HEAD AND NECK

MARIA KAREN ALCANTARA-CAPUZ, MD

OUTLINE OF TOPICS A. SKULL

A. Skull
- Bones
o Newborn vs. Adult
- Division and Foramina
B. Cranial Nerves and Foramen
C. Scalp
D. Face and Facial Trauma (Orbit, Midface,
Mandible)
E. Oral Cavity, Salivary Glands and TMJ
F. Pharynx
G. Neck Embryology, Triangles, Muscles, Fascia
and Neck Spaces
H. Nerves in the Neck
I. Blood Vessels in the Head and Neck: Blood
Supply and Venous Drainage
J. Lymphatic Drainage
K. Thyroid
L. Parathyroid

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 HEAD AND NECK
MARIA KAREN ALCANTARA-CAPUZ, MD

C. Posterior Cranial fossa

 From the petrous portion to the
posterior portion of the occipital
bone

I. BONES B. CRANIAL NERVES AND FORAMINA

PAIRED UNPAIRED ANTERIOR CRANIAL FOSSA
Cranial (4) (4)
Cribriform plate CN1, discharge of CSF
Parietal Frontal
from the nose
Temporal Ethmoid
(rhinorrhea) will result
Sphenoid
from fracture of
OccipitaL
cribriform plate & dural
Facial (12) (2)
tear
Lacrimal Vomer
Palatine Mandible
Ethmoidal Ant & post ethmoidal
Nasal
foramina NVS
Inferior
Conchae Foramen cecum Emissary vein
Maxilla MIDDLE CRANIAL FOSSA
Zygoma
Optic Canal CN I, ophthalmic artery
Superior Orbital CN III, IV, V1, VI,
II. DIVISION & its FORAMINA Fissure ophthalmic vein
A. Anterior Cranial fossa Foramen CN V2
 From the anterior frontal bone to Rotundum
lesser wing of sphenoid F. Ovale CN V3, lesser petrosal
B. Middle Cranial fossa nerve, accessory
 From the lesser wing of the meningeal artery
F. Spinosum Middle meningeal artery,
sphenoid to the petrous temporal
epidural hemorrhage will
bone
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 HEAD AND NECK
MARIA KAREN ALCANTARA-CAPUZ, MD

result from a fracture in f. Tic douloureux (recurrent,

this area stabbing pain)
F. Lacerum Nothing passes VI Abducens a. Convergent strabismus,
Carotid Canal ICA, sympathetic carotid b. Iinability to abduct the eye
plexus c. Horizontal diplopia when
Hiatus of Facial Greater petrosal nerve patient looks toward paretic
Canal muscle;
POSTERIOR CRANIAL FOSSA
Int. Auditory CN VII & VIII, VII Facial a. Paralysis of muscle of facial
Meatus labyrinthine artery, CSF expression (upper and lower
otorrhea (CSF discharge face; called Bell palsy),
into the external auditory b. Loss of efferent limb of
canal) will result from corneal reflex,
fracture of mastoid c. Hyperacusis as a result of
process & dural tear paralysis of stapedius muscle,
Jugular foramen CN IX, X, XI & Internal d. Dry mouth
Jugular vein (sigmoid e. Crocodile tears syndrome
sinus), mass in jugular (tearing during eating) as a
foramen will result in result of aberrant
difficulty of swallowing regeneration after trauma
(dysphagia) & speaking
(dysarthria) uvula VIII a. Disequilibrium, vertigo, and
paralysis & inability to Vestibulocochlear nystagmus
shrug shoulders b. Cochlear lesion (e.g.,
Hypoglossal Canal CN XII acoustic neuroma) results
F. Magnum Spinal cord, spinal in hearing loss and tinnitus
accessory N. vertebral & IX a. Loss of afferent limb of gag
spinal arteries, venous Glossopharyngeal reflex
plexuses of vertebral b. Loss of taste from posterior
canal one third of tongue,
Condyloid F. Emissary vein c. Loss of sensation from
Mastoid F. Emissary vein pharynx, tonsils, fauces, and
back of tongue
I. CRANIAL NERVES and CLINICAL
X Vagus a. Hoarseness or loss of
MANIFESTATIONS of
vocalization
INJURY/DEFECT b. Deviated soft palate
I Olfactory Anosmia c. Uvula deviated to normal
II Optic a. Altered light reflex (afferent side
limb) d. Dysphagia
b. Visual field deficits, e. Loss of efferent limb of gag
c. Blindness reflex, and oculocardiac reflex
III Oculomotor a. Dilated pupil XI Spinal a. Inability to turn head to
b. Ptosis (paralysis of levator Accessory opposite side of injured
palpebral m.) nerve,
c. Altered pupillary reflex b. Inability to shrug shoulder
(efferent limb) XII Hypoglossal a. Tongue deviation to the
d. Eye directed down & out
same side of injured nerve,
e. Diplopia
altered speech (dysarthria)
f. Lack of accommodation
IV Trochlear a. Extorsion of the eye
b. Vertical diplopia that
II. Cranial Nerve Reflexes
increases when looking down
Reflex Afferent limb Efferent
V Trigeminal a. Hemianesthesia of the face
limb
b. Loss of afferent limb of
Corneal Trigeminal n. Facial n.
corneal reflex, & oculocardiac
(Blink) (CNV) (CN VII)
reflex,
c. Paralysis of muscle of Pupillary Optic n. Occulomotor
mastication (Light) (CN II) (CN III)
d. Deviation of jaw to the Gag Glossopharyngeal Vagus n.
injured side, n. (CN IX) (CN X)
e. Hypoaccusis as a result of
paralysis of tensor tympani
muscle,

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 HEAD AND NECK
MARIA KAREN ALCANTARA-CAPUZ, MD

C. SCALP P-Pericranium

 covering of the skull

 has no ostoegenic capabilities
 loosely adherent to skull except at suture
lines/junctions

D. FACE and FACIAL TRAUMA

Muscles
ORGIN – underlying bone
INSERTION- dermis

DIVISION
 Surrounding the eyes
Closing eyes: Orbicularis oculi
Opening eyes: Levator palpebrae sup.
 Surrounding the mouth
S- Skin
Closing mouth: Orbicularis oris
 thick dermis with abundant hair follicles & Dilator of lips:
sebaceous glands - Levator labii superioris
- Levator labii superioris ala que nasi
C-Connective Tissue
- Zygomaticus minor & major
 with fat lobules, abundant nerves & blood - Levator anguli oris
vessels - Risorius-grinning
 held in place by fibrous septa that prevents - Depressor anguli oris
vessels from retracting & narrowing - Depressor labii inferioris
causing profuse bleeding in scalp wounds - Mentalis
when lacerated
 Cheek muscles
A- Aponeurosis
Buccinator: blowing / sucking muscles
 fibrous tissue that covers the dome of the skull;  Surrounding the nose
attached to it anteriorly & posteriorly are the Sphincter muscle: Compressor naris
frontalis & occipitalis muscles Dilator muscle- dilator naris
 wounds gape widely when this layer is  Surrounds the ears
split or cutpull of the frontal and Anterior, posterior & superior auricularis m.
occipital parts anteriorly and posteriorly -move the auricles

L-Loose Connective Tissue

 potential space that contains the emissary veins
which communicate with the diploe of the and
dural sinus of the cranium- “Dangerous layer
of the scalp”
 Infectioncavernous sinus thrombosis
 responsible for the mobility of the scalp
Nerve Supply
 Facial nerve
 Motor innervation
 Enters the internal acoustic meatus, passes
through the facial canal in the petrous
portion the temporal bone & descends to
emerge from the stylomastoid foramen
 Passes through the parotid gland before
dividing into its 5 terminal branches
 Gives rise to 2 branches that innervate:
o Stylohyoid m
o Posterior belly of digastric

 5 terminal branches:
- Temporal
- Zygomatic
- Buccal
- Mandibular
- Cervical

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 HEAD AND NECK
MARIA KAREN ALCANTARA-CAPUZ, MD

 Trigeminal nerve  Le fort II: pyramidal fracture that includes

 Sensory innervation of face is by 3 divisions both maxillae and nasal bones, medial portions
of CN V, with some contributions of the of both •maxillary antra, infra-orbital rims,
cervical plexus. orbits, orbital floors (ant.-post. views).

 Trigeminal neuralgia or tic doulourex  Le Fort III: includes Le Fort II and a fracture
 episodes of brief, intense, facial pain in one of of both zygomatic bones= craniofacial
disarticulation and cerebrospinal fluid leakage
the three distributions of CN V, pain so intense that
(ant.-post. views).
patient winces producing a facial muscle tic
Orbital Blow Out Fracture
Blood Supply
 Facial artery
 Superficial temporal artery
 Ophthalmic artery

Venous drainage
 Ophthalmic vein
 Facial veinangular vein
 joined to pterygoid venous plexus by
deep facial vein & to the cavernous sinus via
the superior ophthalmic vein
drains into IJV by joining retromandibular
vein to form common facial v.
 Retromandibular v.
 Superficial Temporal v.  Direct blow to the front of the orbit
 Internal maxillary v.  Increase in intraorbital pressure resulting in fx of
the thin orbital floor
 orbital soft tissues may herniate into the
underlying maxillary paranasal sinus
 Clinical signs:
 diplopia
 paresthesia (fx through infraorbital
foramen)
 enopthalmos
 limited upward gaze

Mandibular Fracture

FACIAL TRAUMA

Zygomatic fracture
 Trauma to cheekbone
 Appears as flattened cheek

Midface Fractures

 vulnerable location, 2nd most fractured facial

bone next to nasal bone
 U shape renders it liable to multiple fx
 Common sites of fracture
1. Condyle 36%
2. Body 21%
Le Fort Classification: 3. Angle 20%
 Le Fort I- horizontal detachment of the 4. Parasymphysis 14%
maxilla at the level of the nasal floor

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 HEAD AND NECK
MARIA KAREN ALCANTARA-CAPUZ, MD

5. Coronoid, ramus, alveolus, symphysis all o Superior & Inferior Longitudinal

less than 3% each o Transverse & Vertical
6. Weak areas include the 3rd molar  Alters the shape
 NS: CN XII
(particularly when impacted) and the canine fossa
o Extrinsic:
o Genioglossus: rotrusion
 MALOCCLUSSION is highly suggestive of fx o Hyoglossus: Depression
o Palatoglossus: Elevation
E. ORAL CAVITY, SALIVARY GLANDS and o Styloglossus; Retraction
TEMPOROMANDIBULAR JOINT  NS: CN XII except
palatoglossus w/c is
ORAL CAVITY innervated by CN X
2 Parts:  Alters position
 Vestibule: bounded externally by cheek and  Blood supply: - Lingual artery
lips; gums and teeth internally  Venous drainage: IJV
o Receives opening of parotid duct  Lymphatic Drainage
 Oral cavity proper: Boundaries: o Tip- submental lymph node
o Roof: palate o Post 1/3 deep cervical lymph nodes
o Floor: tongue, mylohyoid (diaphragm) o Sides anterior 2/3- Submandibular &
& geniohyoid o Median anterior 2/3- deep cervical lymph
o Anterior & Lateral: gums & teeth nodes
o Posterior: oropharyngeal isthmus
Summary of Innervation of the Tongue
Palate Sensory Taste
 Hard palate Anterior 2/3 CN V3 CN VII
-Anterior 4/5 of palate Posterior 1/3 CN IX CN IX
-Bony framework: palatine process of maxillae &
Muscles Motor: CN XII except
horizontal plate of palatine bone
palatoglossal CN X
-Sensory ns.: CN V
 Soft palate
SALIVARY GLANDS
-posterior 1/5 of palate
-fibromuscular fold extending from the posterior
Parotid Gland- largest of the 3 salivary gland,
border of hard palate
occupies retromandibular space
- Sensory ns: CN IX
 covered by the investing layer of deep cervical
fascia
Muscles of the Palate
 secretes a serous saliva that enters the mouth
MUSCLES NS ACTION
via parotid duct (Stensen’s ductcrosses
Palatoglossus CN X Elevates
masseter and pierces buccinator & opens into
Palatopharyngeus CN X Elevates /closes vestibule at the level of 2nd upper molar tooth)
nasopharynx  innervated by CN IX via auriculotemporal nerve
Tensor veli CN V2 Tenses
 divided by the facial nerve into superficial &
Levator palatini CN X Elevates deep lobes
Uvulae M CN X Elevates
 Pleomorphic adenoma- most common benign
Tongue- muscular mobile organ tumor of the salivary glands
 divided into anterior 2/3 (oral) and posterior 1/3  Frey syndrome- “gustatory sweating”
(pharyngeal) by inverted V shaped sulcus o Post-operative phenomenon following
terminalis. parotid surgery, face lift;
 at the apex of which is known as the foramen o Aberrant reinnervation of postganglionic
cecum, the site of embryological origin of parasympathetic neurons to nearby
thyroid gland dennervated sweat glands and blood vessels
 divided into right & left half by the median resulting in flushing and sweating in the
fibrous septum sympathetically void skin in response to
 Lingual Papilla are scattered on the surface of mastication and salivation
the tongue o (Auriculotemporal nerve carries
o Circumvallate papillae- Largest, anterior postganglionic sympathetic nerve fibers to
& parallel to sulcus terminalis the sweat glands of the head and
o Fungiform- Small red dots at tip and postganglionic parasympathetic nerve fibers
lateral borders to the parotid gland for salivation)
o Filiform- Most numerous
o Foliate-Small lateral folds Submandibular Gland
 All have taste buds EXCEPT filiform  Divided into deep and superficial lobe by the
mylohyoid muscle
 2 Types of Muscles
 Covered by the investing layer of the deep
o Intrinsic:
cervical fascia

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 HEAD AND NECK
MARIA KAREN ALCANTARA-CAPUZ, MD

 Wharton duct arises from the deep lobe and  Palatopharyngeus

open into the floor of the mouth lateral to o Pharyngobasilar layer
frenulum of tongue o Mucosa
 NS: parasympathetic secreto-motor fibers of CN
VII via the chorda tympani  NS: Pharyngeal plexus- made up of CN IX,
 Common site of sialolithiasis CN X and sympathetic fibers from superior
cervical ganglion
Sublingual Gland  Waldeyers’ Ring
 Lies beneath the mucous membrane on the floor  Lymphoid tissue that surrounds the pharynx
of the mouth within sublingual fold o Pharyngeal Tonsil/ Adenoid
 Empties into the floor of the mouth via the 10- o Tubal/ Gerlach
12 short ducts o Palatine
 NS: same as the submandibular gland o Lingual

Temporomandibular joint- ginglymodiarthrodial G. NECK: EMBRYOLOGY, TRIANGLES,

or gliding and hinge joint MUSCLES, FASCIA and SPACES
 Articulation between condylar process of the  Embryology of Neck
mandible & the mandibular fossa of the PA Muscles CN Cartilage
squamous portion of the temporal bone 1st Muscles of 5 (Meckel’s
mastication & (V2 Cartilage)
&3)
Muscles of mastication mylohyoid, Malleus,
 Facilitate biting & chewing digastric anterior Incus,
 Embryologically, derived from 1st brachial arch & belly, tensor veli maxilla,
innervated by CN V3 palatini, and zygomatic,
 Actions: tensor tympani temporal &
Closes jaw/ Elevator muscles mandible
o Masseter (retrude)
o Medial Ptreygoid (produce grinding 2nd Muscles of facial 7 (Reichert’s
motion) expression & Cartilage)
o Temporalis (retrude) digastric Stapes,
Opens jaw/ Depressor posterior belly, styloid,
o Lateral Pterygoid (side to side) stylohyoid, & lesser
stapedius cornu,
F. PHARYNX muscles, upper /2
 Funnel shaped fibromuscular tube that extends of hyoid
from the base of the skull to the lower border of 3rd stylopharyngeus 9
cricoid cartilage th
soft palate 10 Laryngeal
 Divisions: 4
except the (SLN) cartilages
o Nasopharynx- extends from the base tensor veli
of the skull to the level of soft palate; palatini, muscles
Opens anteriorly and communicates of the pharynx
with nasal cavity via the choanae except
o Communicates with the middle ear via stylopharyngeus,
the Eustachian tube whose function is to & the
equalize pressure cricopharyngeus
o Oropharynx- extends from the soft muscle
palate to the tip of the epiglottis
5th Intrinsic muscle 10th Laryngeal
o Communicates w/ mouth anteriorly
of the larynx RLN cartilage
o Laryngopharynx- extends from the tip
(except the
of the epiglottis to the lower border of
cricothyroid) &
the cricoid cartilage
o on each side of the opening of larynx is upper muscle of
the piriform recesses the esophagus
 Layers:
o Buccopharyngeal fascia- join the BONES & LANDMARKS
pretracheal layer Hyoid bone; CV 3
o Muscular layer  Serves as movable base for the tongue
 Circular  Divides the muscles into suprahyoid
 Superior, Middle & & infrahyoid grp
Inferior Pharyngeal  Laryngeal prominence (Adam’s apple)
Constrictors  Cricoid cartilage: CV6
 Longutudinal  Styloid process- origin to 3 muscles & 2
 Stylopharyngeus ligaments
 Salpingopharyngeus o Stylohyoid (CN 7)
o Styloglossus (CN XII)

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 HEAD AND NECK
MARIA KAREN ALCANTARA-CAPUZ, MD

o Stylopharyngeus (CN IX) C: Muscles that form the floor of the posterior
 Trachea triangle, cervical plexus, occipital artery

TRIANGLES OF THE NECK

 Subclavian/ supraclavicular
B: Inferior belly of omohyoid, medial
border of clavicle, infero-posterior border of SCM
C: Subclavian artery & vein, apex of lungs, roots of
brachial plexus, deep cervical nodes

FASCIAL LAYERS

I- Anterior

a. Submandibular/ Digastric
b. Submental
c. Carotid
d. Muscular

II-Posterior I-Superficial Cervical Fascia

a. Occipital
b. Subclavian/ Supraclavicular
- ANTERIOR and POSTERIOR TRIANGLE
divided by the sternocleidomastoid
1. Anterior triangle
 Submandibular
B: anterior & posterior belly of digastric, inferior
border of mandible
C: Submandibular gland, nodes, facial A & V
 Submental
B: Anterior belly digastric, mylohyoid & hyoid bone
C. lymph nodes
 Carotid
B: Superior belly of omohyoid, posterior belly of
omohyoid, anterior border of SCM
C: Ascending Pharyngeal, Internal Carotid A
Internal Jugular Vein, Vagus n. & Hypoglossal N
 Muscular
B: Superior belly of omohyoid, Anterior border of
SCM, Midline of neck
C: Strap muscles, Thyroid & parathyroid gland
Larynx, trachea, esophagus, Recurrent laryngeal n.,
Lymph nodes
2. Posterior triangle
 Occipital
B: Trapezius, posterior border of SCM, inferior belly
of omohyoid
II-Deep Cervical Fascia
a. Superficial Layer (Investing)
b. Middle Layer (Muscular/ Visceral/ Pretracheal)
c. Deep Layer (Prevertebral)
I. Superficial Fascia
 Platysma
II. Deep Fascia
1. Superficial layer of the deep cervical fascia
(Investing)
 Attachments:
 Superiorly: mandible, mastoid, external occipital
protuberance & superiot nuchal line
 Inferiorly: acromion, spine of scapula, clavicle &
manubrium sterni (space of Burns)
 Encloses SCM & trapezius
 Encloses parotid & submandibular gland
2. Middle Layer of the deep cervical fascia
(Pretracheal/ Muscular/ Visceral layer)
 Attachments:
 Superiorly: hyoid/ thyroid cartilage
 Inferiorly: Pericardium
 Encloses the a) strap muscles b) visceral
(pharynx, larynx, esophagus, trachea & thyroid
gland
 Continuous w/ buccopharyngeal fascia

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 HEAD AND NECK
MARIA KAREN ALCANTARA-CAPUZ, MD

3. Deep Layer of the deep cervical fascia

(Prevertebral layer)
 Attachments:
 Superiorly: Ext occipital protuberance & basilar
part of occipital bone
 Inferiorly: Diaphragm
 Continuous w/ endothoracic fascia & ant long.
ligament
 Encloses the vertebral column & its associated
muscles

Carotid Sheath- formed by all three layers of

deep fascia
 Contains common carotid artery, Internal
Jugular Vein, Vagus nerve, & lymph nodes

 NECK SPACES Branches of the Cervical Plexus

Cutaneous Branch
 Lesser occipital (C2) -Scalp & behind auricle
 Great auricular n (C2-C3)-Angle of mandible,
parotid gland & auricle
 Transverse cervical (C2-3)-skin front of neck
 Supraclavicular n (C3-4)-skin over clavicle and
shoulder

Muscular Branch
 Ansa cervicalis-C1 joins hypoglossal nerve to
supply geniohyoid & thyrohyoid
-Some fibers leave hypoglossal as descendens
hypoglossi which unite with the descendens
cervicalis (C2-3) to form ansa cervicalis
-supply omohyoid, sternohyoid & strenothyroid
 Phrenic nerve- -from C 3-5
-contains motor, sensory, sympathetic
-motor to diaphragm & sensory to its central
part
-sensory to 3 P’s
o Pericardium
o Pleura
o Peritoneum
 Twigs from plexus-Prevertebral muscles, SCM
(C2-3, propioceptive), trapezius (C3-4, propio)

C. BRACHIAL PLEXUS
H. NERVES in the NECK
 Formed in the posterior triangle of the neck by
A. CERVICAL SPINAL NERVE: the union of anterior rami of C5- T1
 Rami  Passes between the anterior scalene and middle
o Dorsal –deep muscles of the back of scalene m
the neck  Divided into roots (between the anterior and
o Ventral-deep & superficial muscles of middle scalene), trunks, (posterior triangle of
anterior superficial neck the neck), division (cervico-axillary area) & cords
(n relation to the axillary artery)
B. CERVICAL PLEXUS
 formed by the ventral rami of C1-C4
 rami joined by connecting branches that form a
loop anterior to the origin of levator scapulae &
scalene medius
 covered by the prevertebral fascia

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 HEAD AND NECK
MARIA KAREN ALCANTARA-CAPUZ, MD

 Deep temporal arteries

 Pterygoid branches (to muscles)
 Buccal artery
 Post. superior alveolar artery
 Infra-orbital artery

 Artery of pterygoid canal
 Descending palatine artery
 Sphenopalatine artery
- Septal and lateral nasal aa.

4. Subclavian Artery
 Vertebral artery
o Anterior spinal
o Posterior spinal
o (Posterior-inferior Cerebellar) PICA
 Internal thoracic artery
o Ant. intercostal arteries
o Sup. epigastric artery
o Musculophrenic artery
 Thyrocervical trunk
D. CRANIAL NERVES (discussed with Skull and o Inferior thyroid artery
Foramina) o Ascending cervical artery
o Suprascapular artery
I. BLOOD VESSELS IN the HEAD and NECK o Acromial branch
Blood Supply of the Head and Neck o Transverse cervical artery
From heart (Left Ventricle) o Dorsal scapular artery
 Costocervical trunk
1. Ascending Aorta o Deep cervical artery
 Right and left coronary arteries o Supreme intercostal artery
2. Aortic Arch

 Left Common Carotid Artery *Dorsal scapular artery may arise from the
 Left Subclavian Artery transverse cervical or as a separate branch of
 Brachiocephalic Trunk (right) the subclavian artery
 Thyroid ima artery
3. Common Carotid Artery
 Carotid body/
 Carotid sinus
 Internal Carotid Artery (to brain)
o Ophthalmic artery
o Posterior Communicating
o Anterior choroidal
o Anterior cerebral
o Middle cerebral
 External Carotid Artery
o Superior thyroid artery
o Ascending pharyngeal artery
o Lingual artery

o Facial artery
 Tonsillar artery
 Labial branches
 Nasal branches
 Angular artery
o Occipital artery

o Posterior auricular artery
o Superficial temporal artery
 Zygomatic
o Temporal a.
o Maxillary artery
 Inferior alveolar artery
- Dental, peridental a.
 Mental, mylohyoid aa.
 Middle meningeal artery


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 HEAD AND NECK
MARIA KAREN ALCANTARA-CAPUZ, MD

Carotid Artery Circle of Willis

Schema of External Carotid A. Subclavian Artery

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 HEAD AND NECK
MARIA KAREN ALCANTARA-CAPUZ, MD

VENOUS DRAINAGE

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 HEAD AND NECK
MARIA KAREN ALCANTARA-CAPUZ, MD

Cervical Lymph Node Levels

 I A- Submental (Floor of the mouth, anterior

tongue, anterior alveolar ridge, lower lip)
 I B- Submandibular (Oral cavity, anterior
nasal cavity, soft tissue of midface,
submandibular gland)
 II A and II B- Upper Jugular (Oral cavity,
nasal cavity, nasopharynx, oropharynx,
hypopharynx, larynx, parotid gland)
 III- Middle Jugular (Oral cavity, nasopharynx,
oropharynx, hypopharynx, larynx)
 IV- Lower Jugular (Hypopharynx, cervical
esophagus, larynx)
 VA and VB- Posterior Triangle (VA-
Nasopharynx, oropharynx; VB- Thyroid gland
 VI- Anterior/ Central Compartment
(Thyroid, glottis and subglottic larynx, pyriform
sinus, cervical esophagus)

K. THYROID

J. LYMPHATIC DRAINAGE

 Thyroid begins as an epithelial proliferation

in the floor of the pharynx known as the
foramen cecum
 Descends in front of the pharyngeal gut as a
bilobed diverticulum
 During this migration, the thyroid remains
connected to the tongue by a narrow canal
called the thyroglossal duct -w/c later
disappears

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 HEAD AND NECK
MARIA KAREN ALCANTARA-CAPUZ, MD

Blood Supply:
o Superior thyroid artery, a branch of the
external carotid artery, descends to the upper
pole of each lobe, accompanied by the
external laryngeal nerve
o Inferior thyroid artery, a branch of the
thyrocervical trunk, ascends behind the gland to
the level of the cricoid cartilage; recurrent
laryngeal nerve crosses either in front of
or behind the artery, or it may pass
between its branches.
o Thyroidea ima, if present, may arise from the
brachiocephalic artery or the arch of the aorta.
It ascends in front of the trachea to the isthmus

Venous Drainage:
o Superior thyroid v. which drains into the
internal jugular vein;
o Middle thyroid v. which drains into the
internal jugular vein
o Inferior thyroid v. -inferior thyroid veins of
(Anterior view) the two sides anastomose with one another as
they descend in front of the trachea; they drain
into the left brachiocephalic vein in the thorax.

