("Blue Boxes")

Section Back Page General Clinical Issue 277 Abnormal Vertebral Curvatures Sub-type Kyphosis Lordosis Scoliosis 279 Spina Bifida S.B. Occulta S.B. Cystica Symptoms, etc. Abnormal increase in thoracic curvature Anterior rotation of the pelvis Abnormal increase in lumbar curvature Abnormal lateral curvature Rotation of the Vertebrae Laminae of L5/S1 fail to develop and fuse Usually no back problems One or more vertebral arches may fail to develop Associated with herniation of meninges/spinal cord Neurological symptoms present Cervical fractures occur often T11/T12 fracture is MOST common non-cervical At L5/S1 articulation results in back/lower limb pain Annuli Fibrosi degenerate with age Nucleosa Pulposa may herniate into vertebral canal Localized pain and Dermatome Pain 95% of Lumbar at L4/L5 or L5/S1 Incomplete dislocation of atlantoaxial joint Complete dislocation can lead to quadriplegia or death Stretching or Microscopic Tearing of Muscle Fibers Usually Lumbar Intervertebral Joints Low Back Pain Prolonged turning of head can lead to blackouts, etc. Inserted into subarachnoid space Inserted between L3/L4 or L4/L5 vertebrae Anaesthetic injected into epidural space Can lead to paralysis and muscle weakness Venous plexus that could help for metastasis of cancer cells to vertebrae or brain from abdomen or pelvis Symptoms, etc. Weakest part is the junction of middle and lateral thirds Axillary Nerve Radial Nerve Median Nerve Ulnar Nerve Break proximal to wrist joint MOST common injury to wrist (large lunate crushes it) Avascular Necrosis => degenerative joint disease MOST commonly used for venipuncture Paralysis of serratus anterior Also leads to inability to abduct beyond horizontal position Occurs when axillary nerve is severely injured Round contour of shoulder flattens out. Painful abduction of arm MOST common rotator cuff injury

284 Dislocation of Vertebrae 292 Spondylolisthesis 286 Herniation of IV discs 305

290 Rupture of Transverse Ligament of Atlas

Atlantoaxial Subluxation

300 Back Strain

301 Ischemia of Brain Stem 306 Lumbar Spinal Tap

Arteriosclerosis

Epidural Block Laminectomy 310 Ischemia of Spinal Cord 310 Vertebral Venous Plexus Section Upper Limb Arm Forearm Hand Page General Clinical Issue 410 Fracture of Clavicle 412 Fracture of Humerus Sub-type Surgical Neck Radial Groove Distal Humerus Medial Epicondoyle Colles Fracture Scaphoid Fracture Medial Cubital Vein Winged Scapula

412 Fracture of Radius 414 Fracture of Hand 422 Venipuncture 425 Long Thoracic N. Injury 427 Atrophy of Deltoid 427 Subacromial Bursitis 427 Supraspinatous Tendon 485 Rupture/Tendonitis 432 Compression of Axillary Artery 432 Injury to Axillary Vein 436 Big Axillary Nodes

444 Biceps Tendonitis 443 Brachial Plexus Injuries DR. CUMA 448 448 Radial Nerve

Can be compressed at lateral border of 1st rib Many occur around scapula dorsal scapular, suprascapular, subscapular arteries Profuse Bleeding and Possible entry of air (air emboli) in blood Humeral Nodes First to be involved with lymphangitis from hand infections, pectoral region or breast infection and superior abdomen Axillary Nodes MOST common site of metastases of breast cancer Tendonitis Common cause of shoulder pain Torn Tendon Detached muscle belly in distal anterior arm (Popeye Deformity) C5/C6 Waiter's Tip Position Drop Radial Claw Ulnar Median Ape MC Nerve Paralysis of Coracobrachialis, Biceps, Brachialis Wrist Drop At Brachial Plexus Anastamoses

At Brachial Plexus 478 478 460 475 Median Nerve Ulnar Nerve Elbow Tendonitis Carpal Tunnel Syndrome Ape (Claw) Hand

