MAD Killa

Anatomy: Back

Q: How many spinal nerves are there, and how many vertebra are there?
A: There are 7, 12, 5, 5, 4 vertebra
There are 8, 12, 5, 5, 1 spinal nerves

Q: Curvature of the vertebral column. What are primary and secondary structure. Difference in female
A: Thoracic and Sacral are kyphoses, while cervical and lumbar is lordoses. Primary structure of thoracic and scaral are formed during fetal stage. They are formed because of difference in the height of the bone itself. The secondary structure of lumbar is lordosis. It is formed becasue of height difference in IV disc. Cervical formed when infant holds his head. Lumbar curvature formed when the infant begins to walk . The lumbosacral angle is more and the coccyx protudes less into the the pelvis

Q: Describe the parts of the vertebra
A: Vertebral body: the largest part of the vertebra, shaped like a short cylinder. Supports the spine and entire body.

Pedicle: part of the arch. This short, strong process extends posteriorly from the posterolateral surface of the vertebral body forming the two side of the vertebral foramen. It is paired and connects the body with the transverse process.

Intervertebral notch: notches on the superior and inferior surface of the vertebral pedicle. The superior intervertebral notch of one vertebra combined with the inferior intervertebral notch of the adjacent vertebra forms the intervertebral foramen.

Intervertebral foramen: opening between the pedicles of adjacent vertebra. It is the opening for the passage of the spinal nerves out from the spinal cord.

Lamina: part of the arch. This broad flat plate of bone is located between the transverse process and the spinous process of the vertebra. It is paired. It gives attachment to the ligamenta flava, which span the intervals between the laminae of adjacent vertebrae.

Transverse process: lateral process that extends from the junction of the pedicle and the lamina of the vertebra. It is the site for muscle attachment and rib articulation.

Spinous process: posterior mid-line process arising from the junction of the two laminae of the vertebrae. The spinous processes are important sites of muscle attachment.

Articular processes: processes that project inferiorly and superiorly from the junction of the lamina and pedicle of the vertebra. There are two superior and two inferior processes on each vertebra, and they articulate with adjacent vertebrae through synovial joints. Clinicians refer to these as "facet joints."

Vertebral canal: the opening formed by the combination of the body and the vertebral arch. It contains the spinal cord, meninges, epidural fat, and the internal vertebral plexus of veins.

Anterior longitudinal ligament: ligament that runs from superior to inferior along the anterior surface of the body of the vertebrae. It helps attach the bodies of the vertebrae to each other.

Posterior longitudinal ligament: ligament that goes from superior to inferior along the posterior surfaces of all vertebral bodies, joining them together. It is broader at the discs and narrower at the bodies, giving it a scalloped edge. It is located in the vertebral canal but it is NOT penetrated by the needle during spinal tap.

Ligamenta flava: ligaments formed predominantly by elastic fibers which join the laminae of adjacent vertebrae. These are paired and are penetrated by a needle during a spinal tap. (Latin, flavus = yellow)

Intervertebral disc: fibrocartilaginous disc between adjacent vertebral bodies which are important shock absorbers and give the spine flexibility. The discs are composed of two parts:

Annulus fibrosus: outer fibrous rim. (Latin, annulus = ring)

Nucleus pulposus: pulpy mass located inside the annulus.

Q: Describe those special vertebra
Cervical in general: trianglar. Has transverse foramin on the side with vertebra artery passing through it, but absent in C7. Their spinous process bifurcate. Large vertebral forman for spinal enlargement

Atlas (C1): has no vertebral body, only anterior and posterior arches, and it articulates with the odontoid process of C2. The two holes looks like an eight, one anterior and the other posterior with traverse ligament in between.

Axis (C2): dens (odontoid process) projects superiorly from its body and articulates with the anterior arch of the atlas. There is no rotation of the skull with respect to the atlas, so the first moveable joint in the spinal column is the C1-C2 joint - the "axis" of rotation if you will. There is no IV disc between C1 and C2. Has anterior and posterior tubercle.

Vertebra prominens (C7): also called "spina prominens". Although the two terms are used interchangeably, one is most often referring to the spinous process of C7. It is long and non-bifid, and is palpable through the skin at the nape of the neck. There is no traverse forman for C7.

Thoracic in general: heart shape body, circular vertebral foramen. The length of the traverse process decrease from T1 to T12. Small vertebral foramen. Traverse Tubercle has facets for ribs. Spinous process is long and points downward

Lumbar in general: triangular vertebral foramen, massive vertebra body. Traverse process is long and slender

Sacral: There are only four "sacral foramen" on the side. The fifth is from sacral hiatus on the posterior side. Fused spinous process form the median crest. fused articular process form the intermediate sacral crest. Fused transeverse process form the lateral sacral crest
sacral cornua is forms the edge of the sacral foramen. It is the projection of the inferior articular process.
The flat part is ala. The superior border has superior sacral notch.

Coccyx, distal three vertebrae fuse during middle life to form the coccyx.

Q: Surface anatomy of the back
A: C7 is the first spinous process that can be felt, although T1 may be the most prominent.

The posterior superior illac spines can be palpated on the two side on the waist. At the level, the spinous process is S2

The horizontal line joinging the illac crest is the L4-L5 IV disc

Sacral hiatus at the suoperior part of the intergluteal cleft

Q: Dislocation of the vertebrae
A: Cervial bone could be dislocated, and displaced back to the original place. Although the vertebra may not be seen as dislocated, but damage could be done on the spinal cord.

Dislocation is uncommon in thoracic and lumbar because of the interlocking of the articular surfaces, but fracutre is possible if enough force is applied.

Q: VAN of the vertebra
-> Lumbar Artery -> Spinal Branch (inside IV Foramen) -> anterior and posterior vertebral canal branch
-> Anterior and Posterior Internal Plexus -> Basivertebral veins -> Anterior and Posterior External Vertebral Venous Plexsus
-> anterior ramus -> meningeal branches of spinal nerves -> run back to IV foramen and supply anuli fibrosis ligament ...
Q: Composition of IV Disc
Anulus fibrosus, Outer concentric fibrocartilage with concentric lamellae

Nucleus pulposus, Gelatinous central mass. At first water, then dehydrated, gain collagen, loss its resistance to deformation

epiphsial rim, superior and inferior layer

anterior longitudinal ligament, covering the vertebra

posterior longitudinal ligament, narrower, weaker

Zygapophyseal joint, a vertebral joint between the superior articular process of one vertebra and the inferior articular process of the one adjacent.

interspinous ligament, between the spinous process of adjacent vertebra
supraspinous ligament, continuation of interspinous, still between two process

nuchal ligament, when interspinous ligament extend posterior, they all merge to form a sheet of nuchal ligament
intertranverse ligament, between traverse process

ligamentum flavum surround the posterior arch, joins together become interspinous ligament

Q: IV disc in Cervical Spine
A: There is no IV disc between C1 and C2.
Between C3-C6, not totally covered by IV disc. There is an articular cavity of uncovertebral joint filled with sonovial fluid. This is a frequent site of spur fomration (projecting processes of bone that cause neck pain)
The last disc is between L5 and S1.

Q: Atlanto-occiptial joint, Atlantoaxial joint
A: The anterior and posterior atlantoocciptial membrane join the C1 and cranium together, extending from the anterior and posterior arch. Allow the yes movement.

Atlantoaxial joint: two lateral atlantoaxial joint and one median atlantoaxial joint
lateral atlantoaxial joint is between lateral mass of C1 and superior facet of C2, a gliding type joitn
median atlantoaxial joint between dens of C2 and anterior arch, a pivot joint
The longitudinal bands extends, become the cruciate ligament, and attach to the occipital bone, form a cross with traverse ligament
The alar ligament attach from the dens to the lateral margins of foramen magnum, to prevent excessive rotation
Tectorial membrane extends from C2 to occipital bone covers the traverse ligament posteriorly

Q: Two enlagement of the spinal cord
A: Cervical enlargement from C4 to T1 goes to brachial plexus of nerves for upper limbs
Lumbosacral enlargement contribute to lumbar and sacral plexuses. Those from lumbosacral enlargement and medullary cone form cauda equina (horse tail)

Q: Herniation
A: Herniation of the annulus fibrosus in lumbar region compressing nerve

Q: The coverings and the supporting structures of the spinal cord.
Epidural space, space outside Dura mater

Dura mater: outermost covering membrane forming the spinal dural sac This is tough, pierced by spinal nerves, and anchored inferiorly to coccyx as the filum terminale (externum). It extends through the intervertebral foramina and along the dorsal and ventral nerve roots to a point distal to the spinal ganglia, forming dural root sleeves. The dural sac proper ends at the level of S2, and is anchored inferiorly to the coccyx by the coccygeal ligament, or filum terminale (externum).

Subdural space: nothing much is in between dura mater and arachnoid mater. The arachnoid mater is sticked to the dura mater by CSF pressure

Arachnoid mater: delicate membrane made of fibrous and elastic tissue that lines the dural sac and the dural root sleeves. The arachnoid mater encloses the CSF-filled subarachnoid space containing the spinal cord, spinal nerve roots, and spinal ganglia. It is held against the dura but separable from it. In a lumbar spinal puncture, the arachnoid is pierced. NO subdural space exists between dura and arachnoid, it is only a POTENTIAL space.

Subarachnoid space: contains cerebrospinal fluid. Below L2 it contains the cauda equina.

Pia mater: innermost covering membrane of the spinal cord. The pia mater closely follows entire spinal cord and directly covers the roots of spinal nerves and the spinal blood vessels. Inferior to the conus medullaris, the pia continues as the filum terminale. (Latin, pia mater = delicate mother)

Denticulate ligaments: lateral extension of pia mater. These ligaments form a longitudinal shelf separating dorsal and ventral rootlets. Also, by extending laterally from cord and attaching to the dura by way of 21 pairs of denticulations, they suspend the spinal cord in the subarachnoid space.

Q: Describe the terminalis of the spine
Medullary cone, the conical shape of the spinal cord ending.

Conus medullaris: located at L2. This is the tapered termination of the spinal cord proper.

Filum terminale: continuation of the pia mater inferior to the conus medullaris. It descends all the way, pick up layers of arachnoid, duramatter, pass through sacral hiatus, attached to the coccyx, anchoring the spinal cord.

Cauda equina: the collection of nerve roots coming from the end of the spinal cord, within the lumbar cistern, traveling to the vertebral foramina inferior to the conus medullaris. (Latin, cauda equina = horse's tail)

Lumbar cistern is the subarachnoid space posterior to the medullary cone

Q: VAN for the spinal cord
Artery: The vertebral artery runs in the traverse foramen, the two sides merge to for the anterior and posterior spinal arteries
anterior and posterior segmental medullary artery reinforce circulation to area that is needed, such as enlargement.
posterior and anterior radicular arteries from the lumbar artery supply the roots


Q: Muscle groups of the Back
A: Extrinsic are those that control limb movement, and respiration
Superficial Extrinsic are trapezius, latissimus dorsi, levator scapulae and rhomboids
Intermidiate Extrinsic are thin muscle, serratus posterior

Intrinsic are those that produce movement and posture
intermediate intrinsics external to the line from by traverse and spinous. They are the erector spinae
deep intrinsic are between traverse and spinous process. It is called transversospinal

Q: What is The trapizius innervated by?
A: The Trapezius is innervated by the cranial nerve CN 11

Q: Superficial layer of muscles, its attachment, artery, nerve
Trapezius: innervated by the accessory nerve (CN XI).
Latissimus dorsi: innervated by thoracodorsal nerve, made from branches of ventral primary rami of C7 & C8.
Rhomboideus major & minor: innervated by dorsal scapular nerve, a branch of the VPR of C5.
Levator scapulae: innervated by dorsal scapular nerve and branches of the VPR's of C3 & C4.
Serratus posterior (superior and inferior): innervated by intercostal nerves, first four and last four respectively.

Q: Artery and Nerve supplying the muscle
A: spinal accessory split to thoracodorsal and dorsal scapular

Q: Know this part of the scapula
A: acromion, supraspinous fossa, infraspinous fossa, inferior angle , superior angle, subscapular fossa , infraglenoid tubercle , coracoid process

Q: Know this part of the humerus
A: greater tubercle, deltoid tuberosity
MAD Killa

Medical Grand Round: Obesity

Q: What is Epworth Sleepiness Scale (ESS)?
A: You are given eight situations, such as 'watching TV, talking to someone' and you write down how likely you fall asleep when you are in those situations. The score for each event is in a scale from 0 (no chance of falling asleep) to 3 (high chance falling asleep). Summing them up you get a score. Score of 9 or above means that you need to seek medical advice without delay

Q: What is PSG?
A: Polysomnography or PSG is a test used in the study of sleep performed at night during sleep. It monitors many body functions including brain (EEG), eye movements (EOG), muscle activity or skeletal muscle activation (EMG), heart rhythm (ECG), and breathing function or respiratory effort during sleep.