L. PARATHYROID GLANDS

(Posterior view)

SIZE AND LOCATION

 Weighs 10 to 20 grams in normal adults
 Gland lies against C5,6,7 &T1 vertebrae
 Clasps upper part of trachea
 Each lobe extends from middle of thyroid
cartilage to 4th or 5th tracheal ring
 Isthmus extends from 2nd to the 3rd/ 4th tracheal
ring
 Each lobe measures 5cmX2.5cmX2.5cm
 Isthmus measures 1.2cmX1.2cm
 Larger in females than males
 Covered by PRETRACHEAL LAYER OF DEEP
CERVICAL FASCIA
 Pretracheal layer is thick on the inner surface of
the gland where it forms a
SUSPENSORY LIGAMENT OF BERRY which
connects the gland to the cricoid cartilage

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 HEAD AND NECK
MARIA KAREN ALCANTARA-CAPUZ, MD

th rd
Sadler, T. W. (2012). Langman's Medical
 5 week, epithelium of dorsal wing of 3
pouch => inferior parathyroid gland; Embryology 12th Edition. Baltimore, MD:
ventral wing => thymus Lippincott Williams & Wilkins.
 Thymus migrates in caudal and medial
direction, pulling inferior parathyroid with
it
 Parathyroid tissue of 3rd pouch finally rests on
dorsal surface of thyroid gland and forms
inferior parathyroid gland
 Dorsal wing of the fourth pharyngeal
pouch=superior parathyroid gland

Hypoparathyroidism

Mild hypoxia induced by inflation of a blood pressure

cuff can precipitate carpopedal spasm -Trousseau’s
sign

Tapping the parotid gland over the facial nerve can

induce facial muscle spasm - Chvostek’s sign

References
Chung, K. W. (2012). Board Review Series Gross
Anatomy 7th Edition. Baltimore, MD:
Lippincott Williams & Wilkins.

Drake, R. e. (2015). Gray's Anatomy for Students

3rd International Edition. Philadelphia:
Churchill Livingstone Elsevier.

Dudek, R. e. (2015). High Yield Gross Anatomy 5th

Edition. Baltimore, MD: Lippincott Williams &
Wilkins.

Netter, F. (2014). Atlas of Human Anatomy 6th

Edition. Philadelphia: Saunders Elsevier.

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 HEAD AND NECK
MARIA KAREN A. CAPUZ, MD

Choose the best answer: 10. The 1st branchial arch is associated with
1. Which of the following fontanelles in a the development of which of the following neck
newborn skull is expected to close at 18 months to 2 structures?
years of age? A. Facial n.
A. Anterior B. Muscles of mastication
B. Posterior C. Hyoid bone
C. Posterior and Sphenoidal D. Tongue
D. Anterior and Mastoid
11. The inferior parathyroid gland develops
from which of the following embryologic structures?
2. Absence of this part of the skull at birth
A. 3rd branchial arch C. 4th branchial arch
leaves the facial n. unprotected and prone to injury
B. 3 branchial pouch
rd
D. 4th branchial pouch
during difficult delivery:
A. Maxillary process C. Petrous process 12. Metastases to Virchow’s node from
B. Mastoid process D. Styloid process abdominal malignancies will be found in which
triangle of the neck?
3. Which of the following clinical A. Muscular C. Occipital
manifestations is consistent with a middle cranial B. Carotid D. Supraclavicular
fossa foramen injury? st
13. 1 echelon nodes from thyroid gland
A. Anosmia C. Hearing loss
malignancies will be found in which lymph node
B. Blindness D. Facial paralysis
level?
A. IIa C. III
4. A mass located in the jugular foramen will
B. IIb D. VI
cause the patient to experience which of the
following? 14. Ventral rami of C3-5 from the cervical
A. Ipsilateral facial numbness plexus gives rise to which nerve?
B. Loss of taste in the anterior 2/3 of the A. Supraclavicular C. Spinal accessory
tongue B. Phrenic D. Suprascapular
Dysphagia
C. 15. Which of the following vessels is a direct
D. Deviation of tongue to opposite side
branch of the aorta?
A. Right common carotid C. Brachiocephalic
5. The afferent limb of the gag reflex is
B. Right subclavian D. Left vertebral
mediated by which nerve?
A. V C. IX 16. Origin of blood supply to the brain:
B. VII D. X A. Vertebral a. C. Both
B. Internal carotid a. D. Neither
6. Laceration through this layer of the scalp
17. The following structures may be affected
will cause profuse bleeding in scalp wounds:
with injury to the posterior triangle of the neck
A. Skin
EXCEPT for:
B. Connective tissue
A. Phrenic n. C. Hypoglossal n.
C. Aponeurotic layer
B. Spinal accessory n D. Brachial plexus
D. Loose connective tissue
18. A hacking wound penetrating to the level
7. Classification of fractures of the midface is of the sternocleidomastoid m. will potentially injure
known as: the following structures EXCEPT:
A. Blow out C. Tripod A. Superficial cervical fascia
B. Le Fort D. Nasoorbitoethmoidal B. Platysma
C. External jugular v.
8. In a patient with blow-out fracture, which D. Common carotid a.
wall of the orbit is affected?
A. Roof C. Medial 19. Which of the following is a branch of the
B. Floor D. Lateral external carotid a. to the neck?
A. Inferior thyroid a.
9. What type of joint is the B. Transverse cervical a.
temporomandibular joint? C. Lingual a.
A. Ball and socket D. Thyrocervical a.
B. Gliding and hinge
C. Ball and hinge 20. The thyroid gland is embryologically
D. Gliding and socket derived from:
A. 3rd pharyngeal pouch
B. 4th pharyngeal pouch
C. 4th pharyngeal arch
D. Foramen cecum

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OBJECTIVES:
1. Discuss the development of the respiratory
system
2. Discuss the features, NVS and lymphatic venous
drainage of each part the respiratory system
a. Nose
b. Paranasal sinus
c. Larynx
d. Trachea
e. Bronchi
f. Bronchopulmonary segment
g. Lungs
3. Describe the Thoracic wall & cavity
4. Illustrate on the diagram of the chest wall the
borders, fissures and lines of pleural reflection of
the lungs
5. Correlate the anatomy of the respiratory system
with the different diseases seen in different
areas
6. Discuss the mammary gland as to its size,
shape, boundaries, fascial covering,
parenchymal structure, NVS and lymphatic
venous drainage.
7. Correlate the anatomy of the breast with the
disorders seen in this area.
I. EMBRYOLOGY OF THE RESPIRATORY
SYSTEM:
A. Development of Nose
 Nasal placode- primordia of nose and nasal
cavity
 Medial nasal prominence-tip of the nose,
nasal septum, intermaxillary segment
 Lateral nasal prominence-sides ala
 Frontonasal prominence- bridge
B. Development of Nasal cavity
 Nasal pit- deepens
 Oronasal membrane separates the nasal from
the oral cavity
o Breakdowns forms the primitive choana
o Failure of breakdown-leads to choanal
Atresia
 Medial nasal prominence- form the primitive
palate
 Primary & secondary palate separates the nasal
cavity from the oral cavity
1. What is the origin of the respiratory
tract?
A. Foregut
B. Midgut
C. Hindgut
D. Neural crest
E. Septum transversarum
C. Development of Lower Respiratory Tract
 Appears in the 4th week of life
 RESPIRATORY DIVERTICULUM- appear as
an outgrowth from the ventral wall of foregut
o Initially the lung bud is in open
communication from the ventral wall of
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foregut but when diverticulum expands
caudally
o 2 ridges will appear and form the
Tracheoesophageal septum
 TRACHEOESOPHAGEAL SEPTUM will divide
the foregut into the anterior and posterior
portion
D. Development of Lower Respiratory Tract
 With growth in caudal and lateral directions, the
lung bud expands into the body cavity.
 Pericardioperitoneal canals - spaces for the
lungs, are narrow and are gradually filled with
the expanding lung buds
o becoming the primitive pleural cavities.
o mesoderm covers the outside of the
lung
 DERIVATIVES:
o ENDODERM-epithelium & glands in
trachea & bronchi
o SPLANCHNIC MESODERM-smooth
muscles, connective tissue, and cartilage
of the trachea and bronchi & visceral
pleura
o SOMATIC MESODERM- parietal pleura
E. Four stages of Lung Development.
1. Glandular Period (Prenatal Weeks 5 to 17)
 The conducting (airway) system through
the terminal bronchioles develops.
Respiration is not possible.
2. Canalicular Period (Prenatal Weeks 13 to 25)
 Luminal diameter of the conducting system
increases, and respiratory bronchioles,
alveolar ducts, and terminal sacs begin to
appear. Premature fetuses born before
week 20 rarely survive.
3. Terminal Sac Period (Prenatal Weeks 24 to
Birth)
 More terminal sacs form, and alveolar type
I cells and surfactant-producing alveolar
type II cells develop.
 Respiration is possible, and premature
infants can survive with intensive care.
4. Alveolar Period (Late Fetal Stage to 8 Years)
 Respiratory bronchioles, terminal sacs,
alveolar ducts, and alveoli increase in
number.
II. UPPER RESPIRATORY SYSTEM
NOSE
A. EXTERNAL NOSE
 Made up of bone, cartilages & muscles
 Bones, cartilages & muscles
 Roots, bridges, anterior nares, ala muscles
 Nerve supply
o V1- nasal area & tip of nose
o V2- lateral nasal area
 Blood supply
o Facial a.
o (ICA) Ant. ethmoid a.
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2. A 17-y/o boy was punched on the face after E. INTERNAL NOSE: Blood Supply
an altercation. Anterior rhinoscopy showed a  Internal Carotid Artery
fractured nasal septum. Which structures of o Ophthalmic Artery
the nose may have been injured in this Anterior Ethmoid Artery
scenario? Posterior Ethmoid Artery
A. Septal cartilage and nasal bone
 External Carotid Artery
B. Inferior concha and vomer
C. Vomer & perpendicular plate of ethmoid o Internal Maxillary Artery
D. Septal cartilage and middle concha  Sphenopalatine Artery
E. Conchae and vomer  Greater Palatine Artery
o Facial Artery
B. INTERNAL NOSE (Nasal Cavity)  Superior Labial Artery
 Opens anteriorly nostrils /anterior nares  Little’s area/ Kiesselbach’s Plexus
& posteriorly via Choanae or posterior nares o anterior septum
 near the opening of the nares is the vestibule, o Conglomeration of different vessels
lined by stratified squamous epithelium, w/ hairs
F. INTERNAL NOSE: Venous Drainage
know as vibrissae
 Venous drainage-
 made up of o Facial vein
a. respiratory part o Pterygoid plexus
b. olfactory part o Cavernousinus
 Boundaries
o Roof: frontal bone, cribriform plate 3. A 45-year-old woman is suffering from
o Floor: palate numbness over the tip of her nose. Which of
o Posterior: Sphenoid the following nerves is most likely to be
o Medial: Septum damaged?
 Vomer A. Ophthalmic div. of the trigeminal
 Perpendicular plate ethmoid B. Maxillary div. of the trigeminal nerve
 Quadrangular cartilage] C. Mandibular div. of the trigeminal
o Lateral: Maxillary sinus D. Facial nerve
E. Glossopharyngeal nerve

C. INTERNAL NOSE: Lateral wall

 made up of irregular bony protrusion known G. INTERNAL NOSE: Nerve Supply
as conchae,  Sensory:
 covered by mucosa known as turbinate which o Olfactory nerve
contains venous plexuses: o CN V1
o Superior turbinates/ o CN V2
o Middle turbinates  Autonomics
o Inferior turbinates o CN VII- parasympathetic
 Atrium- smooth anterior portion of lateral nasal secretomotor fibers via the
wall pterygopalatine ganglion
 Increases nasal secretion

D. INTERNAL NOSE: Lateral wall 4. A 53-y/o M has nasal obstruction. Nasal

 Underneath each turbinates are openings called
meati where important structures drain
 Important structures drain into these meati
o Superior meatus- posterior ethmoid sinus
o Middle meatus-
anterior ethmoid
maxillary sinus
frontal sinus
o Inferior meatus- nasolacrimal duct
 Sphenoethmoidal recess- sphenoid sinus
 Hiatus semilunaris- semilunar- 2 dimensional
space that runs anterosuperioly going
posteroinferioly
 Ethmoidal bullae- air cells that made up of
middle ethmoid cells
 Infundibulum- anterior end of the hiatus leads
into this funnel-shaped channel
o continuous with the frontal sinus
endoscopic exam showed swelling of the area
of the superior nasal meatus. Which opening
of the paranasal sinuses is most likely
blocked?
A. Middle ethmoidal sinus
B. Maxillary sinus
C. Posterior ethmoidal sinus
D. Anterior ethmoidal sinus
E. Frontal sinus
H. PARANASAL SINUS
 cavities found in the interior of the
maxilla, frontal, sphenoid, and ethmoid bones
 are lined with mucoperiosteum and filled with
air
 they communicate with the nasal cavity
through relatively small apertures.
 maxillary and sphenoidal sinuses are
present in a rudimentary form at birth;

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 Functions:
 Humidification
 Vocal resonance
 Mucus production
 Increased olfactory area
 Absorbs shock to the head
 Regulation of intranasal pressure
I. COMMON DISEASES OF NASAL CAVITY &
PARANASAL SINUS
Nasal polyp-
 soft painless, noncancerous growth on the
lining of nasal passages or sinuses
 result from chronic inflammation, autonomic
dysfunction & genetic
Rhinosinusitis-
 obstruction of the drainage (meati)
 sinus become occluded leading to mucosal
congestion
 mucociliary transport system is impaired
leading to stagnation of the secretions
 Leads to decreased oxygen tension &
increased bacterial growth
Foreign bodies-
 Common in children
 Folded shelf like conchae & septum makes
impaction and retention of foreign object
easy
III: UPPER RESPIRATORY SYSTEM
LARYNX
A. LARYNX
 Function: RESPIRATION, PROTECTION &
PHONATION
 Framework: made up of cartilages held
together by ligaments & membranes and moved
by muscles and covered by mucosa
B. CARTILAGINOUS FRAMEWORK
 Made up of 9 CARTILAGES
o 3 unpaired: Thyroid
Cricoid
Epiglottis
o 3 paired:
arytenoid
corniculate
cuneiform
C. EXTRINSIC LARYNGEAL MEMBRANES
 bind the cartilages to the adjoining structures
and to one another and round out the laryngeal
framework
 MEMBRANES:
o Thyrohyoid membrane- pierce at the
side by the internal laryngeal nerve &
superior laryngeal artery
o Cricothyroid membrane- pierced for
emergency airway with little bleeding
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o Cricotracheal membrane
D. INTRINSIC LARYNGEAL MEMBRANES
 unite the cartilages of the larynx and perform an
important role in the closure of this organ
 MEMBRANES:
o Quadrangular membrane
- upper part, extend fr lateral margin of
epiglottis to the arytenoid and
corniculate cartilages
- and inferiorly forms the vestibular
ligament
o Conus elasticus
- lower part, from upper border of
cricoid cartilage inferiorly extending
to the vocal process of arytenoid
superiorly to form the vocal
ligament
- Vocal lig. Covered by mucosa forms the
true vocal cord
5. Which of the following muscles is the sole
abductor of the larynx?
A. Lateral cricoarytenoid
B. Posterior cricoarytenoid
C. Thyroarytenoid
D. Vocalis
E. interaytenoid
F. MUSCLES OF THE LARYNX
1. Extrinsic –attachment outside larynx
 Infrahyoid- depressor of larynx
 Suprahyoid- elevator of larynx
2. Intrinsic- attachment w/in the larynx
 Cricothyroid- Tensor, adductor
 Lateral cricoarytenoid- Adductor
 Posterior Arytenoid-Abductor
 Vocalis & Thyroarytenoid- Relaxes
 Oblique & transverse arytenoid-
Sphincteric action
(narrows)
 Thyroepiglottic widens the laryngeal
Opening
6. What is the narrowest area in the
larynx?
A. Rima vestibule
B. Rima glottidis
C. Ventricle
D. Infraglottic
E. Saccule
F. SUBDIVISION
1. Supraglottis- from tip of epiglottis
(laryngeal inlet) to midway
between the false and true vocal
cord Includes; epiglottis, vestibule
and false v.c.
2. Glottis- midway between the true and
false vocal cord and 1 cm below
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below it. bb. Recurrent laryngeal nerve

Includes: Anterior and posterior
commissure True v.c.
3. Infraglottis- 1 cm below the line between
the true & false vocal cord up to the
lower border of the cricoid cartilage
Other parts:
*Vestibule – opening & extend from the inlet
to vestibular folds
*Ventricle- space between the vestibular &
vocal fold
*Rima glottides- space between the vocal
Fold
*Rima vestibule- space between the
vestibular fold
-the right hooks around the Right subclavian a
& the left hooks under the arch of the aorta
- Motor: intrinsic muscles EXCEPT Cricothyroid
Sensory: vocal cord & below
7. Which part of the larynx has a good
prognosis in carcinoma of this area?
A. Epiglottis
B. False vocal cord
C. Vocal cord
D. Infraglottis
E. Vestibule
J. LYMPHATIC DRAINAGE
 Superficial lymphatics – intramucosal with
communication between left and right sides
 Deep Lymphatics- submucosal and has
nocommunication between left and right
sides
 Superior deep cervical L.N
o above vocal cords
 Inferior deep cervical L.N.
o inferior to vocal cords
 IN the subdivision of the larynx
o Glottis-least lymphatics supply
Good prognosis among the three

G. BLOOD SUPPLY OF THE LARYNX

 Superior laryngeal artery
Origin: Sup. Thyroid A. from Ext Carotid A
 Inferior laryngeal artery
Origin: Inferior thyroid from Thyrocervical A

H. VENOUS DRAINAGE
 Parallels arterial supply
 Superior laryngeal v. via internal jugular v.
 Inferior laryngeal v. via subclavian v./
brachiocephlic v

I. NERVE SUPPLY:
VAGUS N
-nerve of 4th & 6th brachial arches
- passes through jugular foramen
BRANCHES IN THE NECK
aa. superior laryngeal nerve & branches
a. Internal laryngeal N- pierces tthe
cricothyroid membrane and gives
sensory innervation above glottis &
to the root of tongue (posterior area)
-taste fibers to root of tongue

b. External laryngeal N- innervates the

cricothyroid muscle
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3. EMERGENCY AIRWAY
INFANTS ADULTS
 CRICOTHYROIDTOMY
HEAD Larger o Stab thru the cricothyroid
TONGUE Larger membrane
Epiglottis Omega, o Anesthesia not required
longer &  TRACHEOSTOMY
stiffer o Not usually an emergency
LARYNX o Ideal for temporary or
a.rima glottides permanent intubation
interspace I vertebrae
of C3 & C4 lower
Cut on the 2nd -3rd tracheal
o
cc. Overall 4mm (if in 10-12 mm
ring
diameter 1mm level of wider 4. ENDOTRACHEAL INTUBATION
circumferential cricoid)  Stimulation of mucous membrane of
reduction 75% 44% upper airway during the process of
intubation
dd. Narrowest Level of Rima
cricoid glottides  bradycardia and hypertension
MAJOR AIRWAY Narrower & (mediated by vagus nerves)
CONDUCTING Shorter  POSTINTUBATION STENOSIS
Bifurcation of trachea R 30 degree o Trauma to the proximal
from tracheal axis less vertical trachea that leads to
L more decrease in blood supply
acute IV. THORAX
 region between the neck & abdomen
 bounded by the sternum, ribs and thoracic
vertebrae
flattened in front & back but rounded at the
sides
COMPARATIVE ANATOMY OF THE AIRWAY - protects the lungs & heart and affords
attachment for the muscles of thorax, upper
CLINICAL CONSIDERATIONS: extremities, abdomen & back
 entrance to the thorax called Superior Thoracic
1. LARYNGOSCOPY aperture/ inlet/ Thoracic outlet is small &
2. VOCAL CORD PARALYSIS kidney shaped. The boundaries:
UNILATERAL- unilateral inadvertent o Manubium: anterior
ligation or injury to the o Inner border of Rib1: lateral
recurrent laryngeal n o 1st Thoracic vertebrae: posteror
 BILATERAL- recurrent n. paralysis  outlet from the thorax called Inferior Thoracic
o VC placed in median or paramedian aperture large and separated from the
position abdomen by the diaphragm. The boundaries
o Px presents with difficulty of are:
breathing or stridor o xyphoid process: anterior
o 7 to 10costal cartiages & rib 12: lateral
 PARALYSIS OF THE SUPERIOR LARYNGEAL
o T12 vertebrae: posteriorly
NERVE
 Presents as bowing of vc
 Inability to tense the VC 9. The following correctly describes the
 Seen during ligation of the superior sternal angle of Louis except?
thyroid vessels in thyroidectomy A. At the level of 2nd costal cartilage and 2nd rib
B. Divides the superior from inferior mediastium
wherein the nerve is also injured
C. Lies directly opposite the 4th intervertevral disc
2. HOARSENESS D. Angle made between the manubrium and body of
 PARALYSIS sternum
 VC Cyst, E. All of the above are correct
 nodules,
 CA
8. A needle cricothyrotomy would open into THORACIC WALL
which of the following regions?
A. Rima glottidis A. SKELETON OF THORAX
B. Laryngeal vestibule 1. Sternum
C. Laryngeal ventricle - Breastbone, shaped like a dagger
D. Infraglottic cavity - Parts:
E. Epiglottis o Manubrium

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 Superior margin called Jugular
notch
 Articulates w/
 clavicle,
 1st & upper /2 of 2nd rib
 body of sternum
Sternal Angle of Loiue
 Located at the level where 2nd rib
articulate w/ sternum
(manubroisternal joint)
 the aortic arch ends & begins
 trachea bifurcates into right & left
 inferior border superior
mediastinum
 transverse line pass through the T4
intervertebral disk T4
 attachment point of the 2nd costal
cartilage
 plane of separation between
superior & inferior mediastinum
o Body
Articulates w/ 2nd to 7th costal
o
cartilage
o Xyphoid process
o Cartilaginous at birth and ossify
after middle age
o Level of TV9
2. Ribs
- consist of 12 pairs of bone
- Classification:
o True ribs- 1st to 7th
-attached to the sternum by
costal cartilages
o False ribs- 8th to 12th
-8th to 10th connected to the
costal cartilage immediately
above them
o Floating ribs- 11th to 12th
-connected only to vertebrae
- Parts:
a. Head- 2 articular facets for the
corresponding vertebral
body & vertebral body above it
via costovertebral joint
b. Neck- between head & tubercle
c. Tubercle- 1 non-articular facet & a
smooth articular facet for the
transverse process of
corresponding vertebrae
d. Shaft- thin, flat curved that turns
sharply anteriorly at the angle and
has a costal groove that lodges the
intercostal neurovascular structures
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- Division
o typical ribs
- Rib 3rd to 9th ribs
- have features of the parts of the ribs
o Atypical ribs
Rib 1 – broadest & shortest of the true ribs
- single articular facet for its head
- has scalene tubercle for attachment
of scalene anterior & grooves for
subclavian vessels
Rib 2- has 2 articular facets on its head
-Thinner and 2x longer than the 1st rib
-has tuberosity for attachment of serratus
posterior
Rib 10- single articular facet on its head which
attaches to the 10thTV
Rib 11 to 12th-single articular facet on the
Head
-no neck nor tubercle
B. Lines of Orientation
 Midsternal
 Midclavicular line
 Anterior axillary line
 Midaxillary line
 Posterior axillary line
 Scapular line- passing the inferior angle of
scapula
10. Which of the following structures is
associated with normal quiet expiration?
A. Elastic tissue in the lungs
B. Serratus posterior superior muscles
C. Pectoralis minor muscles
D. Diaphragm
E. Serratus anterior
C.M USCLES
 Attaches to the to the thoracic cage ie
o Sternum
o Ribs
o Vertebrae
 Movement of the thoracic wall is concerned
with increasing and decreasing the vertical
& transverse diameter of the thorax
 Vertical diameter
o Inspiration- increase as diaphragm
moves down
o Expiration- decrease as diaphragm
moves up
 Transverse diameter
o Bucket-handle Inspiratory movement
 Handle of the pail is raised,
its convexity moves laterally
6 | ANATOMY
 RESPIRATORY TRACT & BREAST
PEREGRINA L GONZAGA, MD

 3 IC muscles contract on  Esophagus, R & L vagus nerve, esophageal

inspiration, moves the ribs branches of left gastric vessels, &
laterally and thus increase lymphaticd from the lower/3rd of esophagus
transverse diameter  Sling of muscle fibers from the right crus
Caval opening- at the 8th TV in the central tendon
 Inferior vena cav, terminal branches of right
phrenic nerve
 Other openings:
Sympathetic splanchnic nerves- -pierce the crura
Sympathetic trunks- pass posterior to the medial
arcuate ligament on each side
superior epigastric vessels-pass between the sternal
and costal origins of the diaphragm on each
side
The Difference between Inspiration and
Expiration