Parasthesia Hypothesia Anesthesia 482 Dislocation of AC Joint (Acromioclavicular) 485 Dislocation of Glenohumeral Joint 487 Bursitis of Elbow Section Thorax Page General Clinical Issue 54 Role of Costal Cartilages

Paralysis of Brachioradialis, Supinator, extensors of hand Medial Epicondoyle Claw Hand Repetitive use of extensors of forearm Median Nerve Entrapment => no opposing AND Tingling in lateral 3.5 fingers Diminished Cutaneous in lateral 3.5 fingers Absence of Cutaneous in lateral 3.5 fingers Possible AC/Clavicular Ligament Tears MOST common is Anterior Infero Dislocation

Student's Elbow Sub-type Rib Excision Rib Fractures Flail Chest

54

Supernumerary Ribs

Cervical Lumbar Rib Sternal Biopsies Costoclavicular Syn.

56 56 57 57 60

Sternum Thoracic Outlet Syndrome Dislocation of Ribs Separation of Ribs Paralysis of Diaphragm

62 64 67 67 73 73

Supernumerary Nipples Dyspnea Herpes Zoster Thoracocentesis Pulmonary Collapse Other Lung Issues Pneumothorax Hydrothorax Hemothorax Chlyothorax Pleuritis Lungs Heart Lung Resections Bronchoscopy Shingles

77 91 79

Auscultation/Percussing Inhaling Foreign Bodies

Repeated Flexion/Extension of Forearm Pain is severe during flexion Symptoms, etc. Piece of rib is removed during surgery, which regrows in time Weakest part of rib is anterior to angle Sizeable segment of the anterior/lateral thoracic wall moves freely because of multiple fractures Loose segments move paradoxically (opposite of normal) Articulate with C7 vertebrae and may compress C8/T1 Nerves Tinglings on medial side of medial border of forearm May confuse the identification of vertebral levels Often used for bone marrow samples Pallor and coldness of upper limb skin due to pinched axillary art. at STERNOCOSTAL joint at COSTOCHONDRAL joint Due to injury to Phrenic Nerve Dome pushed superiorly Paradoxical Movement May exist on line from axilla to groin Difficult Breathing Use accessory respiratory muscles to assist thoracic expansion Invades Spinal Ganglion and leads to burning pain at Dermatome at that spinal level Needle is inserted Superior to rib to avoid damage to nerve and vessels (intercostal) Broken lung collapses (recoil) the potential pleural space becomes real space air into pleural cavity Water into pleural cavity Blood into pleural cavity Lymph into pleural cavity Inflammation of pleura, can be heard during auscultation Root of Neck, Inferoposterior thoracic wall (T10) Performed at Intercostal 3,4,5 from lft to rt axillary (dull sound) Bronchopulmonary segments can be resected View Carina Right Lobes are more likely to contain inhaled bodies, etc. Immobile Blood Clot Mobile Blood Clot (leads to obstruction of blood supply) Insensitive to Pain Very sensitive to pain Local and Referred Pain Local pain and referred (intercostal) Referred pain to Neck and over shoulder (C3 to C5) Lymph nodes digest carbon and turn black in color MOST common type is Bronchiolar Carcinoma Metastasize thru pulmonary veins to all parts of body (esp. brain) Surgical Clamp can be placed here during bypass surgeries Inflammation of Pericardium Usually causes chest pain Results in pericardial friction rub Fluid seeps into Pericardial cavity Leads to Cardiac Tamponade (heart compression)

80 82

Pulmonary Thromboembolism Injury to Pleurae

Thrombus Embolus Visceral Parietal Costal/Peripheral Mediastinal/Diaph.

