ANATOMY SURVIVAL GUIDE Only the Essentials to Save You Time High-Yield Anatomy Reviews, Practice Questions, and Must-Know Lab Objective Check-off Lists Created by Students for Students cIWhy You Need the Anatomy Survival Guide... T's all about organization and efficiency folks. You're smart or you wouldn't be in medical school. But smart's not enough. The biggest challenge youll face over the next couple years is the high volume of information and lack of time to thoroughly cover it all. It helps to have high-yield study tools. The Anatomy Survival Guide contain + High-yield lecture exam reviews provide an overview of the more difficult material covered on each exam, * Check-off lists of must-know lab objectives provide a quick and easy way to make sure you've identified the structures most likely to be on the lab practical exams. + Hundreds of practice questions based on previous versions of the ANTR5S! course packet, with many written in a style similar to the actual written exams given in ANTR5S1. How do know if you're learning the material before taking the exam? You do lots and lots of practice questions, that’s how. Do questions as you go through the material to help you identify your weak areas. Important Disclaimer The practice questions provided in the Anatomy Survival Guide have not been reviewed or officially endorsed by either the ANTRSBI course faculty or MSUCOM. The questions were written by a medical student, and are an attempt to reflect the important material in the course. Many students have found them to be an invaluable tool for self-evaluation. We hope you do too. Good luck! Contributors The ASG is the brainchild of Sam Alam, who also wrote hundreds of great questions and organized the ef forts of the MSUCOM Scribe Service in creating the original review notes. Other contributors: Dr. Bice (anatomy reviews, drawings and editing); Dr. Falls (upper limb review), On the cover: Figure 409 Gray, Henry. Anatomy of the Human Body. Philadelphia: Lea & Febiger, 1918; Bartleby.com, 2000. www bartleby.com/107/. (05/08/08) © 2010 Sam Alam and MSUCOM Office of Academic SupportTable of Contents Topic rea Page. | Section 1 - Back and Thorax 1-% High-Yield Review Topics 1 Must-know Lab Objectives Check-off list 10 |Practice Questions 1 Answers to Practice Questions 43 Section 2 - Head and Neck 44 - 90 High-Yield Review Topics 44 Must-know Lab Objectives Check-off list 5t | Practice Questions 60 Answers to Practice Questions 90 Section 3 - Upper Limb gi - 114 High-Yield Review Topics ot High-Yield Review Topics ~ Part 2 199 | Must-know Lab Objectives Check-off list 102 Practice Questions 108 Answers to Practice Questions i 114 Section 4 - Abdomen 115 - 144 High-Vield Review Topics 15 Must-know Lab Objectives Check-off list 124 Practice Questions 130 Answers to Practice Questions _ 144 Section 5 - Pelvis, Perineum & Lower Limb 145 - 200 High-Yield Review Topics for the Pelvis & Perineum | 145 Practice Questions for the Pelvis & Perineum 149 Answers to ee Questions 1600 imb 161 171 Answers to Practice Questions i 192 Must-know Lab Objectives Check- off list 193HiGu-Ytetp Review Topics For THE BACK AND THORAX, 1. Introduction to the nervous system A, Neurons ~ what are they? They are cells of the nervous system, which ate specialized 10 conduct electrical impulses, 1. Basic parts 8. Cell body (soma) contains the nucleus and other organelles , Axon, a cellular projection; often called a nerve “fiber” projects to target 1, GSE. 2. GSA = General Somatic Afferent (aka. SAN 3. GVE = General Viscer 4GVA General Somatic Ffferent (a.k.a. SEN = Somatic Efferent Neuron) ‘Motor neuron whose cell body is located in the ventral horn of the spinal cord or brainstem, b._ Carries efferent (motor) outflow ONLY to skeletal muscles fibers. jomatic Afferent Neuron) nsory neuron whose cell body is located in the dorsal root ganglion (spinal ganglion) 1b, Transmit sensations of touch, pain, vibration, pressure, hot/cold, streteh, and proprioceptive (body position) information Receptors are located in “somatic” structures, e-., skin, bones, joint capsules, and skeletal muscles, 1 Effezent (a.k.a. VEN = Visceral Bfferent Neuron) 1. Neurons of the AUTONOMIC NERVOUS SYSTEM. b. Carry efferent (motor) outflow to smooth muscle, cardiae muscle, and glands. ©. Classified as either sympathetle or parasympather General Visceral Afferent (a.k.a, VAN = Visceral Afferent Neuron) 8, Sensory neuron with cel! bodies located in the dorsal root ganglion, b. Axons follow the pathways of either sympathetic or parasympathetic axons from the organ back to the CNS (jc. are found in visceral nerves) ©. The sensory information relayed by GVAS differs from GSAS, 4. GVAs transmit sensations of visceral pain (nociceptors) and nausea, as well as information about stretch (mechanorecepiors), pressuxe (baroreceptors), internal body temperature (¢hermoreceptors), and blood gas levels and pH (chemoreceptors) Most visceral afferent information is NOT consciously perceived, The primary exceptions are 1) the sense of fullness conveyed by stretch receptors in hollow viscera, such as the stomach, rectum, and bladder, 2) visceral pain, and 3) nausea, £. GVAsdo NOT allow distinctions between hot & cold or fine & course pressure. g- Visceral pain is generally due to over-distension, inflammation, or ischemia lack of oxygen). 1h. Referted pain is a special phenomenon different from visceral pain,E, Structural divisions of the nervous system 1. Central Nervous System (CNS) a, Consists of the brain and spinal cord . The CNS is housed WITHIN the dorsal body cavities (craniaband spinal) 2, Peripheral Nervous System (PNS) a. Consists of the cranial nerves and spinal nerves 1b, These nerves conduct sensory information to the CNS and transmit motor commands to effector organs. TI, Spinal Cord and Spinal Nerves ‘A, Cross-sectional anatomy of the spinal cord 1, Gray matter—central “butterfly” shaped mass; gray matter is composed of cell bodies and UNinyelinated neural fibers, ne dorsal gay hora ventral gray hom ey . lateral gray hom - only in T1-L2 and Z ‘82-84 spinal cord segments inal Nerves 1, Anatomy of a typical spinal nerve ‘a, A spinal cord segment is a region of the spinal cord that gives rise to the dorsal and ventral rootlets that form a single pair of spinal nerves, b, Dorsal roots—contain SENSORY neuron fibers (GSAs and GVAs) ¢. Dorsal root ganglia (a.k.a, spinal ganglia)—contain the cell bodies of SENSORY neurons (GSAs and GVAs) 4, Ventral roots—contain motor neuron fibers (GSEs and GVEs) ¢. Spinal nerve—a very short (< lem) structure that contains BOTH motor and ‘sensory fibers (GSEs, G8As, GVEs, GVAs) f, Ventral primary ramus—the anterior branch of a spinal nerve; contains both motor and sensory fibers . Dorsal primary ramus— the posterior branch of a spinal nerve; contains both motor and sensory fibers 2, Numbering of spinal nerves (31 pairs) a. Cervical - 8 b, Thoracic — 12 ¢. Lumbar 5 4. Sacral ~ 5 €. Coceygeal ~ 1 3. Relationship of spinal nerves to vertebrae ‘a, Spinal nerve raots exit the vertebral canal through an intervertebral or sacral foramen (except for Cl, which exits above the Cl vertebrae), where they ‘merge to form a spinal nerve that almost immediately spits into the dorsal and ventral primary rami (branches) as it emerges from the intervertebral foramen, i. Spinal nerves Cl ~ C7 exit ABOVE the vertebra of the corresponding, umber. Spinal nerve C8 exits BETWEEN the C7 and Ti vertebrae, Spinal nerves TI - Col exit below the vertebra of the corresponding number (TI ~ LS exits immediately BELOW the pedicle), 4, Distribution of spinal nerves throughout the body ‘a, Recurrent Meningeal Nerve (Sinuvertebral nerve or Nerve of Luschika) Ateach vertebral level, a small branch (or branches), called the recurrent ‘meningeal nerve, arises from the spinal nerve. It then passes back through the IV foramon to RENTER the vertebral canal. i. Contains postganglionic (postsynaptic) sympathetic efferent fibers, visceral afferent fibers, and somatic afferent fibers. fi, Innervates the PLL (and ALL), annulus fibrosus of IV dise, epidural blood vessels, anterior dura mater, dural sleeve, and vertebral periosteum,Dorsal Rami 4, Each dorsal ramus supplies a facet joint (articular branch), a segment of intrinsic back muscles (muscular branch), and a sirip of skin on Posterior aspect of body (postetior cutancous branch). ©. Ventral Remi 4. The ventral rami of T1 to TI are called intercostat nerves (TI also contributes tothe brachial plexus) il, The ventral ramus of T12 is the subcostal norve (sub = below; costat = rib), 4, Intercostal and subcostal nerves provide motor and sensory innervation to structures of the ANTEROLATERAL body wall. iii, The remaining ventral rami form four somatic neural plexuses: Cervical plexus CI-C4 | innervates neck, shoulders, upper chest; gives ise lo the phrenis newe (C3, 4, 5 keeps the diaphragin alive) zi | Brachial plexus C5-T1_| Innervates upper limb ‘Lumbar plexus L1-E4 | Innervates lower abdomen, perineum and lower limb Sacral plexus L4-S4 | Innervates pelvis, perineum and lower limb C. Segmental innervation 1. Dermatame—the cutaneous (sensory) distribution ofa spinal nerve (a stip of skin innervated by the dorsal roots ofa single pair of spinal nerves). a. T4= nipple dermatome b, T10-= umbilical dermaiome 2. Myotome—a group of muscles iamervated by a spinal nerve, 8, Most muscles are innervated by more than one spinal nerve. b, Most spinal nerves innervate more than one muscle, €. In other words, there is builtin redundancy. 