Block 2 clinical cor.. - Looking at the World


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Block 2 clinical cor.. - Looking at the World

  1. 1. Block 2 – Clinical Correlates Clinical Correlate Explanation Ascites Effusion of peritoneal cavity with ascitic fluid Peritonitis Inflammation of peritoneal cavity Adhesion Scar tissue that connects parietal and visceral peritoneum Right lateral paracolic gutter Drains fluid above intestine from the liver to the pelvis Hepatorenal pouch Lowest point of peritoneal cavity when patient is lying down (fluid can collect here) Gastric ulcer Lesions of the stomach wall that break and cause contents of stomach to spill into omental bursa (lesser sac) and cause peritonitis and severe hemorrhaging due to erosion of splenic artery by gastric fluid. Appendicitis Acute inflammation of appendicitis caused when stuff gets stuck in it. Will present with high rebound tenderness Vagotomy Surgical section of the vagus n. Pancreatic pseudocyst Inflamed/injured pancreas resulting in pancreatic fluid in the omental bursa Referred pain Severe pain from visceral afferents are perceived as pain from somatic afferents at the same level since they have cell bodies in the same dorsal root ganglion. Pain or discomfort is perceived as an “ache” and can be difficult to localize until it becomes severe. Accessory pancreatic duct May exist superiorly to the main pancreatic duct and enter duodenum at the minor duodenal papilla if the remnant of the duct from the dorsal pancreatic bud was not obliterated. Found in 56% of population Commonly injured spleen “Ruptured spleen” – caused by thin capsule and overlying peritoneum bursting and disrupting parenchyma or pulp of spleen. “Intraperitoneal hemorrhage” – profuse bleeding of spleen that can be caused by rupture. *Most likely to be injured by ribs 9-11. Gallstones Common in females over 40, obese, and fertile. High in cholesterol content. Pain from attack involves gallstone lodged in bile duct. Pain can be referred to epigastric region, infrascapular region on right side in the back, and on top of shoulder (C3, 4) due to
  2. 2. nerve supply by phrenic and periphery nn. Portal hypertension Arises from blockage in drainage of blood from sinusoids in liver to inferior vena cava, forcing blood to take alternate routes to heart. Common in alcoholics because of liver damage. Caput medusa Varicose veins around umbilical. Liver cells are dying and there are lots of connective tissue there. Portal v. takes other routes to try and get to the vena cava (traveling via anastomose between paraumbilical v. of portal system and cutaneous vv. of abdominal wall (superficial epigastric vv.) of the systemic system. Hemorrhoids Will have blood in feces due to anastomose of superior rectal v. of portal system and middle/inferior rectal vv. of systemic system. Esophageal anastomose for portal system If patient vomits, bleeding will occur and will kill them because it will be hard to stop the bleeding. Congenital diaphragmatic hernia Caused by failure of pleuroperitoneal folds to fuse and close the pericardioperitoneal canals. More common on the left side because the liver is not in the way. Esophagotracheal fistula Caused by abnormal separation between the respiratory and esophageal diverticula. Most common form is when posterior end of foregut fuses with the trachea, causing air to enter the stomach. Commonly associated with atresia of the esophagus (blind-ended pouch of esophagus). Annular pancreas Caused when ventral pancreas splits, enclosing part of the duodenum and obstructing it. Omphalocoele Gut doesn’t retract back into the body after forming in the umbilical cord Malrotation of the gut Duodenum could end up in front of the transverse colon, inhibiting peristalsis. Meckel’s Diverticulum Remnant of vitelline duct persists connecting a portion of ileum that sticks out (diverticulum) and is connected to anterior abdominal wall. Cyst of ileum A cyst could form where a part of gut was closed off on either side of the vitelline duct. Continuation of gut into umbilical cord The gut is still continuous with umbilical cord and could cause feces to spew into it. Pelvic kidney Failure of the kidney to ascend and could be misdiagnosed as a tumor of the pelvis which may interfere with pregnancy.