83

Inhalation of Carbon Lung Cancer

85 85

Transverse Pericardial Sin Pericardial Diseases

Pericarditis

Pericardial Effusion

93 95 95 96

Atrial Septal Defects Ventricular Septal Defects Strokes or CV Accidents Heart Murmurs

ASD VSD Mitral Insufficiency Aortic Insufficiency

99 Coronary Variations 99 Myocardial Infarctions 102 Heart Conduction Injury 103 Cardiac Referred Pain

112 Rec. Laryngeal N. Injuries 115 Thoracic Duct Laceration 116 Coll. Veins to Heart Section Abdomen Page General Clinical Issue 122 Closing Abdominal Skin Incisions 129 Abd. Surgical Incisions 131 Palpation of Inguinal Ring 133 Descent of Gonads 137 Hydrocele 137 Hematocele 138 Inguinal Hernias Sub-type

Incisional Hernia Testes Ovaries

Indirect

Direct

139 Testicular Cancer 139 Peritonitis

Testis Scrotum Ascitis Paracentesis

144 Greater Omentum, Func.'s 156 Duodenal Ulcers 160 Ischemia of Small Intestine Ileal Diverticulum

161 Appendicitis

164 Colitis

Colectomy Colonoscope

165 Rupture of Spleen

168 Rupture of Pancreas

168 Pancreatic Cancer

Pancreatic Head

Also can lead to Cardiomegaly (heart enlargement) See Embryo Diseases See Embryo Diseases Thrombi from on walls and block blood supply => Strokes diseased cusps scar and fail to close properly Aortic Semilunar Valve Many are varied Occlusions of major artery leads to ischemia to heart Coronary ischemia leads to damage of AV node Ventricles beat at their own rate, which leads to problems Ischemia and accumulation of metabolic products stimulate pain endings in the myocardium Referred to skin on medial aspect of the left upper limb Nerves supply all intrinsic muscles of larynx (except 1) Affected during brochial/eso carcinoma or aortic arch aneurysm results in chyle escaping which could lead to chylothorax (pg 73) Obstruction of IVC can lead to widening of azygous vein Obstruction of SVC => drainage to abd. wall into azygous system Symptoms, etc. Surgeons also include membranous layer of subcutaneous tissue while suturing because of its added strength Muscles are split along with fibers to lessen scarring Occurs if muscular and aponeuric layers don't heal properly Superolateral to pubic tubercle. If dilated, finger can go in w/ pain Dorsal abdominal wall to deep inguinal rings via gubernacular lig. Same place of origin, ovarian lig and round lig. presence of excess fluid in a persistent processus vaginalis Collection of blood in the cavity of tunica vaginalis Leaves abd. Cavity LATERAL to inferior epigastric vessels enters deep inguinal ring passes through inguinal canal Hernial sac formed by persistent processus vaginals Exits the superficial ring and commonly enters scrotum Leaves abd. Cavity MEDIAL to inferior epigastric vessels Protrudes through INGUINAL TRIANGLE Hernial sac formed by transversalis fascia does NOT traverse entire inguinal canal Cancer metastasizes into lumbar nodes Cancer metastasizes into superficial inguinal nodes Inflammation of Peritoneum => fusion of peritoneum Distension of cavity Needle inserted after anesthetic applied to analyze contents Prevents peritoneum from adhering to the parietal peritoneum Walls off inflamed organs to prevent spread of inflammation MOST common in posterior wall of superior part of duodenum Erosion of gastroduodenal artery leads to severe pain, distention, vomiting, fever, dehydration Congenital anomaly where remnant of yolk stalk ALWAYS on antimesenteric border of ileum may become inflamed similar to an appendicitis Acute inflammation of addendix Pressure of McBurney Point has most tenderness Usually starts as vague pain in preumbilicus region Migrates to right lower quadrant from parietal wall irritation Where ileum, colon, rectum are removed and replaced by a new opening in abdominal wall MOST cancers of large intestine are in rectum (rectosigmoid joint) Most Frequently injured organ with left side blows Causes intraperitoneal hemorrhage and shock Repair is difficult and splenectomy is done to prevent bleeding Due to sudden, severe, forceful compression of abdomen (i.e. seat belt in auto accident) Can result in digestion of organs due to leaking of panc. Juices Most cases of extrahepatic obstrucition due to cancer of HEAD Compresses and obstructs bile duct obstructive jaundice

171 Subphrenic Abscesses 173 173 176 176 176 Hepatic Lobectomies Hepatic Segmentectomies Liver Biopsy Rupture of Liver Cirrhosis of Liver

178 Gallstones Cholecystitis

180 180 182 182

Portal-Systemic Anastom. Portal Hypertension Perinephric Abscess Renal Transplantation