3. Referred visceral pin 4. Visceral pain resulting from injury, inflammation, ischemia, over: or obstruction ofa visceral organ (an organ located in the ventral body cavities) is generally poorly localized, and may be “felt in a somatic structure rather than in the organ in which the ination originates. b. In other words, the input is “misinterpreted” by the CNS. «: This is beeause ofthe common fina pathway between GVAs and GSAS. a. Because of the segmental distribution of nerves and the corresponding ddermatomes, there are specific areas where referred pain is felt. Example: Pain from a heart attack felt in the left arma. UI, Autonomie Nervous System (ANS) The ANS is traditionally defined as « VISCERAL EFFERENT (MOTOR) system (the neurons are GVEs). (Ths is « mater of some debate ~ some include GVAs in the ANS) A. ANS innervation J, Effector organs = smooth musele (eg, muscle found in your respiratory, Gl, reproductive, and urinary tracts and blood vessels), cardiac muscle, and glands, B. ANS participates in important viseeral reflexes (regulatory feedback mechanisms), which control and regulate breathing, blood pressure, heart rate, body temperature, digestion, ‘urination, defecation, production, and response to stres. C: Many pharmaceutical and recreational drugs act on the ANS, typically by either mimicking or blocking the sympathetic or parasympathetie division D. The ANS consists of a TWO-NEURON sequence. 1, This distinguishes it from the Somatic Efferent System, in which a SINGLE neuron runs from the spinal cord out to a skeletal muscle 1 neuron = PREganglionic (presynaptic) neuron i. The eell bodies ofthe preganglionic neuron are located inthe central nervous system (CNS). b. 2" neuron ~ POST ganglionic (postsynaptic or ganglionic) neuron 3Pot and Shoot” Pepersyp seymp i. The cell bodies of the ganglionic neuron are located in aitonomic ‘ganglia in the peripheral nervous system (PNS). reser pt KO ~ = =~ SET all ty all baty 7 ariooth, mental: oils Mian gragent a E. Sympathetic Division of the ANS "Fight or Flight" 1. Anatomically designed to permit a gencralized response to stress, whether physical or psychological (e.g. exereise, fear) 2, Responsible for preparing the body to respond in a “erisis” by ‘promoting energy usage, Increasing aleriness, diverting blood away from ‘non-essential systems, and directing blood toward critical systems (skeletal muscle, heart, lungs, brain). 3, Sympathetic division innervation 'a. Blood vessels throughout the body (Ifa tissue has a blood supply, it's innervated by the sympathetic division). EXCEPTION: Erectile tissues of the genitalia receive parasympathetic innervation, ». Glands located throughout the body. Sweat glands receive ONLY sympathetic innervation. ¢, Visceral organs of the head and neck 4, Visceral orgens of the thoracic cavity ce. Visceral organs of the abdomen and pelvis 4, Sympathetic Nervous System (SNS) Anatomy ‘a, Called the “Thoracolumbar” division because the preganglionic cell bodies are located in the lateral gray horn of the THORACIC and upper LUMBAR spinal cord (TI ~L2). bb. Sympathetic postganglionic cell bodies are located in the peripheral nervous system, relatively near the spinal cord, in structures called AUTONOMIC GANGLIA. This is why, relatively speaking, the PREganglionie sympathetic fibers are short, and the POSTganglionic sympathetic fibers are long. «. Categories of sympathetic autonomic ganglia: Paravertebral and Prevertebral Ganglia. sooth sonal PeatgorlinteFlbece with i cell bodies in sympathetic chain garghe in the head, neck, limbs, body wal, ond therace estgangionic fibers with ‘eel Eades in prevertebral ‘Shdominopelvie viscera PARAvertebral (a.k.a. sympathetic chain) ganglia—located alongside the vertebral column from the cervical region to the coceyx. PREvertebral (a.k.a, collateral) ganglia—located in the abdominal cavity at the major branch points of the abdominal ‘aorta; named for the artery with which they are associated (Celiac, Superior mesenteric, and Inferior mesenteric ganglia). 4. Adrenal medulla (a special case) ‘The adrenal medulla functions as postganglionic sympathetic neurons, and secretes epinephrine (adrenaline) direetly into the bloodstream, producing a widespread and longer-lasting, muscle ond glands innervate sympathetic response. "ADRENALINE RUSH” 5, Sympathetic Eiferent Pathways ‘a, The SNS innervates structures found throughout the body. b. The route taken by the sympathetic neurons depends on what is being nervated. .. Sympathetic innervation of blood vessels and glands located in the and body wall I. Proganglionic fibers exit the ‘thoracic or exit ak lumbar spinal same, leve cord via theventral root, enter the spinal nerve, and go into the ventral ramus. fi. They enter the sympathetic ganglion via a white ramus communicans (white rami are only located from TT and L2). ili. They synapse in a sympathetic ganglion at the same level, OR ascendidescend to a sympathetic ganglion ata different level + Usually, preganglionic fibers originating in spinal levels Ti ~TS ascend, + Many preganglionic fibers originating in spinal levels T6 = 12 (sp. T10 ~L2) descend. iv. The postganglionic fibers reenter the ventral primary rarmus via 4 gray ramus communicans, and can either continue in the ventral primary ramus, or backtrack to the dorsal primary ramus (gray rami are found at all levels). ¥. Postganglionie fibers are distributed to blood vessels and sweat glands via the many named peripheral nerves. 4. Sympathetic innervation blood vessels and glands located in the head Preganglionic fibers exit upper thoracic spinal cord via the veniral root > spinal nerve > venural ramus > sympathetic chain via a white fi, Ascend to superior cervical sympathetic ganglion and synapse, iti, Postganglionic fibers exit the ganglia (NOT via a gray ramus ‘communicans) ~> carotid periaterial plexus, ¢. Sympathetic innervation of viscera in the thoracic eavity 4, Preganglionic fibers exit upper thoracic spinal cord via the venéral root, enter the spinal nerve, then the ventral ramus. 4i, Enter the sympathetic chain via & white ramus communicans. iii, Ascend to cervical sympathetic ganglia and synapse, iv. Postganglionic fibers exit the ganglia (NOT via & gray ramus ‘communicans) as cardiopulmonary nerves.£. Sympathetic innervation of abdominal vi 1, Preganglionic fibers sation md ope 7 Tame pint cod romana vera reece spa nerve, then the ventral ramus, and enter the sympathetic chain via 2 white ramus ii, Preganglionic fibers pass through the sympathetic chain ganglia WITHOUT ssynapsing and become the Greater, Lesser, Least, and Lumbar splanchnic nerves, ill. They enter the preveriebra rai wa abdominal cavity and synapse in PREvertebral gangli. Iv. Posiganglionic fibers travel with abdominal blood vessels to reach, final destination ‘Sympathetic innervation of the adrenal medulla i, Same as above pathway, except that the fibers also pass through the prevertebral ganglia without synapsing, and go directly to the adh medulla @ simi ahhigus SR. Seructare fiber | Symp POSTuang fibers | Visceral seven! bes ental ro x Spinal nerve. x Possible x Dorsal primary rams x x ‘Ventral primary ramus x x x White ramus communicans x Generally not ‘Gray ramus communicans x x Cardiopulmonary neve x x “Thoracic splanchnic n, — x x Structure, Symp pregang cell bodies ‘Symp postgang cell bodies ‘Laferal gray hom Ti —E2, x ‘Sympathetic chain ganglia [Prevertebral gang., Parasympathetie Division of the Autonomic Nervous System Promotes homeostasis, with emphasis on relaxation, food processing, and energy storage "REST AND DIGEST" 2. The parasympathetic division has a much more LIMITED distribution in the body—just to viscera ‘of head (eyes and glands), viscera within the ventral body cavities, and erectile tissues of male and female extemal genitalia 3. The parasympathetic division is also called the “Craniosacral” division because the preganglionic cell bodies are located in the brainstem and sacral spinal cord 4. Postganglionic cell bodies are located in (intramural ganglia) or near the organ innervated (Germinal ganglia) — this means that the PREGANGLIONIC axons are relatively Jong. 5. Craniat nerves innervate organs inthe head, thorax, and abdomen. a, PREganglionic cell bodies are located in the brainstem, b, POSTganglionic cell