  3. 3. Horseshoe kidney During ascent, kidneys get too close to each other and the lower poles fuse anteriorly to the aorta, usually around the inferior mesenteric artery. Can cause problems if there is an aneurysm behind it. Height of kidneys Right kidney is usually lower than the left one due to the liver. Bifid ureter 2 ureters coming out of one kidney. Ureteric calculi (kidney stones) Can get lodged in one of the three ureteric constrictions. Cause sharp, stabbing pain which travels inferioanteriorly from loin (back) to groin and is referred to spinal cord segments T12 – L2 due to the marked distention of the muscular wall of the ureter. Referred visceral pain of Diaphragm Referred to dermatomes C3,4,5 (phrenic n) Referred pain of heart C8-T5 Referred pain of stomach Dermatomes T6-T9 Retropubic space Allows for expansion of the bladder and access to bladder and prostate without entering the peritoneal cavity. Rectal polyps Usually form at curves of rectum. Hemorrhoids External hemorrhoids can be seen on the outside. Result from varicosities in the veins of the rectum and anal canal (see above hemorrhoids entry) Lateral fornix of uterus Can feel uterine artery at this location to determine blood flow. Enlargement of the prostate Common during the aging process. Can interfere with the micturation (urination) due to constriction of the urethra. Ectopic tubal pregnancy Occurs in about 1/250 pregnancies. Most common in women who have had damage to their uterine tubes. Importance of Rectal exams Essential since you can feel the prostate and seminal vesicles of males and the cervix of females. Maintenance of perineal body After parturition and operative procedures, it’s important to properly rebuild the perineal body to maintain its proper anatomical and physiological functions of support to the pelvic diaphragm and to aid in muscular contraction. Bleeding of superficial perineal pouch May occur during parturition when the vascular vestibular bulbs tear from sustained pressure (due to location on either side of vagina) by the fetus or secondary to other obstetric manipulations.
  4. 4. Extent and attachment of Colle’s fascia Is of clinical importance in males because this can help determine the spread of urine which may leak from a rupture of the penile urethra. Urinary extravasation Could go into the superficial perineal pouch following trauma to the perineum that ruptures the portion of the urethra lying below the UG diaphragm. Urine can fill the superficial perineal space and pass ventrally to the scrotum, penis, and spermatic cords, as well as ascend to the lower abdomen where it would lie deep to Scarpa’s fascia. Fistulae and Painful abscesses of anal glands Caused by obstruction and infection of the glands found within anal sinuses. Incontinence of feces Can result due to damage to external anal sphincter, puborectalis m., and internal anal sphincter either surgically or in childbirth. Enlarged or painful medial superficial inguinal nodes Since lymphatic vessels from upper anal canal drain into preaortic nodes (the internal and common iliac nodes), if nodes in this region are painful or enlarged, a prompt rectal examination should occur. Abscesses in ischiorectal and pararectal fossa Can be drained via an incision into the ischiorectal fossa. Usually traverse the fossa posteriorly to connect. Pudendal nerve block Inject an anesthetic near the pudendal nerve before it enters the pudendal canal. To find the correct location of the canal, palpate the ishial tuberosity and place the injection medial to the bone. Will anesthetize dermatomes S2-S2 and the lower portion of the vagina. Infection of abdominal wall Abdominal wall below the arcuate line is more susceptible to infection because muscle is covered by just one layer rather than 2. Protuberance of the abdomen Normal in young infants and children because their GI tracts contain a fair amount of air and livers are quite large. For adult, the most common causes are fat, feces, fetus, flatus, fluid, and food. (6 F’s) Abdominal hernias Most common in the inguinal, umbilical (common in newborns because ant. Abdominal wall is weak in the umbilical ring, acquired hernias here are common in fat people and women), and epigastric regions (through the linea alba). Indirect inguinal hernia Most common, due to failure of the stalk of processus vaginalis to obliterate. Can be