COMMON site for abscess in is subphrenic space Drained by incision to bed of 12th rib Can be done because the right and left portal veins do not communicate significantly Needle puncture made thru 10th intercostal space in M-Axil. L. Liver lacerations ofen cause hemorrhage and rt. Upper quad. Pain Hepatocytes are turned into fibrous tissue MOST common cause of portal hypertension MOST common site is at distal end of hepatopancreatic ampulla May also lodge in hepatic ducts or Cystic duct (biliary colic) Occurs if if stone blocks cystic duct causing backup of bile Pain in epigastric region and shifts to right hypochondrac region Bile may also enter blood and cause obstructive jaundice Portal veins have no valves, so blood flows reverse to new veins Enlarged vericose veins, may rupture and hemorrhage usually transplanted to Iliac Fossa where it has firm support only short lengths of vessels and ureters are needed Artery/Vein joined to ext iliac artery/vein As the kidneys ascend, they get new arteries and old ones go failure of old ones to go => accessory renal vessels Complete or intermittent obstruction of urinary flow Pain is referred to cutaneous T11 to L2 Psoas Sheath thickens and forms canal for pus to flow to inguinal Refers pain from: kidneys, ureters, cecum, appendix, sig. colon, pancreas, lumbar lymph nodes and nerves of post. Abd. Wall Shoulder Area Localized Epigastric and left hypochondriac regions (T6-T9 or T10) Epigastric Region or Right Shoulder (if bad ulcer) (T5-T9, T10) Inferior part of epigastric (T8-T9) Periumbilical region (T5-T9) Hypogastric Region (T10-T12) or Low Left Quadrant (L1-L3) Left hypochondriac region (T6-T8) Periumbilical region (T10) Epigastric region to Rt Hypochondriac (T6-T9) Small of back, lumbar quadrant ro inguinal to genitals (T11-T12) Graft can be sewn over to reduce swelling Anastomose with Superior Epigastric Veins Anastomose with Subcutaneous veins of body wall Collaterals with lumbar veins and azygous system Symptoms, etc. Heavier and Thicker, More prominent bone markings Wider, Shallower, Larger Inlet and Outlet Direct trauma to pelvic bones from lower limbs Joints and Ligaments rela and pelvic movements increase Due to increase in sex hormones, and relaxin Pelvic Floor supports fetal head during delivery Childbirth can cause injury to these areas Can lead to Urinary Stress Incontinence (dribbling urine) Painful spasms of adductor muscles of thigh Prolapses of internal rectal venous plexus Breakdown of Muscularis Mucosae Hypertension of portal system could lead to int. hemorrhoids tend to strangulate and ulcerate Thromboses in the veins of external rectal vecous plexus Due to pregnancy, chronic constipation, inc. abd. Pressure

185 Accessory Renal Vessels 185 Ureteric calculus 226 192 Psoas Abcess 192 Post. Abdominal Pain REFFERED PAIN 189 Diaphragm 199 199 199 199 199 199 199 199 199 200 201 Stomach Duodenum Pancreatic Head Small Intestine (Jej/Ileum) Colon Spleen Appendix Gallbladder & Liver Kidneys and Ureters Abd. Aortic Aneurysm Abd. Pelvic Collateral Ven. Kidney Stone

Iliopsoas

Pleura/Peritoneum Peripheral Regions

Section Pelvis

Page General Clinical Issue 213 Sexual Pelvic Differences 214 Pelvic Fractures 215 Relaxation of Pelvic Joints & Ligaments during Preg. 219 Injury to Pelvic Floor

