Clinical Correlations Exam 1

disc herniation

compression of spinal roots by herniated disc (nucleus pulposus surrounded by annulus fibrosus) as they exit intervertebral foramen

lumbar puncture (spinal tap) & epidural anesthesia

Sample CSF in the area that does not damage spinal cord – done in the region of the cauda equina (~around L4-L5 vertebrae)

lumbar puncture = subarachnoid space

epidural = epidural space

shingles - herpes zoster

Results from reactivation of latent varicella zoster infection within the dorsal root ganglia (or trigeminal ganglion)

when activated causes blistering in those areas that receive input from that spinal level

External Jugular Vein Distention

a markedly distended right external jugular vein (EJV); usually above clavicle

caused by elevated central venous pressure (from blockage of SVC)

Scalene Compression Syndrome (SCS

TYPE OF THORACIC OUTLET SYNDROME

Brachial plexus & subclavian a. become compressed since they pass between anterior & middle scalene m.

low BP in upper limb

Acromioclavicular (AC) joint separation (shoulder separation)

injury to the acromioclavicular ligament and/or coracoclavicular ligament; aka “piano key sign”

Glenohumeral Joint Dislocation (indirect vs direct)

humerus dislocates out of the joint capsule (GHJ reinforced by ligaments/muscles anteriorly, superiorly, and superiorly but NOT inferiorly)

indirect: excessive extenion

direct: hit by a force

Surgical neck of humerus fractures

commonly occur here because it is narrowest (may damage axillary nerve —> deltoid, teres minor)

related to brachial plexus case

elbow dislocation

force moving to proximal ulna causes olcecranon process of ulna out of olecranon fossa of humerus (injury to ulnar nerve)

ulnar collateral ligament tear

(“Tommy John surgery”) tear in ulnar collateral ligament common in baseball players

subluxation/dislocation of radial head

proximal head of radius subluxes (pulled downward from annular ligament)

Boxer’s fracture

fracture at head of 4th and/or 5th metacarpals

Scaphoid fracture

most common carpal bone fracture (results in nonunion and avascular necrosis)

MOI: falling on outstretched hand (force hits the wrist)

most common site of metastasis from breast cancer

axillary nodes (pectoral, apical, and central nodes)

risk of spreading through parasternal nodes

winged scapula

injury to long thoracic nerve resulting in scapula pulling away from posterior thoracic wall

“avoid knife fights”

subacromial impingement of rotator cuff

MOI: repeated ABduction and flexion of arm (throwing, swimming) causes humeral head and rotator cuff tendons, commonly supraspinatous, to impinge on coracoacromial arch

deltoid overrides rotator cuff muscle actions

superior displacement of humeral head

injury to supraspinatous muscle

inability to initiate ABduction

brachial plexus case

inability to ABduct arm + loss of sensation over lateral side of shoulder and proximal arm

surgical neck fracture = injury to axillary nerve and posterior circumflex humeral artery (quadrangular space)

compression of second part of axillary artery

branch of subclavian artery is involved in scapular anastomosis, allowing blood to bypass compression (suprascapular and dorsal scapular arteries involved)

popeye deformity

long head of biceps brachii shortens into middle of brachium (short head remains attached/functional)

lump in middle of upper arm

MOI: forced flexion against resistance or prolonged tendonitis

venipuncture

puncture of vein as part of medical procedure (withdraw blood sample) or for intravenous injection

mainly uses median cubital vein in cubital fossa

lateral epicondylitis (“tennis elbow”)

inflammation of common extensor tendon (sometimes extensor carpi radialis brevis)

MOI: overuse of extending wrist; repeatedly gripping object

anatomical snuffbox

between extensor pollicis longus tendon and extensor pollicis brevis tendon

radial artery, superficial branch of radial nerve, cephalic vein

erb duchenne palsy

superior brachial plexus injury (injury to C5,C6)

musculocutaneous, axillary, suprascapular, radial nerves affected

waiter’s tip position (medially rotated, adducted arm, extended forearm)

wrist drop

inability to extend forearm and hand at wrist

MOI: spiral groove fracture of humerus

injury to radial nerve and deep brachial artery

palmaris longus signficance

absent in 14% of population

smith’s fracture

flexion fracture of radius (displaced anteriorly)

colle’s fracture

extension fracture of radius (displaced posteriorly)