Q: Narcolepsy
A: Narcolepsy is a neurological condition most characterized by overwhelming excessive daytime sleepiness (EDS), even after adequate nighttime sleep

Cataplexy: sudden episodes of loss of muscle function, ranging from slight weakness to complete body collapse. Episodes may be triggered by sudden emotional reactions such as laughter, anger, surprise, or fear, and may last from a few seconds to several minutes. The person remains conscious throughout the episode.

Sleep paralysis: temporary inability to talk or move when waking up. It may last a few seconds to minutes

Hypnagogic hallucinations: vivid, often frightening, dream-like experiences that occur while dozing, falling asleep and/or while awakening.

Automatic behavior: Automatic behavior occurs when a person continues to function (talking, putting things away, etc.) during sleep episodes, but awakens with no memory of performing such activities. It is estimated that up to 40 percent of people with narcolepsy experience automatic behavior during sleep episodes.

Treatment: stimulants such as amphetamins, methamphetamine !

Q: Central Sleep Apnea
A: Central sleep apnea is when you stop breathing during sleep. It is caused by problems with how the brain controls breathing. Common for people with low brain stem lesion. Caused by
Encephalitis affecting the brainstem
Neurodegenerative illnesses
Stroke affecting the brainstem
Cervical spine surgery
Heart failure
Treatment: Treat the cause

Q: What is CPAP, BIPAP?
A: Continuous positive airway pressure (CPAP) is a method of respiratory ventilation used primarily in the treatment of sleep apnea. In sleep apnea, the patient's airway becomes restricted as their muscles relax naturally during sleep, which causes arousal from sleep. The CPAP machine stops this phenomenon by delivering a constant stream of compressed air via a face mask and hose, splinting the airway (keeping it open under air pressure) so that unobstructed breathing becomes possible, reducing and/or preventing apneas and hypopneas

BIPAP: Unlike continuous positive airway pressure (CPAP), VPAP uses an electronic circuit to monitor the patient's breathing, and provides two different pressures, a higher one during inhalation (IPAP) and a lower pressure during exhalation (EPAP). This system is more expensive, and is sometimes used with patients who have a higher than average CPAP pressure and/or who find breathing out against an increased pressure to be uncomfortable or disruptive to their sleep. It can also have a setting to regularly provide ventilation in patients who are unable to regulate their own breathing well. This is used instead of endotracheal intubation in very selected cases and can be used at home too.

Q: Leptin
A: circulating leptin levels give the brain a reading of energy storage for the purposes of regulating appetite and metabolism. It circulates at levels proportional to body fat.
It enters the central nervous system (CNS) in proportion to its plasma concentration.
Its receptors are found in brain neurons involved in regulating energy intake and expenditure.

Q: Obest Metrics
A: BMI doesn't mean anything. Waist size does. In Hong Kong, BMI > 25, and Waist size > 90cm is consider as obest

Q: What is the fancy name for gall stone?
A: Choleithiasis

Q: Weight loss treatment
A: Losing weight is easy (because of medication), keeping it is hard
1) Lifestyle, 500-600kcal deficit per day is the optimal. Too much hurts the body.
10000 steps perday
2) Drugs
Lipase inhibitor: Orlistat (side effect: loose stool, and nothing else, very safe)
Sibutramine acts on CNS, inhibit monoamines to suppress apetide
Rimonaunt (side effect: depression, )
3) Surgical
a) Intragastric ballon, blow a ballon inside stomach,
b) silicon gastric binding, very very safe surgery, putting a clamp on the esophageal stomach junction
c) laparoscopic sleeve gastrectomy, surgical remove parts of the stomach to make it look like a banana
MAD Killa

Anatomy: Pelvis

Q: What is on top of what, regarding gonad artery, common iliac, ureter, ductus deferens?

Q: Artery (Not in order because of variation, look at direction)
A: Common Iliac
-> Internal Iliac
--> Superior Gluteal, first branch, big vessles towards sacrum [gluteus maximus, gluteus medius, gluteus minimus]
---> Lateral Sacral [piriformis]
---> Illolumbar [iliacus, psoas major, quadratus lumborum]
--> Inferior Gluteal, second branch, big vessle towards the back [levator ani, pififormis, gluteus maximus]
--> Middle Rectal [seminal gland, prostate, rectum]
--> Obturator, towards pubic bone in the beginning, parallel to obturator nerve [head of femur]
--> Umbilical, towards pubic bone [ductus deferens] ---> Vesical [bladder]
--> Uterine -> Vaginal
--> Internal Pudental, also towards the back, but not as 'extreme' as Inferior Gluteal, relatively straight
---> inferior rectal
---> perineal [scrotum, labia majora], it descends to back of scrotum
----> posterior scrotum, bulb of penis
---> deep, dorsal artery of penis
-> External Iliac
--> Femoral
--> Inferior epigastric
--> Deep circumflex
--> External Pudendal
---> anterior scrotum

Q: Nerves
A: Iliolumbar over psoas going to iliac crest, -> abdominal skin
Genitofermoral, pierce through surface of psoas major -> femoral and genital branch
Lateral cutaneous, emerge from UNDER psoas towards ASIS -> skin of thigh surface
Fermoral, big nerve, emerge from under psoas, under inguinal ligament -> flexor, extensor of knee
Lumbosacral (Soma) merge with sciatic nerve
Sciatic nerve (Soma), under all muscle, has lots of branch merge together
Obturator, completely covered by psoas, pretty vertical -> adductor

Aortic plexus (Sym)
Superior hypogastric plexus (Sym)
L/R hypogastric nerve (Sym)
Inferior hypogastric plexus (Mixed)
Prostate Nerve Plexus (Mixed)
Pudental (Soma) branch of sciatic

Q: The folds of the rectum
A: They are the (left) superior tranverse rectal fold, (right) middle tranverse rectal fold, (left) inferior tranverse rectal fold

Q: What maintain continence?
A: External anal sphincter (S4, inferior rectal nerve, somatic)
Internal anal sphincter, contraction stimulated by sympathetic, inhibited by para

Q: Features that distinguish between rectum and sigmond colon
A: Sigmond is entirely peritoneal along its length
rectum is 2/3 retroperitoneal
Sigmond has three teniae coli
rectum has two one anterior and one posterior

Q: Describe the point at which the anal canal begins
A: Where puborectalis muscle wraps around rectum, the rectum change direction from anterior inferior to postieror inferior. This turn is called anorectal flexure.

Q: Describe the transition from mucosal membrane to skin in the anus inside the GI tract. Describe the arterial drainage
A: mucosous membrane, anal valve, pectinate line, transitional white line, skin
Superior to the pectinate line go to superior rectal vein -> SMV
Inferior to the pectinate line goes to the middle and inferior rectal vein -> Caval system

Q: Anal Sinuses
A: when compressed by feces, the anal sinuses secrete mucus that aid evactuation of feces from anal canal

Q: Describe the trigone
A: trigone is a triangle inside the the bladder lining. The three tips of the triangle are the left and right ureteric orifice and the urethra orifice

Q: Parts of Bladder
A: Apex facing pubis, fundas facing rectum/uterus, body of bladder in between, neck is inferior

Q: Muscles of the bladder, they form what sphincter, what happen during ejaculation
A: Wall of bladder made up of detrusor muscle. internal urethral sphincter. It contracts during ejactulation to prevent semen from getting into bladder

Q: Describe the flopping of uterus
A: retrorecession is when the entire uterus is pushed back posteriorly
retroversion is refering to the angle of the vagina to the body of the uterus
Anteflexion is refering to the kinking of the uterus body

Q: Describe the functional significance of the suspesory ligament and the round ligament
A: suspesory ligament: peritoneal folds containing the VANL to the ovary
round ligament: attaches the ovary to the uterus. a remnant of a portion of the gubernaculum.

Q: Board ligament of the uterus
A: Imagine a cross
Looking towards the uterus from the ovary ...
Ovary or ligament of the ovary (connect ovary to the uterus body) on the east,
uterine / fallopian tube on the north,
round ligament (connect uterus to the wall) of the uterus on the west
mesometrium on the south
The ligament connect the ovary to the cross is the mesovarium
The ligament connect the uterine tube to the cross is mesosalpinx

Q: The three parts of the fallopian tube from ovary to uterus
A: infundibulum: the funnel-like terminus, with fringed processes called fimbriae that contact the ovary.
ampulla: the widest and longest part, extending laterally to the infundibulum from the isthmus
isthmus: the constricted part adjacent to the uterus

Q: The four parts of uterus
A: body: includes the fundus and the isthmus
fundus: the medial part superior to the uterine tubes
isthmus: the part just superior to the cervix, part of the body
cervix: protrudes into the upper vagina

Q: Parts of Female external genital
Mons Pubis: fat anterior to pubic symphysis
glans clitoris: expanded distal end of the corpus spongiosum which caps the ends of the corpora cavernosa
clitoris: combination of 3 erectile bodies: glans clitoris and 2 corpora cavernosa clitoris
prepuce: fold of smooth skin extending over the glans clitoris
hymen: thin, usually incomplete septum at the inferior vaginal orifice
labia majora: fat-filled elevations of hair-covered skin lying on either side of the vestibule of the vagina
labia minora: paired folds of hairless skin located medial to the labia majora and extending posteroinferiorly from the clitoris. It forms the prepuce, and the frenulum superior and inferior to the glans
vestibule gland, located on the two side, inferior to the vagina opening. Has opening on the two side, superior to the vagina opening. Used for lubrication.
bulb of vestibule: pair of erectile tissue homologous to bulbospongiosus mluscle

Q: What control contience in female?
A: Urinary flow is controlled voluntarily by the striated urethrovaginal sphincter muscle. This action is assisted by the pubococcygeus portion (levator prostate in the male) of the levator ani.

Q: Describe the relative position of ureter and uterine arteries
A: Yellow water under red bridge.

Q: What is the paraurethral gland?
A: It is the prostate in female, provide fluid in female ejaculation. It opens to the urethra near the external orifice.

Q: What is the vagina fornix? deepest part?
A: Around the protuding cervix is the vaginal fornix. There is a anterior posterior and lateral parts. The posterior vaginal fornix is the deepest part closely related to the rectouterine pouch.

Q: Three layers of uterus
A: perimetrium, consists of periotneum
Myometrium, middle muscular coat of smooth muscle. Blood vessels and nerves are located in this coat
Endometnrium, actively involved in menstrual cycle. Blastocyte is embeded to this layer

Q: How is the cervix fixed by ligaments? covered by? clinical significance of bladder infection
A: traverse cervial ligament from cervix to lateral wall of pelvis
uterosacral ligament from cervix to middle of sacrum
it is not covered by broad ligament, therefore infection from bladder can spread to cervix

Q: What is the word describe all the whole female external genital collectively?
A: Vulva and pudendum

Q: Why is cervix a likely place for cancer?
A: change over epitheleum, from squamous to cuboidal. Also there is Human Papilloma Virus
Q: Describe how the ejaculatory duct meet the urethra
A: Ductus deferens emerges from inguinal canal, runs anteriorly, and superior to the bladder, descends and punture the peritoneum at the potential space between rectum and bladder. This is the ampulla of ductus deferus, and it is also where the seminal vesicle wraps around. As it continues, it becomes the ejacularoy duct. l/r ejacularoy duct and postatic duct (seminal colliculus, the opening of postatic duct), postate urethra merge around the same area inside the postate, quit the postate, merge with bulbourethreal duct (two lateral bulbourethral gland is inferior to the postate) and enter to the bulb of penis.

Q: Again ... layers of testes
A: Two layer of tunica vaginalis (parietal and visceral) forms a cresent moon shape cushion anterior to the testis. That cushion is the cavity of tunica vaginals. Posterior to the testes is the epididymis. The surface of the testes is tunica albuginea.