D. NERVES OF THE THORAX

 Intercostal nerves –ventral primary rami

T1-T11 run in the costal groove
 Subcostal nerve –ventral primary rami of
T12
 Between posterior intercostal membrane
of internal intercostal muscle and
parietal pleura and then
MUSCLES OF THORACIC WALL/ respiration  Runs forward intercostal grooves & lies
between internal intercostal muscle and
Muscles Origin Insertion Action innermost intercostal muscle
Diaphragm Vertebrae, Central Inspiration  REMEMBER:
ribs, tendon (Elevator) Inspiration Expiration
xyphoid
Contraction of Relaxation of
External Ribs Ribs Inspiration diaphragm (Increase muscles
Intercostal (Elevator)
vertical diameter) Decrease in thoracic
Innermost Ribs Ribs Inspiration volume
Intercostal (Elevator) Increase in
Subcostalis Ribs Ribs Inspiration intrathoracic pressure
(Elevator) Abdominal pressure
Levator Vertebra Ribs Inspiration decreased
costarum (Elevator) Ribs depressed
Serratus post Vertebra Ribs Inspiration
superior (Elevator) Enlargement of Elastic recoil of lung
Serratus post Vertebra Ribs Expiration Pleural cavities -produce sub
inferior (Depressor) Decrease atmospheric pressure
Internal Ribs Ribs Expiration Intrapulmonary Air expelled
intercostal (Depressor) pressure
(creates (-) pressure)
Transversus Ribs Ribs Expiration
thoracis (Depressor)
Forced Inspiration Forced expiration
a. Contraction of Contraction of anterior
11. All of the following passes thru an opening
intercostal Muscles abdominal & internal
of the diaphragm at the level of the tenth
b. elevation of ribs intercostal (costal
thoracic vertebra except?
A. Esophagus c. sternum moves parts)
anteriorly (bucket
B. Right vagus nerve
C. Right phrenic nerve handle)
D. Left vagus nerve *Increase transverse &
AP diameters
E. Lymphatics
Quiet inspiration Quiet expiration
Diaphragm openings -contraction of -passive process elastic
Aortic opening- at the !2th TV diaphragm recoil
- Aorta, thoracic duct, azygous
Esophageal opening- at the 10th TV Sensory innervation of chest wall;
o 1st -6th ICN
skin, periosteum & parietal
pleura
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o7th – 11th ICN
skin & parietal peritoneum
“Referred pain”
 INTERCOSTAL NERVE BLOCK
o done before lateral cutaneous
branch arises at MAL
o lower rib border
12. The first two posterior intercostal arteries
are branches from what vessel?
A. Superior intercostal artery
B. Internal thoracic artery
C. Musculophrenic artery
D. Subclavian artery
E. Axillary artery
E. ARTERIES OF THE THORAX
 Anterior intercostal artery-branch of internal
thoracic artery
- ICS 1-6: branches of internal
thoracic artery
- ICS 7-9: branches of
musculophrenic artery
 Posterior Intercostal artery
- 1st 2 intercostal space
arise from the superior intercostal artery
a branch of the costercervical trunk
from subclavian artery
- Lower 9 spaces
arise from the thoracic aorta
F. VEINS OF THE THORAX
 Anterior intercostal veins --- Internal
thoracic v ------ Brachiocephalic v
 Post. Intercostal v ---- hemiazygous
(left side) & azygous (right side)--
hemiazygous empty into azygous –
SVC
K. LYMPHATIC DRAINAGE
 Sternal or parasternal nodes
-placed along in the internal thoracic artery
-receive lymph from the medial portion of
breast, intercostal spaces, diaphragm &
supraumbilical region of abdominal wall
-drain into the junction of IJV and SCV
 Intercostal nodes
-lie near heads of ribs
-receive lymph from intercostal space & pleura
-drain into the thoracic duct
 Phrenic nodes
-lie on the thoracic surface of the diaphragm
- receive lymph from pericardium, diaphragm,
and liver
-drain into the sternal and mediastinal lymph
Nodes
H. CLINICAL CONSIDERATION:
1. Thoracic outlet syndrome
 Compression of neurovascular
structures in the thoracic outlet
(space between clavicle & 1st rib)
o Subclavian artery & vein
o Lower trunk of brachial plexus
 Result from anomalous cervical rib
UST FMS MEDICAL BOARD REVIEW 2019
RESPIRATORY TRACT & BREAST
PEREGRINA L GONZAGA, MD
 Pressure on lower trunk produce
pain on the medial forearm & hand
 Wasting of hand muscles
 Pressure on the blood vessels may
compromise circulation of the upper
limb
13. Which rib/ribs is most commonly
fractured?
A. 1st rib
B. 3rd to 7th rib, anteriorly
C. 3rd to 7th rib, posteriorly
D. 5th to 9th rib, anteriorly
E. 5th to 9th rib posteriorly
2. Rib fracture
 Commonly occur just anterior to the
angle of the rib (weakest point of
the rib)
 Rib 1- rarely fracture
o may injure the subclavian
vessels & brachial plexus
 5th – 9th rib-
o most commonly fractured due
to direct blows or crushing
injuries
 Complication:
o Pneumothorax
o Hemothorax
3. Flail Chest
-loss of the stability of the thoracic cage
when a segment of thoracic wall moves
freely because of multiple fracture
-extremely painful & impairs ventilation
14. True about the phrenic nerve:
A. supply the muscles of expiration
B. arises from the dorsal rami of C3-C5
C. has a motor and sensory innervation to
the diaphragm
D. accompanies the pericardiophrenic
vessels on the lateral side of pleura
E. innervate the peripheral side of the
Diaphragm
V. PLEURA & PLEURAL CAVITY
1. PLEURA: 2 parts
a. Parietal pleura
- lines the
a. thoracic wall (Costal)
b. thoracic surface of diaphragm
(diaphragmatic)
c. lateral aspect of mediastinum
(mediastinal)
d. extends root of neck undersurface of
Sibson’s fascia (Cupola/ Apex)
o reaches 1 to 1.5 (2.5-4 cm)
above the medial /3rd of
clavicle
- NS:
Intercostal nerve- peripheral
Phrenic nerve
o mediastinal & diaphragmatic pleura
o central tendon of diaphragm
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PEREGRINA L GONZAGA, MD

diaphragm : motor
 Pneumothorax- accumulation of air in the
-sensitive to pain, temperature & touch pleural cavity
- lungs collapses because of the negative
BS: pressure necessary to keep lung
Internal thoracic expanded has been eliminated
Posterior & superior intercostal - TENSION PNEUMOTHORAX
o life threatening condition
b. Visceral pleura o symptoms: chest pain & dyspnea
-completely covers the undersurface of the lung -TX: a. insertion of needle at 2nd ics
- extends into depths of fissure midclavicular
- NS; b. thoracostomy
- Autonomic nerve from the pulmonary
plexus 15. In thoracentesis, a needle should inserted
-sensitive to stretch w/ vasomotor fibers at the midaxillary line between which of the
BS: following two ribs so as to avoid puncturing
Bronchial artery the lung?
A. Ribs 3 and 5
 the two pleura becomes continuous with each
other at the HILUM of each lung B. Ribs 5 and 7
C. Ribs 7 and 9
 form a cuff that surround the structures leaving
D. Ribs 9 and 11
and entering the lung at LUNG ROOT
 Pulmonary ligament extension of this cuff E. Ribs 11 and 12
that allows movement during respiration
DIFFERENT PROCEDURES:
a. Thoracentesis
2. PLEURAL CAVITY
 to obtain a sample of pleural fluid or to remove
- Potential space between the visceral & parietal
blood or pus.
- Closed sac w/ no communication w/ the other
 done at posterior to mid-axillary line one or 2
side
intercostal space below the fluid level but not
- Contains fluid that lubricates the surface and
below the 9th ICS
allows movement of the lung
- RECESSES:
16. 56-y/o M, figured in a motor vehicular
o Costodiaphragmatic accident, PE: multiple rib fractures and
o Costomediatinal recess- part of the
ecchymoses along right hemithorax, CXR:
pleural cavity where the costal and
blunting of the right costophrenic sulci. At
mediastinal pleura meet
which site will the chest tube be inserted to
Lung Margin Pleural
drain the fluid?
Reflection
A. 2nd ICS right mid clavicular line upper border of
Midclavicular 6th rib 8th rib
the rib
Midaxillary 8th rib 10th rib
B. 7th ICS right posterior axillary line upper border
Vertebral 10 rib
th
12th rib of the rib
column C. 5th ICS right anterior axillary line upper border of
the rib
D. 5th ICS left midaxillary line lower border of the
rib

3. CLINICAL CORRELATION
 Pleuritis- inflammation of the pleura with
exudation into its cavity,
- roughening causes friction rub w/c
can be heard in the stetoscope
- later will lead to Pleural adhesion
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PEREGRINA L GONZAGA, MD

E. 8th ICS right, anterior axillary line, upper border of  cross proximally by the arch of the aorta &
the rib distally by the pulmonary artery
NS: Bronchodilator - sympathetic
Thoracostomy Bronchoconstrictor -parasympathetic
 to evacuate ongoing production of
air/fluid into the pleura cavity 19. Which forms the lower division of the
 Tube inserted through the lower division of the upper lobe of the left
o 5th intercostal space,
lung?
o anterior axillary line
o upper border of the rib (to avoid A. Superior and inferior lingular
intercostal neurovascular
B. Inferior basal
structures which run in the
costal groove C. Anteromedial
o D. Apicoposterior
VI. TRACHEA & BRONCHI E. Inferomedial

17. The trachea extends from the lower VII. LUNGS

border of the cricoid cartilage in the neck to Lungs
approximately the level of the:  Real life they are soft and spongy
 In child- pink; adult become dark and mottled
A. 10th thoracic vertebra  Each lung is conical, covered w/ visceral pleura,
B. Sternal angle being attached to the mediastinum by roots;
C. Xiphisternal joint separated from each other by heart & great
D. Suprasternal notch vessels
E. intervertebral disk TV2  Blunt apex and project above the clavicle by
2.5cm
TRACHEA - Concave base: diaphragm
 commences at lower border of cricoid - Convex costal surface
cartilage - Concave mediatinal surface
 terminates at the sternal angle of Louie
where it bifurcates into left and right main Differences of the R & L Lungs
bronchus R Lung L Lung
 -about 12 cm in length, Size Larger & heavier
 w/ 6 to 20 incomplete hyaline cartilages Shorter & wider
Fissure/s 2 1
 At the bifurcation, the last tracheal ring
forms carina (internally, w/c can be Lobes 3 2
observed by the bronchoscopist) a keel like (2ndary)
ridge of tissue in the sagittal view Segmental 10 8 to 10
- the carina is very sensitive in eliciting cough (Tertiary)
Bronchial 1 2
reflex
artery
 BS: inferior thyroid, bronchial arteries
Diaphragmatic Middle & inferior Inferior
NS: Vagi & recurrent nerves: sympathetic surface
Important Lingula
18. When foreign objects are aspirated into
features (middle lobe
the trachea, they will usually pass into the
counterpart)
right primary bronchus because it is:
& cardiac
A. larger, straighter and shorter than the left
notch
B. more curved, longer and smaller than the left
C. straighter, longer and larger than the left
D. at a 90-degree angle to the trachea 20. Which of the following characterizes a
E. larger, horizontal and longer than the left bronchopulmonary segment?
A. It can be removed surgically
B. It contains pulmonary vein and artery
Right Primary Bronchus
 Right is wider, shorter, more vertical C. It is pyramidal in shape with its base toward the
 More foreign bodes are lodged root lung
 Runs under arch of azygous vein D. Pulmonary artery lies in the connective tissue that
surrounds it
 Divides into three lobe or 2ndary bronchi and
E. All of the above
finally into 10 segmental bronchi
 superior lobe is eparterial because it passes
Bronchopulmonary Segment:
above pulmonary artery the rest are hyparterial
 anatomic, functional & surgical unit
Left Primary bronchus - compose of
 longer, narrower and more horizontal o segmental bronchus
o segmental artery
& divide into 2 lobar bronchi & finally
o lymph vessels
8-10 segmental bronchi
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PEREGRINA L GONZAGA, MD

o autonomic nerves NERVE SUPPLY OF THE LUNG:

- pulmonary vein is inter-segmental A. Pulmonary plexus
- pyramid in shaped, where apex directed  -receive afferent and efferent
toward lung root (parasympathetic preganglionic fibers) from
the vagus, joined by branches (sympathetic
postganglionic fibers) from the sympathetic
BRONCHOPULMONARY SEGMENT cardiac plexus
 -divided into anterior and posterior
 each segmental bronchus divide repeatedly,
as the bronchus becomes smaller,
o u shaped cartilage are replaced by
irregular plates of cartilage which
becomes smaller and fewer in numbers,
o smallest bronchi gives rise to
 BRONCHIOLES
o the walls, possess no cartilage (<1mm in
diameter), lined w/ columnar ciliated
epitheliium
o submucosa lined w/ complete layer of
circularly arranged layer of smooth
muscles
o divide into terminal bronchioles which
give rise outpouching where gaseos
exchange occur known as RESPIRATORY
BRONCHIOLE
o give rise to tubular passage of alveolar
duct w/ numerous outpouching called pulmonary plexus which lies in front and
ALVEOLAR SAC. behind the root of the lung respectively.
o Exchange of air occurs between  Intermediolaeral cell column (Spinal nerves)
alveoli & pulmonary capillaries o sympathetic fibers:
BRONCHODILATOR,
VASOCONSTRICTOR
THE LOWER RESPIRATORY TRACT  Vagus
o parasympathtic:
BLOOD SUPPLY OF THE LUNG:
BRONCHOCONSTRICTOR
A. Arterial Component
1. Respiratory Circuit VASODILATOR
Pulmonary artery SECRETOMOTOR
-carries deoxygenated blood to the lungs for o Concerned w/ reflex control of lungs
aeration
LYMPHATIC VENOUS DRAINAGE
2. Nonrespiratory circuit  SUPERFICIAL-lies beneath the visceral
Bronchial artery pleura & drains over the surface of the lung
-supply the connective tissue of the lungs ----hilum ---- lymph vessels enter the
(including bronchi & visceral pleura) bronchopulmonary node
- the right originates from the posterior
intercostal & the left from the thoracic aorta
-usually one in the right and 2 on the left

B. Venous component
1. Pulmonary vein
 -carry oxygenated blood from the
respiratory part (alveoli) of the lung &
deoxygenated bronchial blood to the left
atrium
2. Bronchial vein
 receives blood from the bronchi and
empty into the azygous vein on the right
and accessory hemiazygous on the left

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 RESPIRATORY TRACT & BREAST
PEREGRINA L GONZAGA, MD

 DEEP- travels along the bronchial o Squamous c30%

pulmonary vessels toward the hilum passing o Originate central bronchi
through the pulmonary nodes (located w/in o AdenoCA
lung substance)—lymph enters the o 40%
o Originate outer edges
bronchopulmonary nodes (hilum of the lung)
o Large cell
 All lymph from the lung leaves the hilum o 10-15%
and drains into tracheobronchial nodes ------ o Originates outer edges
Bronchomediastinal lymph trunks Small cell

Airways: o Most aggressive

o Originate central bronchi
Conducting Respiratory o Metastasize to liver, bone, brain
Nasal Respiratory Bronchioles
Pharynx Alveolar duct BREAST
Larynx Atria
Trachea Alveolar sacs  -extends from 2nd to 6th ribs from the
Bronchi sternum to mid-axillary line
Bronchioles  divided into 4 quadrants,
Terminal Bronchioles upper & lower lateral quadrant
upper & lower medial quadrant
CLINICAL CORRELATION:  supported by suspensory ligament of cooper
that runs from dermis of skin to deep layer of
1. ASPIRATION OF FOREIGN BODY the superficial fascia that provide support
 nipple surrounded by circular pigmented are of
POSITION ENTER LODGE skin known as the areola at 4th ICS
Sitting and Right lower Posterior  modified sweat gland
Standing lobar basal BP  located in the superficial fascia of the anterior
bronchus chest wall overlying the pectoralis major &
Supine Right lower Superior BP serratus anterior muscles and
lobar segment of  extends into the superior lateral quadrant of the
bronchus the right axilla as axillary tail of spencer (where high
lower lobe percentage of tumors occur)
Lying on the Right upper Posterior BP  separated from underlying muscles by the
right side lobar segment of retro-mammary space which allows breast to
bronchus the right have some degree of movement
upper lobe  has 15 to 20 lobes of glandular tissue separated
Lying on the Left upper Inferior by fibrous septa radiate from the nipple. Each
left side lobar lingual lobe open by lactiferous duct on tip of nipple,
bronchus each duct enlarges to form sinus (reservoir for
milk during lactation)

2. ASTHMA BLOOD SUPPLY:

 -swelling & narrowing of the airway
 -airway obstruction characterized by
dyspnea, cough, wheezing coz of spasmodic
contraction of smooth muscles in the
bronchioles
3. CHRONIC BRONCHITIS
 Inflammation of the airway
 Excessive production of mucus that plugs
airways--- dyspnea &cough
4. EMPHYSEMA
 accumulation of air in terminal
Bronchioles & alveolar sacs due to its
destruction
5. Lung CA
- leading cause of CA-related death
- arise either from an alveolar lining of the
lung parenchyma or of epithelium of the
tracheobronchial tree
- Nonsmall cell
 Medial: Internal mammary artery
 Lateral: Lateral thoracic artery from axillary
Pectoral branches of the
Thoracoacromial
Lateral cutaneous from posterior
intercostal artery
VENOUS DRAINAGE:
 Axillary vein via lateral thoracic & lateral
mammary vein
 Internal thoracic vein via medial, mammary
vein, anterior and posterior
intercostal vein (azygous vein)
NERVE SUPPLY:
 Anterior & lateral cutaneous of 4th to 6th
intercostal nerve (ie T4, T5 & T6)

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 RESPIRATORY TRACT & BREAST
PEREGRINA L GONZAGA, MD

21. A Breast exam of a 49-y/o F showed a  produces a sudden upward contraction of

large lump in her right lateral upper breast.
Lymph from breast cancer drains primarily
into which of the following nodes?
A. Apical nodes
B. Anterior (pectoral) nodes
C. Parasternal (internal thoracic) nodes
D. Supraclavicular nodes
E. Lateral pectoral nodes
LYPMHATIC DRAINAGE:
 has lymphatic plexus that communicate freely
called circumareolar, perilobular & interlobular
plexus that drain into deep subareolar plexus
and then lymph flows as follows
 Lateral quadrant- axillary
(humeral, subscapular, pectoral, central and
apical)
Infraclavicular & supraclavicular nodes
Subclavian lymph trunk
 Medial quadrant-
Parasternal lymph node
Bronchomediastinal lymph node
(may also drain into the opposite breast)
 Inferior Quadrant
- right and left breast drain in the
upper abdomen i.e. Inferior phrenic lymph
nodes
the muscle
 invade deep fascia of pectoralis major
SURGICAL PROCEDURE:
 Radical Mastectomy
- -extensive removal of breast and
related structures
a. Pectoralis major & minor
b. axillary lymph nodes & fascia
c. part of thoracic wall
- -complications:
a. injure longthoracic & thoracodorsal
b. postoperative swelling of the upper
limb
 Modified Radical mastectomy
- Excision of entire breast & axillary
lymph nodes with preservation of
pectoralis major & minor
 Lumpectomy is the surgical excision of only
- palpable mass in CA of the breast

CLINICAL CONSIDERATIONS:
Mammography-
 radiographic examination of the breast to
screen for benign & malignant tumors

Sentinel node procedure (Biopsy)

 Surgical procedure to determine the extent and
stage of cancer by use of isotope injected into
the tumor region

22. During a breast examination of a 56-y/o F,

the physician found a palpable mass. Which of
the following characteristics is strongly
associated with breast cancer?
A. Elevated nipple
B. Polymastia
C. Shortening of the clavipectoral fascia
D. Dimpling of the overlying skin prlg
E. Presence of hairs

Breast CA
 upper lateral quadrant =60%
 Different Manifestations of Breast CA
A. depression or dimpling of overlying skin
 attaches to cooper ligament produces
shortening of ligament

B. Peau de orange (texture of orange peel)

 obstruction of subcutaneous lymphatics
 Inflammatory breast CA
 edematous swollen & pitted skin
B. Retracted or inverted nipple
 attach and shorten the lactiferous ducts
D. Contraction of Pectoralis Major

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I. KIDNEYS
= paired organs that lie behind the peritoneum on
the posterior abdominal wall (TV12-LV3)
* the right kidney is slightly lower than the left
kidney (left is related to rib 11posteriorly)
because of the large size of the right lobe
of the liver.
* medial concave border of each kidney is the
hilus, which extends into a large cavity
(the renal sinus).
* the hilus transmits the renal vein, the renal
artery, the renal pelvis, (arranged in an
anterior to posterior) and the sympathetic
nerve fibers.
= Coverings:
* Fibrous capsule which is closely applied to
its outer surface.
* Perirenal fat covers the fibrous capsule.
* Renal fascia also called Gerotas fascia
extension of the fascia transversalis
covering the perirenal fat. It encloses the
kidneys and the suprarenal glands.
* Pararenal fat: This is external to the renal
fascia.
= The perirenal fat, the renal fascia, and the
pararenal fat support the kidneys and hold them in
position on the posterior abdominal wall.
= has an outer cortex and an inner medulla
= Neurovascular Supply
* Renal artery (level of L2) branch of the aorta,
The right is longer and passes beneath the
IVC.
Each renal artery divides into segmental
arteries which are end arteries
* Renal vein (left V is longer) drains into the
inferior vena cava.
= Lymph Drainage
drains into the lateral aortic lymph nodes
around the origin of the renal artery
= Nerve Supply
Renal sympathetic plexus. There is no
(or very minimal) parasympathetic
innervation of the kidneys
CLINICAL NOTES
RENAL PAIN
Renal pain varies from a dull ache to a severe pain
in the flank that may radiate downward into the
lower abdomen. Renal pain can result from
stretching of the kidney capsule or spasm of the
smooth muscle in the renal pelvis. The pain
associated with kidney pathology may be referred
over the T12-L2 dermatomes (i.e., lumbar region,
inguinal region, and anterosuperior thigh).
RENAL COLIC
In renal colic, strong peristaltic waves of contraction
pass down the ureter in an attempt to pass a stone
onward. The afferent nerves from the ureter enter
the spinal cord at segments T11 and 12 and L1 and
2. The spasm of the smooth muscle of the ureter
causes an agonizing colicky pain, which is referred
to the skin areas that are supplied by these -
UST FMS MEDICAL BOARD REVIEW 2019
KIDNEYS/SUPRARENAL GLANDS/URETERS/
URINARY BLADDER/ URETHRA
POSTERIOR ABDOMINAL WALL
BUENA FE A. APEPE, MD
segments of the spinal cord; namely, the flank, loin,
and groin.
II. URETERS
= muscular tubes that measures approximately
10 in. (25 cm) in length
= each ureter and has an upper expanded end
called the renal pelvis.
= has 3 constrictions:
1. at the ureteropelvic junction.
2. as it crosses the pelvic brim to enter the
pelvis
3. as the ureter pierces the bladder wall.
Ureteric stones may be arrested at the
following sites causing hydronephrosis
= Blood Supply
a. Upper end: The renal artery.
b. Middle portion: The testicular or the
ovarian artery.
c. Inferior end: The superior vesical artery.
The veins draining the ureter follow the
arterial supply
= Lymph Drainage
lymph drains into the lateral aortic and
iliac nodes.
= Nerve Supply
ureteric plexus (contains both sympathetic
and parasympathetic components)
III. SUPRARENAL (ADRENAL) GLANDS
= two suprarenal glands located close to the upper
poles of the kidneys (right=pyramid; left=
crescent)
= are retroperitoneal and surrounded by renal
fascia, but they are separated from the kidneys
by the perirenal fat
= has an outer cortex and inner medulla
1. Cortex is derived embryologically from
mesoderm and is divided into three zones.
a. Zona Glomerulosa (ZG) secretes aldosterone,
which is controlled by the renin-angiotensin
system.
b. Zona Fasciculata (ZF) secretes cortisol, which
is controlled by corticotropin-releasing factor
(CRF) and adrenocorticotropic hormone
(ACTH)
c. Zona Reticularis (ZR) secretes dehydroepi-
androsterone (DHEA) and androstenedione.
2. Adrenal Medulla contains chromaffin cells that
are modified postganglionic sympathetic
neurons derived embryologically from neural
crest cells. Chromaffin cells secrete
catecholamines. The secretion product is 90%
epinephrine and 10% norepinephrine.
= Blood supply
a. Branches from the inferior phrenic artery,
the aorta, and the renal arteries
= Venous drainage
a. single vein on each side. the right suprarenal
vein drains into the inferior vena cava; the
left suprarenal vein drains into the left renal
vein.
= Lymph Drainage
lymph drains into the aortic nodes.
= Nerve Supply
1 | ANATOMY

Preganglionic sympathetic nerves from
splanchnic nerves supply the suprarenal
glands. The majority of these fibers end on
cells (modified postganglionic neuronal cell
bodies called chromaffin cells) in the suprarenal
medulla.
IV URINARY BLADDER
= extends upward above the pelvic brim as it
fills; may reach the umbilicus if fully distended.
=maximum capacity of approximately 500 mL.
= Surface is related to the pubic symphysis and
retropubic space (of Retzius)
= Apex connected to the umbilicus by the median
umbilical ligament (remains of urachus)
= Posterior Surface (Fundus or Base)
*In the male, the posterior surface is related to
the rectovesical pouch, rectum, seminal
vesicles, and ampulla of the ductus deferens.
*In the female, the posterior surface is related
to the anterior wall of the vagina.
= Superior surface of the bladder is covered with
peritoneum, which is reflected laterally onto the
lateral pelvic walls.
= Neck is the area where the fundus and the
inferolateral surfaces come together, leading
into the urethra.
*In the male, the neck is related to the
Prostate gland and prostatic urethra.
*In the female, the neck is related to the
urogenital diaphragm
= bundles of smooth muscle fibers known as the
detrusor muscle
= The internal surface of the base of the bladder
is called the trigone, bounded by the two orifices
of the ureters and the internal urethral
orifice. The mucous membrane firmly adheres
to the underlying muscle and is always smooth.
= The crescentic opening of the urethra is
surrounded by a thick circular layer called the
internal sphincter (sphincter vesicate).
= Blood supply
superior and inferior vesical arteries and
from the vaginal artery in females.
= Venous drainage
drained by the prostatic (or vesical) plexus of
veins, which empties into the internal iliac vein.
= Lymph Drainage
lymph drains into internal and external iliac
nodes
= Nerve Supply vesical and prostatic plexuses.
*Parasympathetic nerve (pelvic splanchnic nerve
originating from S2–S4) stimulates to contract
the musculature (detrusor) of the bladder wall,
relaxes the internal urethral sphincter, and
promotes emptying.
* Sympathetic nerve relaxes the detrusor of the
bladder wall and constricts the internal urethral
sphincter
V. URETHRA
A. Female Urethra
= about 3 to 5 cm long
= courses through the urogenital diaphragm
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URINARY BLADDER/ URETHRA
POSTERIOR ABDOMINAL WALL
BUENA FE A. APEPE, MD
where it becomes related to the deep transverse
perineal muscle and sphincter urethrae muscle
(also called external urethral sphincter), both of
which are skeletal muscles innervated by the
pudendal nerve.
= the posterior surface of the female urethra fuses
with the anterior wall of the vagina such that the
external urethral sphincter does not completely
surround the female urethra. This may explain
the high incidences of stress incontinence in
women especially after childbirth.
= terminates into the vestibule of the vagina just
below the clitoris.
B. Male Urethra
= about 18 to 20 cm long
= begins at the internal urethral orifice of the
bladder where the detrusor muscle forms a
complete collar around the neck of the bladder
called the internal urethral sphincter.
= is divided into 3 parts.
1. Prostatic urethra courses through and
is surrounded by the prostate gland.
* urethral crest - elevation at posterior
wall
* prostatic sinus - groove on either side
of the urethral crest that receives
most of the prostatic ducts
* seminal colliculus - site of enlargement
along the urethral crest where the
ejaculatory ducts open
* prostatic utricle - vestigial remnant of
the paramesonephric duct in males
2. Membranous urethra courses through
the urogenital diaphragm where it
becomes related to the deep transverse
perineal muscle and sphincter urethrae
muscle (also called external urethral
sphincter) which completely surrounds
the male urethra.
3. Penile urethra - longest, starts as
bulbous urethra (enclosed by the bulb)
and continue as spongy or bulbous
urethra (traversing the corpus
spongiosum) to terminate at the
urethral meatus (located within the
glans penis)
POSTERIOR ABDOMINAL WALL
I. Abdominal Aorta
= enters the abdomen through the aortic opening
of the diaphragm in front of the twelfth thoracic
vertebra.
= divides into the two common iliac arteries in
front of the fourth lumbar vertebra.
= Branches:
a. Three anterior visceral branches: the celiac
artery, superior mesenteric artery, and
inferior mesenteric A
b. Three lateral visceral branches:
suprarenal artery, renal artery, and
testicular or the ovarian artery.
c. Five lateral abdominal branches:
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BUENA FE A. APEPE, MD

inferior phrenic artery and four lumbar

arteries.
d. Three terminal arteries: two common iliac
arteries and the median sacral artery.