mallet finger

injury to lateral bands on extensor tendon at the distal phalanx

inability to extend distal phalanx

hand of benediction

injury to median nerve at elbow or above

unable to make a fist or flex the thumb/2nd/3rd digitsc

carpal tunnel syndrome

entrapment of median nerve between flexor retinaculum (transverse carpal ligament) and carpal bones

inability to oppose thumb (but sensation remains on palm since it goes superficially)

claw hand

injury to ulnar nerve at elbow

Guyon’s canal syndrome

numbness and tingling on medial hand (can still flex 4th and 5th digits unlike claw hand)

injury to nerve passing through medial anterior wrist

clinical testing interosseous muscles

DAB (dorsal interossei, ABduction)

PAD (palmar interossei, ADduction)

both innervated by ulnar nerve

avocado hand

knife injures median nerve in hand

allen’s test

testing blood flow to hand before surgery (radial and ulnar arteries)

birth defects

leading cause of infant deaths (20% of all infant deaths)

congenital heart defects (most common)

cleft lip and palate (1 in 1600)

sacrococcygeal teratoma

part of primitive streak remains (type of germ cell tumor that contains tissues derived from all 3 germ layers in incomplete stages of differentiation)

rib dislocation

costal cartilage detaches from sternum at sternocostal joint

rib separation

rib detaches from costal cartilage at costo-chondral joint

costochondritis

inflammation of costal cartilage

common cause of chest pain in children/adolescents

flail chest (multiple rib fractures)

2+ contiguous rib fractures with 2+ breaks per rib

during inspiration = lung collapses on affected side and shifts mediastinum toward UNAFFECTED side

during expiration = mediastinum shifts to AFFECTED side

diagnosis

flail chest

cervical rib

extra rib arising from 7th cervical vertebrae (only 1 in 500)

causes a form of thoracic outlet syndrome (compression of lower trunk of brachial plexus or subclavian artery between cervical rib and scalene muscles

pectus excavatum

funnel chest

sternum pushed inward

pectus carinatum

pigeon chest

sternum pushed outward

kyphoscoliosis

combination of kyphosis (abnormal bending of thoracic spine) and scoliosis (lateral bending)

contracted scalene muscles

patients may use these muscles to help breathe when having difficulty breathing normally (advanced lung disease)

tripod position optimizes respiratory mechanics

herpes zoster (shingles)

viral disease characterized by painful skin rash with blisters often in dermatomal pattern

starts as chikcenpox (varicella zoster virus)

affects dorsal root ganglion and travels down nerve axons

thoracocentesis

requires catheter insertion

done middle of rib space or just above lower rib to avoid main neurovascular bundle (VAN)

coractation of aorta

constriction of arch of aorta (congential defect)

may cause rib notching due to collateral circulation involving internal thoracic and intercostal arteries

rib notching

sign of coractation of aorta

collateral circulation involving internal thoracic and intercostal arteries (may result in enlargement of intercostals)

diagnosis

rib notching (coractation of aorta)

pleurisy

inflammation of pleura (inflamed visceral and parietal pleura rub against each other causing sharp pain during breathing, coughing, sneezing)

possible causes: (viral/bacterial) infection, pneumothorax, pulmonary embolism, lung cancer

may cause pleural effusion

pleural effusion

build-up of pleural space particularly in costodiaphragmatic recess (blunting in xray)

caused by pleurisy

diagnosis

pleural effusion

sampling pleural fluid

in costodiaphragmatic recess

4 types of fluids that can accumulate in pleural space

serous (hydrothorax, pleural effusion)

blood (hemothorax)

pus (pylothorax)

lymph (chylothorax)

air (pneumothorax)

pneumothorax

when air gets into pleural space (can occur spontaneously)

caused by pulmonary blebs

diagnosis

pneumothorax

tension pneumothorax

dangerous type of pneumothorax where air enters pleural cavity during inspiration but is NOT expelled during exhalation (buildup of pressure in pleural space)

symptoms: chest pain, tachycardia, tachypnea

left-side tension pneumothorax

collapse of left lung causes deviation of lung and mediastinum to opposite side of chest (mediastinal shift)