Q: Erectile bodies of the penis. What are they covered by?
A: The three primary erectile bodies of the penis are the two corpora cavernosa and the corpus spongiosum. These structures are surrounded by a dense tunica albuginia such that, when they are engorged with blood, the penis becomes erect. The glans penis, the expanded cap of the corpus spongiosum, remains more malleable during erection because it has a much thinner tunica albuginea than the rest of the components of the penis. The corpus spongiosum is rooted as the bulb of the penis, which is attached to the perineal membrane
They are covered by ischiocavernosus and bulbospongiosus

Q: Two splits of ischiocavernosus at the posterior lateral ends are called?
A: Crus of penis

Q: What ligament support the penis?
A: the suspensory ligament of the penis connect between the penis to the pubis

Q: Different parts of Male External Genital
A: glans penis: expanded distal end of the corpus spongiosum which caps the ends of the corpora cavernosa
prepuce / foreskin: fold of smooth skin extending over the glans penis
scrotum : the fatty and membranous layers of the superficial fascia (as seen in the lower abdominal wall) are fused to form the scrotum

Q: Nerve for erection and ejaculation
A: Erection depends on stimuli from parasympathetic neurons carried to the inferior hypogastric plexus primarily by the pelvic splanchnic nerves

Ejaculation and subsidence of erection are controlled by sympathetic nerves which enter the inferior hypogastric plexus from the hypogastric nerve

Q: Seminal Gland. Location? What does it secrete?
A: In between bladder and rectum, superior posterior to postate; secrete thick alkaline fluid

Q: Ejaculatory duct
A: After joinging with seminal gland, ductus deferes become ejaculatory duct, ends when it join with urethra

Q: Two parts, three surface of prostate.
A: base is the one closely related to bladder, apex is the inferior part
Anterior surface extends inferiorly to be part of the urethral sphincter
Posterior surface related to rectum
Inferolateral surface

Q: Lobe of Protstate
A: Inferoposterior lobe is posterior to the urethra, inferior to ejaculatory duct, palpable by digital rectal exam
Middle lobe, enlargement may project into internal urethral orifice

Q: How does Prostate duct open to urethra
A: open into prostatisc sinus then into seminal collicullues, the dilation of the urethra where all the ducts meet.

Q: Bulbourethral gland. Location? How does it contribute fluid
A: These small gland inside the urethra sphincter. The duct cross the perineal membrane drains to urethra.

Q: How is the genital divided into left and right
A: Penile raphe, scrotal raphe, and perineal raphe

Q: Three bones of the bony pelvis
A: Ilium is the superior part
pubis is the inferior anterior medial part
ischium is the inferior posterior lateral part.
The obturator foramen is a 'infinite sign'. the superior, anterior portion is the pubis, the inferior anterior portion is the ischium

Q: Describe the following bone structure: acetabulum, ischium ramus, ischial tuberosity, ischial spine, pubic ramus, pubic crest, pubic symphsis
A: acetabulum: the cup shaped depression for the femur, where the three pelvic bone joins together
ischium ramus forms the INFERIOR BONE of obturator foramen
ischial tuberosity is the POSTERIOR EDGE of the obturator foramen. This is where you sit on.
ischial spine is protrusion of the ischium on the posterior side
pubic ramus is the anterior, superior BONE of the foramen
pubic crest is the anterior thickening / TIP of superior pubic ramus
pubic symphysis is right in the middle right where the two sides meet

Q: Two foramen in the pelvis
A: Obturator foramen is formed by the pubis and the ischium.
The sciatic foramen is formed by the bone and the ligament. The bone contribute a roughly U shaped. The rest is 'sealed' with the ligament

Q: Defien inlet, outlet, greater pelvis, lesser pelvis, perineum
A: Inlet draws from sacral promontory and superior border of pubic symphysis
Outlet is from coccyx tip to inferior border of pubic symphysis
Greater pelvis is superior to the pelvic inlet, bounded by peritoenum superiorlly
Lesesr pelvis is between inlet and outlet
Perineum is below the outlet

Q: Two joints, seven ligaments of the pelvis, (2 between the bones, 2 for sciatic notch, 2 for the symphsis, 1 within coccyx) three foramens and their boundary
A: lumborsacral and scrococygeal joints
iliolumbar ligament, sacroiliac ligament;
sacrotuberous ligament (posterior, inferior, connects the sacrum to the the ischial tuberosity), sacrospinous ligament (anterior, superior, sacrum to the ischial spine);
superior pubic ligament, inferior pubic ligament;
sacrococcygeal ligaments
greater sciatic foraman bound by sacrospinal ligament and pelvic brim.
lesser sciatic foramen bound by scarospinal ligament superiorly, and sacrotuberous liagament inferiorly
Obturator foramen inferiorly bound by the ramus

Q: Attachments the obturator internus. what is the tendinous arch of levator ani? What is its other role regarding the obturator foramen?
A: Look at Figure 3.3A. It has attachement in the ischium ramus, and ischium spine, being posterior to both sacro ligaments, it pass through the lesser sciatic foraman anteriorly, then under the inguinal ligament, traverse laterally, then attach to the greater trochanter of femur.

The tendinous arch of levator ani is the thickening part of obturator internus (look at Table 3.3B will make more sense) extends superiorly from ischium ramus to ischium spine under the pubis bone. This is where levator ani originate from.

Obturator internus almost covers the entire obturator foramen leaving a hole, obturator canal for muscle to pass through.

Here is one ugly picture I draw

The red part is the obturator internus. The blue part is the levator ani.

Q: Attachments of the piriformis, function; obturator internus muscle, covers?
A: behind the sacrum reach the anterior via the greater sciatic foramen, cross the ischium anteriorly attached to the greater trochanter of femur
Bunch of nerves and vessels pass through the foraman together with the muscle
Rotate the femur laterally

obturator internus muscle originate from the obturator foramen, extends superior and laterally, pass between the two ligament, attached to the greater trochanter of femur
It covers the entire obturator foramen, with a small hole called obturator canal for VANL to pass through

Piriforms and obturator internus forms a rotated V

Q: Three muscles of levator ani and their Attachments. What about the coccygeus?
A: iliococcygeus, pubococcygeus, and puborectalis, they basically attaches from the tendinous arch to the coccyx. Coccygeus, being the superiormost, attaches from the ischium spine to the coccygeus.

This muscle forms the pelvic diaphragm, forming b bowl shape layer, supporting and acting as a sling for the organs

Q: What is the puborectalis muscle? What is its significance?
A: The puborectalis muscle is the most medial portion of the levator ani muscle. It passes around the terminal rectum to form the puborectal sling, which kinks the anorectal junction forward to assist in maintaining fecal continence. This muscle marks the transition from rectum to anus.

Q: Major arteries of the pelvis
A: iliolumbar, go superiorly to supply psoas, quadratus lumborum, etc
lateral sacral goes posteriorly to sacram
gluteal to gluteal muscle, hip joints
internal prudendal anus, external genital
uterine in female
obturator to thigh
vesical to bladder

Q: Major nerve of the pelvis
A: superior gluteal: gluteal muscle
sciatic: to the leg
pudendal: genital, urethrea sphincter, anal sphincter

Q: Looking from head to toe, we have the pelvic diaphram made up of levator ani, and obturator internus. Describe the fascia and ligaments on top of it
We first have the membranous pelvic fascia
- tendinous arch of pelvic fascia running from top to bottom with pubovesical ligament / puboprostatic ligament connect bladder / prostate to the pubis
On top of membranous pelvic fascia, we have a layer called endopopelvic fasica.
- Loose type, acting as a cushion for organs to expand
-- retropubic space anterior to the bladder, retrorectal space posterior to the rectum
- dense type, hypogastric sheath, providing passage way for VANL to pass through.
-- lateral ligament of bladder, cardinal ligament and lateral rectal ligament.

Q: Where is the perineum? How is it divided? The boundaries of those trigangle
A: Perineum is the area between anus and the inferior border of the genital. It is roughly diamond shaped, therefore, can be divided into two triangle by an imaginary line between ischial tuberosity.
The anterior, or urogenital triangle has as its apex the pubic symphysis, with the ischiopubic rami as equal sides, and our imaginary line as the base.
The posterior, or anal triangle is upside-down, with our line again as the base, the sacrotuberal ligaments as the equal sides, and the coccyx as the apex.

Q: Define the genital hiatus, ischioanal fossa. What does it transmit
A: There are two 'group' basically. One is called urogenital hiatus for the genital and the urethra; Another one is for the anus.
Ishioanal fossa is basically a donut of fat arround the anus bounded by the pelvic diaphram and obtruator internus

Q: Layers of the UG triangle
7) Pelvic Diaphragm / Levator Ani
6) Superior Fascia of UG Diaphragm
5) Deep pouch (pudendal VAN vessels, urethrae sphincter, deep traverse perienal muscle) / UG Diaphragm, completely close, do not communicate with other space
4) Inferior fascia of UG Diaphragm / Perineal Membrane, provide attachment for external genital
3) Superficial Pouch (ischiocavernosus, bulbospongiosus, superficial tranverse perineal, perineal body, perineal VAN) continuos with traversalis of abdominal wall
2) Superficial Perienal Fascia
1) Skin

Q: Muscular structure of the perineum
A: For the anal triangle, you have the levator ani as the base, then you have the exteranl anal sphincter around the anus
For the urogenital triangle, the two triangle is seperated by the transverse perineal muscle. there is an additional membrane called the perineal membrane that cover the levator ani muscle. Around the urogential hiastus, you have the ischiocavernosus, and the bulbospongiosus. The two 'hiatus' is joined by the perineal body. The anus posteriorly with anococcygeal ligament

Q: Describe the structure, contents, and course of the pudendal canal
A: It pass inferiorly right in between the two sacro ligaments via the less sciatic foraman runs along the pubic bone. It contains the internal pudendal artery, internal pudendal vein, and the pudendal nerve.

Q: Branching of Pudental artery
In short, within the canal, anus + labial major. within the triangle, clitoris

Within pudendal canal:
- inferior rectal artery: supply to lower rectum and anus
- perineal artery: supply to bulbospongiosus muscle and ischiocavernosus muscles, as well as posterior scrotal or posterior labial artery to supply the skin of the respective structures

Within urogenital triangle:
- artery of the bulb of the vestibule (in females) or artery of the bulb of the penis (in males): supply to respective structures
- deep (central) artery of clitoris (in females) or deep (central) artery of the penis (in males) - within corpus cavernosum of appropriate structure
- dorsal artery of clitoris (in females) or dorsal artery of penis (in males): runs entire length of appropriate structure, sending branches to corpus cavernosa and terminate in branches to glans and prepuce.

Q: Braching of Pudental Nerve
Within pudendal canal:
- inferior rectal nerves: supply to external sphincter ani muscle and skin of anus
- perineal nerve: gives off posterior labial nerve (in female) or posterior scrotal nerve (in male), which supplies the skin of the perineum - also gives off the deep perineal nerve, which supplies motor innervation to all of the muscles of the urogenital triangle.

Within urogenital triangle:
- dorsal nerve of clitoris (in female) or dorsal nerve of penis (in male): supply to appropriate structure

Q: Homologous structure of the genital
A: corpus spongiosum: vestibular bulbs
prostate gland: urethral and paraurethral glands
scrotum: labia majora

Q: hemorrhoids; Internal and External
A: External dilation of vein below the pectinate line, can felt outside, clot and can be quite painful. Internal are those above the line, not sensitive to pain.

Q: Imperforate Anus
A: a congenital obstruction of the anal opening.

Q: Sigmoidoscopy
A: a procedure in which a scope is used to view the sigmoid flexure

Q: Hypertrophy vs Hyperplasia
A: Hypertrophy is the enlargement of cell. Hyperplasia is the increase in numbers of cell

Q: Benign prostatic hypertrophy
A: A benign enlargement of the prostate gland which begins normally after age 50, probably secondary to the effects of male hormones. If significant enlargement occurs, it may pinch off the urethra making urination difficult or impossible.

Q: Trans-urethral prostatectomy
A: the surgical removal of the prostate gland. Transurethral prostatectomy is performed through the urethral canal of the penis.

Q: Postate Cancer
A: A family history for prostate cancer and perhaps a diet that is high in fat are considered to be risk factors for this malignancy. Early detection is possible through annual digital rectal examinations and routine PSA testing.

Q: Cervical cancer
A: Cancer of the cervix of the uterus. Very highly correlated with HPV infection.

Q: Hysterectomy
A: The operation of excising the uterus, performed either through the abdominal wall or through the vagina.

Q: Oophorectomy
A: Removal of an ovary or ovaries.

Q: STD lead to infertility
A: chlamydia is probably the STD most often associated with infertility.

Gonorrhea is as well. Both can cause scarring and therefore infertility (e.g., ovarian tubes blocked, etc.).