bodies are located in “autonomic ganglia” Cranial Nerve | Location of postganglionic cal bodies] Tnnervation/Actions om ciliary aailion pupil constriction for Tiiting light) & Ocalomator 2 lens accommodation (for near vision) CN VIE ‘ibmandibular ganglion submandibular & sublingual salivary giands Facial sphenopalatine (ac. ptorygopalatine) Tncrimal (tat) gland and nasal glands ganglion CNX ‘oti ganglia parotid (salivary) plang Glossopharyngeal NX ‘TERMINAL AND INTRAMURAL GANGLIA "THORACIC AND ABDOMINAL VISCHRA Vacus* *This is the only cranial nerve that's important for the back and thorax unit, Innervation of specific structures in the back and thorax ‘GSEs ‘CSAS Wie Gis Sia ‘Yes ‘Yes; Sympathetic Yes Hypodemnia Yes Yes; Sympathotin Yes ‘Bones Yes ‘Yes: Sympathetic Yes Skclowal miscles | Vou Yes ‘Yes: Sympathetic Yes Parietal membrane ‘Yes (innervation from same | Yes: Sympathetic Yes nerves as surface it covers) Visceral membrane ‘Yeu Samos organ Yes Dizphragm Yes: Phrenic m | You: Phronle © Tntersostals | Yes; Sympathetic Yes Lungs Yes: Symp & Vag Yes. Heart ‘Yes; Symp & Vagus Yes [Esophagus Yess upper 13% | Ves upper 11 Yes; Symp & Vagus Yes skeletal muscle IY. Innervation of the heart A Visceral efferent innervation of the heart: 1. Preganglionic sympathetic neurons originate in the lateral gray hom of the upper thoracic spinal cond (71 ~ T6) 2. Postganglionic neurons originate from the three cervical genglia (superior, mide andl inferior cardiac nerves), 2, Receives parasympathetic innervation via the Vagus nerve and its recurrent laryngeal branches 3.Postganglionic sympathetic and preganglionic parasympathetic fibers como together to form the eardiae plexus—locsted near the bifuration of the trachea, ‘These fibers are distributed 1 the heart via the coronary plexus. 4. The heart hasan INTRINSIC myogenie conduction system, and does NOT require ‘cura input inorder to beat (contract) and pump blood4. The intrinsic rate of contraction, set bythe “pacemaker” cells ofthe SA node is approximately 70 ~ 80 beats per minute. ’. Changes in demand for O» roquite alterations inthe invinsi rate of contraction, and this is regulated by the ANS. ‘5. Sympathetic stimulation INCREASES heart rate and force of contraction, and produces vasodilation of the coronary arteries, 6, Parasympathetic stimulation DECREASES heart rate and conduction through the AV node. 7. Sensory innervation of the heart a. The heart is NOT innervated by somatic afferent fibers; however, i is well innervated by visceral afferent fibers. b. Visceral afferent fibers from the heat travel back to the CNS with both the sympathetic (accompanying the middle and inferior cardiac nerves) and the Vagus nerve «, Myocardium is EXTREMELY sensitive to ischemia (inadequate blood supply). This is why pain from a hear attack and angina are so sever. 4. Pain from ischemia i carried by visceral afferents that travel with sympathetic fibers back to spinal cord segments Tl ~T5; ischemic pain is usvally referred to these dermatomnes. e. Visceral afferents traveling with the vagus carry information about blood pressure (baroreceptors) and blood gas levels (chemorecepto) The Heart ‘ ‘A. The heat is a four-chambered DOUBLE pump, about the size of your fist. 1, Right pump sends blood through the PULMONARY circuit 2. Left-pump sends blood through the SYSTEMIC eirenit, B, The heartis often described as being Y fon pyramid or cone-shaped \ 1 apes tie a) wt ‘Points anterior, inferior, and left ». Composed exctusively Ha, UE, Then we learn. ofthe LEFT ventide Py" has Achamors ©. “Apical beat Now, ee pretwre. maximal pulsation of ke ths, the heart ean sometimes be felt and Buttes seen in the 5” intercostal space on the left side ofthe body ~8om from the median plane os Tes vnlly more. 2, Base (anatomical) ite Hee a. Opposite the apex ie b. Points posterior, superior, and right tongpednel A ec. Compased primarily ae > of LEFTattium elas aie zy incon Lvendnele, 3. ‘The heart is skewed toward the intel bri LEFT side of the body (2/3 abet) nie Left 1/3 Right), and is also aakerion rotated to the LEFT 4, The heart is obliquely oriented relative to the median plane of the body 5. The heart is described as having 3 surfaces a, Sternocostal (anterior) surface 1, Composed primarily of RIGHT ven 8b. Diaphragmatic (Inferior) surface Coun’ oa a couple 1. Rests on the diaphragm esions aboot ventricles (mos ee ie 2. Composed of both R& L ventricles (mostly [Vis sunces as left) mensional and boedess Pulmonary (left) surface se dimensional 1. Occupies cardiac impression of the left ng 2. Composed primarily of LEFT veniticle 6. The heat is also described as having borders, which ste the margins ofthe heart's silhouette as seen in chest x-rays (“Cardiac shadow") ight atrium and 1VC Mastly left ventricle (small left auricle contribution) Inferior border Right ventricle (small left ventricle contribution) | Superior (upper border Left trim (aorta and pulmonary trunk emerge superiorly) Posterior order= Left sium Anterior border = Right ventricle and infundibulum i Clinical correlate: Auscultation of heart valves Table 1; Four Classic Auscultatory Areas of the Heart Surface Projection Right space near sternum, ‘Aortic Valve Left 2" intercostal space near stemum Pulmonary Valve Lefi 4 intercostal space near stemum “Tricuspid Valve Lefi 5™ intercostal space in midclavicular plane Mitral Valve ‘Mnemonic for heatt valves from patient's right fo left: All Physicians Take Money ‘The suscultatory arcas actually represent the locations of the heart chamber or blood vessel in which blood is ejected as a result of each heart contraction. The sound of each valve is carried by blood in the direction itis flowing. ‘Avscitaton isthe aot of listing to body ound, usally with 2 Sehossope ‘ternal angle isan VI. Overview of Blood Flow Through the Body SVC, IVC & Coronary Sinus->Right Atrium->R AV valvo-> Right Ventriclo-> Pulmonary Semilunar Valve> Pulmonary Trunk->Pulmonary Arteries->Lungs-> Pulmonary Veins->Left Atrium->L AV valve->Left Ventricle-> Aortic Scmilunar Valve->Aorta-> Systemic Arteries->BodyMust KNOW BACK AND THORAX LAB OBJECTIVES BODY CAVITIES, FASCIA, LAVERS OF THE HODY WALL, AND ANATOMICAL PLANES, Identify the following body eavi Cranial cavity Spinal cavity 2 Thoracic cavity a Abdominal cavity Q. Pelvic cavity Know which are subdivisions of the dorsal body cavity, end which ore subdivisions of the ventral Bady cavity ‘Questions may be confusingly worded, "This is what part of what covity?" dentfy the following layers of the body wall. Skin (aka. integument) Superficial fascia (a.k.a. subcutaneous tissue or hypodermis) Superficial layer of the superficial fascia (a.k.a. Camper's layer or fatty layer) Deep layor of te superficial fascia (aca. Scarpa layer or membranous layer) a a a Deep investing fascia of skeletal muscles (a.k.a. epimysium) Layer(s) of skeletal muscle Parietal layer of serous membrane tify the following anatomical planes, Sagital Midsagital plane (a4, median plane) Parasagittal plane Midelavicular plane Frontal (coronal) plane Horizontal (transverse) plane Subcostal plane Transumbilica plane Supracrisal plane ‘Transtubercular (a... intertuberculat) plane Mid-axillary line ececcouogoug BONES AND JOINTS OF THE BACK AND THORAX Identify the following types of normal spinal curvature. Primary (a.k.a. kyphotic = concave anteriorly) Secondary (a.k.a, lordotie = concave posteriorly) Identify the following features of the vertebral column Cervical region and cervical curvature ‘Thoracic region and thoracie curvature Lumbar region and lumbar curvature Sacrococcygeal curvature Sacrum Coceyx Intervertebral foramina Vertebral canal ooocces 10Identify the following features of vertebrae from a specific region of the vertebral column, Cervical region C1 (Atlas) anterior arch © inferior articular surface fovea (eiculr facet) for dens transverse process wiforamen © posterior arch vertebral foramen superior articular surface 2 (Axis) dens (aa. odontod process) transverse process w/foramen @ body vertebral foramen pedicle superior and inferior articular facets lamina bifid spinous process C3 - C6 (typial cervical vertebrae) a body 2 vertebral foramen pedicle superior and inferior articular processes and facets 3 lamina 1 uncus (ake. uncinate process) transverse process w/foremen bifid spinous process 7 (vertebra prominens) 2 body © vertebral foramen © pedicle Q superior and inferior articular processes and facots 8 lamina @ spinous process (note: not bifid) transverse process w foramen Thoracic region body w/ costal facets and/or demi-facets © vertebral foramen @ pedicle superior and inferior articular processes lamina and facets transverse process and facet spinous process costal facet = whole facet: demi-focet = portil facet Lumbar region a body vertebral foramen. a pedicle 1D superior and inferior articular processes and facets Q lamina 1B _ pars interarticutaris, Q._ transverse process 