II. Inferior Vena Cava

= formed by the union of the common iliac
veins at the level of the fifth lumbar vertebra.

= ascends on the right side of the aorta, pierces

the central tendon of the diaphragm at TV8
and drains into the right atrium of the heart
= Tributaries:
a. Two anterior visceral tributaries (the
hepatic veins).
b. Three lateral visceral tributaries: the right
suprarenal vein (the left vein drains into the
left renal vein), renal veins, and right
testicular or ovarian vein (the left vein drains
into the left renal vein).
c. Five lateral abdominal wall tributaries:
inferior phrenic vein and four lumbar veins.
d. Three veins of origin: two common iliac
veins and the median sacral vein.

III. Muscles of the posterior abdominal wall

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Openings in the Diaphragm
1. Aortic opening lies anterior to the body of
theTV12 between the crurae
= transmits the aorta, the thoracic duct, and
the azygos vein
2. Esophageal opening lies at the level of the TV10
in a sling of muscle fibers derived from the right
crus.
= transmits the esophagus, the right and left
vagus nerves, the esophageal branches of
the left gastric vessels, and the lymphatic
vessels from the lower third of the
esophagus.
3. Caval opening lies at the level of the TV8 in the
central tendon.
= transmits the inferior vena cava and the
terminal branches of the right phrenic nerve
Other structures that pass thru the diaphragm:
1. splanchnic nerves pierce the crura
2. sympathetic trunk passes posterior to the
medial arcuate ligament on each side
3. superior epigastric vessels pass between
the sternal and the costal origins of the
diaphragm
IV. Lymphatics
1. Aortic nodes - found on the anterior surface
of the abdominal aorta.
= divided into the celiac, superior and
inferior mesenteric groups, which lie close to
the origins of these arteries.
= efferent vessels form the intestinal trunk,
which drains into the cisterna chyli.
2. Lateral Aortic (PARA-AORTIC, LUMBAR)
nodes right and left groups that lie alongside
the abdominal aorta, their efferent vessels
form the right and left lumbar trunks that
drain into the cisterna
Cisterna Chyli
= elongated sac which lies on the right side of
the aorta in front of the first two lumbar
vertebrae.
= receives the intestinal trunk, the right and
left lumbar trunks, and the lymph vessels
that descend from the lower part of the
thorax
V. Lumbar plexus
= formed by the anterior rami of the upper four
lumbar nerves (L1-L4).
= arranged around the psoas muscle
= Branches:
1. Iliohypogastric Nerve (L1) emerges from
the lateral border of the psoas
2. Ilioinguinal Nerve (L1) emerges from the
lateral border of the psoas, runs forward
through the inguinal canal and exits
through the superficial inguinal ring.
3. Lateral Cutaneous Nerve of the Thigh (L2
and 3) crosses the iliacus muscle, and
enters the thigh behind the inguinal
ligament
4. Femoral Nerve (L2,3, & 4) the largest
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URINARY BLADDER/ URETHRA
POSTERIOR ABDOMINAL WALL
BUENA FE A. APEPE, MD
branch of the lumbar plexus, descends
between the psoas and the iliacus muscles
to enter the thigh lateral to the femoral
vessels.
5. Genitofemoral Nerve (L1 and 2) emerges
on the anterior surface of the psoas muscle
divides the genital branch which passes
through the deep inguinal ring and
forms a of the spermatic cord and
supplies the cremaster muscle.
6. Obturator Nerve (L2, 3, and 4) emerges
from the medial border of the psoas
muscle and enters the thigh through
the obturator foramen to supply the
medial compartment of the thigh.
It supplies the parietal peritoneum
on the lateral wall.
=Appendicitis or Acute PID may irritate the
obturator nerve endings leading to referred pain to
the inner thigh
VI. Sympathetic trunk
= abdominal part of the sympathetic trunk is
continuous with the thoracic part above and
with the pelvic part of the sympathetic trunk
below.
= runs downward along the medial border of
the psoas muscle on the bodies of the lumbar
vertebrae.
= enters the abdomen from behind the medial
arcuate ligament,
= enters the pelvis by passing behind the
common iliac vessels.
= Branches:
1. White rami communicantes join with the
first two lumbar spinal nerves. (A white
ramus contains preganglionic and afferent
sensory nerve fibers).
2. Gray rami communicantes join each
ganglion to a corresponding lumbar spinal
nerve. (A gray ramus contains
postganglionic
nerve fibers).
= Fibers pass medially to the sympathetic
plexuses on the abdominal aorta and its
branches.
= Fibers pass downward and medially to enter
the pelvis, where together with branches from
the sympathetic nerves in front of the aorta
they form a large bundle of nerve fibers called
the superior hypogastric plexus.
= Aortic Plexus is a continuous plexus around the
abdominal aorta
Regional concentrations are known as:
1. Celiac Plexus
= situated around the root of the celiac artery.
= receives sympathetic fibers from the
greater and lesser splanchnic nerves
= receives parasympathetic fibers from the
Vagus nerve.
= Branches distributed along branches of the
celiac artery.
2. Superior Mesenteric Plexus
= situated around the root of the superior
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mesenteric artery.
= continuous above with the celiac plexus,
= receives a branch from the posterior vagus
nerve.

= Branches are distributed along branches of

the superior mesenteric artery.
3. Inferior Mesenteric Plexus
= situated around the root of the inferior
mesenteric artery
= continuous with the aortic plexus,
= receives branches from the lumbar part of the
sympathetic trunk
= receives parasympathetic fibers from the pelvic
splanchnic nerve.
= Branches are distributed along branches of the
inferior mesenteric artery.

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 PELVIS
BUENA FE A. APEPE, MD

PELVIS Pelvic Organs Common to both Sex:

False Pelvis 1. Urinary bladder:

Boundaries:
Anterior: lower anterior abdominal wall A. Parts:
Posterior: lumbar vertebrae a. Apex – median umbilical ligament is
Laterally: iliac fossa and iliacus attached.
Inferior: pelvic brim/pelvic inlet b. Body – superior surface lined with
= Supports the abdominal contents. peritoneum.
c. Fundus/ Base – rounded, posterior or
True Pelvis basal surface
Boundaries: = Receives ends of 2 ureters
anterior: symphysis pubis, body of pubic = Related to ampulla of vas deferens
bones, and pubic rami. and seminal vesicles and rectum
posterior: sacrum, coccyx and pyriformis in the male
lateral: part of the hip bone below the brim, d. Neck – narrowed inferior part of the
obturator internus, obturator membrane fundus
& fascia, sacrospinous ligaments, = in the male, attached to superior
sacrotuberous ligaments surface of prostate gland
inferior: Pelvic diaphragm composed of: = Related to superior end of the
a. Levator ani Vagina
b. Coccygeus
superior: pelvic inlet or pelvic brim B. Cavity:
boundaries of inlet 1. Vesical trigone – with openings of the
anterior: symphysis pubis 2 ureters and urethra
lateral: iliopectineal lines = Surrounded by internal sphincter
posterior: coccyx urethra (Detrussor- smooth m)
= contains the pelvic organs
C. Nerve Supply:
Sex Differences of the Pelvis: Parasympathetic – filling and emptying.
Sympathetic – controls the internal
Female Male sphincter urethra
1. False Pelvis Shallow Deep
2. Pelvic inlet Transversely Heart shaped D. Blood supply- Superior and inferior
oval vesical artery
3. Pelvic cavity Roomier Less roomy
4. Pelvic outlet Larger Smaller 2. Rectum:
5. Sacrum Short/wide Long/narrow = Average length: 12 cm.
6. Pubic arch Wide Triangular/ = Extent: SV3 to tip of coccyx
Narrow = Mucosa: - with transverse rectal folds
7. Ischial tuberosity Everted Turned in = Narrowed at ano-rectal junction,
surrounded by puborectalis segment
Pelvic Cavity of levator ani
= Blood Supply:
lined by Upper half – superior rectal from
1. Peritoneum: inferior mesenteric artery.
Visceral= drapes over pelvic organs, Lower half – middle rectal from
and form pouches: internal Iliac artery.
in the male: rectovesical pouch,
in the female: vesicouterine pouch and MALE PELVIC ORGANS:
pouch of Douglas.
1. Prostate gland:
2. Endopelvic fascia: = Base - upper part, attached to inferior
Visceral – covers organs surface of urinary bladder
Parietal – covers body walls and muscle = Apex - sits on the pelvic diaphragm
Condensations: = Lobes - anterior, posterior, right lateral
retropubic fat of Retzius, puboprostatic left lateral, Median
ligament, pubovesical ligament, fascia of = Traversed by urethra (prostatic urethra)
Denonvillier, cardinal and uterosacral = Support- puboprostatic ligament and levator
ligaments, presacral fascia or Waldeyer's prostate muscle
fascia, lines the anterior aspect of the = Blood supply:
sacrum, enclosing the sacral vessels Inferior vesical and middle rectal arteries
and nerves.

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2. Seminal Vesicles
= Length: 5cm
= Each duct joins with ampulla of vas deferens
as ejaculatory ducts that penetrates the
prostate gland.
3. Urethra:
= Length: 18-20cm.
= Parts:
a. Prostatic – 3 cm. widest and most dilatable
part; pierced by ejaculatory ducts at its
upper part; traverses the prostate gland.
b. Membranous – 1.3 cms.; shortest,
traverses the urogenital diaphragm;
encircled by external sphincter urethra
muscle.
c. Penile - longest, variable in length; starts
as a bulb; traverses the corpus spongiosum
4. Vas deferens – 45cm long, pelvic part crosses
the ureter at the base of the urinary bladder
5. Bulbo-urethral glands (Cowper’s gland)
= Located within the fibers of the urogenital
diaphragm
= its duct penetrates the perineal membrane
to end at the penile urethra
FEMALE Pelvic ORGANS:
1. Ovary – paired, 2-3 cms. by 1-3 cms
= enveloped by mesovarium
= Located in a depression of the endopelvic
fascia (fossa ovarica) below bifurcation of the
common iliac vessels.
= Poles: superior (tubal) and inferior (uterine)
= Ligaments:
a. True (round ligament of the ovary0– from
uterine pole to the ovary.
b. False (suspensory ligament)- from ovary to
pelvic wall
= Blood supply and its origin
Ovarian artery – abdominal aorta
= Drainage:
a. Right ovarian vein into the inferior vena
cava
b. Left ovarian vein into the left renal vein
2. Fallopian tubes (oviducts, uterine tubes)
= Average length: 10-12 cms.
= Enveloped by mesosalphinx
= Parts:
a. Intramural or interstitial – most fixed;
within the uterine muscle at lateral angle of
the fundus
b. Isthmus – 2.5 cm. narrowed
c. Ampulla – widest, sinuous part, site of
fertilization
d. Infundibulum – expanded end with finger
-like fimbriae, and abdominal opening at
its end.
= Blood supply: branches from ovarian and
uterine artery
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PELVIS
BUENA FE A. APEPE, MD
3. Uterus:
= Parts:
a. Fundus – above the level of the entrance
of the fallopian tubes
b. Body – narrowed inferiorly as the isthmus.
c. Isthmus – invaginated into the upper end
of the vagina
d. Cervix
Supravaginal – above the vagina
Intravaginal – enclosed by the vaginal
fornices
= openings – internal and external os.
= Peritoneum – serosa covering the uterus;
hanging at the sides-broad ligament.
= Position – slight anteverso-flexion
= Support: endopelvic condensations:
a. Cardinal/Mckenrodt/ transverse cervical
b. Utero-sacral ligament/ Sacrocervical
c. Pubocervical
= Other ligaments attached to the uterus
Round ligament of the uterus – from
superior pole of uterus, thru the inguinal
canal and attached to labia majora.
= Blood supply –
a. Uterine artery from internal iliac artery
b. Ovarian from abdominal aorta
= Drainage:
a. uterine veins - internal iliac
vein into common iliac vein to inferior
vena cava.
b. Left ovarian V - left renal V - IVC
c. Right ovarian V- IVC
4. Vagina:
= Average length – 7-9 cms.
= Segments:
upper end – receives the lower half of the
cervix termed as fornices
lower end – surrounded by perineal muscles
and levator ani.
= Blood supply: vaginal artery
from internal iliac artery
PELVIC NEUROVASCULAR STRUCTURES:
1. Internal iliac artery:
= Origin: common iliac artery
= Commencement: sacroiliac joint
= Branches
a. Anterior division - superior vesical
obturator, middle rectal, inf gluteal,
uterine (female), internal pudendal
inferior vesical/ vaginal.
b. Posterior division – superior gluteal,
ilio-lumbar, lateral sacral
2. Internal Iliac vein: Tributaries: veins that
accompany the branches of the
internal iliac artery.
= Termination: sacroilliac joint, joins
external iliac vein to form the common
iliac vein.
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 PELVIS
BUENA FE A. APEPE, MD

3. Sacral Plexus: inferior - Colles fascia

= Formed by anterior rami of L4, 5 and = contents
S1-S4 in front of pyriformis. *Male
= Innervates most of the muscles and skin of root of the penis (bulb, crura)
the buttocks and lower extremity. paired posterior scrotal nerves
= Longest branch is sciatic nerve which is the- Paired posterior scrotal arteries
only nerve to the leg. Muscles – ischiocavernosus,
= other branches: bulbospongiosus,
*Superior and inferior gluteal superficial transverse perineal
*Pudendal n * Female
root of clitoris
4. Autonomic Nerves Muscles: bulbospongiosus
= pelvic part of Sympathetic trunk ischiacavernosus
continuous from the abdominal portion, superficial transverse perineal
and the 2 trunks unite in front of the bulb of the vestibule
coccyx to form the ganglion impar Bartholin’s glands
= Branches: artery of crura and of bulb
a. Superior hypogastric plexus labial nerves
b. 2 Hypogastric nerves b. Deep perineal pouch:
c. Inferior hypogastric plexus/Pelvic plexus = boundaries
d. Sacral splanchnic nerves Inferior - perineal membrane
= pelvic part of the Parasympathetic is Superior- superior fascia of the
represented by the Pelvic splanchnic urogenital diaphragm
nerves which arise from the lateral horn of = contents
the spinal cord levels S2, S3, S4. These * Male
preganglionic fibers synapse in ganglia of the membranous urethra
inferior hypogastric plexus. Cowper’s gland
external sphincter urethra
5. Lymphatic nodes and vessels: Deep transverse perineal muscle
= arranged in a chain along the main blood
vessels and are named after the blood Internal pudendal NVS
vessels with which they are associated. * Female
* Internal Iliac nodes to the Common iliac vagina
then to the Aortic nodes. The nodes urethra
received lymph from the uterus, lower external sphincter urethra
rectum and upper vagina deep transverse perineal muscle
= Drainage of the other pelvic organs: Internal pudendal NVS
* Lymph from the upper rectum to the
sigmoid colon drains into the Inferior Anal Triangle
Mesenteric nodes = contents
* Lymph from the testes, epididymis, External anal sphincter
ovaries and fallopian tubes drain along Ischiorectal fossa on each side of the
the gonadal vessels to the aortic nodes. anal canal
* Lymph from the round ligament, perineum, Adipose tissue
vulva, scrotum, penis drain to the superficial Inferior rectal NVS
inguinal nodes.
EXTERNAL GENITALIA:
PERINEUM
A. Male Genitalia:
= Divided into 2 by an imaginary line between the
ischial tuberosities 1. Penis:
1. Anterior half - (urogenital triangle) = 2 corpora cavernosum
separated posteriorly into 2 crura.
2. Posterior half – (anal triangle) = 1 corpus spongiosum
= Blood supply & Venous drainage traversed by the urethra;
a. Internal pudendal A & V expanded anterior end - glans penis;
b. External pudendal A& V expanded posterior end- bulb of the penis
= Nerve supply = Neurovascular supply:
a. Ilioinguinal Arterial: from internal pudendal artery
b. Genital branch of genitofemoral 1) Deep arteries
c. Pudendal 2) Dorsal arteries
d. Post cutaneous n. to the thigh 3) Arteries to the bulb
* Urogenital Triangle: Venous: deep dorsal vein into superficial
a. Superficial perineal pouch: dorsal vein.
= boundaries Plexus of veins around the
superior- perineal membrane prostate gland and urinary bladder.
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BUENA FE A. APEPE, MD

Nerves: Internal pudendal nerve

parasympathetic to cavernous
sinuses.
2. Testes:
= Lodged in the scrotum
= Suspended by its coverings derived from-
the different layers of the abdominal wall.
a. Tunica vaginalis – peritoneum
b. Internal spermatic fascia – fascia
transversalis
c. Cremaster Muscle – internal oblique
muscle
d. External spermatic fascia- external
oblique aponeuroses
= Blood supply –Testicular artery from
abdominal aorta.
= Venous drainage:
right testicular V into the IVC
left testicular V into the left renal V

3. Scrotum:
= lined with skin, Darto’s muscles and
Colle’s fascia.
= Blood Supply:
a. External pudendal from femoral A
b. Scrotal branches from external
pudendal artery
= Nerve Supply:
a. Ilioinguinal nerve
b. Scrotal branches of internal pudendal
nerve
c. Autonomic nerves

4. Epididymis:
= 5-7 meters long
= with head, body and tail

5. Vas deferens:
= 45 cm. long
= Passes thru superficial inguinal ring, inguinal
canal, deep inguinal ring into the pelvic cavity.
= Blood supply:
Artery to the vas deferens from the internal
pudendal artery.

B. Female Genitalia

= Parts: mons pubis, labia majora and minora,

pudendal cleft, vestibule, clitoris.
= Orifices at the vestibule:
a. Urethra
b. Vagina
c. Paraurethral glands
d. Bartholins glands
= Blood supply:
a. Internal pudendal A
b. External pudendal A
= Nerve supply:
a. Pudendal

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Choose the best answer
1. The following statement describes the
walls of the true pelvis, EXCEPT:
A. the anterior wall is formed by the bodies
of the pubic bone
B. the piriformis lines the posterior wall
C. the levator ani and coccygeus cover the
lateral wall of the pelvic cavity
D. the obturator internus muscles cover
most of the lateral wall
2. Which of the following characteristics will
make vaginal delivery with ease or with no difficulty?
A. Subpubic angle of 90 degrees or greater
B. Heart shaped inlet
C. Pelvic cavity is deep
D. Prominent medial projection of the ischial
spines
3. True of the culdesac / pouch of Douglas
A. It is formed by parietal pelvic fascia.
B. It commonly contains coils of jejunum.
C. It lies anterior to the vagina.
D. It lies behind the body of the uterus and
above the posterior fornix
4. The middle (median) lobe of the prostate
lies:
A. inferior to the ejaculatory ducts.
B. superior to the ejaculatory ducts and
posterior to the upper part of the prostatic
urethra.
C. anterior to the prostatic urethra.
D. lateral to the lower part of the prostatic
urethra
5. Which of the following lobes of the
prostate gland is commonly involve in BPH that
obstructs the prostatic urethra?
A. Anterior
B. Posterior
C. Lateral
D. Middle
6. Prostatic ducts open into which of the ff
structures?
A. seminal colliculus
B. prostatic utricle
C. prostatic sinus
D. bulbous urethra
E. membranous urethra
7. The extension of the vaginal lumen around
the intravaginal part of the uterine cervix is the:
A. Cervical canal
B. Uterine lumen
C. Fornix
D. Rectouterine Pouch
8. Which of the ff arteries does not enter the
true pelvis?
A. Testicular
B. Superior Rectal
C. Ovarian
D. Internal Iliac
UST FMS MEDICAL BOARD REVIEW 2019
REVIEW TEST
BUENA FE A. APEPE
9. Aortic nodes most likely receive lymph
from the which of the ff structures
A. mons pubis
B. round ligament of the uterus
C. Clitoris
D. Testis
10. Which of the following statements is
TRUE re: Sacral plexus
A. It lies behind the piriformis muscle
B. It is also called the pelvic plexus
C. It is formed by the anterior rami of L4-5,
S1-4
D. Its branches innervate muscles of the
gluteal region, pelvis and lower extremities
11. The boundaries of the perineum include
all the following EXCEPT:
A. Ischiopubic rami
B. Ischial tuberosity
C. Sacrospinal ligament
D. Sacrotuberal ligament
12. A young man was diagnosed as having
infected Cowper’s gland. Which of the following
structure maybe affected by this infection?
A. Glans penis
B. seminal vesicle
C. external urethral sphincter (S. Urethrae)
D. scrotum
13. In males, traumatic injury to the
perineum may rupture the bulb of the penis or the
penile urethra. The resulting leakage of blood or
urine may be found in all of the following areas
except which?
A. anterior abdominal wall
B. superficial perineal pouch
C. scrotum
D. ischiorectal fossa
14. During a vaginal delivery, a surgeon
performed median episiotomy in which he cut deep
through the perineal body. Which of the following
would be EXCLUDED in the incision?
A. Bulbospongiosus muscle
B. External anal sphincter muscle
C. Ischiocavernosus muscle
D. Deep transverse perineal muscles)
15. Which of the following openings is not
located in the vestibule of the vulva?
A. Skenes duct
B. Greater Vestibular duct
C. Vagina
D. Anal opening
16. Following a radical prostatectomy, the
patient is incapable of achieving erection. Which of
the following nerves is most likely damaged?
A. Pudendal
B. Sacral splanchnic
C. Dorsal nerve to the penis
D. Pelvic splanchnic
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 REVIEW TEST
BUENA FE A. APEPE

17. What artery supplies blood to the major 24. A patient with history of Pulmonary
erectile body in both the male and female? Tuberculosis presents with pus surfacing in the
A. Artery of the bulb superomedial part of the thigh. To which muscle did
B. Dorsal artery of the penis/clitoris the TB most likely spread?
C. Deep artery of the penis/clitoris A. Transversus Abdominis
D. Posterior labial/scrotal artery B. Internal Oblique
C. Psoas Major
18. Part of the scrotum responsible for the D. Quadratus Lumborum
wrinkling appearance of its skin is the:
A. Colle’s fascia 25. TRUE of the Suprarenal gland?
B. Dartos muscle A. surrounded by renal capsule and fascia
C. Fascia transversalis B. is pyramidal on the right and semilunar
D. Cremaster on the left
C. enclosed by peritoneum
19. A 40-year-old farmer complained of D. drained by three pairs of suprarenal veins
painful swelling found on the right side of the anal
margin. A diagnosis of Ischiorectal abscess was
made. Which of the ff. statements is NOT true?
A. The fat in the ischiorectal fossae is rich in
vascular supply
B. The inferior rectal vessels and nerve cross
the ischiorectal fossa from the lateral to the
medial side
C. The fat in the ischiorectal fossa is prone
to infection
D. If left untreated may develop into fistula
or anal sinus.