MEDICAL EMERGENCY

diagnosis

left side tension pneumothorax (right side if right lung is collapsed)

diagnosis

left side tension pneumothorax

pulmonary embolism

blockage of pulmonary artery or one of its branches by a substance (blood clot) that has traveled from else in body through bloodstream

sx: difficulty breathing, chest pain upon inspiration, low blood oxygen levels, cyanosis, rapid breathing, rapid heart rate

diagnosis

pulmonary embolism

inhalation of sympathomimetic substance

relax smooth muscle in bronchi and dilate airways (albuterol)

pericardial effusion

fluid in pericardial cavity

diagnosis

pericardial effusion

“water-bottle” silohuette

cardiac tamponade

acute version of pericardial effusion

space around heart fills with blood/fluid (puts pressure on heart)

becks triad

muffled heart sounds, jugular distension, low arterial pressure

coronary artery disease

build up of cholesterol “plaque” in coronary arteries makes it difficult to supply heart with blood, oxygen, nutrients

heart uses 3 perfusion strategies

3 perfusion strategies (CAD)

coronary artery collateralization (new capillary growth)

reverse blood flow in thebesian veins

endogenous bypass via vasa vasorum

(what happens if these don’t work?)

coronary artery bypass graft (CABG)

solution for when 3 perfusion strategies for CAD don’t work (take vein/artery from elsewhere and attach to ascending aorta to bypass problematic area)

graft options: great saphenous vein, radial artery, internal thoracic artery

most common vessels to be occluded in coronary artery disease

left anterior interventricular artery

right coronary artery

circumflex artery

transplanted heart

no external nervous input, no sensory input

tumor growing in mediastinal area has affected patient’s speaking

recurrent laryngeal branch of vagus nerve

hiatal hernia

part of stomach protrudes up into chest through diaphragm

portal hypertension

venous return from GI tract cannot get through to portal system of liver. therefore, it will try to fin ways of gettting around using superficial veins (which become enlarged)

seen in patients with liver disease, ascites

caput medusae

cluster of swollen veins in abdomen (usually with paraumbilical veins)

patients with liver cirrhosis, parasitic infections (ascites)

diagnosis

caput medusae

cremasteric reflex

stroke inner surface of thigh near testis → testis should pull up closer to body

used to test genitofemoral nerve (L1/L2) and testicular torsion

testicular torsion

testicle rotates, twisting the spermatic cord that brings blood to scrotum (reduced blood flow causes severe pain/swelling)

inguinal hernia (direct vs indirect)

direct (acquired): does NOT go through inguinal canal, medial to lateral umbilical fold

indirect (congential): does go through inguinal canal, lateral to lateral umbilical fold

identify the types of hernias

ascites

accumulation of protein-containing fluid within abdomen (enlarged abdomen)

caused by liver cirrhosis, cancer, kidney failure, pancreatitis, tuberculosis

gastroesophageal reflux disease (GERD)

stomach acid frequently flows back into esophagus which can irritate lining of esophagus (acid reflux)

caused by weakened sphincter

can cause esophageal ulcer, esophageal stricture, Barrett’s esophagus (precancerous changes to esophagus)

peptic ulcer disease

open sores on inside lining of stomach and upper portion of small intestine (duodenum)

includes gastric and dudodenal ulcers

commonly caused by bacterium H. Pylori

ligament of treitz

suspensory ligament of duodenum

can use as landmark for diagnosing intestinal malrotation and partial rotation AND discriminating upper/lower GI bleeding

ileocecal junction

can diagnose irritable bowel syndrome and Crohn’s disease by looking here

pancreatic endocrine malfunction

diabetes mellitus: high blood sugar due to not being able to produce insulin to regulate blood sugard

pancreatic exocrine malfunction

diarrhea and malnutrition (pancrease can’t produce digestive enzymes)

head of pancreas clinical significance

near numerous ducts/blood vessels (close relationship to duodenum)

jaundice

pressure on bile duct

irreversible cirrhosis

scarring of liver caused by alcohol abuse, hepatitis infection, autoimmune disease

presents as hobnail appearance, ascites, splenomegaly

diagnosis

liver cirrhosis

Crohn’s disease

inflammation of ileocecal junction

presents as labial/gingival/mucosal swelling, cobblestoning of buccal mucosa, mucosal tags

diarrhea, stomach pain, bloody stool, reduced appetite, weight loss

diverticulosis

false diverticula (external vaginations of mucosa colon) develop along intestine

commonly found in sigmoid colon

diagnosis

diverticulosis

volvulus of sigmoid colon

rotations/twisting of loop of sigmoid colon (obstruction of lumen of descending colon)