1D spinous process Identify the spinous process of C7 (vertebra prominens) based on its surface anatomy. Identify examples of the following joints of the vertebral column, 1D Zygapophyseal (a.k.a, facet joint) Intervertebral dise joint and intervertebral disc (annulus fibrosis and nucleus pulposus) _Uncovertebral (only in the cervical region, C2 - C6) Identify the following ligaments of the vertebral column, ALL (anterior longitudinal ligament) 2 Interspinal ligaments Q PLL (posterior longitudinal ligament) Q_Intertransverse ligaments Q Ligamentum flavum Q_Supraspinal ligament Identify the following features of the thoracie eage. Q» Ribs 112 (ue, false, Hosting) Q Manubrium D Superior thoraci¢ aperture Q Jugular notch (a.k.a, suprastemal notch) Inferior thoracic aperture B Stemal angle (of Louis) Q Costal cartilages 0 Body: Q Costal margin 1D Xiphoid process 2 StermumIdentify the transverse thoracie plane. Identify the epigastric body region, Identify the following features of a typical rib. Head w/ superior and inferior facets Neck Tubercle and articular facet Angle Shaft or body Costal groove coecce Identify the following features on the 1* rib, Q. Scalene tubercle © Grooves forthe subclavian artery and vein Teen is of the thoracic cage, ify the following Costovertebral Costotransverse Manubriosternal Stemocostal Costochondral junction cceoo MUSCLES OF THE BACK AND THORAX Identify the following intrinsic back muscles. 1 Splenius capitis 1D Semispinalis capitis Q-Splenius cervicis 1D Semispinalis cervicis G Tliocostalis B_Semispinalis thoracis Q_Longissimus O Multfidus B Spinatis 2 Rotatores [MNEMONIC: I Love Spaghetti = erector spinae muscles from lateral to medial Identity the posterionand-anterioniayers-of-tie thoracolumbar fascia. Identity the following museles of the thoracic wall. A Extemnal intercostal muscles and membrane Internal intercostal muscles and membrane Innermost intercostal muscles Subcostal muscles ‘Transversus thoracis muscles Levator costarum muscles ouccoo Identify the following components of the neurovascular bundle. 1D Posterior intercostal vein Posterior intercostal artery 1B _Intercostal nerve MNEMONEC: Order from superior to infer AN Identify the following architectural features of the diaphragm. Central tendon a Rand Lerura @ Vena caval foramen (18) B Medierarenate-igament @ Esophageal hiatus (T10) D Medial arcuate ligaments Aortic hiams (112) Lateral arcuate ligaments MNEMONIC for vertebral levels: I Ate (8) 10 Eggs At Midnight (12) IVC= 8: Esophagus = 10; Aorta 12 12‘Tite FEMALE BREAST Identify each of the following structures of the breast. in (2.42, culancous membrane, integument) Nipple Arcola and Montgomery's tuberoles Superficial layer of superficial fascia Suspensory ligaments (of Cooper Loctiferous ducts anetsineser Retromammay fascia (2.a. deep layer of superficial fascia) Retromammary space Deep investing fascia ofthe pectoralis major muscle ‘manomary fat euocescoo Identify the following features of the surface anatomy of the breast. axillary tal inframammary fold upper outer (superior lateral) quadrant upper inner (superior medial) quadrant lower inner (inferior medial) quadrant Tower outer (inferior lateral) quadrant eoocog Identify the location of the following lymphatic structures that drain the breast. Pectoral (anterior) axillary lymph nodes @Subscapular (posterior) axillary lymph nodes Q Central axillary lymph nodes Q Apical (subclavian) axillary lymph nodes Q-Parasternal Lymph Nodes Q Subarcolar Lymphatic Plexus 1D _Interpectoral (Rotter’s) lymph nodes ‘ORIGINS OF THE PERIPHERAL NERVOUS SYSTEM Identify the following features of the spinal cord and spinal nerves, 2 Cervical, thoracic, lumbar and sacral spinal cord Q Spinal nerve GQ Duremater Ventral primary rami Epidural space Dorsal primary rami Subarachnoid space 2 Comus medullaris Ventral roots Cauda equina @ Darsal roots Dorsal root ganglia (DRG, a.k.a, spinal ganglion) Identify the following structures on the plastic model of a cross-section through the spinal cord. 1D White matter Dorsal roots 5 Gray matter Ventral roots Dorsal gray hom Dorsal root ganglion Ventral gray hom Q. Spinal nerve Lateral gray horn Identify the following clinically important dermatomes. Base of neck aud anterior shoulder? C4 Nipple? T4 D Umbiticus? T10 2 Groin? L1 co Identify the following components of the sympathetic division of the ANS within the thoracic cavity, Sympathetic chain and sympathetic chain ganglia Rami communicantes Greater thoracic splanchnic nn,PULMONARY CaviriEs, Identify the following features of the pulmonary cavities, @ Costl parietal pleura Visceral pleura Diaphragmatic parietal pleura © Palmonary ligament GQ Mediastinal parietal pleura Pleural cavity (space) Pleural cupula (cervical pleura) © Costodiaphragmatic recess 2 Suprapleatal mennbrane (Sibson’s fascia) © Costomediastinal recess LUNGS, TRACHEA, AND BRONCHIAL TREE Identify the following features of the lungs. (O Lung hilum Oblique fissure of right ung Lang root Horizontal fissure of right ling a Costl surface Superior and inferior lobes of left lung @ Diaphragmatic surface Oblique fissure of left lng Q Mediastinal surface Lingua @ Superior, middle and inferior lobes ofright «Cardiac impression Jung 1D Cardiae noteh che following structures ofthe trachea and bronchial cree. a trachea primary bronchi (a.k.a. main bronchi) carina secondary bronchi (a.k.a. lobar bronchi) Identify the following components of the pulmonary circulatory system. pulmonary wank Rand L pulmonary aa, (OTigamentum arteriosum pulmonary wy. “MEDIASTINUM AND PERICARDIAL SAC Identify the following specific subdivisions of the mediastinum. Superior mediastinum Anterior inferior mediastinum Q Middle inferior mediastinum Posterior inferior mediastinum Identify the transverse thoracic plane, Identify the following contents of the superior mediastinum. Q R&L brachiocephalic wv. 2 Leommon carotid a, Superior vena cava Trachea and its bifurcation Aortic arch R&LPhrenic na @ Brachiocephalic trank OO R&L Vagus nn, QL subclavian a, 1 Esophagus Identify the following contents of the middle mediastinum. Q Pericardial sac OQ Heart Root of great vessels (SVC, aorta, pulmonary trunk) Identify the following structures/issue layers that surround the heart. Q Mediastinal parietal pleura Pericardial cavity Q Pericardiophrenic vessels and phrenic Transverse pericardial sinus nerve (in situ) 2 Oblique pericardial sinus QFibrous pericardium Visceral serous pericardium (a.k.a. Parietal serous pericardium cpicardium) 4Identify the following contents of the posterior mediastinum. Esophagus R&L Vagus nerves R &L Sympathetic chains Azygos vein Thoracie duet ococo Adentify the following branches of the vagus nerves. Right recurrent laryngeal nerve (Hooks under the R subelavian artery) Q_ Left recurrent laryngeal nerve (Hooks under the aortic arch; landmark = ligementum arteriostm) ANATOMY OF Tite HEART Identify the following external features of the heart. D Apex Rand L atria and their auricles QBase (anatomical) G Rand L ventricles Q Anterior (sternocostal) surface G_ Coronary groove (aka. atioventeicular 1G Infetior (diaphragmatic) surface sulcus) D- Right border of the heart Anterior and posterior interventricular Q Left border of the heart (obtuse margin) ‘grooves (sulci) Inferior border of the heart (acute margin) Identify the bony landmarks and anatomical planes used to locate the surface projection of each of the following structures. Surface projection of the apex of the heart Surface projection of the superior, inferior and left borders of the heart R atrioventricular (tricuspid) valve auscultatory location L atrioventricular (bicuspid or mitral) valve auscultatory location Pulmonary semilunar valve auscultatory location Aortic semilunar valve auscultatory location oeocou Identify the following internal features of the right a Opening of superior vena cava Crista terminalis oo Opening of inferior vena cava Sinus venarum Opening of coronary sinus Interatrial septum D_ Opening of R AV (‘ricuspid) valve Fossa ovalis (or patent foramen ovale, if 1G Pectinate musele present) the following internal features of the right ventricle. 1 Cusps of R AV valve (ak. tricuspid Papillary muscles valve) 1D Trabeculae cameae 2 Interventricular septum—membranous 2 Moderator band (a.k.a. septomarginal portion ‘tabecula) @ _Interventricular septum—muscular portion 2 Conus arteriosus (a.k.a. infundibulum) 1 Tendinous cords (a.k.a, chordae tendineae) Pulmonary semilunar valve Identify the following internal features of the left atrium, 1D Openings of the four pulmonary veins Q_Interatrial septum with valve remnant of the foramen ovale Q Opening of the L AV valve (a.k.a, bicuspid or mitral valve) Identify the following internal features of the left ventricle. G2 Cusps of L AV valve (a.k.a, bicuspid or G_Interventricular septum-—membranous mitral valve) portion 2 Tendinous cords (2.k.2, chordae tendineae) Q_Interventricular septum—musculas portion Q Papitfary muscles Aortic vestibule @ Trabeculae camese Aortic semilunar valve 15Identify the locations (not the structures themselves) of the following components ofthe cardiac ‘conduction system. 