PID (Pelvic Inflammatory Disease) is a description of a disease process in the pelvis (just what is sounds like -- inflammation). It can be caused by Chlamydia as well as other STDs and some unknown anaerobic organisms.

Q: Hysterosalpingography
A: Radiography of the uterus and uterine tubes after the injection of a contrast medium.

Q: Prolapse of Uterus
A: Radiography of the uterus and uterine tubes after the injection of a contrast medium.

Q: Cystocele
A: a condition where the bladder herniates into the vaginal canal and usually results in stress incontinence.

Q: Leiomyomas
A: Benign uterine tumors also referred to as uterine fibroids that can cause pelvic pain and bleeding in some females.

Q: Cystoscopy
A: visual examination of the urinary tract with a cystoscope

Q: Damage to the inferior hypogastric plexus
A: The functions in a male which may be affected include micturition (resulting in urinary retention), erection (erectile impotence), ejaculation (ejaculatory impotence), intestinal motility especially in the rectum (reduced motility or paralysis, causing constipation), and functioning of the internal anal sphincter.

Q: Pudendal nerve block
A: the area anesthetized is the skin of the perineum; this nerve block does not, however, abolish sensation from the anterior part of the perineum, which is innervated by the ilioinguinal nerve and the genitofemoral nerve. It will also not anesthetize the perineal branch of the posterior femoral cutaneous nerve. Also, it does not abolish pain from uterine contractions that ascend to the spinal cord via the sympathetic afferent nerves. In the transvaginal procedure the ischial spine is the landmark used for the insertion of the needle

Q: vasectomy
A: surgical sterilization procedure performed in males where a segment of the ductus deferens is removed

Q: orchiectomy
A: surgical removal of the testes

Q: ischioanal abscess
A: frequent in older people, and are often a result of infections in the anal canal; usually starts as an inflammation of the crypts, which leads to the invasion of normal rectal flora into the ischioanal fossa, and thereby causes an infection

Q: spinal anesthesia
A: an anesthetic agent is injected directly into the subarachnoid space at the L3/L4 vertebral level-anesthetizes essentially everything inferior to the waist; the anesthesia takes effect in about a minute; can result in the patient experiencing a headache due to fluid leaking from the puncture site

Q: epidural anesthesia
A: injection of anesthetic agents into the epidural space as opposed to injection into the subarachnoid space; usually takes 10 to 20 minutes to take effect and has a direct effect on the spinal nerves; often used for operations below the diaphragm and consequently is used in childbirth and cesarean sections. have the advantage of blocking pelvic pain in general while allowing the mother to remain awake without interfering with uterine contractions.

Q: Vaginal speculum
A: A tool used to open up the vagina

Q: How does a female with ovarian cancer feel pain in the mid thigh?
A: Because the ovarian cancer compress the obturator nerve.


Q: Two ligament from the pubis to internal organ
A: pubovesical (bladder) and puboprostatic (prostate) ligaments
Q: Potential space in male and female
A: both have retropubic space, between bladder and pubis
female: rectouterine pouch, supierior to uterus
male: rectovesicla pouch, superior to bladder
MAD Killa

Clinical: ABG

Basic Equation H2O + CO2 = H+ + HCO3-
The lung control pH by removing CO2, duh!
The kidney control pH by removing H (equalibrium to the right, HCO3- increase, ph increase), or by removing HCO3 (equalibrium to the right, H+ increase, ph decrease)
Anion Gap = Na+ - (Cl- + HCO3-)

Step one, determine acidosis or alkalosis
if pH < 7.38, acidosis
if pH > 7.42, alkalosis

Step two, determine if pCO2 or HCO3 is high or low, draw it out
Step three, considering the ph, look at whether pCO2 is HCO3 is causing it, then determine whether it is repiratory or metabolic
eg. ph is acidic, H is increased, pCO2 is increased, HCO3 is increased
HCO3 increased will only make it more alkaline, so it has to be pCO2, so lung deal with CO2, so respiratory acidosis with metabolic (renal) compensation
eg. ph is acidic, H is increased, pCO2 is decreased, HCO3 is decreased
In that case, only decrease of a base HCO3 will lead to acidic ph, so it has to be metabolic acidosis with respiatory compensation
eg. ph is basic, H is decreased, pCO2 decreased, HCO3 is normal
Just simple respiratory alkalosis
eg. ph is basic, H is decreased, pCO2 is increased, HCO3 is increasd
basic because of HCO3, so metabolic alkalosis with respiratory compensation

No sweat! Pretty simple!

Anion Gap (to determine source of metabolic acidosis) positive minus negative.
Anion Gap = Na+ - (Cl- + HCO3-)
If normal, DURHAM, Diarrhea, Ureteral diversion, Renal tubular acidosis, Hyperalimentation, Acetazolamide, Miscellaneous conditions
If it is increased, it can mean MUD PILES, Methanol poisoning, Uremia, Diabetic ketoacidosis, Paraldehyde poisoning, Ischaemia, Lactic acidosis, Ethylene glycol poisoning, Salicylate poisoning
MAD Killa

Histology: Connective Tissue

- Fibrocytes are the most common cell type with a few organelles in connective tissues.
- when stimulated by tissue damaged, the fibrocyte is transformed into a fibroblast, which contains large amounts of the organelles which are necessary for the synthesis and excretion of proteins needed to repair the tissue damage

- a large central lipid droplet, when well fed
- multiple small droplets resembling a fibroblast, if starved
- secrete the protein leptin which provides brain centers which regulate appetite with feedback about the bodies fat reserves. Leptin deficiency is the cause of obesity

- monocyte from bone marrow differetiate into macrophage in the connective tissue
- change their appearance depending on the demand for phagocytotic activity. May resemble a fibrocyte

Mast Cell
- discharge their vesicle when encounter antigen
- histamine and heparin
- stand out as large, dark dots among smaller and lighter stained nuclei

- snuclei stin very dark
- produce antibodies, so very basophilic

- typically rounded or oval, large cells, which contain large amounts of bright red granules in their cytoplasm.

- mesenchymal cells give rise to other cell types of the connective tissue
- regenerate blood vessels or smooth muscle which have been lost as a consequence of tissue damage.

Dense connective tissue
- Irregular not show a clear orientation within the tissue
- regular the fibres run parallel to each other. eg. tendons, ligaments and the fasciae and aponeuroses of muscles

Loose connective tissue
- rich in vessels and nerve
MAD Killa

Histology: Epithelium

Q: How to determine number of cell layers?
A: Oblique intersections are everywhere. A single layer can appears to be many layers if not cut properly, so this cannot be avoided. The number of epithelial cell layers will usually be the smallest number of layers visible anywhere along the surface lined by the epithelium.

Q: Basal membrane
A: basal membrane are protein secreted by both epithelia and connective tissue. Basal lamina are fibers from epithelia, and reticular lamina are those from connective tissue

Things to consider
- Shape of Nucleus, circular? enlogated?
- Variation of Cell
- Keratin?
- How many layers? 1, 2, 2+?
- Celia?

- bind with negative charge
- active synthesis

- smooth ER, protein, cytoplasm

Simple Squamous
- vessel, alveoli, bowman,
- thin layer of squashed nucleus linked by cytoplasm
- rapid PASSive diffusion

Simple Cuboidol
- round nucleus
- duct, for ACTive transport
- ducts of glands, kidney tubules, gallbaldder

Simple Columnar
- long cell with oval shaped, centered nucleus
- ACTIVE absorption
- could be ciliated (used this to rule out cuboidol)
- digestive tract,

Psuedostratified columnar
- respiratory track
- mucos secreting globlet cell
- consistently two layers, one large, one small, but you can spot some cell
that has only one cell
- elongated nucleus
- could be ciliated
- large vacuole like globlet cell can be found on surface

Stratified Cubodoid
- divert liquit out of duct
- no exchange, large duct

Stratified Squamous
- multilayer, Uneven distribution of nuclei with the lumen side having less nuclei
- skin
- keratin?

- even distributed nucleus, with LOTS of layers, can looks cuboidal or squamous
- for stretching , bladder

Celia, Sterocilia, Microvilli
- Celia is the only type that can move, 9+2 microtubules, trachea, uterine tube
- microvilli cannot move, small intestine
- Sterocilia are very long microvill, epididymis
- both microvilli and sterocilia are made of actin. They are virtually the same thing, but sterocilia is a little longer

Serous, Mucous
- Mucous is glycoprotein, meant to be slippery, palely stain
- Serous, is protein, stain blue
- may arranged as mixed, in structure called serous demilune

Secretary Mechanism
- Merocrine, exocytosis, no membrane is lost, no vescile formed outside cell
- apocrine, exocytosis with cytosplasm, cytosplasm, membrane is lost
- holocrine, the entire cell is disintegrated

Mucus acinar vs Serous Acina
- Serous has purple cytosplasm, weakly stain nucleus
- mucus has dark blue nucleus
MAD Killa

Medical Grand Round: 2 Uncommon Convulsive Disorder

Q: Common Site for Fracture
A: lower lumbar, narrow neck of femur bone connecting hip, bone of forearm

Q: Test for Bone Density; How do you interpret the result?
A: Dual Energy Xray Absorptiometry (DEXA), Quantitative CT Scan; T score compare with young adult, -1 is normal; Z score compare with same age. Please note that bone density vary from place to place.

Q: Prednisone
A: synthetic corticosteroid drug uses as immunosuppressant, for autoimmnume disease, prevent rejection of organ. Should not stop immediately, because the body stop synthesizing cortisol, so reducing dose gradually is the best. Stop abruptly could cause Addison Disease

Q: Codeine phosphate
A: Opiate

Q: Tiotropium
A: long-acting anticholinergic bronchodilator for COPD, muscarinic receptor antagonist

Q: Tramadol
A: Atypical Opiate for severe pain

Q: Noepinphrine as Neurotransmitter
A: Attention

Q: Dopamine
A: Used to increase heart rate, and BP. Cannot cross blood brain barrier, so not affect CNS. LDOPA can cross the barrier, precursor of epinephrine; Shortage of Dopamine on basal ganglia can cause jerky movement;; in frontal lobe, dopamine control flow of information from other area. Can cause ADD, negative schizophrenia; Increase dopamine in striatum assocate with pleasure; Cocaine are dopamine uptake inhibitor

Q: Serotonin
A: MDMA causes excessive 5 HT release, precursor of serotonine. Cause well being, comfort. Dangerously high level will cause serotonin syndrome. SSRI, MAOI increase serotonin to treat depression

A: cause hyperpolarization, GABA agonist can be used for anti-anxiety and anti-convulsive

Q: Famotidine
A: H2 receptor antagonist, inhibit stomach acid for peptic ulcer

A: EEG picks up the activity of large groups of neurons.
Delta has the lowest frequency, very young
theta, hyperventilation, deep day dream, light sleep
alpha, drowsiness,
beta, benzodiazapens, busy thinking
gamma, problem solving, preception, fear

Abnormalties usually found during sleep.

Normal: mostly alpha, beta, two side show similar pattern, no abnormal bursts, no sudden slowing have brief response after each flash

Abnormal: Burst, sudden slowing, may indicate stroke, epilepsy, infection, tumor.
Assymetry, indicate some problem in specific area
Excess delta wave, or excess theta in awake patient
no activity: brain dead, high dose sedation

Q: Myoclonus
A: involuntary twitchin of muscle
hiccups are myoclonus of diaphragm
Sleep start, myoclonux when falling asleep

Q: Mydriasis
A: excessive dilation of pupil due to disease

Q: Opisthotonos
extreme hyperextensio nof muscle, so arching position of spinal cord
another words for extension posturing

Q: Serotonin Syndrome
A: basically overdose of serotonin
after durgs like SSRI, MDMA, MAOI, TCA, especially when used together
symptoms are hyperreflex, increase bile sound, clonus, autonomic instabililty (hypertension, hypotension), agitation, tachycardia
Treatment: take the medication off
MAD Killa

Medical Grand Round: Infectious Disease Emergency

Q: S/S of myelodysplastic syndromes, cause, risk group, treatment
A: neutropenia, anemia and thrombocytopenia, mutation of bone marrow cell; chemotherapy, people exposed to gasoline, benzene; bone marrow transplant

Q: Erythema, definition, cause
A: abnormal redness of the skin caused by capillary congestion, sign of inflmmation, red dilated capillaries; infection, massage, electrical treatments, allergies, exercise or solar radiation

Q: Lymphangitis, definition
A: inflammation of the lymphatic channels that occurs as a result of infection at a site distal to the channel.

