pulmonary Hypoplasia
Transposition of the Great Vessels
Congenital Diaphragmatic Hernia
Tracheoesophageal Fistula
Pu
l
1.
Tracheoesophageal Fistula
In most common form (seen at
left), esophagus ends in blind
pouch
 Trouble with feeding a
prominent symptom at birth

The 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?
0%
m
e
lat
er
al
P
La
t
rm
ed
ia
te
M
M
es
od
er
es
od
er
ho
r
No
to
c
In
te
0%
m
0%
d
0%
er
m
4.
to
d
3.
ro
ec
2.
Neuroectoderm
Notochord
Intermediate Mesoderm
Lateral Plate Mesoderm
Ne
u
1.
10
Nucleus Pulposus is the only remnant of
the notochord in the adult human
 Remember your germ layers

Which of the following is not derived from neural
crest cells?
0%
M
el
a
no
cy
t
ro
ns
ot
or
Ne
u
M
Ga
ng
l
er
ic
En
t
0%
es
0%
ia
0%
gli
a
4.
Ga
n
3.
Ro
ot
2.
Dorsal Root Ganglia
Enteric Ganglia
Motor Neurons
Melanocytes
Do
rs
al
1.
10
Neural Crest Cells
“the fourth germ layer”
 know the derivatives and consequences
of failed migration

Surface Anatomy
Generally 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 underneath
 Don’t forget the posterior thorax

A stab wound through the manubrium damages a
vessel coursing almost horizontally. Which of the
following was most likely lacerated?
Left Brachiocephalic Vein
2. Right Brachiocephalic
Vein
3. SVC
4. Left Common Carotid
1.
ot
id
Ve
ic
Le
f
tC
om
m
on
ph
al
io
ce
ac
h
Br
gh
t
Ri
0%
Ca
r
n
Ve
i
lic
ph
a
ce
hi
o
ra
c
tB
Le
f
:10
0%
SV
C
0%
in
0%
MAL
1st
ICS
Posterior
Segment
of
Superior
2nd
ICS
Posterior
Segment
of
Superior
MCL
PS
Median
PS
MCL
MAL
Anterior Segment
of Superior
Axillary Vessels
Anterior
Segment
of
Superior
SVC
Aortic
Arch,
Left
Brachioc
ephalic
V.
Anterior
Segment
of Superior
Aortic Knob
Anterior
Segment
of Superior
Axillary
Vessels
AP
Segment of
Superior
1st
ICS
Ascending
Aorta
Anterior
Segment
of Superior
Pulmonary
Trunk
Anterior
Segment
of Superior
AP
Segment of
Superior
2nd
ICS
RV
Anterior
Segment
of Superior
Conus
Arteriosus
Superior
Lingular of
Superior
Superior
Lingular of
Superior
3rd
ICS
RV
Inferior
Lingular of
Superior
LV
*Nipple
Superior
Lingular of
Superior
4th
ICS
Anteromedial
Basal of
Inferior
5th
ICS
Anterior Segment
of Superior
PS of S
3rd
ICS
4th
ICS
Lateral
Segment
of Middle
LS of
Middle
Anterior
Basal of
Inferior
5th
ICS
Anterior
Basal of
Inferior
6th
ICS
Anterior
Basal of
Inferior
LS of
Middle
LS of
Middle
MS of
Middle
Anterior
Segment
of
Superior
RA
MS of
Middle
Medial
Segment
of Middle
RA
MS of
Middle
Medial
Segment
of Middle
RA/IVC
*Nipple
LS of
Middle
Anterior
Segment
of
Superior
SVC
RV
RV
DIAPHRAGM
RV
*No pleura
IL of S
LV (apex)
AMB of
Inferior
AMB
of I
LB
of I
6th
ICS
Which heart chamber is at greatest risk
from a thoracic stab wound?
Ri
gh
t
Ve
n
tri
At
r iu
m
Ri
0%
c le
0%
gh
t
tri
c
tV
en
:10
0%
le
0%
Le
f
4.
iu
m
3.
tA
tr
2.
Left Atrium
Left Ventricle
Right Atrium
Right Ventricle
Le
f
1.
MAL
1st
ICS
Posterior
Segment
of
Superior
2nd
ICS
Posterior
Segment
of
Superior
MCL
PS
Median
PS
MCL
MAL
Anterior Segment
of Superior
Axillary Vessels
Anterior
Segment
of
Superior
SVC
Aortic
Arch,
Left
Brachioc
ephalic
V.
Anterior
Segment
of Superior
Aortic Knob
Anterior
Segment
of Superior
Axillary
Vessels
AP
Segment of
Superior
1st
ICS
Ascending
Aorta
Anterior
Segment
of Superior
Pulmonary
Trunk
Anterior
Segment
of Superior
AP
Segment of
Superior
2nd
ICS
RV
Anterior
Segment
of Superior
Conus
Arteriosus
Superior
Lingular of
Superior
Superior
Lingular of
Superior
3rd
ICS
RV
Inferior
Lingular of
Superior
LV
*Nipple
Superior
Lingular of
Superior
4th
ICS
Anteromedial
Basal of
Inferior
5th
ICS
Anterior Segment
of Superior
PS of S
3rd
ICS
4th
ICS
Lateral
Segment
of Middle
LS of
Middle
Anterior
Basal of
Inferior
5th
ICS
Anterior
Basal of
Inferior
6th
ICS
Anterior
Basal of
Inferior
LS of
Middle
LS of
Middle
MS of
Middle
Anterior
Segment
of
Superior
RA
MS of
Middle
Medial
Segment
of Middle
RA
MS of
Middle
Medial
Segment
of Middle
RA/IVC
*Nipple
LS of
Middle
Anterior
Segment
of
Superior
SVC
RV
RV
DIAPHRAGM
RV
*No pleura
IL of S
LV (apex)
AMB of
Inferior
AMB
of I
LB
of I
6th
ICS
Which rib does the horizontal fissure
approximate most closely?
0%
0%
en
th
0%
Se
v
0%
th
0%
Six
5.
h
4.
Fif
t
3.
10
Fo
ur
th
2.
Third
Fourth
Fifth
Sixth
Seventh
Th
ir d
1.
Study Tips
Study the TBL’s! Use them to guide your
review.
 Learn the Blue Boxes, especially the
Chapter 1 ones (summary online)
 Don’t forget lymph and embryo!
 Review as many bodies as possible

Mock Practical





Saturday morning: 10 am – 4 pm
There will be bodies tagged in the lab, as well as
radiographs
Complete on your own, giving yourself a minute
for the A and B questions
Tags will be left on until Saturday afternoon
Answers will be posted in the lab
Good Luck!
[email protected]