2 Sinoattial (SA) node Q Atrioventricular (AV) node GQ AV bundle (bundle of HIS) a Rand L bundle branches Identify the following arteries that supply blood to the heart. @ Reoronary artery and its ostium (opening GQ Lcoronary artery and its ostium (opening, from aorta) from aorta) a Rmarginal a (2 Anterior interventricular a (aka, anterior Posterior interventricular a. (aka. ‘descending a.) posterior descending a.) Q Ciroumflex a a SAnodal artery Identify the following voins that drain blood from the heart, Q Coronary sinus Great cardiac v. (a.k.a. anterior interventricular v.) Middle cardiac v. (aka. posterior interventricular v.) Small cardiac v. "THORACIC VASCULATURE AND LYMPHATICS. Identify the major systemic arteries in the thorax. Ascending aorta Aortic arch and its branches QBrachiovephalic trunk QL subclavian a @ L-common carotid a Descending aorta Internal thoracic a. (a.k.a infernal mammary 2.) Posterior intercostal aa. Lateral thoracie a. (branches from the axillary a.) MNEMONIC: To remember the order of the branches off the aortic arch, remember your ABCS = Aortic arch- Beochiocephelic trunk-left Common caretic-left subclavian oo oo Identify the R and L venous angles (at the union of internal jugular and subclavian veins). Identify the major veins of the caval system. Inferior vena cava Superior vena cava Rand L brachiocephalic wv Rand L subclavian w. R and L internal jugular vy. cooco Identify the major veins of the azygos system. a Azygos Q Hemiazygos v 2 Accessory hemiazygos v. Posterior intercostal vv. Tdentify the thoracte duct Know the major routes of lymphatic drainage of the breast (75% of lymph from breast goes to the axillary lymph nodes). 16Identify the following structures on a cross-section of the thorax. a Sccecoueecoeoce Steroum Anterior mediastinum R& L costomediastinal recesses ‘Thoracie vertebrae Vertebral canal Spinal cord Subarachnoid space Intercostal muscles Costa pleura Mediastinal pleura Visceral pleura Pleural eavity Lang Trachea Carina R&L primary bronchi 7 oo eooooceoooecce Esophagus Azygos v. Pericardial sac Ascending aorta Descending aorta Aortic arch svc Ratrium Latrium R ventricle L ventricle Interventricular septum Pulmonary trunk R&L pulmonary aa, Pulmonary w.PRACTICE QUESTIONS InTRoDUCTION 70 TISSUES AND MEMBRANES ‘Which ofthe four basic tissue types in the body originates from all three germ layers (mesoderm, endoderm and ectogerm)? CH) Bpitetial tissue Connective tissue Muscle tissue Nervous tise 2. Connective tissue develops primarily from what germ layer? ‘a. Endoderm (b.) Mesoderin fc. Eetoderm 4. Epithelium 3. Which body cavity is NOT lined by a serous membrane? ‘Thora Spinal c. Abdominopelvie d. Mediastinus ture? 4, Which layer CANNOT hold a. 1, Serous membrane b. Deep investing fascia cx Deep layer of the superficial fascia @& Mose 5. From superficial to deep, what is the correct order of layers that your sealpel would cut through if you ‘were to make an incision in a patient’s body wall? a, Deep superficial fascia, superficial superficial fascia, deep investing fascia, muscle (bY Dermis, superficial superficial fascia, deep superficial fascia, deep investing fascia Superficial superficial fascia, deep investing fascia, muscle, deep superficial fascia 4d. Epidermis, dermis, deep investing fascia, deep superficial fascia 6. This fascia provides a cleavage cleft between & serous membrane and the deep fascia of the overlying muscles, a, Scarpa’s fascia b. Camper's fascia Investing fascia Internal fascia e. Superficial fascia 7. ‘To minimize surgical scarring in a patient, in which direction would you make yout incision? a. Perpendicular to Langer’s lines b> Parallel to Lenger’s lines ©. Vertically 4d, Perpendicular to desmatomes BONES AND JOINTS OF THE THORAX 8. What external landmark would you use to locate the T3-T4 dise space? a. Angle of Louis b. _ Xiphoid & Sternal notch Costal margin Laryngeal prominence 1810, 12, 13. 15. 16, What major surface landmark can you use to localize the clinically important carina, beginning of the aortic arch, and T4-TS dise space? a. Umbilicus b. Xiphoid process e. Stemal notch Ge Sternal angle of Louis fe. Midelavicular plane Which is considered a typical rib? ' 2O%8 3 u Which is considered a “false” ib? 1 2 3 yu You're asked to insert @ needle into & patient's pleural space to withdraw excess fluid. Which of the following actions would you take to accomplish this? 4. Inset the needle into the steenomanubrial joint CB» Insert the needle in the intercostal space immediately superior to ib 10 Insert the nce immediately inferior to rib 10 in the intercostal space 4, Insert the neeie in the second intercostal space immediately lateral tothe sternum €. Panic and stick yourself in the neck In an anterior approach, what structure would you first encounter (e.g. stick with @ needle)? a. Subelavian artery » Subclavian vein © Anterior scalene muscle 4. Middle scalene muscle Whats MOST responsible for limiting vertebral rotation in the thorace region? 2. Zygapophyseal joins ‘0° Intervertebral dies ._Spinous processes G&S Ribeage ©. Transverse processes Which is NOT pert of the “posterior element” of a vertebra? b. Pedicle ©. Spinous process 4. Transverse process 5 Vertebral body ‘When performing a lumbar puncture to withdraw cerebrospinal fluid, you should insert the needle between the spinous processes of which vertebrae? a. TIZL1 b LIL 12.13 1344 82.83 1917 19, 20. 2 22 23. 24. 25, ‘The spine would be Most destabilized by a fracture of a a. Vertebral body (CS Lamina €. Spinious process d. Rib .. What voluntary motion(s) occurs at the joint between the SAP of the atlas and occipital condyles? a. Flexion of head only b.__ Extension of head only ._)Flexion and extension a. Rotation What voluntary motion is allowed by the joint between the dens of the axis and the anterior arch of the atlas? 8. Flexion only b, Extension only c. Flexion and extension £4,° Rotation ‘The uncoverteral joints are found in what region ofthe vertebral column? 4. Cervical region from Ci to C2 & Cervical region from C3 10 C6 Cervical region from C1 to C7 @. Thoracic region from TI 9 T12 fe. Lumbar region from L1 to LS [Which ib usually anculstes with nor than one vertebral Body? a. Rib SS Rib SE Rib a. RbIZ ‘A patient comes into the ER after suffering a severe neck wound from a motor vehicle accident. You notice on X-ray thatthe transverse process of CS has been fractured. You suspect intemal bleeding and quickly send the patient to surgery. Whot artery has mos likely been damaged? & Vertebral anery Internal thoracie artery c. Axillary artery 4. Subclavian artery The vertebral artery docs NOT pass through the BN C7 transverse foramen C6 transverse foramen c. Cl transverse foramen 4. Foramen magnum fe. Who cares about such trivia The vertebral body of T7 articulates with what sibs)? 2. Rib 6 only SHH Ribs 6 and7 ©. Ribs 7only a. Ribs 7and 8 Rib 4 articufates with what vertebral body bodies? “Ax T3only GT and T4 ©. Téonly 4. T4and Ts 202, 28. 29. 30, 31, 22. 33 ‘An attending physician asks you t perform an OB block on a pregnant patient. At what anatomical landmark would you seck entry into the epidural space o accomplish this feat? a, Coccyx 12:13 spinous processes ‘Sacral hiatus 4, Sacral promontory Jf Noe dices ero Dr Rechte because he knows anatomy! ‘An oblique lumbar X-ray shows a fracture of the “Scotty dog's” neck. This is a fracture of the a. Dens b. Transverse process cc. Spinous process d. Pedicle o ars interarticolaris ‘Whats the term for the pathologic condition in which the neural arch does not close posteriorly? a. Hangman’s fracture Spina bifida © Sneral hiatus dd. Uneus ©. Kyphosis, Another name for the primary spinal curve is a. Scoliosis ®& Kypliosistyphotc ©. Lardosisllordatic &. ‘diopati Jn what region(s) ofthe vertebral column i the primary spinal eure retained into adulthood? a Cervical Those © Lumber 4. Sacral” paren (4S Band D & ‘There is No intervertebral dise between A herniated intervertebral dise is when the inner. ruptures through the outer layer. Nucleus pulposus “Annutus fibrosis ©. Mucosa 4. Serosa ‘Your patient is diagnosed with a lumbar dise herniation, You anticipate that the herniation is in the direction, a. Directly posterior b. Anterior Posterolateral Superior Inferior 2134. Toperform a facet block to eliminate back pain, what jlnt would you anesthe? 