Q: Thrombophlebitis, definition, S/S, treatment, risk factor
A: phlebitis (vein inflammation) related to a blood clot or thrombus; tenderness over the vein, skin redness or inflammation; anticogulant, throbolytic, pain medication, antibotics, routine RICE to reduce inflamation; IV lines

Q: Erysipelas, definition, S/S, Treatment
A: acute streptococcus bacterial skin infection, resulting in inflammation and characteristically extending into underlying fat tissue; high fevers, shaking chills, fatigue, headaches, vomiting, and general illness within 48 hours of the initial infection. Signature symptom: raised advancing edges ; penicillins or erythromycin

Q: Celluitis, definition, S/S
A: an bacterial inflammation of the connective tissue underlying the skin; redness, swelling, warmth, and pain or tenderness

Q: Cellulite, definition
A: dimpling of skin commonly found in woman face, caused by the protrusion of subcutaneous fat into the dermis creating an undulating dermal-subcutaneous fat junction adipose tissue

Q: Necrotizing fasciitis, definition. S/S
A: "flesh-eating bacteria", is a rare infection of the deeper layers of skin and subcutaneous tissues (fascia); tissues become red, hot and swollen, often within hours. Skin color may progress to violet and blisters may form, with subsequent necrosis (death) of subcutaneous tissues. Patients with necrotizing fasciitis typically have a fever and appear very ill. More severe cases progress within hours, and the death rate is high, about 25%.

Q: Vibrio vulnificus. Gram What? Source? Treatment? Risk Factor
A: Gram Negative; could get it from swimming; doxycycline or cephalosporins; Common For Male. Estrogen somehow has protective effect

Q: Streptococcus. Gram what? S/S. Treatment
A: gram positive; shock, multisystem organ failure, and death, tonsilitis, pneumonia, arithitis, peritonitis, meningitis, necrotizing fasciitis; penicillin, erythromycin and clindamycin.

Q: Myositis. Test
A: a general term for inflammation of the muscles. likely to be caused by autoimmune conditions, rather than directly due to infection; Elevation of creatine kinase in blood is indicative of myositis.

Q: Gastroenteritis. Definition. Treatment
A: Gastroenteritis involves diarrhea or vomiting, with noninflammatory infection; fluoroquinolone.

Q: Ecchymosis. Definition; Color Change
A: a bruise or contusion or ecchymosis is a kind of injury, usually caused by blunt impact, in which the capillaries are damaged, allowing blood to seep into the surrounding tissue; Red -> Purple/Black -> Yellow

Q: Hematoma. Definition,
A: Collection of Blood, internal bleeding;

Q: Bilrubin Cycle; Color
A: RBC decompose to CO2, iron and bilverdin. Bilverdin -> Bilrubin; bound to albumin to liver; made soluble by glucuronic acid -> bilirubinglucuronide, goes to bile. Half to bilirubinglucuronide convert to urobilinogen and absorbed. Some urobilinogen is excreted in peep as urobilin

Q: Explain HyperBilirublin of Neonates. Consequences
A: They lack the bacteria to break down bilirubin intestine, so a lot of them are absorbed. That explain Jaundice and pale shit; Kernicterus, damage to the brain centers of infants caused by jaundice.

Q: HyperBilrubinmia
A: PreHepatic, hemolysis, increased unconjugated bilirubin
Hepatic, acute hepatitis, hepatotoxicity and alcoholic liver disease, whereby cell necrosis reduces the liver's ability to metabolise
PostHepatic, pale stools and dark urine, cholestasis, is caused by an interruption to the drainage of bile in the biliary system. The most common causes are gallstones in the common bile duct

Q: Indirect and Direct Bilrubin
A: unconjugated bilirubin = indirect bilirubin = insoluble bilirubin. bilirubin = direct bilirubin

Q: Albumin, Decrease means
A: Albumin levels are decreased in chronic liver disease, such as cirrhosis.

Q: ALT, Incrase means
A: When a cell is damaged, it leaks this enzyme into the blood, where it is measured. ALT rises dramatically in acute liver damage, such as viral hepatitis or paracetamol (acetaminophen) overdose.

Q: AST, Ratio means
A: Not too specific. ALT>AST: acute viral hepatitis or drug-induced hepatitis; ALT
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Q: S/S of myelodysplastic syndromes, cause, risk group, treatment
A: neutropenia, anemia and thrombocytopenia, mutation of bone marrow cell; chemotherapy, people exposed to gasoline, benzene; bone marrow transplant

Q: Erythema, definition, cause
A: abnormal redness of the skin caused by capillary congestion, sign of inflmmation, red dilated capillaries; infection, massage, electrical treatments, allergies, exercise or solar radiation

Q: Lymphangitis, definition
A: inflammation of the lymphatic channels that occurs as a result of infection at a site distal to the channel.

Q: Thrombophlebitis, definition, S/S, treatment, risk factor
A: phlebitis (vein inflammation) related to a blood clot or thrombus; tenderness over the vein, skin redness or inflammation; anticogulant, throbolytic, pain medication, antibotics, routine RICE to reduce inflamation; IV lines

Q: Erysipelas, definition, S/S, Treatment
A: acute streptococcus bacterial skin infection, resulting in inflammation and characteristically extending into underlying fat tissue; high fevers, shaking chills, fatigue, headaches, vomiting, and general illness within 48 hours of the initial infection. Signature symptom: raised advancing edges ; penicillins or erythromycin

Q: Celluitis, definition, S/S
A: an bacterial inflammation of the connective tissue underlying the skin; redness, swelling, warmth, and pain or tenderness

Q: Cellulite, definition
A: dimpling of skin commonly found in woman face, caused by the protrusion of subcutaneous fat into the dermis creating an undulating dermal-subcutaneous fat junction adipose tissue

Q: Necrotizing fasciitis, definition. S/S
A: "flesh-eating bacteria", is a rare infection of the deeper layers of skin and subcutaneous tissues (fascia); tissues become red, hot and swollen, often within hours. Skin color may progress to violet and blisters may form, with subsequent necrosis (death) of subcutaneous tissues. Patients with necrotizing fasciitis typically have a fever and appear very ill. More severe cases progress within hours, and the death rate is high, about 25%.

Q: Vibrio vulnificus. Gram What? Source? Treatment? Risk Factor
A: Gram Negative; could get it from swimming; doxycycline or cephalosporins; Common For Male. Estrogen somehow has protective effect

Q: Streptococcus. Gram what? S/S. Treatment
A: gram positive; shock, multisystem organ failure, and death, tonsilitis, pneumonia, arithitis, peritonitis, meningitis, necrotizing fasciitis; penicillin, erythromycin and clindamycin.

Q: Myositis. Test
A: a general term for inflammation of the muscles. likely to be caused by autoimmune conditions, rather than directly due to infection; Elevation of creatine kinase in blood is indicative of myositis.

Q: Gastroenteritis. Definition. Treatment
A: Gastroenteritis involves diarrhea or vomiting, with noninflammatory infection; fluoroquinolone.

Q: Ecchymosis. Definition; Color Change
A: a bruise or contusion or ecchymosis is a kind of injury, usually caused by blunt impact, in which the capillaries are damaged, allowing blood to seep into the surrounding tissue; Red -> Purple/Black -> Yellow

Q: Hematoma. Definition,
A: Collection of Blood, internal bleeding;

Q: Bilrubin Cycle; Color
A: RBC decompose to CO2, iron and bilverdin. Bilverdin -> Bilrubin; bound to albumin to liver; made soluble by glucuronic acid -> bilirubinglucuronide, goes to bile. Half to bilirubinglucuronide convert to urobilinogen and absorbed. Some urobilinogen is excreted in peep as urobilin

Q: Explain HyperBilirublin of Neonates. Consequences
A: They lack the bacteria to break down bilirubin intestine, so a lot of them are absorbed. That explain Jaundice and pale shit; Kernicterus, damage to the brain centers of infants caused by jaundice.

Q: HyperBilrubinmia
A: PreHepatic, hemolysis, increased unconjugated bilirubin
Hepatic, acute hepatitis, hepatotoxicity and alcoholic liver disease, whereby cell necrosis reduces the liver's ability to metabolise
PostHepatic, pale stools and dark urine, cholestasis, is caused by an interruption to the drainage of bile in the biliary system. The most common causes are gallstones in the common bile duct

Q: Indirect and Direct Bilrubin
A: unconjugated bilirubin = indirect bilirubin = insoluble bilirubin. bilirubin = direct bilirubin

Q: Albumin, Decrease means
A: Albumin levels are decreased in chronic liver disease, such as cirrhosis.

Q: ALT, Incrase means
A: When a cell is damaged, it leaks this enzyme into the blood, where it is measured. ALT rises dramatically in acute liver damage, such as viral hepatitis or paracetamol (acetaminophen) overdose.

Q: AST, Ratio means
A: Not too specific. ALT>AST: acute viral hepatitis or drug-induced hepatitis; ALT<AST: alcoholic cirrhosis

Q: ALP, Increase Means
A: ALP levels in plasma will rise with large bile duct obstruction

Q: ALP, what is, present in
A: hydrolase enzyme responsible for removing phosphate from nucleotide, protein, present in liver, bile duct, kidney, bone, and the placenta

Q: CPK. Elevation means
A: Creatine kinase, Elevation of CK is an indication of damage to muscle

Q: Debridement
A: removal of dead, damaged, or infected tissue to improve the healing potential of the remaining healthy tissue. Often Surgical

Q: Maggot therapy,
A: Debridement. Maggots only eat necrotic tissue.

A: for autoimmune disease, suppresses harmful inflammation, bind with abnormal antibody, and get rid of them

A: Endoscopic retrograde cholangiopancreatography (ERCP) is a technique that combines the use of endoscopy and fluoroscopy to diagnose and treat certain problems of the biliary or pancreatic ductal systems. For Obstructive jaundice, gallstone

Q: Cushing's syndrome
A: endocrine disorder caused by excessive levels of the endogenous corticosteroid hormone cortisol, rapid weight gain, growth of fat pads along the collar bone and on the back of the neck (known as a buffalo hump)

Q: Klebsiella pneumoniae. Gram what; Common Infection; Treatment
A: Gram Negative. Rank Second after E Coli for UTI; chronic pulmonary disease, enteric pathogenicity, nasal mucosa atrophy, nosocomial infection, increase resistance; aminoglycosides and cephalosporins

Q: Rales, Also called? When? What Disease? Cause
A: Crackles, during inhation, pneumonia, atelectasis, acute bronchitis, Pulmonary edema; popping sounds produced are created when air is forced through respiratory passages that are narrowed by fluid, mucus, or pus

Q: Ronchi, sound like? what disease.
A: long, low frequency, like someone farting. indicate congestion and mucus in the larger bronchial tubes, indicate inflammation of the bronchial tubes, expire ronchi -> obstruction of airway, thus are found mainly in bronchitis

Q: Activated Protein C
A: an antithrombotic effect by inhibiting factors Va and VIIIa. For Sepsis?

Q: Mycoplasma pneumoniae, treatment
A: live inside cell, lack a peptidoglycan cell wall, so antibodies that attack cell wall will not work, upper and lower respiratory tract, causing pharyngitis, bronchitis and pneumonia, use Second generation macrolide antibiotics and second generation quinolones

Q: Chlamydia trachomatis, treatment
A: Chlamydia trachomatis, live inside cell, major infectious cause of human eye and genital disease, STD, use clindamycin

Q: Chlamydia pneumoniae, life cycle, also called, treatment
A: Phagocyte, but not destoryed by lysosome, replicate inside, walking pneumonia, use macrolides!

Q: Aminoglycoside
A: For Gram Negative (Pseudomonas, Enterobacter) and mycobacteria. Mainly For serious infections such as septicemia, complicated intraabdominal infections, complicated urinary tract infections. Famous for its toxicty ototoxicity and nephrotoxicity. ANA-GSK: Aminoglycoside, Neomycin, Amikacin, Getamycin, Stetomycin, Kenamycin

Q: Macrolides
A: MACE, Macrolides, Azithomycin, Clarithomycin, Erythomycin, attack ribosome
MAD Killa


Q: What are the common Fatty Acid?
A: Palmitic C14
Stearic C16
Palmitolecic C16:1:9
Oleic C18:1:9

Q: Two common glycerophospholipid backbone
A: Glycerol, sphingosine

Q: What is Ceramides?
A: Sphinosine + Fatty Acid

Q: What is the membranous myelin sheath which surrounds nerve cell axons? What is it made of?
A: Sphingomyelin, a ceramide with a phosphocholine

Q: Cerebrosides? Ganglioside? Function? What is it made of?
A: A cerebroside is a sphingolipid (ceramide) with a monosaccharide such as glucose or galactose as polar head group.
A ganglioside is a ceramide with a polar head group that is a complex oligosaccharide, including the acidic sugar derivative sialic acid. See p. 388.
Cerebrosides and gangliosides, which are collectively called glycosphingolipids, are commonly found in the outer leaflet of the plasma membrane bilayer, with their sugar chains extending out from the cell surface.