  5. 5. congenital, or acquired (weakness is present but made worse by heavy lifting, etc). Hernia always presents LATERAL to inferior epigastric artery, and passes through deep and superficial inguinal ring. Usually enters the scrotal sac, leaving a bulge in the abdominal wall. Direct inguinal hernia Doesn’t pass through deep inguinal ring, presents MEDIAL to inferior epigastric artery and protrudes through Hesselbach’s triangle. Usually occurs in men over 40 y/o and due to weakness in abdominal wall. Very seldomly will enter scrotal sac. Femoral hernia More common in women due to pressure on leg created by pregnancy, smaller bones but wider hips. Hernia usually presents on MEDIAL side next to the femoral vein in the empty space of the femoral triangle. Surrounded by transversalis fascia anteriorly and fascia from iliacus posteriorly. Fractures of Sternum Most common site is sternal angle. Should suspect the following: - Possibility of traumatic diaphragmatic laceration and herniation of abdominal contents into thoracic cavity. - Trauma to heart or surrounding pericardium. Sternal puncture Needle pierces the thin layer of cortical bone on sternum and enters vascular cancellous tissue. Useful in obtaining specimens in suspected blood diseases or disorders. Pectus excavatum When sternum is depressed, anterior wall appears “sunken,” may only be a cosmetic problem but could compromise respiration. Thoracic thoracentesis Place needle or tube in the midportion intercostal space to avoid neurovascular bundle. Nerve block anesthesia of ribs Deliver anesthesia close to inferior border of rib. Rib notching May occur if there is obstruction to aorta causing blood to be shunted through various pathways of collateral flow, including intercostals aa. The increased expansion of these arteries cause them to erode the overlying bone. Rib pain Along with subsequent radiographs, may be
  6. 6. the first sign of cancer in the breast or prostate gland since ribs are frequent sites of metastasis for those. Flail chest Due to several bilateral multiple fractures of the ribs resulting in paradoxical respiration Rib fractures May cause: - pleural lacerations and pneumothorax with or without medistinal shift - subcutaneous emphysema - hemothorax secondary to lung laceration or tear of intercostals vessel. - Lower rib fractures could be associated with diaphragmatic tears and subsequent hernia - Right rib fractures associated with liver laceration - Left rib fractures associated with spleen laceration Chest Tubes Insert above a rib and make your way up. Internal thoracic or mammary nodes Frequently associated with carcinoma of breast when tumor is in the medial half of breast or when the axillary nerves are blocked with metastatic tumor and lymph flow is directed medially. Pneumothorax Air in the pleural cavity. Most common cause is spontaneous rupture of a part of the lung. Relieved by placement of tube for drainage. Tension pneumothorax Condition where tear only in parietal pleura so air can only go in, causing pressure build-up that subsequently collapses the lung and cause central mediastinal structures to get pushed against opposite lung. Referred pain of lungs The site of referred pain secondary to inflammation or irritation of pleura is often associated with which part of the pleura is involved. If costal pleura is irritated, pain is usually present in the chest wall over the area of irritation. Post ductal coarctation Congenital aortic narrowing distal to the subclavian artery. Results in rib notching as blood attempts to reach aorta via reversed blood flow through anastomoses between the intercostals branches of the internal thoracic a. and the aorta. ** Internal thoracic a. can also be used during coronary artery bypass surgery. Superior Vena Cava syndrome Results from obstruction of the superior vena