2. Median allanoaxil joint b.Allantoocciita joint @) Zypapopnyseal joint i Intervertebral die joint 2 Menna’s joint home ofthe dubs 35, Which ligament is most likely injured in a hyperextension injury such as “whiplash”? a. Posterior longitudinal ligament Anterior longitudinal ligament igamentum flavum, 4. Alar ligament €.Supraspinous ligament raspinous Tig ’ a“ high stuctresinvervated by a von mu? o {~ i [36 Interns ligaments yi es ” Suprspinovsigament e presenta aaa GE, Baeavophyseal joint é “E” Stemomanubrial joint \ 37. Which of the following is responsible for holding the dens of the axis against the anterior arch of the atlas, thereby preventing the dens from dislocating posteriorly inta the spinal cord (fatal)? 2. Ligamentum nuchae bb. Supraspinous ligament ‘Transverse ligament of the atlas Alar ligaments 38, What ligament checks rotation and limits side-to-side motions of the head? a, Ligamentum nuchae b. Suprespinous cc. Transverse ligament of the atlas, @ Alar 39, What rib articulates with the sternomanubrial joint at the angle of Louis and allows easy palpatory identification of rib interspaces (e.g. for auscultation of heart sounds)? a. Ribl 7 Rib? Rib 3 d. Riba 40, Deep intrinsic back muscles are innervated by dorsal rami, while the superficial intrinsic ‘back muscles are innervated bby dorsal rami. a. Multisegmentally, segmentally ‘Segmentally, multisegmentally “2E Neither A or B are true; all the intrinsic back muscles are innervated by ventral r ‘Tae BREAST AL. ‘The breast is entirely formed within the (G) superficial layer ofthe superficial fascia deep layer ofthe superficial fascia ¢. retromammary space a. dermis e. epidermis 242, What is the dermatome of the nipple? Va C7 b 72 14 To e Lt 443. With regard to the breast the potential space between the deep layer of the superficial fascia and the deep investing layer over the pectoral muscles is called the Retromammary space Posterior space . Pleural space 4. Superficial recess ©. Pectoral recess 44, Retromammary fascias actualy 4, Superficial superficial fascia G&S Deep superficial fascia Deep investing fsc 4. Specialized layer of fascia only associated with the breast 45. What rib level marks the sharp demarcation of inframammary fold? a arb SM rib oF nib Trib 46, The axiary tai common location of breast malignancy. ‘The axillary tai is par of oF continous with hat breast quad’? Ca) Upper oer Upper inner ©. Lower outer 4. Lowee inner 47. The___are small nodular elevations om the surface ofthe steola, whieh represent subeutancous glands that secrete a scbaceous substance GQ) Areolar tubercles (glands of Montgomery) 8. Lactferous ducts ©. Mammary nodules 4. Axillary glands e. Glands of Spence while the support tissue of the breast is 48, ‘The fimetional portion of the breast issue i called called 3a.” Sivoma, parenchyma Parenchyma toma © Lables, lobes & Superficial faci, doep fascia ©. Glands, skin 49. What is the correct order of progression from deep to superficial? a. Lactiferous sinus, alveoli, lactiferous duct Alveoli, lactiferous sinus, lactiferous duct Alveoli, lactiferous duct, lactiferous sinus 2350. Which of the following parts of a breast lobe is strongly associated with fibrocystic disease and inereases or decteases in size depending on age or hormonal levels? ‘a, Lobules| b. Alveoli c._ Lactiferous sinuses &) Suspensory igaments 52, Via which pathway do most breast cancers spread? a. Artery eb. Veins Lymph [Nerve 53, Whjek fegion is responsible for most lymph drainage from all four breast quadrants? a.) VAxillary bo Parasternal c. Umbilical 4. Contralateral breast -Muscies oF THe BACK AND THORAX 54, Thorscolumbar asia 2. Is als called lumbovental fascia BL Enclose ll the intrinsic back museles €.Encloses the trapezius, rhomboid, and serratus antriar muscles 4, Does not extend into the neck (Ce) Idetned as single ayer of fascia hat covers the inini Bask muscles superficially 55. Which muscle/muscle group is innervated by ventral rami? + ranveroapnai Erector singe ot f., Splentus (a: Trapezius ds 56, Unie conctin of he nemedite yer of tanevesepinnl ms produces ipsilateral sidebending and conalateral rotation ie Ge Conteatsterl sidebending ond ipsilateral rotation pw Tpit! sidcbening and ipsilateral eta 4. Contalacrlsdebeeding and conrlteral tion fe. Backward bending (extension) 57. Which of the following muscles of the transversospinalis group spans the shortest distance? a. Multifidus Rotatores . Semispinalis é. Splenius fe. Spinalis© 772 tar 3 32 F ual. 8 “& 58. The external intercostal muscles the ribs, white the internal intercostal muscles mostly the ribs, ‘a. Depress, depress b, Depress, elevate c. Blevate, elevate © Flevate, depress 59. Whot layer is immediately intemal (deep) to the innermost intercostal muscles? Inte intercostal mscles Endothoracie fascia % Parietat pleura Visceral pleura ce. Thoracolumbar fascia 60. All three sets of intercostal muscles are innervated by Dorsal rami Ventral rami bse brachial plexus “ae Sinuveriebral nerves 61. ‘The lateral arcuate ligament is formed from the Investing fascia ofthe quadratus lumborum %. Investing fascia of the psoas major cc. Investing fascia of the erura 4d. Mascle fibers ofthe diaphragm, 62. ‘The __forms the median arcuate ligament and ereates the opening into the abdomen known as the sortie hiat Left crus Right crus Intersection of the erura ¢.Thoracolumbar fascia 63. Which ofthe following is typically located at the T10 vertebral level? a. Aortic hiatus Gy Bsophageal hiatus ©. Vena caval foramen 4. Sternal angle 64. In addition to the esophagus, what other structure(s) traverses the esophageal hiatus? a. Thoracic duct BD Vagal trunks ‘c. Sympathetic chains 4, Greater thoracic splanchnic nerves ce. Right phrenic nerve 65. In addition othe IVC, what other stuctre traverses the Ven coval foramen? ‘a. Thorac dul BAaygos vein . Vagus nerve a. Sympathetic chain Rh prenic nerve 2566, During deep inhalation, the diaphragm 1. Contracts, becomes more domed and moves inferiorly b. Relaxes, flattens and moves superiorly Centra, fans and moves iniry Relaxes, becomes more domed and moves superiorly e. Contracts, becomes more domed and moves superiorly 67. Identify the FALSE statement. ue ‘a. The phrenic nerves pierce the central tendon of the diaphragm J 1. “The chet blood supply to te diaphragm i from the inferior phtene arteries Loss of one phrenic neve is compile with ie. 'G." The intercostal nerves supply motor innervation to the diaphragm. 2 The pericardial sac is atached to the central tendon of the dapheegm. INNERVATION OF THE BACK AND THORAX 68, Visceral serous membranes receive __ innervation Somatic, visceral b._ Somatic, somatic 7 Visceral, somatic [- Visceral, visceral innervation while parietal serous membranes receive 69. Sympathetic and parasympathetic neurons are classified as 2. General visceral afferent b. General somatic afferent ¢._ General somatic efferent @ General visceral efferent 70. Severing the T4 dorsal root would result in ‘Loss of sensation from the nipple b. Paralysis of intercostal muscles innervated by the T4 spinal nerve ¢. Both loss of sensation and muscle paralysis d. Lack of sweating in the T4 dermatome ‘71. Severing the T10 ventral ramus would result in a. Loss of sensation from the skin of the back over the T1O vertebra 1b. Weakness or paralysis of some intrinsic back muscles \g. Weakness or paralysis of some intercostal and abdominal muscles, Loss of sensation from a strip of abdominal skin at the level of the umbilicus : 72. White rami communicans convey Postganglionic sympathetic neural fibers Somatic afferent neural fibers Preganglionine sympathetic neural fibers Preganglionic parasympathetic neural fibers All types of neural fibers 7B. The greater thoracic splanchnic nerve 8, Arises from spinal levels T10 and TH b. Terminates at the cardiac plexus nveys postganglionic sympathetic neural fibers Contains neural fibers that synapse in the celiac ganglion fe. Innervates thoracic viscera 2674, While trying to inject anesthesia around a spinal nerve asi exits the intervertebral foramen you suddenly twitch end sever the recurrent meningeal nerve. As a result, which of the following structures will not be innervated”? a PLL b. Supraspinous ligament ©. Skin of the back at that spinal level 4d. Some intrinsic back muscles A facet joint Tee ed ee i: scmcaee ee b. The left recurrent laryngeal nerve: nt cee et et Gan The left greater thoracic splanchnic nerve 76. On the left, what structure serves as a good landmark to locate the left recurrent laryngeal nerve? @® Subclavian artery ’. Brachiocephalic vein ©. Phrenic nerve ¢.Ligamentum arteriosum ©. Transverse pericardial sinus 77. Which of the following correctly describes « portion of the course of the right phrenic nerve? a, Descends along the medial side of the right brachiocephaic vein and SVC 'b. Passes posterior to where the azygos vein terminates into the SVC ©. Passes posterior to the right lung root d._Ittravels along with the imternal thoracic artery and vein @ypSome ofits ders go through the vena caval foramen Meprasrinum, 78. Which of the following structures is located NvueeLy within the mediastinum’? a. Thoracie duct b. Phrenic nerves Pericardial sac Vagus nerves e. Esophagus ‘79. What subdivision