Q: How does disinfectant work? Alchohol? Chlorine? Iodine?
A: Alchohol act by "denaturing" or altering the molecular structure of bacterial proteins, destroying the cell. Alcohols kill vegetative forms of bacteria but have no action on spores or viruses.
Chlorine and hypochlorites are bactericidal and act by oxidizing the cell membrane.
Iodine combines with cell protein and is an active germicidal agent with a moderate activity against spores. It is effective against the tubercle bacillus and many other viruses.

Q: Surface Antigen of RBC. What are they made of?
A: Ceramide + Sugars. O type doesn't have the galactose at the end

Q: Three possible way for protein to sticks with or stay in membrane
A: Lipoprotein, integral protein, and protein - integral protein

Q: How do Snake venom kill people?
A: It contains phospolipase that remove fatty acid from phosphtidylcholine on RBC, causing hemolysis

Q: HIV bind with what receptor on what cell?
A: gp120, CD4, CCR5 of Thelper cell

Q: Structure of Sodium Voltage Channel
A: 4 transmembrane domain as voltage sensor. Each domain has 6 alpha helix.
Potassium of 6 alpha helix, and that's it.

Q: Pufferfish toxin are called? What does it do?
A: Tetrodotoxine, block voltage gated sodium channel

Q: Red Tide toxin? What is it called? What does it do?
A: Saxitoxin, block voltage gated sodium channel

Q: Toxin from posionous fish of deep sea... What is it called? What does it do? What are the symptoms?
A: Ciguatera open ions channels, cause vomiting, diarrhea, reveral of hot and cold sensation

Q: General term for channel for facilated diffusion
A: Permease

Q: Four types of Active Transporter. Describe each of them
A: P type has phosphorylation and vanadate (a powerful inhibitor that cleaves phosophoester) inhibition,
2 alpha, 2 beta
alpha has 12 TMD and phosphorylation site
beta has one TMB and obligosaccharide

V type stands for vacuole, for acidation in lysosome

F type, F1 generate ATP, F0 generate is H channel

ABC, ATP binding Cassette for active transport of hydrophobic chemical and Chloride Ion

Q: Copper Storage Disease. What is it called? Cause? Treatment?
A: Wilsons: A Gene code for Ptype ATPase that excrete copper from liver as in ceruloplasmin, an plasma enzyme with Copper in it. Its job is to Change Fe 2+ to Fe 3+, which can be transported in blood. Mutation caused piled up of copper. cirrhosis is the commonest hepatic presentation. dementia, mood disorders or psychosis. parkinsons. Treatment is use penicilamine to remove excessive copper. Should also supply zine because it also remove zinc.

Q: What is ATP7A?
A: Exist in Golgi, supply copper to certain enzyme, absorption of copper from food in intestine. So lead to Menkes disease, definiceny in copper, sparse and coarse hair, growth failure, and deterioration of the nervous system, seizure. Treatment: give copper

Q: What is CFTR?
A: It is a ABC Chloride Transporter. It transport Chloride ion. Water follow to make mucus more fluid. Mutation can mucus obstruction of gase exchange, fibrosis ...

Q: Multiple Resistance in Cancer?
A: P glycoprotein actively remove hydrophobic protein non specifically.

Q: Describe how glucose is taken into capillaries from intestine lumen
A: NaK ATPase pump Na to capillaries, so Na concentration is low. Glucose is pumped in cell together with Na. Glucose diffuse to capillaries with facilated transport.
MAD Killa


gastroduodenal lies posterior to the first part of duodenum, split to superior pancreadodudenal and right gastroomental

ureter get its artery from renal, testicular and vesical

suprarenal get artery from aorta, inferior phrenic, and renal artery

superior epigastric artery is posterior to the retus abdominius muscle

inferior mesenteric vein came from splenic vein

renal vein is in front of renal artery in kidney hilium

intestinal right, left lumbar trunks drains into cisterna chyli

testes, kidney, ureter, suprarenal drains into lateral aortic nodes

cistern chyli is at the level of L1

Epidymides lies posterior to the testis

inferior epigastric, a branch of external iliac cross over inguinal canal

Spermatic cord contains testicular artery, genital branch of genitofermoral nerve for cremasteric reflex
Illiinguinal nerve fro root of penis, scrotum in male

The sigmond colon begin at the level of pelvic brim

SMA is in front of the third section duodenum

First 2/3 Tranverse Colon belongs to midgut

The appendix after childhood can reach the pelvic cavity

transplyoric plane is on first lumbar where the pyloric sphincter is

fundus of gallbladder is on the right ninth costal cartilage. It is the only part surrounded by peritoneum. (the body and neck is not)

Scarpa fasica continous with colles fascia in the perineum

The abdominal wall is inervated by SIX thoracic nerve and L1

Middle and inferior rectal artery is from systemic vein

indirect hernia goes through deep ring, descend lateral to inferior epigastric; direct descends medially to inferior epigastric

The foregut ends at the second duodenum


Q: Describe the layers from outside to inside cutting the rectus abdominus
A: skin, fat layer (camper fasica), anterior layer of rectus sheath, rectus abdominuis, posterior layer of rectus sheath, parietal peritoneum.

Q: Positions facts: Asymetric of renal and portal vein, cisterna chyli level, where do arota split, what structure do inferior epigastric pass through
A: Left Suprarenal and Left Goand Vein comes from left renal vein
IMV comes from splenic vein, instead of from portal vein
cisterna chyli on the first two lumbar
aorta split to common illac at L4
Inferior eipigastric pass anteriorly the inguinal artery

Q: Describe the inguinal canal
Lets get the record straight. lets define what we mean by roof, ceiling, floor ...
floor = inferior wall from ASIS to umbilicus.
Anterior wall = surface
Conjoint tendon is merging of internal oblique aponeurosis and traversalis

Conjoint tendon archs medially from superficial / anterior to deep / posterior.
That's why we say the roof is the conjoint tendon especially in the middle
The floor is Inguinal Ligament
For the anterior wall, covered by external obblique. As we go laterally, it is covered by conjoint tendon
For the posterior wall, we have transallis fasica, As we go medially it is covered by conjoint tendon.

If you want to refine further, those two muscles dont joint together until they reach the posterior side of the canal.
The root, since they didn't joint together yet, so they are internal oblique and tranversalis muscle
The floor is still injuinal ligament. There is also a luncanar ligament which is a splitting of inguinal ligament as it goes laterally from pubic tubercle.
anterior wall, is by external oblique. As we go laterally, it is covered by internal oblique. and then by Tranversalis muscle as it goes laterally. Some people say anterior wall is just external oblique and internal oblique, because tranversalis is too far away
posterior wall, they are now joined togehter, so conjoint tendon and transallis fascia

In conclusion
roof: 2 muscle: internal abdominal oblique and transversus abdominis muscles.
floor: 2 ligament: inguinal ligament, lacunar ligament
anterior wall: 2 muscle: extenal and internal oblique
Posterior wall: 2 muscle: traversalis and conjoint tendon

Q: Define the following term: tunica vaginalis, gubernaculum testis, tunica albuginea, pampiniform plexus, synificance of asymetry of testicular vein.
A: tunica vaginalis is the sealed sac formed by the peritoneum
gubernaculum is a cord / ligament that connect fetal testis to the scrotum
tunica albuginear outer tissue of the testis covering those epididymis
paimpiniform plexus is just the venous network of testes.
The right vein drains to low pressure IVC, while the left drains to high pressure renal vein. so left side may tend to bulg.

Q: N of peritoneum, N and pain in visceral peritoneum
A: lower six thoracic and first lumbar somatic nerve, can sense pain, temp, pressure, touch, so it hurts! visceral supplied by autonomic nerve of that viscera, can sense stretch, poorly localised dull pain in the visceral peritoneum


Q: Two orifice, Two curvature, Four parts of stomach
A: cardiac and pyloric orifice, greater and lesser curvatre, fundas, body, pyloric antrum, pylorus

Q: VANL of stomach
A: Artery: right and left gastric arteries supply lesser curvature, right and left gastroomental for greater, short for fundas
Vein: Same thing
Lymph: to celiac nodes
Nerve: symp: celiac plexus, para: vagus nerve

Q: 4 parts of duodenum
A: first part, outside, not retroperitoneal, 1st lumbar level
second part, has major and minor duoduenal pailla
third part runs horizontally
fourth part, upside down U called duodenojenunal flexure held by ligament of treitz to right curx of diaphgram

Q: VANL of duodenum
A: Artery: superior pancreaticoduoduenal artery for upper part, inferior for lower part
Vein: same
Lymph: celiac node for upper part, SM nodes for lower part
Nerve: Symp and Para by celiac and SM plexses


Q: VAVN of jejunum and ileum
A: Artery, Vein: SMA and SMV
Lymph: SM node via intermediate mesenteric nodes
Nerve: Superior mesenteric plexus

Q: VANL of Cecum
A: Artery, Vein: ileocolic artery
Nerve: Sympathetic and vagus nerve via SM plexus
Lymph drains to SM nodes

Q: Two stimualation of the ileocecum valve
A: Distented Cecum will increase the valve muscle tone, tigtening it up. Hormone gastrin (increase acid in stomach) relax the valve, making space in the intestine

Q: How is the appendix suspended? How do you found it? Pain of Appendix. Landmark for appendix
A: The appendix is suspended by a mesentery called mesoappendix. You can found the appendix by tracing the teniae coli of the cecum; pain is from 10th thoracic segment, so regerred pain is umbilicus. Then it inflammed the parietal peritoneum, become percise, severe and localized. Landmark is half way between umbilicus and ASIS.

Q: VANL of appendix
A: Artery, Vein: appendicular artery from cecal artery
Lymph: nodes in mesoappendix then to SM node
Nerve: superior mesenteric plexus

Q: Those colic flexure
A: the left colic flexure is higher than right colic flexure. the left flexure is held by phrenicocolic ligament. The right is held by mesocolon

Q: VANL of traverse colon
A: Artery: the two third is by middle colic artery, the other one third is left colic artery
Lymph: 2/3 to SM node, 1/3 IM node
Nerve: 2/3 to SM plexus, 1/3 IM plexus

Q: Ligamentum teres divides? remains of? Ligamentum Vensoum divides? remains of? IVC divides? gall bladder lies between?
A: Teres divies left and quadrate, remains of umbilical vein. Venosum divides left and caudate, remains of ductus venosus, IVC divides right and caduate. gall bladder lies between right and quadrate


Q: Parts of Gallbladder, Function
A: Fundus, body, neck; function is to concentrate bile by removing water

Q: VANL of GallBladder
A: Artery, Vein: Cystic Artery
Lymph, cystic lymph node to hepatic node to celiac nodes
Nerve: Celiac plexus, response to cholecystokinin produced by duodenum in reponse to food

Q: Describe the relative positions of portal triage
A: portal vein posterior, artery on the left, bile duct on the right

Q: Trace all the duct from the duodenum
A: Common Bile Duct
-> Common hepatic duct
--> L/R Hepatic Duct
-> Cystic Duct
Main Pancreatic Duct
Acessory Duct

Q: Special Characteristics of these ducts
A: Cystic duct is S shaped with spiral vavle, The bile duct drains to ampulla of Vater, open into the lumen called major duodenal papilla with sphincter of Oddi

Q: Parts of Pancreas
A: Head,
Uncinate Process sandwitched between SM Vessels and Portal
Tail to hilum of spleen in the splenicorenal ligament

Q: Renal Structer
A: 12 renal pyramdis with their apex pointing to cetner
Renal papilla
2 or 3 minor calyx to 1 major calyx
renal pelvis

Q: VANL of Kideny
A: Artery Renal Artery, Renal plexus, and lateral aortic lymph node (at the orgin of renal artery)
Q: Location of the spleen, three impressions
A: 9-11 rib, colic, kidney, gastric impression

Q: 3 restriction of the ureter
A: renal pelvis joins the ureter, when it cross plevic brim with iliac arter in front, and perierces bladder wall
Gonad artery cross the ureter in front

