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ANATOMY

Embryology
Embryonic Period: Weeks 3-8, organ system development simultaneous I. T e !eart ". #evelopment $%E&'#E(%) 1. Primitive heart tube - pair o* endocardial eart tubes $mesoderm) *orm +it in cardiogenic region -E!T *use during lateral *olding to *orm primitive heart tube , endocardium -surrounding mesoderm develops into myocardium and epicardium -P!T *orms *ive dilations $-irst "id p. ./) 0. AP septum $aorticopulmonary) -divides truncus arteriosus into aorta and pulmonary trunk -neural crest cells migrate into truncal and bulbar ridges -gro+ and t+ist in spiral, *use to *orm "P septum 3. AV septum $atrioventricular) -partitions "1 canal into rig t and le*t "1 canals -dorsal and ventral AV cushions *use to *orm "1 septum . Atrial septum -septum primum gro+s to+ard "1 septum -!oramen primum bet+een edges o* septum primum and "1 septum2 obliterated + en &P *uses +it "1 cus ions -septum segundum $crescent-s aped) *orms to rig t o* &P and *uses a*ter birt +it &P to *orm atrial septum -!oramen ovale is opening bet+een upper and lo+er parts o* &&2 s unts blood *rom rig t atrium to le*t atrium -*unctional closure soon a*ter birt due to pressure c anges2 anatomical *usion incomplete in 034 o* population2 incidental $Image, see !ig -5ield Embryo)

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I1 septum $interventricular) -muscular "V septum develops into *loor o* ventricle and gro+s to+ard "1 septum2 stops s ort to create I1 *oramen

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-membranous "V septum *orms *ollo+ing *usion o* rig t and le*t bulbar ridges and "1 septum2 closes I1 *oramen 6. "ortic "rc es $-irst "id p. .0) 7. 8ongenital "nomalies 9. "P septal de*ects a. Tetralogy o! #allot -improper alignment o* AP and AV septums -overriding Aorta, Pulmonary stenosis, 1&# $poor AV *usion), rig t ventricular ypertrop y $right$to$le!t shunting% cyanosis) b. T&A $transposition o* great arteries) -"P septum *ails to spiral -right$to$le!t shunting% cyanosis c. Persistent truncus arteriosus -abnormal neural crest cell migration, incomplete development o* "P septum -usually accompanied by de*ect in I1 septum -cyanosis 0. "trial septal de*ects a. Patent *oramen ovale -*oramen secundum de*ect, e:cessive resorption o* &P or && -symptoms may mani*est as late as age 3; -most common "&# 3. 1&#s a. Membranous V'( -most common 1&# -*ails to develop -le*t-to-rig t s unting, pulmonary ypertension -s:: e:cessive *atigue on e:ertion /. 8irculatory anomalies a. 8oarctation o* aorta -abnormally constricted in*. to ductus arteriosus -increased 7P in upper e:tremities, lack o* !emoral pulse, ig risk o* cerebral emorr age and bacterial endocarditis b. P#" $patent ductus arteriosus) -common in premature in*ants, mot ers +it rubella during pregnancy -causes <=( s unting, '0 ric blood back into pulm. circulation -can treat +it indomethacin $prostaglandin synt esis in ibitor2 I remember it by saying, Take yo> P#" indo>, man? "lso used *or acute gout, as in stay indo> or go-out) T e <ungs ". #evelopment -laryngotracheal diverticulum *orms in ventral +all o* *oregut -tracheoesophageal septum divides *oregut into esop agus and trac ea -distal end o* <T# enlarges to *orm lung bud -lung bud = 0 bronc ial buds = primary, secondary, tertiary bronc i , bronc opulmonary segments -/ stages 9. &landular $Weeks 3-9@) -respiration not possible, premature *etuses cannot survive 0. )analicular $Weeks 93-03) -respiratory bronc ioels and terminal sacs2 vasculariAation increases 3. Terminal 'ac $Weeks 0/-birt ) -Type I and II pneumocytes, respiration possible -Premature *etuses +eeks 03-08 can survive /. Alveolar $7irt -year 8) -resp. bronc ioles, terminal sacs, alveolar ducts and alveoli increase in number 7. 8ongenital anomalies 1. Tracheosophageal !istula