of the mediastinum contains both phrenic nerves and both vagus nerves? a. Posterior b. Anterior 80. A tumor growing in the posterior mediastinum could directly affect which of the following structures? ‘Azygos vein 'B. Superior vena cava © Aortic arch 4d, Right atrium of the heart e. Phrenic nerves 27£1. A--yearoM tit brought he ER his moter. She sales te child has walowel sin il now having difficulty eating and feguentyregugitass. A chest xray shows around objected the esophagus at approximately the 1 vertebral level. ‘The eoin io most key stuck atone of physiological conticions- which one? 3. Pharpngocsophogeal B. Agric arch €. Left primary bronchus @ Diaphragm @Q_LKither B or C PULMONARY CavrniEs 82. A patient comes into your office complaining of a bad chest cough. Upon x-raying the patient upright, you notice “blunted” edges on the x-ray atthe level of the 108 through 128 ribs, Normally, these edges are well defined and demarcate the space known as Sternocostal recess Costodiaphragmatic recess Retroesophageal recess Retromammary space Oblique sinus 3. A patient comes to your office complaining of sharp neck and shoulder pain. It is worse when the patient breathes in deeply. There is no apparent injury or other detectable reason forthe pain, and you ‘begin 10 suspect this isa referred pain phenomenon in dermatomes C3C4CS, possibly from a pleural inritation/infection, Iritation of what region of the pleura would most likely produce this referred pain pattern? Visceral pleura Costal parietal pleura Diaphragmatic parietal pleura Mediastinal parietal pleura Both C and D are possibilities 84, Pulmonary cavity and pleural cavity are different names for the seme thing. a, True b. False 85, Parietal pleura is separated from visceral pleura by a. The pleural cavity b. Nothing, they are inseparable cc. Lung tissue dd. Endothoracic fascia e. The mediastinum 86, Parietal pleura is continuous with visceral pleura, ‘a, On the surface of the mediastinum 1b. Throughout the entire pulmonary cavity cc. Atthe hilum of the lungs 4d. Atthe pleural cupula e. On the diaphragm 28LUNGS, TRACHEA, AND BRONCHIAL TREE, 87. A patient is wheeled into the OR and needs to have a subelavian vein (SCV) catheter inserted for a morphine pump. It’s your turn “at bat” and the attending physician asks you to perform this tricky procedure. You would insert the catheter into 48. the left subclavian vein because the vasculature atthe left apex of the lung is less dense ‘making the vein more easily accessible, '. the right subclavian vein because the right apex of the lung is more cephalad, which makes the vein more accessible. ©. the right subclavian vein because the left apex of the lun risk of puncturing the lung or pleural sec. 4. your own subclavian because you wish you paid more attention in anatomy class. is more cephalad, increasing the 88. ‘The mediastinal (inner) surface of each lang has a concavity called a eardiae impression. Which of the following is true? 2, On the right, « shallow impression is produced by the right ventricle b. On the left, a deeper impression is produced by the left atrium ©. On the left, a deeper imipression is produced by the left ventricle 4. Actually, only the left Iung has a cardiac impression 89. ‘The right tung root lies 8. Posterior to the superior vena cava (SVC) 'b. Anterior to the right atrium ©. Posterior to the azygos vein d. Posterior to the thoracic duet ©. Posterior to the vagus nerve 90. Which structure is NOT contained in the lung root? a, Pulmonary veins b. Pulmonary artery ¢. Primary bronchus 4. Postganglionic sympathetic neurons Phrenic nerve 91. ‘The lef ung root sits anterior to the a. Descending aorta b. Aortic arch ©. Phrenic nerve 4. Azygos vein 92. The lobe is best auscultated and percussed posteriorly ‘a. Superior b. Inferior Middle d. Middle and inferior 93. In exhalation, the trachea bifurcation is located directly posterior to the 8. Jugular notch at the T3-T4 intervertebral dise joint b, Stemal angle of Louis (T vertebral level) ©. 4" intercostal space 4. Cricoid cartilage 2994, A young child comes into the ER looking cyanotic with difficulty breathing. You suspect the child has Inhaled something, which is now blocking his airway. Rembering anatomy, you realize that foreign ‘objects, which make it past the vocal cords almost always lodge in the 4, left lung because the left main bronchus is large and angled almost straight down. left lung because the left main bronchus is natrow and therefore things are more Tikely to get stuck there c. sight lung because the right main bronchus is large and angled almost straight down. d. Anatomically speaking, neither Tung is more susceptible than the other. €. Idon’t know my anatomy. 95. Whi i of the following is NOT true of bronchopulmonary segments? ‘a. They are pyramid shoped with the apex pointing atthe lung root and the base pointing towards the lung surface. b. Adjacent segments are separated by connective tissue that can be surgically dissected out from all he others. ¢. Adjacent sepments have an intersegmental vein that lies inthe connective tissue between segments, d. Each segment contains a primary bronchus, # segmental artery, an intrasegmental vein, lymph vessels, and a set of autonomic and visceral afferent nerves 96. ‘The trachea is the distal continuation of the larynx and begins atthe level of a. C4 b. C5 ce. C6 a. c7 97. Which of the following is in the correct order from Ieast dismeter to greatest? a, Primary bronchus, secondary bronchus, tertiary bronchus, bronchiole, terminal bronchiole, respiratory bronchiole b. Respitatory bronchiole, segmental (tertiary) bronchus, secondary (lobar) bronchus, primary ‘bronchus, terminal bronchiole, bronchiole Respiratory bronchiole, terminal bronchiole, bronchiole, segmental (tertiary) bronchus, secondary (lobar) bronchus, primary bronchus, wrachea, larynx 4. Segmental (tertiary) bronchus, secondary (lobar) bronchus, primary bronchus, respiratory bronchiole, terminal bronchiole, bronchiole 98. The trachea is usually palpable at the level of the jugular (sternal) notch b. angie of Louis cc. body of the sternum, 4. xiphoid process 99, Which of the following has NO cartilaginous support? a. Primary bronchi b. Secondary bronchi c. Tertiary bronchi 4d. Bronchioles 100. Which of the following are associated with alveoli? a. Primary bronchi b. Secondary bronchi ©. Tertiary bronchi 4. Terminal bronchiotes 30101.The pulmonary plexus 8. Contains preganglionic sympathetic fibers b. Is located at the tracheal bifurcation cc. Contains postganglionic parasympathetic fibers from the phrenic nerve 6. Contains vagal afferents 102.Parasympathetic efferents are motor to bronchial and bronchiolar smooth muscle, and when stimulated. produce a. bronchodilation bb. bronchoconsttction, cough reflex a. pain FETAL CIRCULATION AND CARDIAC ANOMALIES. 103, Venteicutar septal defects (VSDs) the rarest of all congenital heart defects (CHD) account for 0.25% of all heart defecis affect females more than males are usually found in the membranous septum. result in blood being shunted from the right vent le e to the left vente 104.You're down to the last patient you have to treat in a very busy ER. Upon glancing at her file, you notice that the patient was diagnosed earlier with Tetralogy of Fallot, Below is a listing of the ailments this patient has. Is the diagnosis accurate? a. Yes b. No Pulmonary blood flow normal ASD (atrial septal defect) Aortic stenosis Left ventricular hypertrophy 105. What vessel(s) delivers highly oxygenated blood to the fetus from the mother? 2, Two umbilical arteries b. Two placental arteries ‘©. Single umbilical vein 4. Two placental veins 106.1dentty the FALSE statement. a. About #6 of oxygenated blood going to the fetus goes into the ductus venosum, b. About # of the oxygenated blood going to the fetus goes into the portal vein and percolates through the liver before joining the IVC. ‘The umbilical vein delivers its blood supply to the IVC. 4. The umbilical vein delivers its blood supply to the SVC. ‘The ductus venosus has a contractible sphincter, which controls the fegction of the umbilical vein flow that is distributed to it 107 .dentify the FALS® statement regarding prenatal circulation. 8,” Most blood from the IVC is directed by the septum secundum through the foramen ovale and into the left atrium, b. The foramen ovale has a flap of tissue om the right atrial side that prevents blood from flowing right to left, ‘©. Blood entering the left atrium passes through the mitra or to the lef ventricle and out the dd. Most blood in the pulmonary trunk passes through the ductus arteriosus into the aortic arch to prevent blood from going to the lungs, 31108. Which of the following correctly describes why there’s an immediate diversion of blood away from the placenta and into the baby's lungs at birth? a, Alterations at birth increase vascular resistance of the lungs so that pulmonary blood flow abruptly and markedly increases. Pressure drops in the right atrium after clamping the umbilical cord cc. Left arial pressure is decreased by the sudden inerease in pulmonaty flow. 4d, Lower left atrial pressure forces the flap over the foramen ovale to close. 