20. The vagus nerve passes into the

abdomen by passing through which opening of the
respiratory diaphragm
A. Aortic hiatus
B. Esophageal hiatus
C. Caval foramen
D. Medial arcuate ligament

21. True of the Cisterna Chylii

A. is an elongated lymphatic sac just above
the respiratory diaphragm
B. located at the left side of the abdominal
aorta
C. receives lymph from the entire abdomen
and lower extremities
D. lies in front of TV12

22. Which part is shortest and most fixed of

the male urethra?
A. prostatic
B. membranous
C. bulbous
D. spongy

23. In cases of internal injury to the kidney

without perforating the renal fascia, to which
direction will the blood flows?
A. inferiorly towards the pelvis
B. laterally into the body wall
C. medially across the midline to the other
kidney
D. superiorly into contact with the fascia of
the diaphragm

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 MUSCULOSKELETAL ANATOMY
ROBERT Y. CHAN, MD

GENERALITIES:
2. AMPHIARTHROSIS:
ANATOMIC POSITION: a. Minimal mobility:
1. Standing upright b. Cartilagenous
2. Head and eyes directed anterior c. Synchondrosis: Hyaline cartilage
3. Arms at side, supinated, palms anterior (costochondral jxn)
4. Lower limb together, toes facing anterior d. Symphysis: FIBROCARTILAGE; EX.
Pubic symphysis, intervertebral disc
SKELETAL SYSTEM:
Bone (206) 3. DIARTHOSIS: with movement; with
1. Support the body synovial membrane forming the cavity and
2. Protect organs synovial fluid, ligaments,,capsule
3. Attachment of muscles for movement a. Plane (gliding) uniaxial; one plane of
4. Storage of minerals axis; Ex. Tarsal/carpal bones;
5. Blood formation Sternoclavicular; Acromioclavicular;
6. Sound transduction Sacroiliac
7. Detoxification (store heavy metals) b. Hinge (ginglymus)- allow flexion and
extension only; Ex. Elbow, ankle,
Composition: interphalangeal
1. Organic : Collagen Type I c. Pivot (trocoid) – central bony pivot
2. Inorganic: Calcium hydroxyapatite; turning within a ring; uniaxial; Ex.
Osteocalcium phosphate Atlantoaxial (NO JOINT); Radio-
ulnar joint
Main division: d. Condylar (ellipsoidal) – two convex
1. Axial on two concave condyles;
a. Skull movement two planes but one axis
b. Vertebral column greater motion; usually flexion
c. Bony thorax extension: biaxial; Ex. MCP jt, knee
2. Appendicular joint; Atlanto-occipital jt (YES
a. Shoulder girdle JOINT)
b. Pelvic girdle e. Saddle (Sellar); Biaxial;
c. Limbs flexion/extension; aBDuct/aDDuct;
no rotation; Ex. Carpometacarpal jt
CLASSIFICATION OF BONES: of thumb
f. Ball and Socket (spheroidal) : allows
TYPE OF TISSUE: multiplanar movement: ex. Shoulder
1. CORTICAL – compact, dense, less vascular, and hip joint
less osteogenic, contains osteocytes
(regulate extracellular Calcium SKULL:
concentration),complex arrangement of 1. FRONTAL BONE
lamellae ( haversian system) 2. PARIETAL
2. CANCELLOUS – spongy, less compact, 3. TEMPORAL
more vascular, more osteoblast (bone 4. SPHENOIDAL
forming) and osteocytes (bone resorbing), 5. OCCIPITAL
6. MAXILLARY
SHAPE: 7. PALATINE
1. LONG BONES: longer than wide 8. MANDIBULAR
a. Epiphysis: covered by articular
CORONAL SUTURE: Frontal & Parietal
cartilage
SAGITAL SUTURE: Interparietal
b. Metaphysis: flare
LAMBOID SUTURE: Parietal & Occipital
c. Diaphysis: tubular
d. Physis: growth plate in children PTERION: Thinnest part of the skull overlying
2. SHORT BONES: Cuboidal MIDDLE MENINGEAL ARTERY/VEIN.
3. FLAT BONES: flat Fusion : Frontal, Parietal, Temporal & sphenoid
4. IRREGULAR: Varying shape
ORBITAL MARGIN:
CLASSIFICATION OF JOINTS (Articulation one or 1. Frontal bone
more bones) 2. Zybomatic arch (Temporal)
1. SYNARTHROSIS- 3. Maxilla
a. NO JOINT CAVITY
b. Connected by FIBROUS tissue SPINE:
c. Mobility very minimal 1. 7 Cervical (lordotic curve)
Ex. Sutures of skull; syndesmosis 2. 12 Thoracic (Kyphotic curve)
Tibiofibular ; interosseous 3. 5 Lumbar (lordotic curve
membrane 4. 5 Fused Sacral (kyphotic curve)
Gomphosis of teeth 5. 4 Fused Coccyx
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 MUSCULOSKELETAL ANATOMY
ROBERT Y. CHAN, MD

PARTS OF THE VERTEBRAE: POSTERIOR CHORD:

1. Body UPPER SUBSCAPULAR: C5-C6
2. Arch Subscapularis
- pedicle THORACODORSAL/MIDDLE SUBSCAPULAR C6-C8
- laminae Latissimus dorsi
- sineous process LOWER SUBSCAPULAR C5-C6
- transverse process Subscapularis
-articula process (facet) Teres Major
3. Intervertebral disc: (1/4 length of spine) AXILLARY: C5-C6
a. annulus fibrosus – fibrocartilage Deltoid
b. nucleus pulposus –collagen fibers Teres minor
4. Ligaments – anterior and posterior Lateral cutaneous nerve
RADIAL NERVE C5-C8,T1
CERVICAL SPINE: Triceps
1ST Cervical: ATLAS (NO BODY); YES JOINT with Extensor muscles of arm (Post comp)
OCCIPITAL PROCESS OF SKULL Brachials
Abductor pollicis longus
2ND Cervical: AXIS: with ODONTOID that articulate
with Atlas MEDIAL CHORD:
MEDIAL PECTORAL C8-T1
Nerve roots exit foramen of vertebrae ABOVE the Pectoralis Major and minor
pedicle of the body.. Thus C7 has two cervical nerve MEDIAL CUTANEOUS C8
root; C7 above and C8 below; and henceforth all
nerves exit below the pedicle of the vertebrae (ex. ULNAR NERVE: C8-T1
T1 nerve under T1 vertebrae) Flexors carpi ulnaris
Flexor digitorum profundus (medial)
PHRENIC NERVE (C3-5) - ONLY nerve supply to the Flexor digiti minimi
diaphragm. Opponens digiti minimi
Abductor digiti minimi
IMPORTANT STRUCTURES IN THE NECK: Adductor policis
3rd 4th Lumbricals
SCALENEUS ANTERIOR: separates the Subclavian Palmaris
vein (anterior) and the Subclavian artery and Interossei
Brachial plexus (posterior)
MEDIAN ROOT OF MEDIAN NERVE
BRACHIAL PLEXUS:
MEDIAN NERVE C5-T1
ROOTS: Pronator teres
PHRENIC: C3-C5 Flexor carpi radialis
Diaphragm Palmaris longus
DORSAL SCAPULAR : C5-C7 Flexor digitorum superficialis
Rhomboids, Abductor pollicis brevis
Levator scapulae Flexor pollicis brevis
LONG THORACIC E: C5-C7 Flexor pollicis longus
Serratus anterior Flexor digotum profundus (laeral)
Pronator quadratus
TRUNK: (UPPER)
SUPRASCAPULAR: C5 – C6 CLAVICLE: FIRST BONE TO OSSIFY (5TH – 6TH wk
Supraspinatus AOG; LAST TO COMPLETE: 21 y/o
infraspinatus
SUBCLAVIUS C5-C6: CLAVICLE: MOST COMMONN FRACTURED
Subclavius BONE
Weakest portion: Junction of Medial 2/3 and lateral
CHORDS: 1/3;, Medial portion displaced cephalad by
sternocleidomastoid; distal displaced medially by
LATERAL CHORD: pectoralis major, latissimus dors and serratus
LATERAL PECTORAL: C5-C7:
Pectoralis Major STRUCTURES IN THE SHOULDER GIRDLE:
MUSCULOCUTANEOUS C5-C7
Coracobrachialis ROTATOR CUFF:
Biceps brachii 1. SUPRASPINATUS (aBDuction) –
Skin lateral border of forearm suprascapular nerve
Lateral cutaneous nerve 2. INFRASPINATUS: lateral rotation –
LATERAL ROOT MEDIAN NERVE C5-C8,T1 suprascapular nerve
3. TERES MINOR: lateral rotation – Axillary
nerve
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 MUSCULOSKELETAL ANATOMY
ROBERT Y. CHAN, MD

4. SUBSCAPULARIS: Medial rotation –  VENTRAL RAMI OF SUPERIOR TRUNK OF

subscapular nerve PLEXUS
 Arm aDDucted, forearm Pronated; Medially
QUADRANGULAR SPACE: rotated,, flexed carpal flexors
SUPERIOR: Teres minor  Sensory loss to lateral arm, thumb, index
INFERIOR: Teres major finger
LATERAL: Surgical neck of humerus  C5 – C6 injury (Suprascapular,
MEDIAL: Long head of Biceps musculocutaneous, axillary)
CONTENT: AXILLARY NERVE AND POSTERIOR  “WAITER’S TIP”
CIRUCUMFLEX ARTERY
KLUMPKE’S PARALYSIS
TRIANGULAR SPACE:  Excessive aBDuction of arm
SUPERIOR: Teres Minor  VENTRAL RAMI OF INFERIOR TRUNK OF
INFERIOR: Teres Major PLEXUS
LATERAL: Long head of biceps  Weakness of intrinsic muscle of hand
CONTENT: Circumflex scapular artery  MCP extension due to weakness of opposing
lumbrical and interossei
AXILLARY TRIANGLE:  Thumb aDDucted and imobile
ANT: Pectoralis major and minor; subclavius  Sensory loss of median hand, ring and little
POST: Subscapularis, Latissimus dorsi;Teres Major finger
MEDIAL: 2nd to 6th rib; Serratus anterior  C8-T1 injury (median and Ulnar)
LATERAL: Humerus, Biceps brachii, coracobracialis  “CLAW HAND” OR “APE HAND”
APEX: Ant: Clavicle; Post: Scapula; Medial: 1st rib
CONTENTS: AXILLARY ARTERY AND VEIN, AXILLARY NERVE LESSION:
BRACHIAL PLEXUS  Dislocation of humeral head OR fracture of
surgical neck of humerus
SHOULDER DISLOCATION:  Weakness to aBDuct arm (deltoid) and
Anterior medial and internal rotated due to strong lateral rotation (teres minor)
aDDuctors and subscapularis.  May also injure posterior Circumlex artery
Kocher’s maneuver, aBDuct and externally rotate to
negate the action of subscapularis, then swing the RADIAL NERVE
elbow medially to lever the head laterally and  Injury at fractures of the spiral groove area
slipping back to position. of the humerus; injury to Posterior
Interosseous nerve in the Arcade of Frosh
MOST FIXED PART OF THE RADIAL NERVE IN THE (supinator)
ARM: Lateral intermuscular septum  Weakness of wrist extensors
 Numbness at dorsal 1st web of hand
CUBITAL FOSSA: between thumb and index finger
LATERAL: Brachioradialis  “WRIST DROP”
MEDIAL: Pronator teres
BASE: Imaginary line between condyles MEDIAN NERVE INJURY
CONTENTS:  Supracondylar fracture injuring the Median
Median nerve nerve; compression at pronator terres
Bifurcation-f Brachial artery (radial neck)  Numbness of thumb, index, middle and
- radial and ulnar artery lateral half of ring finger
Biceps tendon  Weakness of flexion of wrist; flexion of
Radial nerve thumb, index and middle finger
 “HAND OF BENEDICTION” when there is no
MEDIAL EPICONDYLITIS: GOLFER’S ELBOW flexion of the thumb, index and middle
Common FLEXOR tendon finger, when attempting to make a fist.
Flexor Carpi ulnaris MEDIAN NERVE INJURY:
Palmaris Longus  At Flexor Retinaculum of hand, compression
Flexor Carpi Radialis  Weakness of Thenar muscles causing
Pronator teres aDDuction and extension of thumb
LATERAL EPICONDYLITIS: TENNIS ELBOW  “Ape hand” weakness of lumbricals
Common EXTENSOR tendon
Extensor Carpi Radialis brevis ULNAR NERVE INJURY:
Extensor Digitorum  Medial epicondyle fracture
Extensor Digiti minimi  Weakness of flexion of medial fingers
Extensor Carpi Ulnaris  Numbness medial and ½ digit
 “CLAW HAND” due to weakness of medial 2
NERVE LESSIONS: lumbricals and hypothernar eminence.
ERB DUCHENNE’S SYNDROME:
 Birth injury; fall on shoulder

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 MUSCULOSKELETAL ANATOMY
ROBERT Y. CHAN, MD

SCAPULAR WINGING MEDIAL ROTATION: Gluteus medius and minimus

 Trauma to LONG THORACIC NERVE due to
surgeries causing Serratus anterior
weakness.
 Winging of vertebral border of scapula on
FRACTURE OF RADIUS”
Colle’s: Disatl 1inc of radius with dorsal
displacement; Dinner Fork deformity
Smith’s: Distal 1 inch disappear with volar
displacement; Garden spade” deformity.
ANATOMIC SNUFF BOX:
Lat: tendon of EPB, APL,
Floor: Scaphoid and Trapezium
CARPAL TUNNEL:
Contents: 4 Flexor Digitorum Superficiais,
4 Flexor digitorum profundus,
Flexor pollicis longus
Median nerve,
FRACTURE OF THE RADIUS:
Level of pronator teres: Distal pronated and
proximal supinated by action of Biceps.
Proximal 1/3: supinate arm
Distal 1/3: pronate
DISPLACED FRACTURE OF THE FEMORAL
NECK: disruption of Medial circumflex femoral
artery which supplies femoral head; causing
Avascular necrosis of the head in the future
Minimal Lateral rotation due to presence of capsule
= Y ligament of Bigelow (strongest ligament in the
body)
INTERTROCANTERIC FRACTURES: Fracture
beyond Capsule. Unopposed external rotators
FEMORAL FRACTURE:
BENEATH LESSER TROACNTER: Proximal femur
flexed due to iliopsoas; distal displaced medially and
superiorly due to unopposed aDDuctors and
Quadriceps femoris
SUPRACONDYLAR FRACTURES: distal fragment
rotated posteriorly due to Gastrocnemius
(superior gluteal)
LATERAL ROTATIOON: Piriformis , gemmilus
)(Sacral plexus)
POPLITEAL FOSSA
Superior: Semimembranosus, Biceps femoris
Inferior: Medial and lateral head of Gastrocnemius
Contents: Popliteal artery and vein, Tibial nerve
COMPARTMENS OF THE LEG
ANTERIOR: Ankle dorsiflexion, toe extension and
invertion (deep peroneal)
LATERAL: Evertor (superficial peroneal)
SUPERFICIAL POSTERIOR: plantarflex foot
(posterior tibial)
DEEP POSTERIOR: Invertor, toe flexors (posterior
tibial)
NERVE INJURIES OF LOWER LIMB:
FEMORAL NERVE: inability to extend knee
SCIATIC NERVE: due to misplaced gluteal
injections; Foot drop
ABDOMINAL HERNIAS:
DIRECT HERNIA: weakness of the falx inguinalis
(conjoint tendon) of the inguinal floor in
Hesselbach’s triangle (INFERIOR: Inguinal ligament;
SUPEROLATERAL: Inferior epigastric vessels;
MEDIAL: Linea alba
INDIRECT HERNIA: conjenital weakness of deep
inguinal ring lateral to the inferior epigastric vessels.
FEMORAL HERNIA: weakness of the posterior wall of
the Femoral cannal. Seen inferior to the inguinal
ligament
PANTALOON HERNIA: combined directl and Indirect
hernia

FEMORAL TRIANGLE:
Superior: Inguinal ligament
Lateral: Sartorius
Medial: Adductor longus
CONTENTS: Femoral Nerve, Artery Vein

HUNTER’S CANNAL:
Medial: Sartorius
Lateral: Vastus medialis
Posterior: Adductor longus, Magnus
Contents: Femoral artery and vein; Saphenous nerve

RANGE OF MOTION OF HIP:

FLEXION: Anterior compartment ( Femoral nerve)
EXTENSION: Posterior compartment (Siatic)
aDDuction: Medial compartment (Obturator)
aBDuction: Gluteus medius and minimus (superior
gluteal)

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 MUSCULOSKELETAL ANATOMY
ROBERT Y. CHAN, MD

SOURCE: SNELL

SHOULDER MOTION

MUSCLE ORIGIN INSERTION NERVE SUPPLY 2ndary ACTION

ABDUCTION
Deltoid Lateral third of Middle of lateral Axillary nerve (Post. Ant fibers: flex
clavicle; acromion, surface of shaft of Cord – C5-C6 shoulder / medially
spine of scapula humerus rotate arm
Post fibers: extend
shoulder / laterally
rotate arm
Supraspinatus Supraspinatus fossa Anterior Greater Suprascapular Stabilizes shoulder
of scapula tuberosity of (Upper trunk: C5-C6) joint
humerus; capsule of
shoulder joint
LATERAL ROTATION
Infraspinatus Infraspinous fossa of Posterior Greater Suprascapular
scapula (3 heads) tuberosity of (Upper trunk: C5-C6)
humerus; capsule of
shoulder joint
Teres minor Upper two-thirds of Posterior Greater Axillary nerve (post
lateral border of tuberosity of cord; C5-C6)
scapula humerus; capsule of
shoulder joint
MEDIAL ROTATION
Subscapularis Subscapular fossa Lesser tuberosity of Upper and lower
humerus subscapular nerves
(Post cord: C5-C6)
Teres Major Lower third lateral Medial lip of the Lower subscapular aDDucts arm
border of scapula bicipital groove of (post cord: C5-6)
humerus

SHOULDER ADDUCTION

MUSCLE ORIGIN INSERTION NERVE SUPPLY 2ndary ACTION

Latissiumus dorsi Iliac crest, lumbar Floor of bicipital Thoracdorsal nerve Extend and
fascia, spine of T7 – groove of humerus (Post cord, C6-8) medially rotate arm
T12; 9th to 12th rib
Pectoralis Major Clavicle, sternum,1st Lateral lip of bicipital Medial pectoral Medially rotate arm;
to 6th costal groove of humerus ( Medial cord- C8- flex arm
cartilage T1)

Lateral pectoral
nerves
( Lateral cord – C5-
7)

Pectoralis minor 3rd to 5th rib Coronoid process of Medial pectoral Depresses shoulder
scapula (Medial cord - c8-T1)

Serratus anterior 1st to 8th ribs Medial border of Long thoracic nerve Draw scapula
inferior angle of (Roots of C5-C7) forward on chest
scapula wall; rotates
scapula

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 MUSCULOSKELETAL ANATOMY
ROBERT Y. CHAN, MD

ANTERIOR ARM MUSCLES

MUSCLE ORIGIN INSERTION NERVE SUPPLY 2ndary ACTION

SHOULDER FLEXION
Coracobrachialis Coracoid process of Medial aspect of Musculocutaneous Weak adductor of
scapula shaft of humerus (lateral cord : C5-C7) arm
ELBOW FLEXOR
Biceps brachii LONG HEAD:
supraglenoid Tuberosity of radius Musculocutaneous Supinator of
tubercle of scapula and bicipital (lateral cord : C5-C7) forearm; weak
SHORT HEAD: aponeurosis of deep flexor of shoulder
Coracoid process of fascia of forearm joint
scapula
Brachialis Front of lower half Coronoid process of Musculocutaneous
of humerus ulna (lateral cord : C5-C7)
Brachioradialis Lateral Styloid process of Radial (C5-T1) rotate forearm to
supracondylar ridge radius midprone position
of humerus

POSTERIOR ARM MUSCLES

MUSCLE ORIGIN INSERTION NERVE SUPPLY 2ndary ACTION

TRICEPS
Long head Infraglenoid tubercle
of scapula
Lateral head Upper half of Olecranon process Radial (post cord: Extensor of
posterior surface of C5-T1) shoulder joint
humerus
Medial head Lower half of
posterior surface of
shaft of humerus

ANTERIOR COMPARTMENT OF FOREARM

MUSCLE ORIGIN INSERTION NERVE SUPPLY 2ndary ACTION

SUPERFICIAL (medial to lateral: USPRP)
Flexor carpi ulnaris Humeral head: Pisiform, hook of Flexion of hand
Medial epicondyle Hamate; base of 5th Ulnar nerve (C8-T1) ADDuction of hand
of humerus metacarpal
(Common flexor
tendon)
Ulnar head:
olecranon process
of ulna
Flexor digitorum Humeral head: Middle phalanx of Flexes Proximal
superficialis Medial Epicondyle four fingers Interphalangeal joint
of humerus Assist flexing
Radial head: Median nerve (C8- Metacarpophalangeal
anterior surface of T1) joint and wrist joint
radiuse
Palmaris Longus Medial Epicondyle Flexor retinaculum Flexes wrist joint
of humerus of palmar
(Common flexor aponeurosis
tendon)

Flexor carpi radialis Medial Epicondyle Base of 2nd and 3rd Flexion of wrist joint
of humerus metacarpal bones ABDuction of hand at
(Common flexor palmar wrist
tendon)
Pronator teres Humeral head: Lateral aspect of Pronation
medial epicondyle shaft of radius Flexion of forearm
of humerus

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ROBERT Y. CHAN, MD

Ulnar head:
coronoid process of
ulna
DEEP
Flexor pollicis Anterior surface of Distal phalanx of Median nerve Flexes distal phalanx of
longus radius thumb (Anterior thumb
interosseuous
branch C8-T1)
Pronator quadratus Anterior surface of Anterior surface of Median nerve Pronates forearm
distal ulna distal radius (Anterior
interosseuous
branch C8-T1)
Flexor digitorum Anterior surface of Distal phalanx of Ulnar (C8-T1) ring Flexes distal
profundus ulna, interosseous medial four fingers and little finger interphalangeal joint of
membrane Median (C8-T1) fingers; assist in flexion
middle and index of PIP and MCP joint
finger

POSTERIOR COMPARTMENT OF FOREARM

MUSCLE ORIGIN INSERTION NERVE SUPPLY 2ndary ACTION

SUPERFICIAL ( medial to lateral)
Extensor carpi Base of 5th Extend and aDDucts
ulnaris metacarpal Deep branch of wrist joint
Extensor digiti Lateral epicondyle Extensor expansion radial (posterior Extend
minimi of humerus of little finger interosseous nerve metacarpophalangeal
(common Extensor PIN) joint of little finger
Extensor digitorum tendon) Middle and distal Extends fingers and
phalanges of the hand
fingers
Extensor carpi Base of the third Extends and aBDuct the
radialis brevis metacarpal hand and wrist
LATERAL COMPARTMENT
Extensor carpi Lateral epicondylar Base of second Extend and aBDuct
radialis longus ridge of humerus metacarpal Radial hand and wrist
Anconeus Lateral epicondyle Olecranon process Extends elbow joint
of humerus of ulna
Supinator Lateral epicondyle Medial aspect of the Deep branch of Supinator of forearm
of humerus; anular neck and shaft of radial (posterior
ligament of superior radius interosseous nerve
radioulnar joint and PIN)
ulna
DEEP ( medial to lateral)
Extensor indicis Extensor expansion Extends
Shaft of ULNA and of index finger Deep branch of metacarpophalangeal
interosseous radial (posterior joint of index finger
Externsor pollcis membrane Base of distal interosseous nerve Extends distal phalanx
longus phalanx of thumb PIN) of thumb
Extensor pollicis Shaft of RADIUS Base of proximal Extends
brevis and interosseous phalanx of thumb metacarpophalangeal
membrane joint of thumb
Abductor pollicis Shaft of radius and Base of first aBDucts and extend
longus ulna metacarpal thumb

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ROBERT Y. CHAN, MD

GLUTEAL REGION

MUSCLE ORIGIN INSERTION NERVE SUPPLY 2ndary ACTION

HIP EXTENSOR
Gluteus maximus Outer surface of Iliotibial tract; Inferior gluteal Laterally rotate
ilium, sacrum, coccyx Greater trocanther of nerve thigh; through ITB
and scrotuberous femur tract extends knee
ligament joint
Tensor fasciae latae Iliac crest Iliotibial tract Superior gluteal Extend knee joint
HIP ABDUCTOR
Gluteus medius Tilts pelvis when
Outer surface of Greater trochanter of Superior gluteal walking
Gluteus minimus ilium femur Tilts pelvis when
walking, medial
rotate thigh
LATERAL ROTATOR OF THIGH AT HIP
Piriformis Anterior surface of First and second
sacrum Greater trochanter of sacral nerves
Gemellus superior Spine of ischium femur
Obturator internus Inner surface of
obturator membrane Sacral plexus
Gemellus inferior
Quadratus femoris Ischial tuberosity Quadrate tubercle of
upper end of femur

POSTERIOR COMPARTMENT OF THIGH

MUSCLE ORIGIN INSERTION NERVE SUPPLY 2ndary ACTION

KNEE FLEXION AND HIP EXTENSION
Biceps femoris Sciatic
LONG HEAD: ischial LONG HEAD: Tibial
tuberosity Head of fibula portion Lateral rotation leg

SHORT HEAD: shaft SHORT HEAD:

of femur Common peroneal
portion
Semitendinosus Ischial tuberosity Upper part of medial Sciatic (tibial Medial rotation leg
surface of tibia portion)
Semimembranosus Ischial tuberosity Medial condyle of
tibia

ANTERIOR COMPARTMENT OF THIGH

MUSCLE ORIGIN INSERTION NERVE SUPPLY 2ndary ACTION

HIP FLEXOR
SARTORIUS Anterior Superior Upper medial surface Femoral Laterally rotates
Iliac Spine (ASIS) of Shaft of tibia (PES thigh;
ANSERINUS) Flexes and medially
rotates tibia at knee
joint
Iliacus Illiac fossa Lesser trochanter of Flex trunk when
femur sitting up from lying
down
Psoas Thoracic vertebrae Lesser trochanter of Lumbar plexus Flexes trunk when
12; Lumbar femur sitting up from lying
vertebrae 1-5 down
Pectineus Superior ramus of Upper shaft of femur Femoral aDDuct thing at hip
pubis joint
KNEE EXTENSOR (QUADRICEPS FEMORIS)
Rectus femoris Straight head:
Anterior Inferior Iliac
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 MUSCULOSKELETAL ANATOMY
ROBERT Y. CHAN, MD

spine (AIIS) Quadriceps tendon of Femoral Flexes thigh at hip

Reflected head: ilium patella joint
at acetabulum
Vastus lateralis Upper end of shaft
of femur
Vastus medialis Upper end of shaft
of femur
Vastus intermedius Shaft of femur

MEDIAL COMPARTMENT OF THIGH

MUSCLE ORIGIN INSERTION NERVE SUPPLY 2ndary ACTION

HIP aDDuctor
Gracilis Inferior ramus of Upper part of shaft Flex knee joint
pubis and ischium of tibia (PES Obturator
ANSERINUS)
Adductor longus Body of pubis Posterior shaft of Lateral rotation
femur
Adductor brevis Inferior ramus of Posterior shaft of Lateral rotation
pubis femur
Adductor magnus Inferior ramus of Posterior shaft of ADDUCTOR: aDDutor/ lateral
pubis, ischium and femur; adductor Obturator rotation;
ischial tuberosity tubercle of femur
HAMSTRING: Sciatic extend thigh at hip
Obturator externus Outer surface of Greater trochanter Obturator Lateral rotation
obturator
membrane

ANTERIOR COMPARTMENT OF LEG

MUSCLE ORIGIN INSERTION NERVE SUPPLY 2ndary ACTION

DORSIFLEXION OF ANKLE
Tibialis anterior Shaft of TIBIA and Medial cuneiform and Invert foot; holds
interosseous base of first up arch
membrane metatarsal Deep peroneal
Extensor halluces Base of distal phalanx Extends big toe;
Shaft of FIBULA and of great toe invert foot
Extensor digitorum interosseous Extensor expansion Extends toes
longus membrane of four toes
Peroneus tertius Base of fifth Everts foot
metatarsal

LATERAL COMPARTMENT OF THE LEG

MUSCLE ORIGIN INSERTION NERVE SUPPLY ACTION

Peroneus longus Inferior aspect of the Plantar flex ankle;
Shaft of fibula base of 1st Superficial peroneal EVERTS foot; hold
metatarsal and up lateral
medial cuneiform longtitudinal arch of
Peroneus brevis Base of the 5th foot
metatarsal

UST FMS MEDICAL BOARD REVIEW 2019 5 | ANATOMY

 MUSCULOSKELETAL ANATOMY
ROBERT Y. CHAN, MD

POSTERIOR COMPARTMENT OF THE LEG

MUSCLE ORIGIN INSERTION NERVE SUPPLY 2ndary ACTION

SUPERFICIAL
Gastrocnemius Medial and lateral Achilles tendon to Planatar flexes foot
condyle of femur calcaneus at ankle; flexes knee
joint
Soleus Shaft of tibia and
fibula
Plantaris Lateral supracondylar Calcaneus Posterior Tibial
femur
DEEP
Popliteus Lateral condyle of Shaft of tibia Flexes knee, lateral
femur rotation of femur on
tibia
Flexor digitorum Shaft of TIBIA Base of distal Flex distal phalanx,
longus phalanges of toes plantar flex foot
Tibialis posterior Shaft of tibia and Tuberosity of Posterior Tibial Plantar flex foot,
fibula navicular bone INVERTS foot
Flexor halluces longus Shaft of FIBULA Base of distal Flex distal phalanx
phalanges of Big toe of Big toe, plantar
flex foot
DORSUM OF FOOT
Extensor digitorum Lateral calcaneus Proximal phalanx of Deep peroneal eXtend 1st to 4th toe
(halluces) brevis Big toe and 2nd to 4th
toe