Inf. Epigastric Sup. Epigastric Epidural Ven. Plexus Sub-type Males Females

221 Injury to Pelvic Nerves 252 Hemorrhoids

Obturator Nerve

Internal External

POST MIDTERM Pelvis Post Midterm 254 Disruption of Perineal Body Prolapse of Vagina Episiotomy 261 Rupture of Male Urethra Final Support of of Pelvic Viscera Can be stretched/torn during childbirth Removes support from inferior part of posterior wall of vagina Surginal Incision of the perineum and lower, posterior vaginal wall Made to enlarge Vaginal Orifice and Prevent Jagged Tearing Rupture of Spongy Urethra Results in urine passing into superficial perineal pouch Could flow into scrotum, penis Will NOT flow into thigh (fascia lata) Will NOT flow into anal canal (perineal fascia and membrane) Painful collections of Pus Tenderness/Fullness between anus and ischial tuberosity Can open into: anal canal, rectum, perianal skin, ischioanal fossa Normally bypassed sinuses of corpora cavernosa and filled Parasympathetic Stimulation Bulbospongiosus/Ischiocavernosus compress dorsal veins Semen goes to prostatic urethra via ejaculatory ducts Semen Expelled from urethra as a result of: 1. Closure of Urethral Sphincter (SYMP. L1/L2) 2. Contraction of prostatic/urethral muscles (PARA. S2-S4) 3. Contraction of Bulbospongiosus (Pudendal, S2-S4) Female Urethra is Very Distensible, so Easy to put catheter Not Palpable unless infected Pudendal Nerve Block Anesthesia given during childbirth Pudendal does most, but not all Ilioinguinal does anterior part Posterior Cutaneous done also Could Fracture Pubic Rami Could Fracture Acetabula Fairly Common Injury Often Interrupt Blood Supply Usually between greater and lesser trochanters Angle of Inclination Varies with Age, Sex, Devt of Femur Angle of Inclination DECREASED => mild shortening of limb Angle of Inclination INCREASED Blow to the Knee Sudden Contraction of Quadriceps MOST Common LONG bone to be FRACTURED MOST Common site of COMPOUND Fracture Skin and Blood Vessels are Torn A) Through Nutrient Canal => Nonunion of Bone Fragments B) Narrowest @ Junction of Inf. And Middle Thirds Fractures occur just PROXIMAL to LATERAL malleolus Excessive Inverted Position => Ankle Ligament Tear Talus Hits Lateral Malleolus and Shears It Off

264 Ischioanal Abscesses

270 Erection, Emission, Ejaculation

Erection

Emission Ejaculation

274 Dilation of Urethra Infl. of Bartholin Gl. Pudend/Ilioinguinal Nerve Blocks

Lower Limb

319 Fractures of Hip Bone

Anteroposterior Compression Lateral Compression

319 Femoral Fractures

320 Patellar Fractures 321 Tibial/Fibular Fractures

Coxa Vara Coxa Valga Transverse Tibia

Fibula

324 Fractures of Foot Bones

332 Incompetent Valves 335 Testing Quadriceps Fxn

Calcaneus Metatarsals Phalanges Vericose Veins

Patellar Tendon Refl. Chondromalacia Pat. Genu Valgum Genu Varum 341 Groin Pull 341 Transplantation of Gracilis 344 Femoral Pulse Cannulation of Vein Femoral Hernia

Veins become dilated, which lead to reverse flow when muscles contract Should extend leg against resistance Tests L2-L4 Nerves Results from Quadriceps Imbalance Knock knee Bow Leg Usually involves flexor and adductor muscles used to replace hand muscles and anal sphincter Palpable just inferior to midpoint of inguinal ligament Normally a strong pulse Used for passing catheter to heart Femoral Ring is site of femoral hernia

346 Trochanteric/Ischial Bursitis 351 Sup. Gluteal N. Injury 351 351 352 357 357 Sciatic Nerve Injury Hermatoma of Buttock Pulled Hamstrings Popliteal Pulse Popliteal Aneurysm

360 Common Fibular Nerve

360 365 365 369

Ant Tibialis Strain Infl. Of Calcaneal Tendon Calcaneal Tendon Relflex Tibial N. Injury

Shin Splints

371 Posterior Tibial Pulse 372 Plantar Fascitis 375 Ext. Dig. Brevis Contusion 376 Sural Nerve Grafts 376 Plantar Reflex

Deep Tendon Refl.

377 Dorsalis Pedis Pulse 379 Wounds of Sole of Foot 383 Femoral Neck Injury 383 Dislocation of Hip

"Wounded Sole"

389 Knee Joint Injuries

Unhappy Triad

390 Bursitis of Knee

Ant. Drawer Sign Post. Drawer Sign Suprapatellar Burs. Prepatellar Bursitis Subcutaneous Infrapatellar Burs. Deep Infrapat. Burs.