  7. 7. cava resulting in fluid accumulation and edema in head, neck, and upper limbs presenting as redness around neck and face. Tearing of ligamentum arteriosa Can cause severe bleeding of aorta during trauma Aortic arch injury Due to severe upper chest trauma. Can cause mediastinal widening due to hemorrhage or to pseudoaneurysm that is developing in the wall of the aorta itself. Aspiration into the lungs Most likely occurs in the right primary bronchus because it is more vertical and its lumen is wider. Thoracic aorta aneurysms Thoracic aorta is prone to these. When aortic arch develops an aneurysm, the left recurrent laryngeal n. can be compressed resulting in hoarseness of the patient’s voice. Pericarditis Inflammation of the pericardial sac. Can cause fluid accumulation in pericardial cavity which can impede motion of the heart. Tamponade Accumulation of fluid in pericardial cavity. Pericardiocentesis Procedure to remove fluid from cavity. Involves placing needle into sac. Can obtain samples for potential infectious agents. Transesophogeal echocardiography Putting a little Doppler imaging device down the esophagus to take images of the heart with no sternum or ribs getting in the way. Takes advantage of the anatomy that esophagus is immediately posterior to heart Right- or Left-sided heart failure When right or left sides of the heart fail to pump. Dextrocardia When heart is on the right side of the chest and you can feel the strongest heart sounds to the right of the sternum. Situs inversus When other organs in addition the heart are similarly reversed in orientation. First sign of is seen by looping of heart Dominance of heart Clinically important because during heart attacks, many times the blockage occurs at the Left coronary artery. However, since most hearts (2/3rds of the time) hearts are Right- dominant, people can survive heart attacks. Ischemia Inadequate blood supply to an organ Infarction Extreme ischemia, implying permanent injury Arteriosclerosis Most common cause of infarction Scarring of heart valves Valves may be permanently scarred following infections (like rheumatic fever) and become
  8. 8. narrowed (stenosis) resulting in retrograde leakage of blood. Mitral valve prolapsed Usually a benign condition of incompetency of leaflets of mitral valve. Present in up to 10% of population. Heart sounds (lub-dub) First sound is due to the bi/tricuspid valves closing and pumping blood out of the heart (beginning of systole). The second sound is due to the pulmonary/aortic valves closing and the heart filling up with blood (beginning of diastole) Myocardial infarction Heart attack. Referred pain from heart includes “crushing, tightening” chest pains and also pain to the arm, neck or jaw. Respiratory Distress Syndrome (“Hyaline Membrane Syndrome”) Developes in premature infants due to inadequate levels of surfactant in the lungs. Type II pneumocytes produce surfactant beginning at month 6, with sufficient levels at month 7. Accounts for 20% of neonatal deaths. Can be treated with artificial surfactant and glucocorticoids to stimulate the cells to make surfactant. Defects of atrial septation 1) Failure to close - can cause higher blood pressure on left side of heart can cause left-right blood flow between atria, overburdening the right side of the heart and leading to cardiac failure 2) Patent foramen ovale – when foramen ovale didn’t seal after birth and blood continues to be shunted through it. 3) Left heart hypoplasia – premature closing of the foramen ovale during fetal life, causing underdevelopment of the left side of the heart. Incompatible with postnatal life since there isn’t enough blood flow from aorta to rest of the body. Ostium primum atrial septal defect Failure of final closure of atrial septum due to inadequate development of endocardial cushions Membranous ventricular septum defect Failure of final closure of ventricular septum. Most common congenital heart defect. Formed when muscular and membranous septal portions fail to fuse with each other. Persistant AV canal Most severe defect involving endocardial cushion development. Common in Down
  9. 9. Syndrome, causes significant Left-Right blood flow due to large hole. Tetralogy of Fallot Over-riding aorta (receiving blood from both right and left sides) Ventricular septal defect (in the membranous part) pulmonary stEnosis (narrowing of the pulmonary arteries) veNtricular hypertrophy (really big ventricles) Irreversible pulmonary hypertension When the ductus arteriosus doesn’t close and after birth, blood is shunted from the aorta to the lungs. Sometimes can be life-saving by allowing a shunt when other congenital heart disorders are associated with it. Preductal coarctation Ductus arteriosus persists after birth, causing flow to the descending aorta to be entirely deoxygenated blood from the right side of the heart. Requires surgical correction.