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-abnormal communication bBt trac ea and esop agus2 mal*ormation o* septum -s:: gagging and cyanosis a!ter !eeding, abd. distention a*ter crying, re*lu: o* gastric contents into lungs +espiratory distress syndrome -de*iciency o* sur*actant -common in premature in*ants, in*ants +it diabetic mot ers, *etuses +it prolonged IC asp y:ia -t:: t yro:ine and cortisol to mot er Pulmonary hypoplasia -secondary to congenital diap ragmatic ernia $into pleural cavity) and bilateral renal agenesis

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<iver ". #evelopment -hepatic diverticulum $endoderm o* *oregut) *orms in septum transversum $surrounding mesoderm, also plays part in development o* diap ragm) -!# sends hepatic cell cords into &T -8ell cords surround vitelline veins, + ic *orm epatic sinusoids Didney ". #evelopment -Intermediate mesoderm *orms elevation along dorsal body +all , urogenital ridge -portion o* CE ridge, called nephrogenic cord% *orms 3 sets o* kidneys 9. Pronephros completely regresses 0. Mesonephros *orms mesonep ric $+ol**ian) duct 3. Metanephros develops *rom metanep ric mesoderm and ureteric bud $outgro+t o* mesonep ric duct)2 becomes de*initive adult kidney -ascends during development *rom sacral region to adult location at T90-<3 7. 8ongenital anomalies 9. +enal agenesis - *ailure o* ureteric bud to develop 0. -orseshoe .idney F in*erior poles *use, kidney trapped be ind in*. mesenteric artery 3. /ilm0s tumor F malignant tumor in c ildren, probably o* embryonic origin, good prog /. 1rachal cyst F remnant o* allantois, urine drainage *rom umbilicus 3. Pheochromocytoma F c roma**in cell tumor, generally along migratory pat o* neural crest cells 8G& ". #evelopment 9. Notochord induces overlying ectoderm to di**erentiate into neuroectoderm to *orm neural plate2 notoc ord becomes nucleus pulposus 0. Geural plate *olds to *orm neural tube -some cells di**. into neural crest cells -craniocaudal *olding 3. 1esicles 7. 8ongenital anomalies 9. 'pina bi!ida $ ig "-P levels) 0. Anencephaly $ ig "-P levels) -9B9;;; birt s -most common serious birt de*ect in stillborns 3. Arnold$)hiari F erniation o* cerebellum into *oramen magnum /. (andy$/al.er F ydrocep alus *rom atresia o* *oramena o* <usc ka and %agendie 3. -ydrocephalus F most commonly *rom stenosis o* cerebral aHueduct 6. #etal alcohol syndrome F most common cause o* %(2 microcep aly, eart disease @. 8raniop aryngioma F congenital cystic tumor, remnants o* (at ke>s pouc Eut $EG#'#E(% I %E&'#E(%) ". #evelopment 9. -oregut: celiac artery -esop agus, stomac , liver, gallbladder, pancreas, upper duodenum 0. %idgut: superior mesenteric artery -lo+er duodenum, JeJunum, ileum, cecum, appendi:, ascending colon, pro:imal 0B3 transverse colon 3. !indgut: in*erior mesenteric artery