ABDOMINAL MUSCLES

MUSCLE ORIGIN INSERTION NERVE SUPPLY 2ndary ACTION

COMPRESS ABDOMINAL CONTENTS
Rectus Abdominis Symphysis pubis 5th – 7th costal Thoracic nerve 7 – 12 Flex vertebral
and pubic crest cartilage column
Transversus Lower six costal Xiphoid process,
abdominis cartilage, iliac crest, linea alba, sumphisis
lateral third of pubis, conjoint
inguinal ligament tendon Thoracic nerve 7-12;
Internal oblique Lumbar fascia, iliac Lower three ribs, iliohypogastric,
crest, lateral two costal cartilage, ilioinguinal Pulls down rib in
thirds of inguinal xiphoid process, forced expiration
ligament linea alba, symphysis
pubis, conjoint
tendon
Externnal oblique Xiphoid process,
Lower eight ribs lineaalba, pubic
crest, pubic tubercle,
iliac crest

UST FMS MEDICAL BOARD REVIEW 2019 6 | ANATOMY

 REVIEW TEST
ROBERT Y. CHAN, MD

Choose the best answer: 8. A 65 y/o man complains of swelling of his

right testicle everytime he coughs and strains, which
1. Part of the bone that is compact, less diminishes when he is lying down . What kind of
osteogenic, less vascular, contains osteocytes and hernia does he have?
A. Direct
haversian system, but stronger per unit volume B. Indirect
A. Cortical C. Femoral
B. Cancellous D. Pantaloon
C. Growth plate
D. periosteum 9. A 60 y/o female slipped in her bathroom
and fell on her shoulder. She felt pain in her
2. Which part of the bone is bounded by shoulder area with increased severity when she
cartilage? moves her arm. Later she felt difficulty to abduct the
A. Metaphysis arm and lateral rotation with numbness of the
shoulder . What nerve is affected?
B. Epiphysis A. Long thoracic
C. Diaphysis B. Musculocutaneous
D. Physis C. Radial
D. Axillary
3. What type of joint is appreciated in the
intercarpal area? 10. A man could only abduct his arm to 15
A. Gomphosis degrees but no further. What muscle is paralyzed?
B. Synchondrosis A. Rhomboid minor
C. Planar B. Deltoid
C. Supraspinatus
D. Sellar
D. Teres minor
4. What is the dangerous area of the skull? 11. A house painter was doing an overhead
A. Perion
painting when he felt pain on the tip of his shoulder.
B. Bregman
On physical examination there is tenderness at the
C. occiput
greater tuberosity and with pain on 45 degrees of
D. Vertex
abduction. What is his possible pathology?
A. Fracture of the surgical neck
5. A 15 y/o bou jumped head first into shallow B. Deltoid insertion rupture
waters. He was then noted to be floating face down C. Rotator cuff pathology
aimlessly and immobile. He as immediately fished D. Trapezius strain
out. He was noted to be wide-eyed and blinking
rapidly, with flaring nostrils, contracting neck 12. A 7 y/o girl fell from her bike on an
muscles and gasping for air but cannot speak. What outstreached arm. She experienced severe pain on
is his most probable injury? her elbow with deformity, accompanied by weakness
A. C2
of wrist flexion and flexion of thumb, index and
B. C4
middle fingers. Her most probable nerve injury
C. C6
would be:
D. T1 A. Radial
B. Median
6. A 12 y/o girl has chronic cough of 3 months C. ulnar
duration with progressive weight loss. She then D. Musculocutaneous
noted back pain and progressive numbness on her
legs up to her inguinal area and bowel and bladder 13. A 55 y/o female complains of chronic wrist
changes. On PE she has (+)Beevor’s sign test (+) pain. On PE she feels numbness in the lateral 3
abdominal cremasteric, MMT 3/5 on both lower fingers, with thenar atrophy, (+) tinnels sign. What
extremities, with lax sphincteric tone. Which is her most likely problem?
vertebral level is her lesion? A. Ulnar tunnel syndrome
A. Cervical B. Cervical spondylosis
B. Thoracic C. Carpal tunnel syndrome
C. Lumbar
D. De Quuervaine’s
D. Sacral
14. Innervation of the folowing muscles is
7. A 55 y/o man was attempting to lift a 50 kg from the radial nerve EXCEPT:
sack of rice when he sudden;y felt severe pain and A. Brachialis
shooting sensation to his right medial ankle. He B. Abductor pollicis longus
noted that he has difficulty to lift his right big toe C. Abductor pollicis brevis
and numbness on his medial aspect of his medial D. Extensor digitorum
spect of his leg, (+) SLR, (-) Faber, MMT 3/5
external hallucis longus, What is the level of his 15. The main flexor of the elbow is:
pathology? A. Brachialis
A. L2-L3 B. Biceps brachii short head
B. L3-L4 C. Biceps brachii long head
C. L4-L5
D. Brachioradialis
D. L5-S1

UST FMS MEDICAL BOARD REVIEW 2019 | ANATOMY

 REVIEW TEST
ROBERT Y. CHAN, MD

16. A man, after pulling a heavy baggage from

the carousel experienced sevre pain in his lateral
elbow. He most likely have
A. Medial epicondylitis
B. Lateral epicondylitis
C. Ulnar nerve irritation
D. Cervical spondylosis

17. The femoral nerve arises form what

segment of the spinal cord?
A. L1 & l2
B. L2 & L3
C. L2, L3 & L4
D. L5, S1-S3

18. Which of the following muscles are foot

everters?
A. Tibialis posterior
B. Flexor hallucis longus
C. Peroneus longus
D. Tibialis anterior

19. The muscles attached to the greater

trochanter EXCEPT:
A. Gluteus medius
B. Piriformis
C. Gluteus medius
D. Iliopsoas

20. What muscle will compensate if the

supinator is paralyzed?
A. Extensor carpi ulnaris
B. Brachialis
C. Biceps brachii
D. Triceps

UST FMS MEDICAL BOARD REVIEW 2019 | ANATOMY

 CARDIOVASCULAR/MEDIASTINUM
MARIA LOURDES SANTOS, MD

MEDIASTINUM SVC
-median partition of the chest cavity in between the Azygous
2 pleurae Aortic arch -L Common Carotid
L Subclavian
BORDERS: Brachiocephalic
Superior -Root of the neck, thoracic inlet/outlet c. Nerves:
(1st rib, TV1, suprasternal notch) Vagus -L Recurrent laryngeal
Inferior -Respiratory diaphragm Phrenic
d. Trachea
e. Esophagus
f. Thoracic duct

B. INFERIOR MEDIASTINUM:
Below sternal angle and disc between TV4-5
Divided into ANTERIOR/MIDDLE/POSTERIOR by the
PERICARDIUM

B.1. Anterior Mediastinum -behind body of

sternum and in front of pericardium
Contents:
a. Thymus gland
b. Lymph nodes
c. Adipose Tissue
B.2. Middle Mediastinum - between the
PARTS OF MEDIASTINUM pericardium
A. SUPERIOR Contents:
B. INFERIOR a. Heart
 Anterior b. Pericardium
c. Phrenic nerves
 Midddle
d. Roots of the great vessels
 Posterior -ascending aorta
-pulmonary art.& veins
(figure taken from Clinical anatomy by Snell 9th ed) -SVC & IVC
e. Arch of the azygos vein
f. Main bronchi

B.3. Posterior Mediastinum behind pericardium

and TV5-12
Contents:
a. Thoracic aorta
b. Esophagus
c. Thoracic duct
d. azygous/hemiazygous
e. Thoracic sympathetic
f. Posterior intercostal nvs

THYMUS
 Bilobed
 Regresses at puberty
 produces thymosin - T Lymphocyte
production - cell mediated
immune response
 from third pharyngeal pouch
 BS – Inf. Thyroid, int.thoracic

A. SUPERIOR MEDIASTINUM- PERICARDIUM

Superior- root of the neck/thoracic inlet A. PERICARDIUM –outer;
Inferior - sternal angle of Louis - between TV4-5 attached to:
Anterior - manubrium sterni  adventitia of great vessels
Posterior- TV1-TV4 (aorta, pulmonary trunk/veins,
Contents: SVC/IVC)
a. Thymus gland
 central tendon - diaphragm
b. Blood vessels:  sternum – sterno-pericardial ligament
Brachiocephalic veins NS- phrenic
UST FMS MEDICAL BOARD REVIEW 2019 1 | ANATOMY
 CARDIOVASCULAR/MEDIASTINUM
MARIA LOURDES SANTOS, MD

B. SEROUS PERICARDIUM  Base (posterior) - LA & pulmonary veins

 Parietal serous layer
NS. -phrenic D. GROOVES
 Visceral serous layer or epicardium  AV groove or coronary sulcus
NS. -sympathetic trunk & Vagus  IV groove

PERICARDIAL CAVITY - 50ml fluid E. CORONARY ARTERIES

 from aortic sinus of ascending aorta
CLINICAL CORRELATES:  Fills during diastole
TENSION PNEUMOTHORAX
● Pneumothorax + Mediastinum displaced 1. RIGHT CORONARY
to the opposite side o Longer
o Courses in AV groove (Anterior)
PE: trachea and the heart are displaced to the o Branches:
opposite side; absent breath sounds on side  Marginal
of pneumothorax  Posterior
Treatment: interventricular artery
● Needle thoracentesis at 2nd ICS (located in IV groove
midclavicular line posterior)
● The sternal angle is identified -> 2nd CC  artery to SA node
-> 2nd rib _> 2nd ICS in the  AV nodal
 atrial and ventricular
midclavicular line
branches
o areas supplied:
CLINICAL CORRELATES: CARDIAC  RA (including SA & AV
TAMPONADE node, LBB)
results from excessive pericardial fluid in the  All RV except small area
pericardial cavity. EX: stab wound to the heart
to the right of the
 Compresses the thin-walled atria and
interfere with the filling of the heart during anterior IV groove
diastole  Variable part of
 (Inelastic pericardium+ extensive fluid) = diaphragmatic surface of
CARDIAC TAMPONADE LV
 BECK’s TRIAD  Postero-inferior 3rd of
1. Engorged Neck Veins - compression SVC
IV septum
2. Muffled / absent heart sounds
3. Hypotension
 parts of LA

• PERICARDIOCENTESIS 2. LEFT CORONARY

• needle inserted left of the xiphoid in o Short course
an upward and backward direction o Branches:
at an angle of 45° to the skin.  Circumflex - in AV
groove (Posterior)
• At this site, the pleura and lung are  anterior
not damaged because of the interventricular
presence of the cardiac notch in this (LAD) – IV groove
area. anterior)
o Supplies majority of the heart
 greater part of LA
HEART  Most of LV
A. APEX -5th LICS MCL- L.VENTRICLE  Small portion of RV
Downward, forward to the left  Anterior 2/3
B. BORDERS interventricular
 Right – RA septum
 Left – L AURICLE, LV  RBB & LBB
SUMMARY:
 Inferior –RV ,RA
LA& LV- circumflex
 Superior -Great vessels IV septum & apex - Ant.
Interventricular
C. SURFACES RV - Ant Interventricular &
 Sternocostal (anterior) -RA &RV marginal
 Diaphragmatic (inferior) - RV & LV, IVC RA- right coronary

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 CARDIOVASCULAR/MEDIASTINUM
MARIA LOURDES SANTOS, MD

CLINICAL CORRELATES:
CARDIAC TRAUMA:

• Anatomy of the heart relative to the front of

the thoracic cage determines the common
sites of injury.
• R ventricle is most commonly injured -> L
ventricle ->R atrium.
• Anterior interventricular artery from
left coronary artery - most common to
• be damaged

ATHEROSCLEROSIS
Coronary artery blockage results in infarction of part
of myocardium supplied by end arteries (AMI)
Ex. Blockage of L anterior descending
will
lead to infarct of Most of LV, Apex and
interventricular septum – can lead to
pump failure
- Blockage of origin of R coronary that
supply the SA node can affect rhythm of
the heart (Arrhythmia)
F. CARDIAC VEINS
 CORONARY SINUS • 2. REFERRED PAIN in the medial side of
 main venous drainage of heart the arm in MI (part of the chest wall is
 AV groove (Posterior) innervated by upper 4 intercostal nerve &
 drain into RA intercostobrachial nerve (T2) while the
 Tributaries medial side of arm is innervated by
a. Great cardiac vein - in anterior
intercostobrachial and medial cutaneous
IV groove with Anterior nerve T1)
intervenricular artery
b.Small –along with right marginal
c.middle cardiac –in posterior IV groove
with posterior interventricular arter) G. CHAMBERS
d.Oblique
ATRIUM
 Anterior cardiac and vena cordis minimae –direct RIGHT LEFT
to the chamber
(figure taken from BRS) Openings -SVC -Pulmonary veins
-IVC (4)
-Coronary
Sinus - AV opening
-AV opening
-Vena cordis
minimae

Character -Musculi pectinati -Musculi pectinati

istics in auricle &RA only in the auricle

-Fossa ovalis

-Sulcus terminalis
(SA node)

Valves Tricuspid Mitral

VENTRICLE

RIGHT LEFT

IV septum Bulges to the RV (-)

UST FMS MEDICAL BOARD REVIEW 2019 3 | ANATOMY

 CARDIOVASCULAR/MEDIASTINUM
MARIA LOURDES SANTOS, MD

Walls Thinner, Thicker Valves ANATOMICAL CLINICAL AREA

crescentric longer AREA
narrower &
conical Pulmonic Medial end of L 3rd 2nd LICS near
CC sterna border

Trabeculae Aortic Left half, sternum 2nd RICS near

carnae: 3rd ICS sternal border
1. Etched (+) (+)
Mitral Left half sternum 4th 5th LICS MCL
CC
(+) (-)
2.Moderator
Band Tricuspid Right half strernum R half of lower end
4th ICS to 6th of body of sternum
3. 3 smaller 2 bigger
Papillary
Muscle

Valves Pulmonic Aortic

Moderator band contains R bundle of His

Papillary attached to chordate tendinea to

cusps for AV valves (figure taken from BRS)

J.CARDIAC SKELETON:

▪ Fibrous rings: Surrounds AV valves &

Semilunar valves
▪ Separates the muscular walls of atria and
ventricle and provides attachment
▪ Makes valves competent & prevents
overstretching
▪ Basis for electrical discontinuity between
Atrium& ventricles

H. VALVES
K.INNERVATION:
 AV closed at ventricular systole (LUB);
semilunar at diastole (DUB) (figure taken  INTRINSIC
from Clinical anatomy by Snell 9th ed) ◼ SA node –R atrium near sulcus
terminalis
◼ AV node – lower part of atrial
septum
◼ AV Bundle of His- connects atria to ventricle
to cardiac skeleton
▪ R Bundle – Moderator band  purkinje
plexus

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▪ L bundle  purkinje plexus
◼ Blood supply – branch from R coronary
except RBB (Left) & LBB (from Left & right)
 EXTRINSIC
◦ Autonomics – from superior, middle &
inferior cervical and thoracic
sympathetic plus the vagus nerve:
o Superficial Cardiac plexus below
Arch of aorta
o Deep cardiac plexus at the
bifurcation of aorta
LARGE VEINS IN MEDIASTINUM
1. SUPERIOR VENA CAVA
a. From L & R brachiocephalic
b. Azygous vein – tributary
c. Commencement – 1st CC junction
d. Termination- 3rd CC
2. INFERIOR VENA CAVA
a. pierces the central tendon of the
diaphragm opposite the eighth
thoracic vertebra and almost
immediately enters the lowest part
of the right atrium
3. AZYGOS VEINS
a. Origin – union of R ascending
lumbar & R subcostal
b. Tributaries – 8 lower R intercostal
veins, R superior intercostal,
hemiazygous, superior hemiazgous,
esophageal & mediastinal veins
c. Terminates into the SVC level of 5th
TV
4. PULMONARY VEINS
a. 4 in number
b. From the lungs to LA
LARGE ARTERIES IN MEDIASTINUM
1. ASCENDING AORTA
a. Branches – L and R aortic sinus
b. Commencement – base LV
c. Termination – Sternal angle of Louis to be
come Aortic Arch
2. ARCH OF THE AORTA
a. Branches: Brachiocephalic, L common carotid
& L subclavian all given off behind the
manubrium sterni
b. Terminates between the LV4-LV5
3. THORACIC AORTA
a. Commencement- bet LV4-LV5
b. Termination – TV12 to become Abdominal
Aorta
UST FMS MEDICAL BOARD REVIEW 2019
CARDIOVASCULAR/MEDIASTINUM
MARIA LOURDES SANTOS, MD
c. Branches – Posterior intercostals no.3-12,
subcostal, esophageal, bronchial
4. PULMONARY TRUNK– arises from conus
arteriosus of RV, bifurcates into L & R
pulmonary arteries
LYMPHATICS IN THE MEDIASTINUM
1. THORACIC DUCT
a. Origin – cysterna chyli
b. Course enters diaphragm to the R of
descending aorta, median planne behind
esophagus then left to root of the neck
c. Drains L jugular, l subclavian,
bronchomediastinal, lower limbs, abdomen.
Left side thorax, left side UE, left side neck
and L face (the rest by R lymphatic duct)
d. Terminates between L IJV & L Subclavian
2. RIGHT LYMPHATIC
a. Drains the right jugular, right.
subclavian, bronchomdiastinal trunks
that drain the R head and face, R
neck, R UE, R side thorax
b. Terminates between R IJV & R Subclavian
NERVES OF THE MEDIASTINUM:
1. SYMPATHETHIC TRUNKS
a. Continuous with cervical & thoracic
b. Laterally placed on the heads of the ribs
c. Leaves thorax at the sides of body of
12th TV
d. 11-12 ganglions
e. White and gray ramus communicans
passing thru spinal nerves - blood
vessels, sweat glands, arrector pili
i. 1st 5 – heart, aorta, lungs,
esophagus
ii. Lower 8- pregang-
splanchnic nerves -
abdominal viscera
1. 5-9 – greater
2. 10-11- lesser
3. 12 - lowest
Spinal Anesthesia and the Sympathetic
Nervous System
 A high spinal anesthetic may block the
preganglionic sympathetic fibers
passing out from the lower thoracic
segments of the spinal cord
 produces temporary vasodilatation
below this level, with a consequent fall
in blood pressure
5 | ANATOMY
 CARDIOVASCULAR/MEDIASTINUM
MARIA LOURDES SANTOS, MD

 PATHWAY for Oxgenated blood from

Placenta
▪ Umbilical vein  Ductus
venosus IVCRA Foramen
ovale LA LVAorta

 PATHWAY for unoxygenated blood

▪ SVCRARVPulmonary
trunkDuctus arteriosusaorta

2. VAGUS
• Posterior to the root of the lung to form
pulmonary plexus
• Then around the esophagus to form
esophageal plexus
• Before exiting the thoracic cavity via
esophageal hiatus, the Left vagus become
anterior vagal trunk, while right becomes
posterior

3. LEFT RECURRENT LARYNGEAL

• arises as the nerve crosses the arch of the
aorta near ligament arteriosum

4. PHRENIC
• Enters the thorax:
• between the subclavian vessels

• Runs anterior to the root of the lung

w/ pericardiophrenic vessels

• descends between the mediastinal

pleura and the pericardium

• Injury results in – ELEVATION OF

THE IPSILATERAL DIAPHRAGM

FETAL CIRCULATION: (figure taken from BRS)

 Receives oxygenated blood from
placenta

UST FMS MEDICAL BOARD REVIEW 2019 6 | ANATOMY

 CARDIOVASCULAR/MEDIASTINUM
MARIA LOURDES SANTOS, MD

CLINICAL CORRELATES:
ATRIAL SEPTAL DEFECT
 After birth, the foramen ovale becomes
completely closed as the result of the fusion
of the septum primum with the septum
secundum.
 In 25% of hearts, a small opening persists,
(PATENT FORAMEN OVALE) but this is
usually of such a minor nature that it has no
clinical significance.
 Occasionally, the opening is much larger and
results in oxygenated blood from the left
atrium passing over into the right atrium

VENTRICULAR SEPTAL DEFECT

 At birth: the three shunts that partially
bypass the lungs and liver closes
i. Foramen ovale
ii. Ductus arteriosus
iii. Umbilical vessel
 ventricular septum is formed when the
membranous part fuses with the muscular
part
 Less frequent than ASD
 Found in the membranous part of the
septum and can measure 1 to 2 cm in
diameter.
 Blood under high pressure passes through
the defect from L to R à enlarged RV
 Large defects are serious and can shorten life
if surgery is not performed

PATENT DUCTUS ARTERIOSUS

 Fetal life - blood passes through it from the
pulmonary artery -> aorta, bypassing the
lungs
 At birth, it normally constricts, closes =
ligamentum arteriosum
 Results in high-pressure aortic blood passing
into the pulmonary artery, which raises the
pressure in the pulmonary circulation.
 A patent ductus arteriosus is life threatening
and should be ligated and divided
surgically

COARCTATION OF THE AORTA

 narrowing just proximal, opposite, or distal to
the site of attachment of the ligamentum
arteriosum.
 when the ductus arteriosus contracts, the
ductal muscle in the aortic wall also
contracts, and the aortic lumen becomes
narrowed.
– permanent narrowing occurs.
 cardinal sign - absent or diminished
Cardiovascular Silhouette on XRAY:
pulses in the femoral arteries of both
Left border consists of the:
lower limbs
• aortic arch
 To compensate, an enormous collateral
• pulmonary trunk
circulation develops dilatation
• left auricle
– Internal thoracic
• left ventricle
– Subclavian
– Posterior intercostal arteries
Inferior border formed:
• The dilated intercostal arteries erode the
• Right ventricle
lower borders of the ribs, producing
• Left atrium shows no border
characteristic notching, seen on
radiographic examination.
Right border is formed by the:
• SVC
• Right atrium
• IVC

UST FMS MEDICAL BOARD REVIEW 2019 7 | ANATOMY

 CARDIOVASCULAR/MEDIASTINUM
MARIA LOURDES SANTOS, MD

TETRALOGY OF FALLOT
• most common form of cyanotic congenital heart
disease, which is compatible with life for any
length of time.
• R to L shunt

Classically, as described by Fallot, the four

abnormalities that constitute the complex are:
1. VSD
2. Pulmonary stenosis or atresia
3. Right ventricular hypertrophy
4. Overriding of the aorta the aorta straddles the
VSD and seems to originate from both
ventricles.

TRANSPOSITION OF THE GREAT VESSELS

• Cyanotic heart disease
• R to L shunt
• The aorta arises anteriorly from the right
ventricle and the pulmonary trunk posteriorly
from the left ventricle

UST FMS MEDICAL BOARD REVIEW 2019 8 | ANATOMY

 ANTERIOR ABDOMINAL WALL /
CAVITY & DIGESTIVE SYSTEM
MARIA LOURDES SANTOS, MD

ANTERIOR ABDOMINAL WALL / CAVITY & 2. Muscles

DIGESTIVE SYSTEM o on each side – 1 medial and 3 lateral
o lateral muscles becomes aponeurotic near
I. ABDOMINAL WALL the ends and participate in the formation of
rectus sheath
QUADRANTS & REGIONS
o External oblique
 Most superficial lateral muscle
 Downward and medially
 Becomes aponeurotic on medial &
ineferior ends
 Derivatives
 Inguinal ligament
 Ext spermatic fascia

o Internal oblique

 2nd laterally placed muscle layer

Transpyloric plane:
 Upward and medial
 the tips of the 9th costal cartilages
 Becomes aponeurotic on medial end
 fundus of the gallbladder
 Inferior medial end joins the transversus
 neck of the pancreas
abdominis –Conjoint tendon
 pylorus of the stomach
 hilum of the left kidney
o Transversus abdominis
 point of origin of the SMA
 Deepest laterally placed muscle
 point of commencement of the portal vein
 Horizontally oriented fibers
 disc between the 1st and 2nd LV
 Becomes aponeurotic medially
 Joins IO to form conjoint tendon
CLINICAL CORRELATES:
ABDOMINAL PAIN USING QUADRANTS &
o Rectus abdominis
REGIONS-zeroing in on the affected organs
 On each side of midline/línea alba
ANTERIOR ABDOMINAL WALL LAYERS  Has tendinous intersection---―ABS‖
o All layers share same innervation, blood  Lateral border- Linea semilunaris
supply and venous drainage  Covered by rectus sheath
Vascular supply and drainage
Midline 3. Extraperitoneal fat
o Superior epigastric 4. Transversalis fascia
o Inferior epigastric 5. Parietal Peritoneum
Flanks
o Intercostal RECTUS SHEATH (figure from Clin. Anatomy by
o Lumbar Snell 9th ed)
o Deep circumflex iliac
Inguinal region (branches of Femoral artery)  Above the costal margins
o Superficial epigastric o Anterior rectus sheath
o Superficial circumflex iliac
 EO aponeurosis
o Superficial external pudendal arteries
o Posterior rectus sheath
Deep Vein have same names with arteries
Superficial veins mainly drains to lateral thoracic  formed by 5th, 6th and 7th
above and below into femoral vein via superficial costal cartilages and the
epigastric and great saphenous vein (IMPT intercostal spaces
PATHWAY FOR PORTOCAVAL AND CAVAL-CAVAL
ANASTOMOSES)

Layers:

1. Skin/Superficial Fascia
o Camper’s
o Scarpa’s

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 ANTERIOR ABDOMINAL WALL /
CAVITY & DIGESTIVE SYSTEM
MARIA LOURDES SANTOS, MD

 Between costal margin & ASIS
o Anterior rectus sheath
 EO and IO aponeuroses
o Posterior rectus sheath
IO and TA aponeuroses
CLINICAL CORRELATES
VISCERAL PAIN
 dull, poorly localized and referred to
midline
 (GI tract originated midline)
 pain results from overdistension
(stretch) of a viscus or pulling on a
mesentery
 visceral peritoneum- innervated by
autonomic afferent nerves
PARIETAL PAIN
 precisely localized and sharp
 parietal peritoneum innervated by ICN
7-11, subcostal etc...