Q: VANL of ureter
A: Artery: renal artery, testicular artery, superior vesical artery
lateral aortic and iliac nodes
renal, testicular and hypogastric plexuses

Q: Referred pain of ureter
A: upper end: back behind the kidney
middle, inguinal region
lower, penis

Q: VANL of suprarenal glands
A: Artery, inferior phrenic, aorta, renal artery
Vein: right suprarenal to IVC, left suprarenal to left renal vein
Lymph: lateral aortic nodes
Nerve: Preganglion sympathetic nerve

Q: Major nerve
A: iliohypogastric (L1): emerge underneath of posas major; external oblique, internal oblique, transversus
ilioinguinal (L1): same pathway, but go to inguinal canal; external, internal, tranversus, skin of upper thigh, penis, scrotum/labia majora
Lateral cutaneous (L2-3): cross the pelvic brim, enter under the inguinal ligament, inferior to the L1 lumbar nerve; anterior and lateral surfaces of thigh
Genitofemoral (L1-2): easy to identify, perces through the poas major; Cremaster muscle, anterior surface of thigh, and cremasteric reflex
Femoral (L2-4): underneath the posas major, thick nerve, runs under the inguinal ligament; illiacus, pectineus, sartorius, quadriceps
Obturator (L2-4): through the obturator foramen; adductor brevis, adductor longus

Q: Bifurcation of the Aorta. Which level? Into what?
At L4 level, to common iliac artery. The aorta is pretty center, it is just the inferior vena cava is not center

Q: Appendicitis
A: Inflammation (and usually infection) of the appendix, a finger-like projection of the first portion of the colon, that often causes right, lower quadrant abdominal pain, fever and loss of appetite

Q: cholecystitis
A: acute or chronic inflammation of the gallbladder; may necessitate a cholecystectomy or gall bladder removal, which is now usually performed laparoscopically. History may reveal pain, fever with chills and nausea with vomiting.

Q: McBurney's point/incision
A: McBurney's point lies 1/3rd superiomedially along the line between the right anterior superior iliac spine and the umbilicus; this point marks the usual location of the appendix within the right iliac fossa; McBurney's incision is an oblique incision over this point inferomedially directed, and splits the fibers of the external oblique aponeurosis, fibers of internal oblique and transverse abdominal muscles are likewise split to gain access to the appendix

Q: median incision
A: incisions made through the fibrous tissue of the linea alba superior and/or inferior to the umbilicus; linea alba usually only transmits small vessels and nerves, therefore these incisions are relatively harmless and bloodless; however, in some patients these incisions may be problematic as they may cut through vascularized fat; also, as it is poorly vascularized, incisions of the linea alba may result in necrosis if the incisions are not brought together well; lower median incisions are often used in female patients to access the female pelvic viscera; median incisions are generally used for exploratory procedures

Q: subcostal incision
A: provides access to the gallbladder and biliary tract on the right side and the spleen on the left; made parallel to the costal margin but at least 2.5 cm inferior to avoid the 7th and 8th thoracic spinal nerves

Q: rebound tenderness
A: when pressure is applied to an area of the abdominal wall and then suddenly removed, extreme localized pain is felt by the patient usually in response to intraperitoneal inflammation or irritation

Q: umbilical hernia
A: an abnormal protrusion of abdominal contents into a defect in the umbilical area; common in the newborn, but usually resolves by age two

Q: Incisional hernia
A: protrusion of omentum (a fold of peritoneum) or an organ through a surgical incision. If the muscular and aponeurotic layers of the abdomen do not heal properly, an incisional hernia can result. Infection, bowel obstruction, and obesity are predisposing factors to incisional hernias

Q: hydrocele
A: an accumulation of serous fluid in a sac-like cavity adjacent to the testis, a swelling due to the accumulation of serous fluid in the tunica vaginalis of the testis or in the spermatic cord

Q: Meckel's diverticulum
A: congenital anomaly, on the antimesenteric border of ileum (opposite of mesenteric attachment), can mimking the pain produced by appendicitis

Q: Omphalocele
A: herniation of abdominal viscera through umbilical and supraumbilical abdominal wall into a sac covered by peritoneum and amniotic membrane. This sac is thin and can easily rupture.

Q: vagotomy
A: cutting of the vagus nerve. Effects of bilateral vagotomy (cholinergic denervation), 1) decreased motility of stomach and intestine, 2) decreased gastric secretions, 3) decreased tone of gallbladder and bile ducts, 4) increased tone of sphincters (Oddi and lower esophageal sphincter)

Q: splenectomy
A: surgical removal of the spleen. This is sometimes done in leukemia or lymphoma as part of a patient's treatment. The splenic capsule may rupture as a result of trauma.

Q: peritoneal lavage
A: a diagnostic technique performed after trauma to wash out the peritoneal cavity.

Q: Pancreatitis
A: Acute or chronic inflammation of the pancreas, which may be asymptomatic or symptomatic and which is due to autodigestion of pancreatic tissue by its own enzymes. It is caused most often by alcoholism or biliary tract disease; less commonly it may be associated with hyperlipemia, hyperparathyroidism, abdominal trauma (accidental or operative injury), vasculitis or uremia.

Q: ascites
A: An effusion and accumulation of serous fluid in the abdominal cavity.

Q: duodenal stenosis
A: Narrowing of the duodenum. May be congenital or the result of neoplastic growth.

Q: duodenal atresia
A: Congenital duodenal atresia (blind end) of the duodenum, caused by a failure of recanalization of the duodenal lumen during development. It should be noted that 70% of patients with duodenal atresia also have other malformations including Down's Syndrome, cardiac or GI defects.

Q: caput medusae
A: varicose veins radiating from the umbilicus. Ordinarily seen as a sign of cirrhosis of the liver and caused by portal hypertension.

Q: hematemesis
A: vomiting of blood.

Q: Pringle maneuver
A: manually stopping the inflow to the liver by compressing the portal vein and proper hepatic artery. This is utilized in cases when the liver is bleeding and the bleeding must be stopped immediately

Q: cystic kidney
A: polycystic kidney disease (PKD) is a disorder that is characterized by the growth of numerous cysts in the kidneys. The cysts are filled with fluid. PKD cysts can replace much of the mass of the kidneys, thereby reducing kidney function and leading to kidney failure. When PKD causes kidneys to fail, which usually happens only after many years, the patient requires dialysis or kidney transplantation. About one-half of people with the primary form of PKD progress to kidney failure or end-stage renal disease (ESRD). PKD can cause cysts in the liver and problems in other organs, such as the heart and blood vessels in the brain. These complications help doctors distinguish PKD from the usually harmless "simple" cysts that often form in the kidneys in later years of life.


Q: Regarding the nerve for the abdominal wall, which layer does it run in between.
A: The nerve runs between internal and traversus. The cutaneous branches runs between external and internal

Q: Describe the layers on the side
A: Skin, camper fascia (fat layer), scarpa fascia (membraneous layer), external oblique, internal oblique, transverse abdominal muslce, transversalis fascia, extraperitoneal fat, parietal peritoneum

Q: The nine plane
A: Right Hypopchondriac, Right lateral, Right ingurnal, Epigastric, Umbilical, Pubic

Q: What forms the rectus sheath, Where does the posterior rectus sheath become?
A: It is formed by the aponeuroses of the abdominal muscles. The arcuate line is what the posterior become. It then join with the anterior in the fornt

Q: Describe the nerve of the abdomine
A: T7-T11, and subcoatal nerve leaves the intercoastal space, split to anterior cutaneous branches which run on the surface; The original branch run across the muscle between the second and third layer; then it turns around to become the cutananeous branchs on the surface; to meet up with anteior cutaneous branch.

Illionhypogastric and illionguinal just run across the wall

Q: Artery of the wall
Internal Thoracic Artery -> Musculophrenic, SuperiorGastric
Musculophrenic -> False rib Intercoastal Artery
Fermoral Artery -> External Illiac Artery
External Illiac Artery -> Subcostal Inferior Epigastric (deep and medially)
External Illiac Artery -> Depp circumflex Iliac (deep and lateral)
Femoral -> Superficial epigastric (Superficial and Medially)
Femoral -> Superficial Circumflex (Superficial and lateral)

Q: Folds and Fossa
Median Umbilical Fold right in the middle under parietal peritonum
Then Median split to two Medial Umbilical Fold on each side (embryonic umbilical arteries )
Lateral Umbilical Folds on the side (inferior epigastric artery)

Between Medial and Lateral Folds are Medial Inguinal Fossa
Between Median and Medial is Supravescial fossa
Lateralmost is lateral inguinal fossa

Q: Where is the inguinal ligament
A: It is the edge of the external oblique aponeurosis

Q: Spermatid Cord Cross Section
A: External spermatic Fascia, Cremasteric Fascia, Interal Spermatic Fascia, (pampiniform plexus of veins, ductus deferens, testicular artery)

Q: The two opening of inguinal canal
A: Deep internal ring to superficial inguinal ring. The canal liew above the inguinal ligament

Q: How does the Canal picking up muscles as it goes
A: The cord pick up its internal spermatic fascia as traversalis fascia
it picks up its cremastic muscle from internal oblique
As it reach the superficial ring, it picks up the external layer from external oblique

Q: Main Difference in Female
A: It has round ligament inside the canal connected from uterus to labium major.

Q: cross section from posterior to anterior
A: skin, dartos muscle, external oblique, internal oblique, transversalis fascia, epididymis, testis, visceral tunica vaginalis, tunica vaginalis, parietal tunica vaginalis, transversalis ...

Q: Role of Cremateris Fascia and Dartos muscle.
A: dip the testes when cold, relax when hot. To regulate temperature

Q: Where is the testes came from during fetal development
A: It is inside the body around where the ovaries are. The final descent of the testis occurs before or shorthly afater birth.

Q: Cross section of testes from parietal (posterior) to ductus deferens (anterior)
A: Parietal of tunica vaginalis, cavity of tunica vaginalis, visceral of tunica vaginalis, tunica albuginea, seminiferous tubules, straight tubules, rete testis, efferent ductules of testis, epididymis, ductus defernes

Q: The Sperm Path
A: Seminiferous tubules, rete testis, efferent ductules, store in Epididymis, Vas deferens, Ejaculatory duct, postatic Urethra, Penis

Q: Structure of Epididymis
A: Head, coiled end of effernet ductules; body, convoluted duct of epididymis; tail, ducutus deferens

Q: Indirect / Direct Inguinal Hernia
A: the result of the failure of embryonic closure of the internal inguinal ring after the testicle passes through it. When the testis is descened, other organs descends with it. It reach inside the cord, enter scrotum
Direct Inguinal Hernia: The bowel passes medial to inferior epigatris vessls pushing the periotonem throught the superfical inguinal ring. It pass lateral to the cord, and do not enter scrotum

Q: The difference between Intraperitoneal and Extraperitoneal organs
A: Intraperitoneal is inside the visceal cavity, completely covered by visceral cavity. Example are stomach, spleen. Extraperitoneal organs is outside of parietal peritonum; Examples are aorta, vena cava, kidney and vertebral

Q: Where does the ingunal canal extend from and to?
A: Extends from the anterior superior iliac spine to the pubic tubercle

Q: What is inside the peritoneal cavity
A: Surrounded by the visceral membrane. In male, just peritoneal fluid that contains white blood cell and antibdoies. In female, may be able to pass through the uterine tubes, uterine cavity, a potential pathway to the exterior

Q: Peritonitis
A: Gas, infection, inflammation, fecal matter in the peritoneal cavity

Q: Nerve and Sensation of Parietal and Visceral
A: Parietal the same nerve supplying the abdomin wall. It can sense pain, temperature, pressure, well localized; For visceral, supply by the nerve supply of the organ it covered. pain from visceral, poorly localised, no temperature, touch and stretching stimulation.

Q: Name three ligaments of Greater omentum
A: Gastrophrenic ligament, between stomach and diaphragm; Gatrosplenic between stomach and spleen; Gastrocolic between stomach, trasverse colon

Q: Name two ligaments of Lesser omentum
A: heptaogasatric and heptatoduodenal ligaments. The two ligaments are actually continuous

Q: General Structure of Peritoneal Space
A: Liver is the superiormost, Stomach in the middle, The less omentum or the heptogastric ligament in between the stomach and liver
Anterior to the stomach and lesser omentum is the greater sac
The greater omentum, a big flap, hangs from the stomach, covering the small intestine
The tranverse colon is connected superiorly with traverse mesocolon, inferiorly with greater omentum
Inside the greater omentum (a double layer membrane), and posterior to the stomach, anterior to the tranverse mesocolon is the omental bursa
(lesser sac)

Q: Define sphincters
A: Esophaogastric Junction is where the esophagus etner the stomach; The inferior esophageal sphincter is where the diaphragm contract

Q: Cremasteric Reflex
A: A strike at the inguinal muscle and retraction of testes should be seen.