Excessive Friction Pelvis descends on unsupported side Results In waddling (Trendelenberg) gait Impairment of thing extension and leg flexion due to injury of gluteal veins Occur in quick start sports Lack of pulse is sign of femoral artery obstruction Causes Edema and Pain Femoral Artery can be ligated because of genicular arteries MOST commonly injured nerve in lower limb Leads to Foot Drop Also, foot plantarflexes and inverts Anterior Tibial Muscles sweel from overuse Leads to Calf Pain Tests S1 & S2 nerve roots Paralysis of Flexor Muscle in Leg Paralysis of Intrinsic Muscles in Sole of Foot Palpated between Medial Malleolus and Achilles Tendon Easier if foot is inverted Inflammation of Plantar Aponeurosis Heel Spur Syndrome Inflamed Muscle may resemble sprained ankle Sometimes Tibial and Fibular Fail to Unite L4, L5, S1, S2 Roots Lateral Sole is stroked with blunt object Normal Response: flexion of toes Abnormal Resp: dorsiflexion of great toe Palpated when slightly dorsiflexed Plantar Arch injury ==> lots of bleeding Disrupts blood flow to femoral head can lead to aseptic necrosis Acquired dislocation is not common Usually caused in automobile accidents, etc. Posterior dislocations are MOST common Shortens and medially rotates affected limb Common because knee is weight bearing Stability because of ligaments and muscles MOST Common injury is Ligament Sprains Medial (Tibial) Collateral Ligament Ruptures Could possibly tear Medial Meniscus Also tearing of ACL ACL Rupture allows tibia to slide forward PCL Rupture allow tibia to slide posteriorly Caused by bacteria entering bursa from torn skin Friction between skin and patella (==> "housemaid's knee") Excessive friction between skin and tibial tuberosity Edema between patellar ligament and tibia MOST frequently injured JOINT in body (usually sprain) Most often torn ==> Calcaneofibular/ant. Talofibular ligaments Foot is forcibly everted ==> fractures medial malleolus Lateral deviation of great toe proximal phalanx is dorsiflexed and middle phalanx is plantarflexed Results in "fallen arches" Plantar Calcaneonavicular ligament can't support head of talus

395 Ankle Injuries Pott fracture 398 Hallux Valgus 398 Hammer Toe 401 Flatfeet

Section Head

Page General Clinical Issue 501 Fractures of Calvaria 506 Facial Injuries 509 Trigeminal Neuralgia 512 Facial Artery Pulses 512 Carcinoma of Lip 514 Parotid Gland Infection 516 Scalp Injuries/Infections

Sub-type Pterion

521 Thrombophlebitis 521 Metastasis of Tumor Cells 521 Fractures of Cranial Base 522 Dural Origin of Headaches 523 Head Injuries 527 Cerebral Injuries

527 Cisternal Punctures 528 Hydrocephalus 530 Vascular Strokes

530 Transient Ischemic Attacks 531 Fracture of Orbit 537 Ophthalmoscopy 538 Corneal Abrasions

543 Oculomotor Nerve Palsy 543 Abducent Nerve Palsy 543 Horner Syndrome 545 552 552 553 556 560 560 566 Central Retinal Art. Block Mandibular Nerve Block Inf. Alveolar Nerve Block Dislocation of TMJ Gingivitis/Periodontitis Nasopalatine N. Block Greater Palatine N. Block Gag Reflex