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-distal 9B3 o* transverse colon, descending colon, sigmoid colon, upper anal canal /. <o+er anal canal , sur*ace ectoderm $t ink sHuamous cell carcinoma) 7. 8ongenital anomalies 9. Esophageal atresia F mal*ormed trac eoesop ageal septum 0. -ypertrophic pyloric stenosis F ypertrop y o* muscularis e:terna2 proJectile vomiting and small, palpable mass at rig t costal margin 3. E2trahepatic biliary atresia F incomplete canaliAation = occlusion o* biliary duct2 Jaundice, pale *eces, dark urine /. Annular pancreas F ventral and dorsal pancreatic buds *orm ring around duodenum2 obstruction 3. (uodenal atresia F *ailed recanaliAation2 poly ydramnios, bile-containing vomit, stomac distention 6. Omphalocoele F midgut loop *ails to return to abd. cavity2 lig t gray sac at base o* umbilical cord @. Mec.el0s diverticulum F remnant o* yolk sac bBt umbilicus and ileum2 drainage o* meconium *rom umbilicus 8. -irschsprung0s F *ailure o* neural crest cells to *orm myenteric ple:us in sigmoid colon and rectum2 loss o* peristalsis, *ecal retention, abd. distention 't er congenital anomalies ". !ead and neck 9. #irst arch syndrome F various !acial anomalies -lack o* migration o* neural crest cells into p aryngeal arc 9 -Treacher$)ollins% Pierre +obin 0. (i&eorge F p aryngeal pouc es 3 I / *ail to di**. into parat yroids and t ymus2 K*irst arc L !acial anomalies +it cardiovascular anomalies 3. 8le*t palate and cle*t lip $-irst "id p. ./) &keletal &ystem ". #evelopment -lateral *olding -t ree sources: para:ial mesoderm, lateral plate mesoderm, neural crest cells 1. Para2ial mesoderm -gives rise to somiteres 9-@ in ead region -gives rise to somites in postcranial region a. dermatomes F give rise to dermis b. myotomes F give rise to all skeletal muscles belo+ ead c. sclerotomes F give rise to bones o* a:ial skeleton -abnormal induction results in spinal de*ects $scoliosis) 7. 8ongenital "nomalies $not any obvious ones relating directly to somite migration) 9. 8audal dysplasia -re*ers to constellation o* syndromes ranging *rom minor lesions o* lo+er vertebrae to complete *usion o* lo+er limbs -is caused by abnormal gastrulation, in + ic migration o* mesoderm is disturbed -can be associated +it various cranial anomalies: a. VATE+ F vertebral de*ects, anal atresia, trac eoesop ageal *istula, renal de*ects b. VA)TE+3 F similar to 1"TE(, includes cardiovascular de*ects and upper limb de*ects 0. &acrococcygeal teratoma -arises *rom remnants o* primitive streak $see belo+)2 normally degenerates -derived *rom pluripotent cells, develop into various tissue types $ air, bone, nerve) -more common in *emale in*ants, usually malignant, must be removed by 6 mont s -etal 8irculation ". Pattern "orta = (, < umbilical arteries $deo:y) = <e*t umbilical vein $o:y) = ductus venosus = In*. vena cava = (ig t atrium = *oramen ovale = <e*t atrium = <e*t ventricle = "orta (ig t atrium = (ig t ventricle = Pulmonary artery = #uctus arteriosus = "orta 7. Three main s unts 9. (uctus arteriosus: pulmonary trunk to aorta 0. (uctus venosus: bypass liver

M.

3. #oramen ovale: rig t atrium to le*t atrium 8. (emnants $-irst "id p. .0) #. "*ter *irst breat 9. "lveoli are o:ygenated 0. #ecreased pulmonary resistance $lungs e:pand) 3. Increased pulmonary blood *lo+ /. Increased le*t atrial pressure 3. -unctional closure o* *oramen ovale 6. #uctus arteriosus closes via smoot muscle contraction +it in a *e+ ours o* birt @. #uctus venosus closes +it in a *e+ days, mec anism unkno+n Embryonic Plate: Weeks 0-3 $-irst "id p. .9) ". Week T+o 9. Embryoblast $bilaminar disk) a. Epiblast b. !ypoblast c. "mniotic cavity d. 5olk sac 0. Trop oblast $Placenta) a. &yncytiotrop oblast b. 8ytotrop oblast

7. Week T ree 9. Eastrulation -establis es t ree germ layers: ectoderm, mesoderm, endoderm $trilaminar disk by day 09)2 give rise to all tissues and organs -primitive streak *irst indication -all derived *rom epiblast

&ross Anatomy
9. #irect ernia: leaves abdominal cavity medial to in*erior epigastric vessels Indirect ernia: leaves abdominal cavity lateral to in*erior epigastric vessels -emoral ernia: protrusion o* abdominal viscera t roug *emoral ring into *emoral canal <umbar puncture: needle into lumbar cistern bet+een spinous processes <3B</ or </B<3 Pericardiocentesis: +ide bore needle inserted t roug 3t or 6t intercostal space near sternum. 8are*ul not to puncture internal t oracic artery 0. T yroid 83 &ternal notc T0 7i*urcation o* trac ea T/-T3 !eart: 7ase T6-T. "pe: 3t le*t intercostal space 3. #uodenum T90-<9 Didneys T90-<3 8onus medularis <9-<0 adult, <3 ne+born Cmbilicus </

Dnee: 9. Patellar ligament- damage to *emoral nerve or spinal cord <0-</. <oss o* patellar re*le: 0. %8<- tear also tears medial meniscus. Passive abduction o* e:tended leg at knee Joint. 3. <8<- passive adduction o* e:tended leg at knee Joint. /. "8<- anterior dra+er sign. 3. P8<- posterior dra+er sign. 6. Terrible triad- %8<, medial meniscus and "8< tears. !ip: 9. Posterior dislocation- ead o* *emur moves posterior to t e ilio*emoral ligament. Presents +it lo+er limb t at is *le:ed at ip Joint, adducted, medial rotated and s orter t an opposite limb. 0. -racture o* neck o* *emur presents laterally rotated and s ortened.