REFERRED PAIN
 feeling of pain at a location other than
the site of origin of the stimulus but in
area supplied by the same or adjacent
segment of spinal cord.
- both somatic & visceral
structures can produce pain
 Below the ASIS  EX. Somatic referred pain – Pleurisy of
o Anterior rectus sheath lower
 EO, IO, TA aponeuroes  parietal pleura referred to the
o No posterior rectus sheath epigastric area (T7)
 Visceral referred pain – pain in early
part of appendicitis referred to
umbilicus (T10)
INGUINAL CANAL

1. Length -4 cm
2. Openings

◦ Deep (internal) inguinal ring

 posterior wall of the rectus sheath is not
attached to the rectus abdominis
 anterior wall is firmly attached to the
muscle’s tendinous intersections
Contents of the rectus sheath
- Opening in the Fascia transversalis
- Midway from ASIS to symphysis pubis
& 1.3 cm above the inguinal ligament
◦ Superficial (external) inguinal ring
- EO aponeurosis
- Above and medial to pubic tubercle

1. Rectus muscle 3. Boundaries

2. Pyramidalis if present - Ant. -EO aponeurosis
3. Superior epigastric vessels - Post- conjoint tendon, fascia transversalis
4. Inferior epigastric vessels - Sup/Roof - IO/TA
5. Lower six intercostal NVS
- Inf/ Floor -inguinal ligament
CLINICAL CORRELATES:
1. Content
DERMATOMES - Ilioinguinal N-♀♂
The xiphoid process: T7 - ♀ - round ligament & Genital branch of
The umbilicus: T10 genitofemoral N.
The inguinal: L1 - ♂ - spermatic cord:
Vas deferens
Testicular artery
Testicular veins (pampiniform plexus)
Testicular lymph vessels

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Autonomic nerves
Remains of the processus vaginalis
Genital br of genitofemoral N. (to cremaster
muscle)
Hesselbach’s / Inguinal Triangle
Borders (fig. Clin. Anatomy Snell 9th ed)
 INF -Inguinal ligament/Poupart’s
 LAT – Inferior epigastric
 MED -Lateral border of Rectus abdominis-
DERIVATIVES OF ABDOMINAL WALL LAYERS
IN SPERMATIC FASCIA & SCROTAL SAC
Skin
SF campers – Darto’s
Scarpa’s – Colle’s
EO Aponeurosis - External spermatic fascia
IO – cremaster muscle & fascia
TA - none
Transversalis fascia- Int. spermatic fascia
Extraperitoneal fat- none
Parietal Peritoneum- Processus /tunica vaginalis
CLINICAL CORRELATES:
INDIRECT INGUINAL HERNIA
 lateral to the inferior epigastric
 neck narrow-prone to strangulation
 thru the Internal ring Canal external ring
 scrotum or labia majora)
Congenital – non closure/patent processus
Vaginalis
***if opening/ neck of sac/ is small and only
abdominal fluid passes ---HYDROCOELE
UST FMS MEDICAL BOARD REVIEW 2019
ANTERIOR ABDOMINAL WALL /
CAVITY & DIGESTIVE SYSTEM
MARIA LOURDES SANTOS, MD
DIRECT INGUINAL HERNIA
 Medial to the inferior epigastric/Inside
 Neck wide not prone to strangulation
 Inside Hesselbach’s triangle – results from
weakness of abdominal muscles
 Surgical hernia repair may damage:
o iliohypogastric N-anesthesia of the
ipsilateral abdominal wall and
inguinal region passing on top of EO
aponeurosis
o ilioinguinal N- anesthesia of the
ipsilateral penis, scrotum, and medial
thigh.
UNDESCENDED TESTIS (normal testis internal
ring canal external ring versus ECTOPIC
TESTIS – anywhere but the normal route
VARICOCOELE – dilated pampiniform
plexus & testicular Vein ―BAG of WORMS‖
CREMASTER REFLEX – stroking skin of medial
thigh (Sensory distribution of genitofemoral) will
elicit contraction of the cremaster muscle (Motor
distribution of genitofemoral) pulling testis up
against abdominal wall
II. ABDOMINAL CAVITY
DIVISION:
Greater Peritoneal Cavity
▪ Anterior space
▪ Opened by the surgeon’s incisions on the
anterior abdominal wall.
Lesser Peritoneal Cavity
▪ potential space behind the liver & stomach
▪ Includes the partial visceral layer that covers
the retroperitoneal organs (pancreas and
duodenum) anteriorly.
▪ ―omental bursa”
Supramesocolic Space
- Above the transverse colon and mesocolon
Inframesocolic Space
-Below the transverse colon & mesocolon
densely occupied by the organs
Rectouterine pouch (Culdesac)of Douglas –
lowest part of peritoneal cavity in females on upright
position
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 ANTERIOR ABDOMINAL WALL /
CAVITY & DIGESTIVE SYSTEM
MARIA LOURDES SANTOS, MD

Rectovesical pouch – Lowest in malesIn Supine – RESULTS IN INTRAPERITONEAL AND

lowest is R posterior subphrenic space and RETROPERITONEAL ORGANS

CLINICAL CORRELATES: Intraperitoneal

1. Esophagus
US FAST 2. Stomach
3. 1st inch duodenum
 Focused Assessment Sonography for 4. Jejunum
Trauma 5. Ileum
 Blunt abdominal injury 6. Cecum
 Focusing on 4 areas 7. Appendix
o RUQ – Right posterior 8. Transverse colon
subphrenic/Hepatorenal space 9. Sigmoid
o LUQ- Left posterior suphrenic/ 10. Upper 1/3 rectum
splenorenal space 11. Liver
o Pelvic cavity – Rectovesical / 12. Bile ducts
Culdesac of Douglas and 13. Spleen
Uterovesical
o Subxiphoid Retroperitoneal
pelvic cavity  basis for US FAST 1. Rest of duodenum
2. Pancreas
PERITONEAL FOLDS: 3. Ascending colon
4. Descending colon
1. OMENTA - peritoneal fold attached between the 5. Rectum
stomach and some other organ. ****Distal 3rd rectum outside peritoneal
cavity
o Lesser Omentum
 double layered - stomach and liver; 3. LIGAMENTS – thickened peritoneum due mainly
 2 parts: to the enclosed fibrous tissue, with or without
 Hepatogastric: encloses R& L gastric related neurovascular structures: Ex
vessels o Coronary ligament of the liver
 Hepatoduodenal ligament- portal triad o Right and left triangular ligaments
- common bile duct, Portal vein & o Falciform ligament of the liver
Hepatic A.
UMBILICAL LIGAMENTS /FOLDS
o Greater Omentum - four-layered fold
between the stomach and transverse colon Median umbilical fold-Urachus
Medial umbilical fold- Obliterated umbilical A
CLINICAL CORRELATES: Lateral umbilical fold- Inferior epigastric A

FUNCTIONS OF THE GREATER GASTROINTESTINAL TRACT

OMENTUM REMEMBER:
- Blood supply foregut artery - Celiac trunk
Prevents the visceral peritoneum from Esophagus
adhering to parietal peritoneum stomach
Wraps itself around an inflamed organ Proximal half duodenum
protecting other viscera from infection Midgut artery - SMA
Distal half duodenum
ex .Appendicitis
- ”ABDOMINAL POLICEMAN”
Jejunum
Ileum
Cecum
2. MESENTERY double layered fold, attach the Appendix
intestines to the posterior abdominal wall, contains Ascending colon
fat, blood vessels, lymphatics and nerves: transverse colon 2/3
Hindgut artery - IMA
o Mesentery of the SI distal 2/3 transverse
o Root of mesentery -left side of the Descending colon
Sigmoid
2nd LV to the right sacro-iliac fossa
Rectum
o Sigmoid mesocolon Upper half anal canal
o Transverse mesocolon * Venous drainage follows the name of the
o Mesoappendix arteries and all are part of the portal venous system
(EXCEPT cervical and thoracic part esophagus and
middle and distal rectum)

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 ANTERIOR ABDOMINAL WALL /
CAVITY & DIGESTIVE SYSTEM
MARIA LOURDES SANTOS, MD

* Lymphatic drainage follows the names of the

arterial supply/origin of the blood supply
*Innervation:
Parasympathethic *from esophagus to
prox 2/3 of transverse – vagus after which
pelvic splanchnic S2-4
Symphatethic splanchnic nerves from
thoracic sympathethic trunks
Plexuses - parasympathethic and
sympathethic fibers combined around origin
of the blood supply, e.g. Celia plexus,
superior mesenteric plexus etc.
ESOPHAGUS
o Length – 25 cm
o Commencement – CV6
o level of cricopharyngeus as continuation of
pharynx
o Termination – TV11
Dysphagia from solid to liquid
Lymph drainage of lower 1/3 descends through
the esophageal opening in the diaphragm and
ends in the celiac nodes
- Malignant cells tend to spread below the
diaphragm along this route
- Surgical removal of the esophagus and
celiac lymph nodes
- Restoration of continuity of the gut is
accomplished by performing an
esophagojejunostomy
STOMACH
o Left costal margin, epigastric & umbilical region
o Parts: Cardia, Fundus, Body, Pylorus
o 2 Openings: Cardiac and pyloric
o 2 Curvature: Lesser and Greater
o 2 surfaces: anterior & posterior
o Peritoneal attachments: Lesser & greater
omentum; gastrosplenic ligament

o Constrictions o Blood supply (direct or indirect branches of

celiac)
1. Level of CV6, clasping of cricopharyngeus
Lesser curvature:
2. As it is crossed by L bronchus & Arch of the -Left gastric (CELIAC)
aorta Level of TV10, as it passes the diaphragm -Right gastric (HEPATIC)

Segments Blood Venous Lymph Fundus

supply Drainage Drainage -Short gastric (SPLENIC)
Cervical Inferior Inferior Deep
thyroid thyroid cervical Greater curvature
Thoracic Thoracic Azygous Mediastinal -Left gastroepiploic (SPLENIC)
aorta -Right gastroepiploic (GASTRODUO-
Abdominal Left Left Celiac DENAL FROM HEPATIC)
gastric gastric
o Venous drainage
CLINICAL CORRELATES:  Left & right gastric Portal vein
 Left gastroepiploic and short gastric 
CONSTRICTIONS- area where foreign bodies get splenic veinportal vein
lodged; area where strictures develop in caustic  Right gstroepiploic superior mesenteric
injury, common sites of carcinoma, difficulty in vein  portal vein
passing scopes
o Lymph drainage: Left gastric  Celiac
PORTOCAVAL ANASTOMOSIS – Esophageal Right gastric Celiac
tributaries of L gastric anastomose with
esophageal tributaries of the Azygous vein, this o Innervation: Vagus & Thoracic sympathetic
serves as portocaval shunts during portal venous T6-T9
obstruction In Portal hypertension  Esophageal
varices Duodenum
o Epigastric & umbilical region
ACHALASIA – failure of relaxation of the distal o Length/ parts: 25cm
esophagus / cardioesophageal sphincter secondary ◦ Pars superior – 5cm
to degeneration of parasympathetic ◦ Pars descendens – 8cm
plexus/auerbach’s plexus ◦ Pars horizontalis – 8cm
◦ Pars ascendens – 5 cm
Dysphagia from liquids to solid
o Peritoneal lining:
◦ 1st inch of pars superior- complete
Results in proximal dilatation of esophagus and
◦ Rest -Retroperitoneal
narrowing of distal segment  Bird’s beak
o Important clinical relations:
appearance in barium swallow
o 1st part: GB
o 2nd part: Head of Pancreas
ESOPHAGEAL CARCINOMA
Openings of CBD and

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 ANTERIOR ABDOMINAL WALL /
CAVITY & DIGESTIVE SYSTEM
MARIA LOURDES SANTOS, MD

pancreatic ducts b. The acidic chyme is squirted through

o 3rd part the pylorus to impinge on the
Root of the mesentery anterolateral wall of the first part of the
Superior mesenteric vessels duodenum
o 4th part
Duodenojejunal flexure ligament -may perforate anteriorly into the greater peritoneal
of Treitz cavity leading to generalized peritonitis
-posteriorly located duodenal ulcer erodes into the
o Blood Supply: gastroduodenal artery massive hemorrhage
o Superior pancreaticoduodenal (from
gastroduodenal) -In the surgical treatment of chronic gastric and
o Inferior pancreaticoduodenal (from duodenal ulcer, attempts are made to reduce the
SMA) amount of acid secretion by cutting the vagus nerve
(VAGOTOMY) and by removing the gastrin-bearing
o Venous Drainage: area of mucosa, the antrum (ANTRECTOMY)
o Superior pancreaticoduodenal portal
vein DUODENAL TRAUMA
o Inferior pancreaticoduodenal  SMV
3rd part of the duodenum is crushed against the 3rd
o Lymph drainage: lumbar vertebra on severe crushing injuries
o Upper half --pancreaticoduodenal nodes
JEJUNUM & ILEUM
 gastroduodenal nodesceliac nodes
o Lower half --pancreaticoduodenal nodes -Jejunum commences at the duodenojejunal
 superior mesenteric nodes superior flexure marked by the ligament of treitz
mesenteric artery.
-no demarcation but gradual change into ileum.
CLINICAL CORRELATES: Ileum terminates at ileocecal junction

GASTRIC ULCERS Length: 20 ft / 6 meters long

occurs in the alkaline producing mucosa, usually on Attached to posterior abdominal wall by root of the
or close to the lesser curvature. mesentery

It later involves the muscular coat, and will, in time Jejunum Ileum
involve the visceral peritoneum (PERFORATED
GASTRIC ULCER)
Length 8 ft 12 ft
Posteriorly located:
Wall thickness Thick wall, Thin wall narrow
o erodes into the left gastric or splenic artery 
wide, reddish lumen, lighter
massive hemorrhage
color
o abscess in the lesser peritoneal cavity
o erosion of pancreas Arterial arcades Few and large Numerous and
small
Anteriorly located:
o May be difficult to differentiate from pain and Mesenteric fat Scanty; near Plenty
tenderness of acute appendicitis once gastric lateral wall
fluid gravitates to the RLQ via the right free end
of the greater omentum Lymph nodes Solitary lymph Submucosal
nodules at aggregates –
DUODENAL ULCER anti- payers patches
mesenteric
-consequence of the secretion of acid in excess of border
the amount that can be efficiently disposed by the
duodenum Plica circulars Larger, smaller widely
numerous separated
-Anatomical reasons why duodenal ulcer is common closely set
in 1st part of duodenum:
a. Not adequately supplied by blood Blood supply all Jejunal Ileal branches
from the superior pancreaticoduodenal from L side of branches Ileo-colic
artery, especially in its proximal part. It SMA
is supplied by a small branch from the Venous Jejunal veins Ileal veins
hepatic or gastroduodenal artery drainage Ileocolic vein

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 ANTERIOR ABDOMINAL WALL /
CAVITY & DIGESTIVE SYSTEM
MARIA LOURDES SANTOS, MD

Lymphatic Mesenteric Mesenteric o Lymph drainage: mesenteric nods  superior

mesenteric nodes
drainage nodes  nodes 
superior superior
o Innervation: Via superiormesenteric plexus
mesenteric mesenteric
Para-Vagus
nodes nodes
Symp-splanchnic
Innervation P-Vagus P-Vagus
S-splanchnic S-splanchnic VERMIFORM APPENDIX
Via
Via
superiormese o Location: Right iliac fossa
superiormesente o Length - 8-13 cm
nteric plexus
ric plexus o Completely covered by peritoneum, has
mesoappendix
CLINICAL CORRELATE: o Base located where taenia coli converges at the
posteromedial surface of cecum
MECKEL’S DIVERTICULUM
o Tip variable: Most common – pelvic, retrocecal
o antimesenteric border of the ileum about
2 ft. from the ileocecal junction o Blood supply: Appendiceal A from posterior
o about 2 in long cecal A
o about 2% of individuals
o may possess a small area of gastric o Venous drainage: Appendiceal V  posterior
mucosa, and bleeding may occur from a cecal Aileocolic VSMV
―gastric‖ ulcer in its mucous membrane
 pain from this ulcer may be o Lymphatic drainage: nodes in the
confused with the pain from mesoappendix to superior mesenteric nodes
appendicitis
o may present as obstruction if with o Innervation: Via superiormesenteric plexus
presence of fibrous band Para-Vagus Symp-splanchnic

LARGE INTESTINES

Characteristic features
◦ External distinguishing:
- Large calibre
- Taenia coli
- Appendices epiplocae
- Haustrations & Sacculations

◦ Internal distinguishing
- Plica semilunaris
- Villi

◦ Supplied by br. from right side of SMA up until

2/3 of transverse, rest supplied by IMA until RECTUM
upper anal canal
o Location: Pelvic cavity
◦ Venous drainage until upper ranal canal will drain o Commencement: SV3
to the portal system; middle and lower 3rd rectum o Termination: tip pf coccyx or pelvic diaphragm
to caval system o Length: 13 cm

CECUM : o Peritoneal covering:

o Location: R iliac fossa  Upper 3rd - anterior & sides

o Length :6cm  Middle 3rd -anterior
o Completely covered by peritoneum no  Lower 3rd – none  extraperitoneal
MESOCOLON
o Valves: Ileocecal Valve (Bauhin’s) &Gaerlach o Relations :

o Blood supply: ant & post cecal from Ileocecal Posterior: (same for ♀♂ )
● Sacrum, coccyx, Pyriformis,coccygeus
o Venous drainage: ant & post cecal to SMV ● Sacral plexus

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 ANTERIOR ABDOMINAL WALL /
CAVITY & DIGESTIVE SYSTEM
MARIA LOURDES SANTOS, MD

● Sympathetic trunks o Length: 4 cm

(♂ ) Anterior o Relations :
Anterior:
● Upper 2/3 – sigmoid, ileum
● Perineal body
● Lower 3rd – post surface of bladder, vas
deferens, seminal vesicle, ● Urogenital diaphragm
prostate gland ● Membranous urethra &Bulb of the penis
(♀ ) Anterior ● Lower part of the vagina
● Sigmoid Posterior:
● Ileal coils ● Anococygeal body
● Vagina Lateral
● Ischiorectal fossa
o Blood supply:
o Upper 3rd- Single Sup.Rectal (IMA) o Structure: divided into 2 parts by dentate -
o Middle 3rd –Paired Middle rectal A (Int. Iliac) /pectinate line
o Lower 3rd – Paired Inferior rectal (Inferior
Pudendal) Upper half:
o Lining: Columnar epithelium w/ anal
o Venous Drainage: o columns, anal walls
o Upper 3rd- Sup.Rectal IMV splenic o From hindgut - endoderm
Portal o Blood supply & drainage: Superior rectal
o Lymph drainage: Inferior mesenteric nodes
o Middle 3rd –Middle rectal  Int. Iliac V o Nerve supply- autonomics thru hypogastric
Common Iliac IVC plexus-Sensitive to stretch only

o Lower 3rd – Paired Inferior rectal Inferior Lower half:

Pudendal Int Iliac Common
iliac  IVC o Lining: Stratified squamous, No anal
 column
o Lymph Drainage: o From ectoderm
o UPPER pararectal nodes and then into o Blood supply & drainage: Inferior rectal
inferior mesenteric nodes o Lymph Drainage: medial group of superficial
o LOWER part of the rectum follows the inguinal nodes
middle rectal artery to the internal iliac
nodes o Nerve supply: Inferior rectal nerve
 Sensitive to touch, pain &
o Nerve Supply Temperature
o Inferior hypogastric plexuses. The rectum is
sensitive only to stretch. o Sphincters:

● Involuntary internal sphincter

● Upper end of canal
● Smooth circular muscle
● Voluntary external sphincter
● sheath of voluntary muscles:
Subcutaneous
Superficial
Deep

ANAL CANAL

o Location: perineum
o Commencement: tip pf coccyx or pelvic
diaphragm (Puborectalis), where the rectal
ampulla tapers

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HEMORRHOIDS
● INTERNAL-Varicosities of the tributaries of
superior rectal V & A
● Lie in anal columns at 3,7,11 o’clock
● Fold of mucous membrane &
submucosa containing a varicosed-
tributary of SRV and terminal branch
of the SRA
● painless only aching sensation
● Valveless
● classified by the degree of tissue
prolapse into the anal canal
● 1st-4th degree
● EXTERNAL-Varicosities of the tributaries of
Inferior rectal & A
● Run laterally from anal margins
● Covered by mucous membrane of
the lower half of anal canal or skin
● Innervated by inferior rectal nerves
● sensitive to pain temp, touch and
pressure
PERIANAL ABSCESS
 produced by fecal trauma to the anal mucosa
 Infection may gain entrance to the submucosa
through a small mucosal lesion, or the abscess
may complicate an anal fissure or the infection
of an anal mucosal gland.
UST FMS MEDICAL BOARD REVIEW 2019
ANTERIOR ABDOMINAL WALL /
CAVITY & DIGESTIVE SYSTEM
MARIA LOURDES SANTOS, MD
 The abscess may be localized to:
o submucosa (submucous abscess)
o beneath the perianal skin (subcutaneous
abscess)
o may occupy the ischiorectal fossa
(ischiorectal abscess).
 Anatomically, these abscesses are closely related
to the different parts of the external sphincter
and levator ani muscles
FISTULA
 result of spread or inadequate treatment of anal
abscesses
 fistula opens at one end at the lumen of the anal
canal or lower rectum and at the other end on
the skin surface close to the anus
 If the abscess opens onto only one surface, it is
known as a sinus
FISSURE
● ends of the anal columns are connected folds
called anal Valves
● constipation, torn down to the anus from a fecal
mass catching on the fold of mucous membrane
= elongated ulcer  anal fissure
● extremely painful
● most commonly in the midline posterior >
anterior
● caused by the lack of support provided
by the superficial part of the external
sphincter in these areas
● inferior rectal nerve, results in reflex
spasm of the external anal sphincter,
aggravating the condition.
Because of the intense pain -may have to be
examined under local anesthesia
III. PORTOCAVAL ANASTOMOSIS (pic from Clin
Ana by Snell)
1. Left gastric esophageal veins
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 ANTERIOR ABDOMINAL WALL /
CAVITY & DIGESTIVE SYSTEM
MARIA LOURDES SANTOS, MD

2. Superior rectal  middle & inferior rectal 1. Right Lobe

veins 2. Left lobe
-Quadrate
3. Paraumbilical periumbilical veins -Caudate (dual supply from L & R branches)

4. Other minor anastomosing bypasses:

● Retroperitoneal veins IVC and
azygous veins

Functional Division of Left and Right Lobe:

-Line from fossa of GB to IV

◦ Each division has its own corresponding:

o branches of the portal vein
o branches of hepatic artery
o hepatic ducts

o Blood supply and drainage:

Hepatic artery (30%) & portal vein (70%)

↓
Interlobar branches
↓
Intralobular branches
↓
Sinusoids
↓
Central veins
ACCESSORY ORGANS ↓
Sublobular veins
LIVER ↓
Hepatic veins
o Covered by glisson’s capsule ↓
o Location: Right hypochondrium to epigastric to IVC
left hypochondrium
o Topography, o Bile ducts:
Superior border
R 5th rib, MCL Hepatic cells Bile canaliculiBile ductules
L 5th ICS, MCL Bile ducts Smaller Hepatic ducts R & L hepatic
Inferior border, 1cm below the costal arch ducts  Common Hepatic duct
10th rib, right MAL
Left end of superior border CHD + (Cystic duct of GB) = CBD

o Attachments: COMMON BILE DUCT

◦ Lesser Omentum
◦ Hepatoduodenal ligament o Within the hepatoduodenal ligament
◦ Falciform ligament o 6-15cms curving course downwards
◦ Coronary ligament o Parts: Supraduodenal Retroduodenal
◦ Triangular ligament Infraduodenal, Intrapancreatic
o Has Sphincter choledochus of Boyden
o Surfaces o Joined by the main pancreatic duct of
◦ Antero-superior Wirsung to form the AMPULLA Of VATER
◦ Inferior/visceral In turn guarded by the Sphincter of Oddi
◦ Posterior - *bare area – devoid of
peritoneum

o Division: Left and Right Lobe

-Line from fossa of GB to IV
UST FMS MEDICAL BOARD REVIEW 2019 10 | ANATOMY

CLINICAL CORRELATES
LIVER RESECTION -Each liver segment can be
resected safely without fear of necrosis for each
segment has its own blood supply; drainage &
duct
PORTAL HYPERTENSION -Dilatation of
o PARTS:
porocaval anastomosis in portal hypertension
from liver cirrhosis Ex. Esophageal varices,
haemorrhoids, caput medusa
PRINGLE MANEUVER: temporarily can control
bleeding in liver trauma by clamping of
hepatoduodenal ligament: Portal Vein & Hepatic
artery
JAUNDICE
Stones in the CBD
Periampullary mass (duodenum 2nd part,
pancreatic head, distal common bile duct)
GALLBLADDER
o Fossa at inferior surface of the liver
o Suspended by the cystic duct
o Cystic artery – rt hepatic artery
o Cystic vein – portal vein
o 8-10 cms x 3-5cm; 30-50 ml
o Parts
 Fundus -Very close to the anterior abd. wall:
along Transpyloric
 Body
 Hartman’s pouch
 Neck
 Cystic duct - Spiral valves of heister
CLINICAL CORRELATES:
CYTOHEPATIC TRIANGLE OF CALOT
BORDERS: Cystic duct -lateral
CHD - Medial
inferior border of liver - superior
CONTENT: Cystic artery
ACUTE CHOLECYSTITIS
Pain and tenderness in the right upper
quadrant or epigastrium radiating to the back
(T7-T9)
(+) murphy’s sign - arrest on inspiratory effort
on palpating R subcostal
 irritation of the sub-diaphragmatic
parietal peritoneum by the inflamed
Gallbladder (supplied in part by the
phrenic nerve (C3, 4, and 5)
referred pain over the shoulder
 skin in this area is supplied by the
supraclavicular nerves (C3 and 4)
UST FMS MEDICAL BOARD REVIEW 2019
ANTERIOR ABDOMINAL WALL /
CAVITY & DIGESTIVE SYSTEM
MARIA LOURDES SANTOS, MD
PANCREAS
o Lobulated elongated gland 10-18 cms
o Epigastric & umbilical regions; Tail - L
hypochondriac
o In the stomach bed
o Exocrine & endocrine
▪ Head- C of duodenum
 Uncinate process inferior extension
of head, hooks posteriorly behind the
superior mesenteric vessel
▪ Neck – Related to commencement of portal
vein
▪ Body
▪ Tail – related to hilum of spleen
 PANCREATIC DUCTS:
Main pancreatic duct of “Wirsung”
o drains head, body & tail
o end near the medial border of the head
+ CBD = AMPULLA OF VATER penetrate
the postero-medial border of 2nd part
of duodenum  greater duodenal
papilla
Accessory pancreatic duct of Santorini
o drains upper portion of head
o may communicate with the main
pancreatic duct
o opens also on the postero-medial
surface via lesser duodenal papilla
o Blood supply:
o HEAD:
 Superior pancreaticoduodenal from
gastroduodenal
 Inferior pancreaticoduodenal from
SMA
o BODY & TAIL- Pancreatic branches
from splenic
o Venous drainage:
 Superior pancreaticoduodenal Portal
vein
 Inferior pancreaticoduodenal SMV
o Lymph drainage: along the arteries that
supply the gland  celiac and superior
mesenteric lymph nodes.
o Nerve Supply
Sympathetic and parasympathetic (post
vagal) nerve fibers supply the area via
celiac and superior mesenteric plexus
11 | ANATOMY