568 Excision of Submand. Gl. 573 Nasal Fractures 575 Epistasis 576 Rhinitis

Symptoms, etc. Overlies anterior branches of middle meningeal artery Untreated artery hemorrhage may cause death in few hours Injuries cause marked swellings because of no deep fascia Paroxysm (sharp pain) Maxillary Nerve is most commonly involved Can be felt on inf. Border of mandible Compression of Facial art. Does not stop bleeding b/o anastomoses Usually lower lip. Common to smokers ex: Mumps Pain when chewing, may extend to parotid duct Partially detached Can be replaced if at least one vessel is intact b/o anastomoses Danger Area Loose Connective Tissue fourth layer b/c infections ==> emissary vv. Scalp Infection cannot pass posteriorly, laterally Infection goes into eyelids and root of nose Lacerations MOST common type of head injury required surgical care Profuse bleeding b/o anastomoses and no retraction of arteries b/o CT Of Facial Vein May lead to thrombophlebities of cavernous sinuses Tumors in neck can spread to brain via internal vertebral venous plexuses May tear internal carotid within cavernous sinus (atriventricular fistula) Cavernous Sinuses get bigger => blood into ophtalmic => bulging eyes Distension of scalp/meningeal vessels one cause of headache Can cause epidural hemorrhage => concussion, drowsiness, coma Concussion abrupt, brief loss of consciousness after blow to head Contusion Pia can rip and allow blood into subarachnoid space Lacerations Rupture blood vessels => increased pressure and cerebral compression Compressions Produced by: 1. Intracranial collections of Blood 2. Obstruction of CSF circulation/absorption 3. Intracranial tumors/abscesses 4. Edema of the brain CSF obtained from post. Cerebromedullary cistern See Embryo Clinicals Cerebrovascular Acc. Occurs when anastomoses in brain is not working properly Hemorrhagic Stroke Occurs due to rupture of aneurysm Berry Aneurysm most common type: occurs near cerebral arterial circle (of Willis) Neurological Symptoms from ischemia Blowout Fracture Displacement of orbital walls into maxillary/sphenoid/ethmoidal sinuses Exophthalmos Protrusion of eyeball (due to tumor in orbit or hyperthyroidism) Physicians view fundus of eye Detachment of Retina May follow blow to eye; Laser surgery might prevent blindness Ulcers/Transplants When sensory innervation (VII) of cornea is lost => ulcers Presbyopia Reduction of focusing power of lenses Cataracts Clouding of lens (replaced with plastic lens) Glaucoma Aqueous humor (not funny), not drained as well => blindness (perm.) Affects Most Eye Muscles, Levator Palpebrae Superioris, Sphincter Pup. Results in ptosis, dilation of pupils, abducted and depressed (down/out) Loss of Lateral Gaze (lateral rectus muscle) => diplopia Paralysis of Sup Tarsal muscle (sympathetic inn) => ptosis Constricted pupil, sinking/redness/dryness of eye End Artery => instant blindness Done where it enters IT Fossa (auriculotemp., inf. Alv., lingual, buccal) Injected around mandibular foramen Dislocates anteriorly and mouth remains open Periodontitis: inflammation of gingivae => absorption of bone Injected into incisive foramen Injected into Gr. Palatine Foramen Afferent by IX; Efferent by X occurs because of no initiation of swallowing (raising of mylohoid m.) Common procedure; Risk of cutting mandibular branch of Facial (VII) Direct Blow Could fracture cribriform plate => CSF rhinorrhea Lateral Blow May result in deformities Nose Bleeding (most common in Kiesselbach's (Little's) area) Occurs during upper respiratory tract infections Infections may spread to: 1. Anterior Cranial Fossa via Cribriform Plate

577 Ethmoidal Cell Infection 577 Maxillary Sinus Infection 582 Otoscopy Otitis Media Tympanic Perforation Mastoiditis 584 584 588 Page 595 596 601 601 602 605 609 Paralysis of Stapedius Pharyngotympanic Tube Blockage Motion Sickness General Clinical Issue Sub-type Platysma Injury SCM Injury Subclavian Vein Puncture External Jug Vein Prominence Post. Triangle Dissection Severance of Phrenic N. Ext. Carotid Ligation

Section Neck

612 Internal Jugular Pulse 616 Cervicothoracic Ganglion Block 616 Lesion of Sympathetic Trunk

618 621 629 629 630 630 638 639

Radical Neck Dissections Pyramidal Lobe of Thyroid Gland Laryngeal N. Injuries Recurrent (inferior) Aspiration of Foreign Bodies Tracheotomy Tracheostomy Tonsillitis Zones of Neck Trauma Zone I