& oulder: 9. #islocation- may be anterior or posterior. I* anterior t en a:illary nerve may be damaged. 0. &eparation- results in a do+n+ard displacement o* clavicle. 8lavicle: 9. -racture- most common at medial 9B3. (esults in up+ard displacement o* pro:imal *raagment and do+n+ard displacement o* distal *ragment /. 7rac ial Ple:us: 9. ":illary n- dislocation o* s oulder, abduction $deltoid) and lateral rotation $teres minor) are compromised. 0. <ong t oracic n- +inging o* scapula $serratus anterior). 3. (adial n- +rist drop $e:tensors o* *orearm). /. %edian n- ape and $t umb muscles) and *le:ors o* *orearm i* damage is at elbo+ or above. 3. Clnar n- cla+ and and radial deviation o* and, loss o* some *le:ors i* at elbo+ or above. 3. Perip eral nerves: 9. 8ommon peroneal n- *oot drop $tibialis anterior m) and inversion $peroneus muscles). 0. #eep peroneal n. entrapment- 8ompression o* anterior compartment muscles o* t e lo+er leg by ski boot or at letic s oes t at are too tig t. 8auses pain in t e dorsum o* t e *oot t at radiates to t e space bet+een t e *irst t+o toes. 6. !ands: 9. 8arpel Tunnel &yndrome- compression o* median nerve by in*lammation, +eakend *le:ion and abduciton and opposition o* t umb, loss o* e:tension o* inde: and middle *ingers, sensory loss o* inde:, middle and al* o* ring *ingers and palmar part o* t umb. 0. 8ubital tunnel syndrome- sorry I +as not able to *ind t is one. 3. #upuytren>s contracture- progressive *ibrosis o* palmar aponeurosis, pulls digits into marked *le:ion at %8P Joints. @. 7lood-testes barrier: T ere is a barrier t at e:ists bet+een t e blood vessels t at supply t e testes $branc es o* t e testicular artery and vein) and t e duct system in + ic spermatoAoa are produced and transported. T e testis is derived partly *rom celomic mesoderm and partly *rom intermediate mesoderm +it t e blood vessels migrating in around t e duct system. 8. "bdominal arteries: 9. 8eliac trunk$8T)--'(EECT-le*t gastric a., splenic a., epatic a. 0. &uperior messenteric a.$&%")- %I#ECT- part o* duodenum t roug pro:imal 0B3 o* transverse colon. 3. In*erior mesenteric a.$I%")-!IG#ECT- distal 9B3 o* transverse colon to upper rectum 8ollaterals: 9. Internal t oracic a. to superior epigastric a. to in*erior epigastric a. 0. &uperior pancreaticoduodenal a.$*rom 8T) to in*erior pancreaticoduodenal a. $*rom &%") 3. %iddle colic a. $*rom &%") to le*t colic artery $*rom I%") /. %arginal a. $*rom &%" and I%") 3. &uperior rectal a. $*rom I%") to middle rectal a. $*rom internal iliac a.) .. 7one: 9. %etap ysis: bet+een epip ysis and diap ysis. 0. Epip ysis: gro+t plate responsible *or linear bone gro+t . 3. #iap ysis: long part o* bone responsible *or annular bone gro+t . $"dd istology and neuroanatomy 9-0)

Neuroanatomy
3. -earing -Cnlike ot er sensory systems, t e central auditory pat +ays ave bilateral representation o! sounds $sound *rom 9 ear reac es auditory corte: in bot emisp eres). -Pat +ay -*irst neruons in spiral ganglion synapse in coc lear nucleus -second neurons synapse bilaterally in superior olivary nuclei -t ird neurons travel in t e lateral lemniscus to synapse in t e in*erior colliculus -*ourt neurons t en synapse in t e medial geniculate nucleus -t e *ibers t en go to t e transverse temporal gyrus o* t e corte: -8onduction and nerve dea*ness -/eber test $*ore ead) -lateraliAes to t e a!!ected ear 4ith conduction dea!ness and to t e una!!ected ear 4ith nerve dea!ness