109.Which vessel(s) deliver deoxygenated fetal blood to the placenta for reoxygenation? a. Umbilical arteries b. Umbilical vein cc. Superior vena cava 4. Inferior vena cava 110. Which of the following fetal circulatory structures becomes the ligamentum teres? a. Foramen ovale b. Ductus arteriosum ¢. Ductus venosum 4. Pulmonary vein © Umbilical vein 111.A patient comes into your office complaining of shortness of breath. Upon listening to his heart, you notice an irregular heart sound each time the atria contract (post systole). ‘The sound appears to be traveling from the left atrium to the right atrium. What might be this patient's hear ailment? Mitral valve insufficiency Bad gas Patent (open) foramen ovale ‘Tricuspid valve insufficie sp PERICARDIAL SAC AND HEART 112.Which layer is NOT part of the pericardial sac’? a. Mediastinal parietal pleura b. Fibrous pericardium cc. Parietal serous pericardium d, Visceral serous pericardium 113.Daring inspiration, the pericardium becomes more _. During expiration, the pericardium ‘becomes more a. Horizontal; Elongated >. Elongated; Horizontal ©. Neither, the pericardium is unaffected by respiration 114.The innervation of the parietal pericardium is a. Somatic by the vagus nerve b. Visceral by the vagus nerve Visceral by the phrenic nerve 4. Somatic by the phrenic nerve 115,Coronaty arteries, cardiac veins, and fat are located between which two layers? ‘a. Mediastinal parietal pleura and fibrous pericardium b.” Fibrous pericardium and parietal pericardium ¢. Parietal pericardium and visceral pericardium 4. Visceral pericardium and myocardium 32116.0n x-ray, your patient's “cardiac shadow” a larger than normal appearance as a result of significant fluid accumulation. This fluid most is likely located between the 8. mediastinal parietal pleura and fibrous pericardium, fibrous pericardium and parietal serous pericardium, ©. parietal and visceral layers of the serous pericardium, 4d. epicardium and myocardium. 117.With reference to the above question, testing shows that there is minimal change in blood flow volume being pumped from all chambers. Accordingly, do you think the condition is chronic or acute? 4, Chronic (gradual and long-standing) b. Acute (sudden) 118 Inflammation of the pericardium (pericarditis) interferes with the lubricating function of the serous ‘membrane, producing a friction rub between the pericardial membranes. If present, will pericarditis produce pain in a patient? a. Yes, because visceral pericardium is somatically innervated, b. Yes, because parietal pericardium is somatically innervated, ©. No, beeause pericardium is not innervated d. No, because pericardium is insensitive to pain, 119.Afier incision ofthe fibrous and parietal pericardium, a finger in the pericardial sac can be inserted ‘behind the aorta and pulmonary trunk and emerge anterior the SVC via the. a. Conus sinus b. Oblique sinus cc. Transverse sinus Lateral sinus ©. Costomediastinal sinus 120. You're asked to inject some epinephrine directly into a patient's heart. Which of the following correctly ists the layers you would penetrate? 8, "Fibrous pericardium, mediastinal parietal pleura, parictal serous pericardium, pericardial space, visceral serous pericardium, myocardium, endocardium b, Pericardial space, visceral serous pericardium, myocardium, mediastinal parietal pleura, fibrous pericardium, parietal serous pericardium ©. Mediastinal parietal pleura, fibrous pericardium, parietal serous pericardium, pericardial space, visceral serous pericardium, myocardium, endocardium 4, Enough already 121. Innervation to myocardium (heart muscle) is a. Sympathetic only b, Parasympathetic only ©. Sympathetic and parasympathetic 4. Sympathetic, parasympathetic and somatic 122.The cardiac skeleton forms a series of continuous rings around the heart valves, Certain portions of the cardiae skeleton thicken and form fibrous trigones, The right trigone is located a, Between the mitral ring, ticuspid ring, and aortic ring >, Between the pulmonary ring, mitral ring, and eortie ring c. Between the mitral ring and pulmonery ring 4, Do Treally have to know about trigones? 123 ‘The left trigone is located a. Between the outside margins of the sortie ring and the tricuspid ring D. Atthe outside edge of the aortic ring only Between the outside margins of the aortic ring and pulmonary ring 4. Between the outside margins of the aortic ring and mitrat ring 33124.Extensions from this portion of the fibrous skeleton form the membranous portion of the interventricular septa, the membranous septum. atrioventricula a. Left wigone b. Right trigone c. Tendon of the conus 4. SAnode e AV anode 125.Which is NOT a major function of the fibrous cardiac skeleton? ‘a, Prevention of valve distention by increased blood volume b. Anchor for cardiac muscle fibers cc. Electrical conduction barrier between the right and left atria 4d. Electrical conduction barrier between the atria and ventricles 126. What structure pierces the fibrous skeleton and serves as an electrical conduit between the atria and ventricles? a. Bundle of His b. SA node fc. AV node dd. Purkinje fibers 127-Palpation over the teft 5* intercostal space ems from midline corresponds to what heart chamnber? 4. Right atrium b. Left atrium c. Right ventricle €.Leit ventricle 128.The apex of the heart consists of a. Left ventricle b. Right ventricle cc. Nearly equal pars left and right ventricle Left ventricle and left atrium 129,qhe anatomical base of the heart consists mostly of a. Right atrium b. Left atrium c. Right ventricle 4d. Left ventricle 130.The anterior (sternocostal) surface of the heart is primarily composed of a. Right atrium b. Left atrium cc. Right ventricle 4d, Left ventricle 131,The inferior (diaphragmatic) surface of the heart is composed of Mostly right ventricle and some left ventricle 1b. Mostly left ventricle and some right ventricle cc. Mostly left atrium dd. Mostly right atrium 132:The tight border of the heart is composed of a. Right ventricle and IVC b. Right atrium and ascending aorta c. Right ventricle and SVC dd. Right atriom and 1VCThe left (pulmonary) border ofthe heart is composed of 2, Mostly let atrium with slight left auricle b,Leftand right strium c. Mostly left ventricle with slight left auricle 4. Left and right ventricle 134,The inferior border of the heart is composed of 2. Mostly right atrium with slight right venteicle b. Mostly right ventricle with slight left ventricle ¢. Mostly left atrium with slight Ieft ventricle d. Mostly left ventricle with slight right ventricle 135.This groove on the external heart is shallow and located atthe junction of the right auricle with the sinus venarum, a. Sulcus terminalis b. Crista terminalis ©. Coronary groove 4d, Interventrieular groove 136.The deep groove between the atria and ventricles on both the right and left is called the coronary groove. Which vessel is Nor within this groove? a. Coronary sinus b. Circumflex artery cc. Right coronary artery 4. Marginal artery 137-The aortic valve is best auscultated Left of the patient’s sternal border at the second intercostal space Left of the patient’s sternal border at the fourth intercostal space Right ofthe patiemt’s sternal border at the second intercostal space Loft ofthe patient's sternal border at the fifth intercostal space ems left ofthe patient’s midline atthe fifth intercostal space 138.The tricuspid valve is best auscultated a. Left of the patient's stemal border atthe second intercostal space 'b. Leftof the patient's sternal border at the fourth intercostal space c. Right of the patient's sternal border at the sccond intercostal space 4, Sems left ofthe patient's midline at the fifth intercostal space 139.The pulmonic valve is best auscultated Left ofthe patient's sternal border at the second intercostal space Left ofthe patient's sternal border atthe fourth intercostal space Right of the patient’s sternal border at the second intercostal space Left ofthe patient's sternal border atthe fifth intercostal space ‘Sems felt of the patient’s midline atthe fifth intercostal space 140-The mitral valve is best heard Left of the patient's sternal border a the second intercostal space Left of the patient's sternal border at the fourth intercostal space Right of the patient's sternal border at the second intercostal space Left of the patient’s sternal border atthe fifth intercostal space Sems left of the patient's midline at the fifth intercostal space 141 The right atcium, a. Receives blood returning from systemic ciseulation . Receives blood returning from bronchial circulation ©. Receives blood returning from pulmonary circulation 4. Botha and b 35