Zone II

Zone III

Section Cranial Nerves

Page 650 653 655

General Clinical Issue Olfactory N. Injury Edema of Retina Oculomotor Nerve Palsy

Sub-type

Results in

655 Trochlear N. Injury 655 Trigeminal N. Injury

Results in

658 Abducent N. Injury 660 Facial Nerve Injury Results in

509 535

Bell Palsy

2. Nasopharynx and Retropharyngeal Soft Tissues 3. Middle ear via Pharyngotympanic (Auditory, Eustachian) tube 4. Paranasal Sinuses 5. Lacrimal Apparatus and Conjunctiva Could break through wall of orbit => blindness Poor drainage because openings of sinuses are on top Helix Pulled Up, Out and Back to straighten meatus Middle Ear Infection usually due to upper respiratory infections Done posteroinferiorly due avoid vessels and chorda tympani Infection of mastoid cells b/o otitis media Leads to increased volume leads to retraction of tympanic membrane => impairs hearing Due to fluctuating stimulation of maculae of memb labyrinth of ear Symptoms, etc. Causes skin to fall away in slack folds Can result in torticollis (wry neck) => difficulty to turn to opposite side Often used for central line placement Becomes prominent during heart failure CN XI Injury (See below) Paralysis of diaphragm (agent injected on ant. surface of ant. Scalene) Blood flow is slowed down, but not stopped Anastomosing is done by Occipital branch Can be palpated superior to the medial end of clavicle May relieve spasms involving brain and upper limb Horner Syndrome; symptoms: 1. Pupillary constriction 2. Ptosis of upper eyelid 3. Sinking in of Eye 4. Vasodilation and Absence of sweating Most cutaneous branches of cervical plexus are removed Present in 50% of thyroid glands Leads to Paralysis of Vocal Fold => Hoarseness Vocal Folds Tense and Close Rima Glottidis => Choking Temporary opening of trachea Long-Term opening of trachea Usually in Palatine Tonsils Root of Neck to Clavicles Injury to: Cervical Pleurae, Lung Apices, Thyroid and Parathyroid Glds. Trachea, Esophagus, Common Carotids, Jugulars, C1-C7 Cricoid to angles of mandible (MOST COMMON) Injury to: Thyroid Gld Apices, Thyroid/Cricoid cartilages, larynx laryngopharynx, carotids, juguluars, esophagus, C1-C7 Superior to angles of mandible Injury to: Salivary Glands, Facial Nerve, Oral/Nasal Cavities, Oropharynx, Nasopharynx Symptoms, etc. Loss of Smell (due to injury to cribriform plate) Inc in CSF pressure => edema of retina Ptosis Down & Out Eyeball NO pupillary or accomodation reflex Dilation of Pupil Paralysis of Superior Oblique Muscle => diplopia Paralysis of Muscles of mastication Loss of ability to sense soft tactile, thermal, painful in face Loss of corneal reflex Paralysis of Lateral Rectus => Medial Deviation of Eye MOST commonly injured MOTOR nerve Paralysis of Facial Muscles Loss of Taste to Anterior 2/3 of tongue Altered Secretion of Lacrimal & Submandibular/Sublingual Glands Paralysis of Stylohyoid, Post Digastric Increased Volume when Hearing Common during surgery of parotid gland Inflammation of Facial N. near stylomastoid for. (MOST Common)

660 Vestibular N. Injury 663 Glossopharyngeal N. Injury

666 Vagus N. Injury

667 XI Spinal Root Injury 668 Hypoglossal N. Injury

Conductive Deafness Involves External or Middle Ear Sensorineural Deafness Diseases in Cochlea or in pathway to cochlea Results in Loss of Taste to Posterior 1/3 of Tongue Loss of Gag Reflex Loss of Sensory to Oropharynx, Middle Ear Paralysis of Stylopharyngeus Altered Secretion of Parotid Gland Pharyngeal branches Difficulty in swallowing (dysphagia) Weak Voice and Tires Easily Lesion to Recurrent is more common b/o longer course Weakness/Atrophy of Trapezius & SCM Vulnerable During Tonsillectomy Deviates toward paralyzed side b/o "anchoring effect"