-+inne test $mastoid process) -distinguis es bet+een better bone or air conduction o* sound /. E2traocular muscles $see -irst "id pg. 999 and table 9;.9 pg. 998 in 7asic 8linical Geuroanatomy) -%ovements and innervation -%edial (ectus F 8G III F adduction $in) -&uperior (ectus F 8G III F elevation $a*ter abduction) $up) -In*erior rectus F 8G III F depression $a*ter abduction) $do+n) -In*erior obliHue F 8G III F elevation and adduction $up and in) -&uperior obliHue F 8G I1 F depression and adduction $do+n and out) -<ateral rectus F 8G 1I F abduction $out) -3esions -8G III F eye turned do+n and out, ptosis, mydriasis -8G I1 F eye slig tly up and in F diplopia going do+n stairs F tilting ead a+ay *rom t e a**ected side to correct t e diplopia -8G 1I F eye deviates medially $abductor paralysis) 3 and 6. )hemical synapse% neurotransmitters% receptors% second messengers% e!!ects 7(& p ys. 93-98 -8 emical synapse $7(& p ys pg. 93-9/) -Presynaptic cell -action potential F depolariAation o* presynaptic terminal F )a*5 enters presynaptic terminal 6 release o! neurotransmitter into cle!t $Postsynaptic cell -neurotransmitter binds to receptors causing a c ange in permeability to ion -in ibitory neurotransmitters yperpolariAe F e:citatory depolariAe -(eceptor types $7(& p ys pg.33-38) -alp a 9 receptors F e:citatory F epi and norepi F "P, and increase intracellular )a*5 -alp a 0 receptors F in ibatory F in ibit adenylate cyclase and decrease cAMP -beta 9 receptors F e:citatory F epi and norepi F activate adenylate cylcase F cAMP -beta 0 receptors F rela:ation F epi and norepi F activate adenylate cyclase F cAMP @. 7lood supply to brain $see -irst "id pg. 990, 7(& Pat pg. 336-33@) -Embolism F most *reHuently to middle cerebral artery leading to contralateral paralysis, motor de*ects, sensory de*ects, ap asias -T rombosis F *rom at erosclerosis o* carotids, vertebral and basilar aa., and middle cerebral aa. -!emorr age F hypertension and coagulation disorders F most o*ten in basal ganglia, pons, *rontal lobe, cerebellum 8. 7asal Eanglia $globus pallidus, caudate, putamen) $-irst "id pg. 9;.) -initiation o* voluntary movements and control o* postural adJustments -Pat ology o* t e basal ganglia -Gegative signs: akinesia, bradydinesia, abnormal postural adJustments -Positive signs $dyskinesia at rest): ypertonicity $rigidity), tremors, c orea, at etosis, ballismus --untington disease 6 degeneration o* striatal neurons $putamen and caudate) -Par.inson disease 6 degeneration o* t e dopamine neurons in the substantia nigra $Tardive dyskinesia F e:posure to manganese and drugs F ypersensitivity to dopamine agonists -!emiballismus F lesions in contralateral subt alamic nucleus .. Pituitary associations -'ptic c iasm sits on top o* pituitary F bilateral emianopsia -&its in t e sella turcica - local pressure e**ects ypopatuitarism 9;. 7rain %(I and 8T -"bcess or cysticercosis 8T and %(I F ring en ancing lesion -%ultiple sclerosis %(I F multiple *ocal areas o* demyelination $plaHues) in brain and spinal cord

-!untington>s disease F atrop y o* t e caudate nucleus, putamen, and *rontal corte: F looks like ventricles ave enlarged 99. Pupillary lig t re*le: - doesn0t involve corte2 -#irect response F a**erent pat +ay is optic nerve o* eye tested F e**erent pat +ay is 8G III to t e eye tested -8onsensual response F a**erent pat +ay is optic nerve o* eye tested F e**erent pat +ay is 8G III o* opposite eye -"ccomodation F pupils constrict, eyes converge, lense more conve: F depends on 8G III and visual association corte2