Q: Hydroceal
A: Fluid connected in the tunica vaginalis

Q: Define
Pouch of Douglas
mesentery of the small intestine
Greater omentum
Lesser Omentum
Lesser peritoneal Cavity
Epiploic foramen / Omental Foramen
Falciform ligament
Coronary ligament
Paracolic gutter
Gastrolienal ligament
Lienorenal ligament

A: Pouch of Douglas, Anterior surface of Rectum from the Peritoneal Cavity
Mesentery of Small Intestine, those that hang the intestine from the posterior wall
Greater omentum hangs from the stomach, covering the intestine
Lesser omentum hangs the stomach
Lesser Peritoneal Cavity, the cavity surrounded by the lesser omentum
Epiploic foramen / Omental Foramen, the greater and lesser sac is actually connected. At certain cross section, the Lesser omentum is disconnected. This passageway is the epiploic foramen
Falciform ligament, attached the diaphragm all the way down to the umbilius, divide the liver into two
Cornary ligament, connect the liver with diaphragm, merge to become falciform ligament
Paracolic gutter, the grooves between lateral aspect of ascending colon and abdominal wall connecting between supracolic and infracolic compartments
Gastrolienal ligament, ligament between stomach and spleen
Lienorenal ligament, between spleen and kidney

Q: What is Gastric Fold or Gatric Channel
A: Folds or channel that guide food to duodenum

Q: Four part of duodenum
A: Superior, horizontal
Descending, runs inferiorly
Horizontal, cross anterior to inferior vena cava and aorta, posterior to superior mesenteric artery
Ascending, then join jejunum with deodenojejunal flexure, hung by suspensory muscle of duodenum or the ligament of Treitz

Q: The ampulla is refered to as? what important characteristic does it have compare to the rest of the duedonem?
A: the superior part of duodenum, has mesentery and is mobile. The other part has no mesentery and are immobile.

Q: Characteristics of Artery and Venous supply of Jejunum and ileum
A: SMA branches to form plexus of arterial arcades that give rise to straight artery - vasa recta
SMV joins with splenic vein then to portal vein.

Q: Lymph nodes of Jejunum and Ileum
A: Juxta intestinal lymph nodes then meseteric lymph node then superior mesenteric lymph node

Q: Never of Jejunum and Ileum
A: Sympathetic: Greater, lesser and least splanchnic nerve comes to celiac trunk

Q: Nerve of Jejunum and Ilenum. What type of sensation does it feel
A: sym: T8-T10 become superiro mesenteric nerve plexus; para: posterior vagal trunk
no pain, but sudden distention, and transient ischemai

Q: Common site of duodenal ulcer
A: posterior wall of superior part of duodenum. may perforate the wall, premitting content into peritoneal cavity and produce peritonitis. If erosion to the gastroduodenal artery, server hemorrhage into periotoneal cavity.

Q: How do you distinguish ilenum and jejunum?
A: There are more arcades in ilenum before branching out to vasa recta. The circular folds inside jejunum is more distinct. Jejunum is thicker. Ileum is longer

Q: What is ascites?
A: When the peritonum produce excess fluid

Q: What is the Inferior Epigastric Artery lying on?
A: Traversalis facsia

Q: What are the three branches of celiac trunk?
A: left gastric, common hepatic, splenic

Q: What is suspending the deodunum?
A: Ligament of Treitz pull the superior part of deudonum to right cruz of diaphragm

Q: What are the parts of pancreas?
A: Head of pancreas, uncinate process (the inferior part of the head, seperate from head by SMA), neck (where the MSA, MSV pass posterior behind), body, tail (inside peritoneum)

Q: How does the pancreatic duct drains to duodenum
A: Major Pancreatic Duct split to Accessory Pancreatic Duct. The two drains to major and minor duodenal papilla. The common bile duct also drains to major duodenal papilla

Q: Junction of small and large intestine. Inside it is?
A: ileocecal junction
Thickened muscle which forms the iliocolic valve

Q: Bands of fibers on the large intestine. They are called?
A: Taeniae coli

Q: What are those sac in the large intestine called?
A: haustra

Q: Two major flexure of large intestine
A: hepatic flexure and splenic flexure

Q: Major recess
A: retrocecal recess

Q: How is the artery to the appendix supply blood to it?
A: Appendicular artery Via mesoappendix

Q: VANL Of Cecum
A: Illeocolic Artery, Ileocolic Vein,
Superior mesenteric plexus -> Sym: T10-12, Para: Vagus Nerve
Ileocolic lymph node -> Superior mesenteric lymph node

Q: How do portain vein join with Inferior Vena Cava? What happen if the person drinks too much alcohol?
A: The portal vein goes into the liver, then merge and join the IVC.
There are three other plexses
Esophgeal Plexses
Paraumbilical Plexses
Rectal Plexses
Chronic alcoholism May block the passage in the liver. Those plexsus may swell and hemorrahge.

Q: Identify Parts of liver
right lobe
falciform ligament
left lobe
coronary ligament
gall bladder
cystic duct
portal vein
hepatic arteries
common bile duct
quadrate lobe
ligamentum teres
ligamentum venosum
inferior vena cava groove
porta hepatis
coronary ligament
left triangular ligament
right triangular ligament
bare area
caudate lobe
quadrate lobe
left sagittal fissure
transverse fissure
right sagittal fossa
esophageal impression
gastric impression
renal impression
colic impression

Q: Bile Ducts
Descending Part of Deudenum
-> Common Bile Duct
-> Cystic Duct
-> R/L Bile Duct

Q: Land Mark for Fundus
Intersection fo rectus Abdominas with 9th rib

Q: Cirrhosis
A: Cirrhosis of the liver is the result of atrophy of the liver parenchyma and a hypertrophy of the connective tissue. Over time, there will be jaundice and portal hypertension.

Q: Nerve
T5-T9 -> Greater splanchinic nerve -> Celiac Ganglion -> Spleen, Stomach, Liver, Pancreas, Duodenum
T10-T11 -> Lesser Splanchnic Nerve -> Aorticorenal ganglia -> Kidney, Gonad
T12 -> Least Splanchnic Nerve -> Suprearenal, aorticorenal ganglia
L1-L3 -> Lumbar Splanchnic Nerve
-> Superior Mesenteric -> Right, Middle Colic, Intestine
-> Inferior Mesenteric -> Left Colic, Rectum
Vagus Nerve -> Stomach, Spleen, Liver, Duodenum, Pancreas, Kidney, Gona, Right, Middle Colic
S2-S4 -> Pelvic Splanchnic Nerve -> Left Colic, Rectum

Q: Major Plexes of Abdomine
A: Celiac Plexus: from greater and lesser splanchnic nerve, vagus nerve to organs on celiac artery
SM Plexus:
Renal Plexus:
IM Plexus: pelvic splanchnic nerve from para
Aortic plexus is between SM and IM
Hypogastric plexus is between internal illac artery

Q: Major muscle on posterior wall
A: Psoas, attached on transverse process of T12 and L5, lesser trochanter of femur. flex femur up
Quadratus lumborum: iliolumbar ligament and T12, depress 12 rib during respiration
Illicus: iliac recess and lesser trochanter, flex thigh

Q: Vein
-> Right, Middle, Left Hepatic Vein
---> Portal Vein
-----> Left Gastric -> Lesser Curvature of Stomach
-----> Splenic Vein
-------> Short Gastric Vein -> Fundas of Stomach
-------> Left Gastro omental vein -> Left Greater Curvature of Stomach
-------> Inferior Mesenteric Vein
---------> Left Colic Vein
---------> Sigmond Vein
---------> Superior Rectal Vein
-----> Superior Mesenteric Vein
-------> Pancreaticoduodenal vein -> head of Pancreas, Descending portion of deudenum
-------> Middle Colic Vein
-------> Right Colic Vein
-------> Ileocolic Vein
-------> Appendicular Vein
-------> Intestinal Vein
-> L/R Suprarenal Vein
-> L Renal Vein
---> Hemiazygous vein
---> Left Testicular vein
-> R Renal Vein
---> Lumbar Vein
-----> Azygos Vein
-> Right Testicular Vein
-> L/R Common Iliac Vein
-> L/R Internal / External Iliac Vein
-> Median Sacral Vein

Q: Artery
-> Inferior Phrenic Artery
-> Suprareanal Artery
-> Celiac Trunk
---> Left Gastric -> Esophagus, Lesser Curvature of Stomach
---> Splenic -> Tail of Pancreas
-----> Left Gastroomental -> Greater Curvature of Stomach
-----> Short Gastric -> Fundas of Stomach
---> Common Hepatic
-----> Gastroduodenal -> Stomach, Pancreas, Deodenum
-------> Superior Pancreatico Duodenal Artery -> Proximal of Deodenum, head of pancreas
-------> R. Gastro omental -> Greater Curavature of Stomach
-----> Right Gastric, right side of lesser curvature of stomach
-----> Proper Hepatic
-------> Cystic -> Gall bladder and cystic duct
-------> L/R Hepatic Artery
-> SMA
---> Posterior Pancreatico Duodenal Artery -> Distal of Duodenum, head of Pancreas
---> Middle Colic Artery -> Tranverse Colon
---> Right Colic Artery -> Ascending Colon
---> Intestinal Artery -> Jejunum and Ilenum
---> Ileocolic artery -> Illenum, cecum, ascending colon
---> Appendicular Artery -> Appendix
-> L/R Renal Artery
-> Testicular Artery
-> IMA
---> Left colic -> descending colong
---> Sigmoid -> Sigmond Colon
---> Superior Rectal -> Proximal Rectum
-> L/R Common Iliac Artery
---> L/R Internal Iliac Artery
---> L/R External Iliac Artery
-> Median Sacral Artery

Q: Jaundice
Jaundice is an accumulation of bile pigment in the blood stream. This is frequently a result of obstruction of the duct system.

Q: Spleen visceral neighbor, three ligaments
A: Greater curvature of stomach, Renal, and splenic flexure of colon
phrenicocolic ligament , gastrolienal ligament , lienorenal ligament

Q: Three function of spleen
A: Reticuloendothelial tissue - concerned with phagocytosis of erythrocytes and cell debris from the blood stream. This same tissue may produce foci of haemopoiesis when RBC's are needed.

Venous sinusoids along with the power of the spleen to contract, provides a method for expelling the contained blood to meet increased circulatory demands in certain animals.

White pulp provides lymphocytes and a source of plasma cells and hence antibodies for the cellular and humoral specific immune defenses.

Q: Major ligament
hepatoduedenum, hepatogastric
gastrophrenic, gastarosplenic, gastrocolic

Q: Major Recess
Subphrenic, hepatorenal

Q: Kidney from the outside to inside
A: paranephric fat, renal fascia and perinephric fat
Renal fascia become periureteric fascia

Q: Who do you identify the renal artery vein looking at the hilum
A: renal vein is anterior to renal artery

Q: Three muscle on the posterior wall
A: quadratus lumborum on the side, on the cliff, it merge to form medial arcuate ligament.
Medially, we have psoas major
On the inferior side, we have illacus

Psoas major and illacus form the iliopsoas

Q: The three layres of thoracolumbar fascia
A: The anterior, middle, and posterior part
The anterior cover thoracolumbar fascia. The middle in between back muscle and thoracolumbar fasica, and the posterior is behind the back muscle.

Q: Major nerve of the posterior surface
A: fermoral, obturator, sciatic, genitofermoral nerve, lumbosacral trunk

Q: how does External illac artery supply the abdomin
A: deep iliac circumflex, and inferior epigastric

Q: What are the paired artery
A: Suprarenal, renal, gonad, inferior phrenic (a little inferior to hiatus), lumbar (L4)

Q: Lymph
Cistern chyle
<- descending thoracic lymphatic trunk
<- intestinal lymphatic trunk <- preaortic lymph node <- intestine, liver, spleen, pancreas
<- lumbar lympathic trunk
<- lumbar node <- posterior abdominal wall, kidney, ureters, gonads
<- inferior mesenteric node <- descending colon, pelvis,
<- common iliac node <- lower limbs