CLINICAL CORRELATES:
GALLSTONE PANCREATITIS
Stone from CBD can obstruct the opening of
the main pancreatic duct because of the
common channel (Ampulla of vater)
obstructing flow and causing extravasation of
pancreatic enzyme to the parenchyma
GALLSTONE ILEUS
Stone in GB fundus perforates wall erode
either duodenum or transverse colon which
may cause intestinal/gut obstruction
PANCREATIC PSEUDOCYST
Inflammation of the pancreas can lead to
pancreatic fluid accumulation in the lesser
sac—> lead to adhesions and the closing off
of the lesser sac to form a pseudocyst
PERIAMPULLARY TUMORS
Composed of head of pancreas, distal CBD
tumors, duodenal tumors
Said tumors obstruct biliary flow - causing
obstructive jaundice
-Surgical treatment: Whipple’s Procedure
or Pancreaticoduodenectomy
o Head of pancreas
o Duodenum
o CBD
o Gallbladder
 they share common blood supply, venous
and Lymphatic drainage
PANCREATIC TAIL & SPLENECTOMY
The presence of the tail of the pancreas in the
splenico-renal ligament sometimes results in
its damage during splenectomy.
The damaged pancreas releases enzymes that
start to digest surrounding tissues, with
serious consequences
UST FMS MEDICAL BOARD REVIEW 2019
ANTERIOR ABDOMINAL WALL /
CAVITY & DIGESTIVE SYSTEM
MARIA LOURDES SANTOS, MD
PORTAL VEIN
o Union of Splenic Vein & SMV
o Drains all the blood from the GI tract
o 7-8 cms long
o From behind the neck of the pancreas it Courses
superiorly to the R, behind the pars superioris in
the hepatoduodenal lig.
o Divides into L & R branch at the porta
o R PORTAL BRANCH recieves cystic vein
o L PORTAL BRANCH connected to the
ligamentum venosum & arteriosum +
paraumbilical veins of sappey –CAPUT
MEDUSAE in Portal hypertension
o ESOPHAGEAL VARICES
o HEMMORRHOIDS
o RETROPERITONEAL VEINS DILATATION
o SPLENIC ENLARGEMENT
SPLEEN
o Soft and violaceous, pliable with smooth muscle
in its elastic fibrous capsule extending to its
parenchyma
o 12 cm in length 7cm wide and 3-4 cm
thick,150gm
o Location:
 Left hypochondriac, posterior edge
extending into the epigastric region
 Between fundus of the stomach &
diaphragm
 Between 9-11th rib, long axis of the 10 th
o Curved, concave, visceral surface - hilum
o Closely related to tail of pancreas
o Notched anterior border
CLINICAL CORRELATE:
SPLENOMEGALY
o extends downward and medially
o left colic flexure and the phrenic colic
ligament prevent a direct downward
enlargement of the organ
o As the enlarged spleen projects below the
left costal margin, its notched anterior
border can be recognized by palpation
through the anterior abdominal wall.
12 | ANATOMY
 REVIEW TEST
MARIA LOURDES SANTOS, MD

Choose the best answer: 12. During surgical closure of PDA, care must
be taken in clamping the Ductus to avoid injury to
1.Sound of closure of the cardiac valve that is
what important structure immediately close to it?
heard best over the sternal end of right 4th
A. Left phrenic nerve
intercostal space:
B. Thoracic duct
A. aortic
C. Left recurrent laryngeal nerve
B. ventral
D. Trachea
C. pulmonic
13. Veins that drain into the coronary sinus
D. tricuspid
EXCEPT:
2.The main venous drainage of the heart is the
A. Great cardiac
A. great cardiac vein
B. Middle cardiac
B. coronary sinus
C. Oblique
C. azygos vein
D. Vena cordis minimae
D. inferior vena cava
14. The SA node is located:
3.Apex beat is located in the same auscultatory
A. at the top of the crista terminalis
area of which of following heart valve:
B. Near the opening of the superior vena cava
A. aortic
C. Both
B. pulmonic
D. Neither
C. mitral
15. The aorta is located in which mediastinal
D. tricuspid
compartment(s)?
4. A stab wound in an the anterior chest wall
A. Anterior only
just to the right of sternum at 4th ICS would most
B. Middle only
likely injure the following structure:
C. Anterior and middle
A. superior vena cava
D. Middle and posterior
B. right atrium
16. A stethoscope placed over the right second
C. right ventricle
intercostal space just lateral to the sternum would
D. inferior vena cava
be best positioned to detect sounds associated with
5.The thoracic duct passes through the
which heart valve?
diaphragm through the:
A. aortic
A. aortic hiatus
B. mitral
B. esophageal hiatus
C. pulmonary
C. caval foramen
D. tricuspid
D. sternocostal hiatus
17. Which valves would be open during
6. The vagus nerves enters the abdominal
ventricular systole?
cavity through the:
A. Aortic and pulmonary
A. aortic opening of the diaphragm
B. Mitral and aortic
B. esophageal opening of the diaphragm
C. Aortic and tricuspid
C. vena caval opening of the diaphragm
D. Tricuspid and mitral
D. central tendon of the diaphragm
18. Part of the aorta where the aorta sinus are
. 7. The right lymphatic duct drains the
located:
following:
A. Ascending
A. R side of thorax
B. Arch
B. pelvic cavity
C. Descending
C. abdominal cavity
D. Abdominal
D. both lower extremity
19. Branch of the left coronary artery:
8. The motor innervations of the diaphragm:
A. Marginal
A. Ansa cervicalis
B. Posterior Interventricular
B. vagus
C. Circumflex
C. Phrenic
D. Anterior cardiac
D. Lower intercostals
20.Muscles found in the internal surface of the
9. Accompanies the Anterior interventricular
auricles:
artery:
A. Pectinate
A. Middle cardiac
B. Auricular
B. great cardiac
C. Trabeculae carnae
C. Small cardiac
D. Etched
D. Coronary sinus
10.Attachment(s) of the chordate tendinae:
DIGESTIVE
A. Papillary muscle
B. Cusps
1.Intraperitoneal organ:
C. both
A. lower third of rectum
D. Neither
B. jejunum
11. Which of the following comprises the
C. kidney
largest portion of the sternocostal surface of
D. Duodenum
the heart?
A. left atrium B. right atrium
C. Left ventricle D. right ventricle

UST FMS MEDICAL BOARD REVIEW 2019 | ANATOMY

 REVIEW TEST
MARIA LOURDES SANTOS, MD

2. An occlusion of the superior mesenteric 12. A hernial sac with loops of intestines
artery would result in necrosis of each of the protruding through the abdominal wall just above
following EXCEPT the: the inguinal ligament and medial to the inferior
A. ascending colon epigastric vessels, is what type of hernia:
B. rectum A. An incisional hernia
C. cecum B. femoral hernia
D. ileum C. direct inguinal hernia
3. Commences behind the neck of the pancreas D. indirect inguinal hernia
A. inferior vena cava 13. If a hernia enters into the scrotum, it is
B. celiac trunk most likely a(n):
C. portal vein A. Direct inguinal hernia
D. Supeior mesenteric vein B. Femoral hernia
4. The following are direct source of blood C. Indirect inguinal hernia
supply of the stomach: D. Obturator hernia
A. splenic 14. The superficial inguinal ring is an opening in
B. gastroduodenal which structure?
C. hepatic proper artery A. External abdominal oblique aponeurosis
D Left gastric B. Internal abdominal oblique muscle
5. In appendectomy, the structure that can be C. Falx inguinalis
traced as a guide for looking for the appendix: D. Transversalis fascia
A. haustra 15. The boundaries of the inguinal triangle
B. appendices epiplocae include all EXCEPT:
C. taenia coli A. Arcuate line
D. sacculations B. Inguinal ligament
6. The fundus of the gallbladder is located at C. Inferior epigastric vessels
the level of: D. Lateral border of rectus abdominus muscle
A. 7th costal cartilage 16. Which of the following abdominal layers
B. 8th costal cartilage does NOT contribute to the covering of the testes
C. 6t cartilage A. external oblique aponeurosis
D. 9th costal cartilage B. transversus abdominis
7. In midline vertical incision the following C. internal oblique muscles
structure is traversed after the skin and D. transversalis fascia
superficial fáscia: 17. Which of the following features distinguish
A. Extraperitoneal tissue & parietal peritoneum the ileum from the jujenum
B. Fascia transversalis A. fewer mesenteric arterial arcades
C. Linea alba B. longer vasa recta
D. Rectus sheath C. more fat in its mesentery
8. A right subcostal incision was used for open D. thicker wall
cholecystectomy, which part of the gallbladder will 18. A tumor in the uncinate process of the
be seen immediately by the surgeon after opening pancreas will most likely compress which of the
the parietal peritoneum following structures?
A. Body A. splenic artery
B. main pancreatic duct
B. Cystic duct
C. portal vein
C. Fundus
D. superior mesenteric artery
D. Neck 19. Which of the following pairs of veins form a
9. Pancreatic endocrine secretions exits the portal-caval anastomosis?
pancreas via: A. hepatic veins and IVC
A. Major Pancreatic duct B. superior rectal vein & IVC
B. Minor pancreatic duct C. azygous and left gastric
C. Pancreatic arteries D. suprarenal and renal
D. Pancreatic veins 20. The division between the true right and left
10. Part of the rectum supplied by branch of lobes of the liver may be visualized on the outside of
the inferior mesenteric artery: the liver as a plane passing through the:
A. Upper 1/3 rectum A. gallbladder fossa and round ligament of liver
B. Upper half rectum B. falciform ligament and ligamentum venosum
C. lower 1/3 rectum C. gallbladder fossa and inferior vena cava
D. lower half D. gallbladder fossa and right triangular ligament
11. Which of the following nerves would carry
afferent impulses of the cremasteric reflex?
A. Iliohypogastric
B. Genitofemoral
C. Femoral
D. Subcostal

UST FMS MEDICAL BOARD REVIEW 2019 | ANATOMY

 HISTOLOGY
JOSEPHINE M. LUMITAO, MD

CYTOLOGY CYTOPLASMIC INCLUSIONS:

 Lifeless accumulations of metabolites or cell
products regarded as dispensable and often
temporary constituents; not essential for
survival of the cell
1. Pigments – a. Endogenous
b. Exogenous
2. Lipid- in adipose cells
3. Glycogen particles- abundant in liver cells
4. Crystals- seen in Sertoli and Leydig cells of male
reproductive system
5. Secretory granules- Ex: zymogen granules in
pancreas
6. Vacuoles

NUCLEUS:

PARTS OF THE CELL:

1. Plasmalemma – the outer limiting membrane

that serves as a selective barrier
2. Cytoplasm – the protoplasm outside of the
nucleus which contains the different organelles and
inclusions of the cells
3. Nucleus – contains the genetic material of the
cell

 Found in all cells except RBC & platelets

 Shape, size & number vary
 Stains blue because of its nucleic acids,
basic proteins and also acidic proteins
Functions:
 Archive of the cell; repository of the
hereditary factors
 Source of ribosomal, messenger and
transfer RNA

NUCLEAR CHROMATIN:
 Nuclear material that contains DNA and
PLASMALEMMA- “Fluid Mosaic Model” proteins; the structural manifestation of
chromosomes in interphase.
 The membrane proteins are globular and 2 Types:
float like icebergs in a sea of lipid A. Heterochromatin – the condensed coiled
part; metabolically inert
CYTOPLASMIC ORGANELLES: B. Euchromatin – the dispersed, less coiled
1. Endoplasmic reticulum: regions of the chromosome; active in
1.1. RER- protein synthesis protein synthesis
1.2. SER- Ca++ entry /exit in sarcoplasmic
reticulum; steroid hormone synthesis; HCl NUCLEOLUS:
and neutral fat synthesis
2. Golgi Complex- concentration and packaging
of secretory material
3. Mitochondria- mobile “power plant” of cell
4. Lysosomes- intracellular digestion
5. Centriole / centrosome- cell replication
6. Peroxisomes or Microbodies- prevents
accumulation of H2O2 in body
7. Filaments- maintain shape and rigidity of the
cell: - Myofilaments
- Tonofilaments
8. Microtubules- maintain shape and rigidity  A round conspicuous structure eccentrically
located in the nucleus; rich in RNA and basic
9. Annulate lamellae- serve as communication
proteins; intensely basophilic due to the
between nucleus and cytoplasm
presence of ribonucleoproteins

UST FMS MEDICAL BOARD REVIEW 2019 1 | HISTOLOGY


Function:
 Site of ribosomal RNA synthesis
FUNDAMENTAL TISSUES:
1. EPITHELIUM
2. CONNECTIVE TISSUE
3. MUSCULAR TISSUE
4. NERVOUS TISSUE
EPITHELIUM
 Closely packed cells arranged in sheets or
columns with one end free, other is attached
to basement membrane.
 Cells are flat, cuboidal or columnar; they
have scanty intercellular substance and are
avascular;
 Line body surfaces or body cavities.
 Their nomenclature reflects the number of
layer of cells and the shape of cell on the
free surface
CONNECTIVE TISSUE
Made up of cells with abundant intercellular
substance (glycosaminoglycans), with fibers and
abundant blood vessels
Primarily for support
Cells are: fibroblasts, undifferentiated mesenchymal
cell, adipose cell, mast cell, plasma cell and all the
blood cells
Fibers are : Collagenous variety types 1-VII and
elastic fibers
Generally vascular except for Mucus CT
CARTILAGE
 Special type of connective tissue where
ground substance (matrix) is solid but
pliable
 Cells are called chondroblasts and
chondrocytes; outermost covering is called
perichondrium
 Avascular
 Types of Cartilage:
a. Hyaline – Matrix is rich in fine
collagenous fibers
a.1 Adult hyaline (respiratory system);
a.2 Articular hyaline- articulating
surfaces of boneswith incomplete
perichondrium and
a.3 Fetal hyaline- found in developing
embryo and serves as framework for
intracartilaginous ossification
b. Elastic Cartilage – matrix is rich in elastic
fibers. Distribution: Epiglottis
c. Fibrocartilage – bundles of collagenous
fibers; absence of perichondrium; found
in symphysis pubis and intervertebral
disc.
BONE
Rigid type of connective tissue where matrix is solid
and brittle
 Bone cells are: osteoprogenitor cells,
osteoblasts, osteocytes and osteoclasts;
Vascular
 Structurally, two types of bone:
UST FMS MEDICAL BOARD REVIEW 2019
HISTOLOGY
JOSEPHINE M. LUMITAO, MD
 Spongy or cancellous bone- anastomosing
bony trabeculae with intercommunicating
marrow cavity; predominates in epiphysis
 Compact bone- covered externally by
periosteum; with Haversian and interstitial
systems; internally covered by endosteum;
shows Haversian and Volkmann’s canal;
predominates more in diaphysis
 According to how they are formed:
Membrane bones formed through
intramembranous ossification (flat bones)
and
 Cartilage or Substitution bones formed by
intracartilagenous ossification (long bones of
body)
MUSCULAR TISSUE
o Cells are cylindrical, acidophilic in
staining with myofibrils, specialized for
contraction
o Types of muscle:
o Smooth – centrally located nuclei, no
striations, involuntary, visceral in
distribution
o Cardiac muscle- striated involuntary
muscle with centrally located nucleus;
shows branching and intercalated disc;
myocardium
o Skeletal muscle- striated muscle fiber
with multiple peripheral nuclei; covered
by endomysium, perimysium and
epimysium
 E/M shows alternating dark A
band made of myosin filaments
and light I bands made up of actin
filaments
 Triad (T tubule and 2 terminal
cisternae) is responsible for spread
of contraction through muscle fiber
NERVOUS TISSUE
 Unit of structure is multipolar neuron with
processes: dendrites and axon to receive
and transmit stimulus
 Divided into Central Nervous System and
Peripheral nervous system
 Peripheral Nervous system:
cells are called ganglion cells: Dorsal root ganglion
cell which is pseudounipolar in shape and sensory in
function and the Autonomic ganglion cell which is
multipolar in shape and motor in function
Myelin is essential for saltatory conduction in nerve
fibers; Schwann cell produces myelin in the PNS on
a 1 Schwann cell: 1 internode ratio.
 Central Nervous system
Gray matter- shows abundant multipolar neurons
and protoplasmic astrocytes
White matter- shows myelinated nerve fibers and
oligodendroglia
Supporting cells are Neuroglia made up of:
1. Ependymal cells lining central canal and
ventricles of brain
2. Astrocytes – with perivascular feet that
contributes to blood brain barrier; types
are protoplasmic astrocytes (gray
2 | HISTOLOGY

matter) and fibrous astrocytes(white
matter)
3. Oligodendroglia- source of myelin in
CNS; myelinates several internodes at a
given time
4. Microglia- phagocyte in CNS
CIRCULATORY SYSTEM
Characteristics, in general of the Vascular system:
 Hollow organs possessing a lumen
 Except the capillaries and very small vessels,
walls possess 3 coats:
*Tunica intima- An inner coat lined by endothelium
*Tunica media- Middle muscular coat
*Tunica adventitia- Outermost fibrous coat
CAPILLARY:
 Composed of only a single layer of
endothelial cells rolled up in the form of a
tube
 Modified smooth muscle cells called
Pericytes or Cells of Rouget are isolated cells
continuous with the basal lamina of the
endothelial cells
 Thin wall appears as a mere line with
occasional bulges representing nuclei
 Classified into: Continuous capillaries (brain)
; Fenestrated capillaries (endocrine organs
and glomerulus) and sinusoidal capillaries
(lymphoid organs)
ARTERIOLE:
 Prime controller of blood pressure
 Thick muscular wall with a small corrugated
lumen
 Very thick tunica media composed of
smooth muscle
UST FMS MEDICAL BOARD REVIEW 2019
HISTOLOGY
JOSEPHINE M. LUMITAO, MD
MEDIUM-SIZED ARTERY: (Distributing/Muscular
artery):
 Tunica intima appears often corrugated or
scalloped after death; contains fenestrated
membrane of Henle
 Tunica media is the thickest and most
prominent coat
 Lumen may show very little blood after
death
 Arterial wall is rigid and less easily collapsed
 Tunica adventitia contains areolar tissue
with blood vessels (vasa vasorum) and
nerves (nervi vasorum)
LARGE OR ELASTIC ARTERY:
 Represented by the aorta, subclavian,
common carotid and iliac arteries
 Thick tunica intima which is not sharply
demarcated with the underlying tunica
media because of an indistinct fenestrated
membrane of Henle
 Tunica media contains an abundance of
elastic fibers; smooth muscle fibers are
spirally disposed between the elastic fibers
 Thin tunica adventitia
Medium-sized VEIN w/ Valves
MEDIUM-SIZED VEIN:
 Thin tunica intima supported by scanty
areolar CT
 Very thin tunica media
 Most prominent tunica adventitia with elastic
and collagenous bundles
 In the lower extremities, the tunica intima
form paired reduplications called valves
LARGE VEIN:
 Tunica intima with lining epithelium
possessing an abundant lamina propria
 Poorly developed tunica media
 Tunica adventitia is several times thicker
than the tunica media
 Prominent longitudinal layers of smooth
muscle and elastic network in the outermost
coat
LYMPHATIC VESSELS:
 Resemble the wall of the vein of equal size
 Large-sized lumen compared to thickness of
its wall
 Presence of valves
3 | HISTOLOGY

LYMPHATIC CAPILLARIES:
 Thin-walled vessels of variable shape
 Contain a fibrinous coagulum with very few
cells mostly lymphocytes
 Presence of anchoring filaments
HEART:
 Three coats: Endocardium, Myocardium, and
Epicardium
 Endocardium - homologous to the tunica
intima and is lined by endothelium
 Myocardium - corresponds to the tunica
media, with cardiac muscle fibers arranged
in a complex, spiral course, forming the
main mass of the heart
USTFMS MEDICAL BOARD REVIEW 2019
 Epicardium – external coat consisting of a
serous membrane covered by mesothelium
PURKINJE FIBERS:
 Specialized conducting fibers of the heart
 Morphologically different from cardiac
muscle due to larger diameter, fewer
branches and striations, but rich in glycogen
and mitochondria
GASTROINTESTINAL SYSTEM
GENERAL PLAN of the Alimentary Tract proper
Four distinct layers:
 Mucosa- Epithelium, tunica propria and
muscularis mucosa
 Submucosa- generally no glands except in
the esophagus and duodenum; presence of
Meissner’s& Heller’s plexus
 Muscularis propria or externa- smooth
muscle layers arranged in an inner circular &
outer longitudinal (ICOL) disposition;
Auerbach’s or myenteric plexus located
between the 2 layers
 Adventitia or Serous outer coat- contains the
blood vessels, lymph vessels and nerves
ESOPHAGUS:
 Lined by stratified squamous, non-
keratinizing epithelium
 Superficial esophageal glands in the tunica
propria of the upper and lower third
UST FMS MEDICAL BOARD REVIEW 2019
HISTOLOGY
JOSEPHINE M. LUMITAO, MD
 Deep esophageal glands in the submucosa
 Skeletal muscle found in the upper third and
middle third of the esophagus, smooth
muscles in middle and lower 3rd of
esophagus
 Fibrous outermost coat (not an
intraperitoneal organ)
STOMACH: Cardia – Body – Pylorus
 Lined by simple columnar epithelium
 Cardiac glands are compound tubular
 Fundic glands are long branched tubular
 Pyloric glands are coiled tubular
 FUNDIC glands contains the following:
1. Chief or Zymogenic cells- principal cells that
secrete pepsinogen
2. Parietal or HCl cells- secrete HCl and intrinsic
factor
3. Mucous cells- either surface mucous or neck
mucous cells
4. Neuroendocrine/Argentaffin cells- secrete
serotonin, endorphin, gastrin, histamine,
somatostatin, enteroglucagon
5. Stem cells- undifferentiated cells in neck of glands
 PYLORIC glands- contain G-cells secreting
gasrin
 NO glands in the submucosa
 Muscularis is thick and divided into three:
inner oblique, middle circular and outer
longitudinal smooth muscle layers
SMALL INTESTINE:
 Four distinct coats with the presence of
intestinal villi (to increase surface area for
absorption)
 Lined by simple columnar cells w/ a distinct
striated cuticular border (microvilli) and
goblet cells
 Presence of intestinal glands or crypts of
Liebekühn with granule cells of Paneth at
base secreting lysozyme, with bactericidal
action
 Abundant lymphoid tissue in tunica propria
4 | HISTOLOGY

*DUODENUM:
 Foliate-shaped intestinal villi
 Presence of Brunner’s glands in the
submucosa producing alkaline secretion
to counteract the acidic cyime
*JEJUNUM and ILEUm
 Rounded (clavate) villi in the jejunum
and filiform or conical villi in the ileum
 NO glands in the submucosa
 Plicae circularis or Valves of Kerckring
are spirally disposed
 Peyer’s patches or Agminate nodules are
located in the terminal ileum
APPENDIX:
X- sec. of APPENDIX
 Known as “Abdominal tonsil” due to
abundance of lymphoid tissue in tunica
propria
 Lined by simple columnar cells w/ a thin
cuticular border and more Argentaffin cells
 Absence of intestinal villi
 Fewer and small intestinal glands
 Thin muscularis mucosa
LARGE INTESTINE:
 Absence of intestinal villi
 Mucosa lined by simple columnar cells with
an indistinct cuticular border and more
goblet cells
 Intestinal crypts are larger and longer w/
numerous goblet cells
 Solitary lymph nodules in tunica propria
 NO glands in submucosa
 Presence of taenia coli, haustrae and
appendices epiploicae
LIVER:
UST FMS MEDICAL BOARD REVIEW 2019
HISTOLOGY
JOSEPHINE M. LUMITAO, MD
 Presence of hexagonal lobules with a central
vein in the center
 Glisson’s capsule
 Hepatic plates, 1-2 cell thickness radially
disposed from central vein towards
periphery
 Abundant thin-walled sinusoids found
between liver cells lined by endothelial cells,
Ito cells(lipocytes) & Kupffer cells
 Angles of the lobules contain portal canal
with the hepatic trinity (interlobular
branches of portal vein, hepatic artery and
bile duct)
 Presence of the perisinusoidal space of Disse
PANCREAS:
 Both an exocrine and endocrine gland
 No distinct CT capsule
 Purely serous acini
 Presence of centro-acinar cells
 Long intercalary portion of intralobular
ducts; no salivary portion
 Presence of pancreatic islets representing
the endocrine portion
GALL BLADDER:
 Lined by simple tall columnar epithelium
 Highly folded mucosa with gland-like
invaginations called Rokitansky-Aschoff
sinuses that increase in over-distention
 Absence of true glands
 Abundance of lymph vessels in its outermost
coat
ORAL TISSUES
TONGUE:
 Lined by stratified squamous, non-
keratinizing epithelium
 Dorsal surface contains an anterior
papillary(2/3) and a posterior tonsillar(1/3)
portion
 Papillae consist of filliform, fungiform and
circumvallate types
 Circumvallate papillae contain abundant
taste buds in their lateral walls
 Bulk of tongue is made up of skeletal muscle
fibers disposed in three directions
 Serous glands of von Ebner are found
beneath the circumvallate papillae
5 | HISTOLOGY

SALIVARY GLANDS:
* PAROTID GLAND
- Purely serous acini
- Largest of all salivary glands
- Thick capsule w/ dense CT
trabeculae
- Prominent intralobular ducts
- Main secretory duct (Stensen’s duct)
*SUBMANDIBULAR/SUBMAXILLARY GLAND
- Mixed gland (mucous and serous),
predominantly serous
- Shorter but thicker crescents of Gianuzzi
- Prominent salivary ducts
- Main secretory duct (Wharton’s duct)
*SUBLINGUAL GLAND
- Mixed gland (mucous and serous),
predominantly mucous
- Thinner and longer crescents of Gianuzzi
- Secretory ducts (of Bartholin and
Rivinus)
- No intercalary segment
RESPIRATORY SYSTEM
NASAL CAVITY
*VESTIBULE:
 Lined by stratified squamous, non-
keratinizing epithelium
 Presence of sweat and sebaceous glands
and long stiff hairs w/out arrectores pili
muscles (vibrissae)
*OLFACTORY MUCOSA:
 Lined by pseudostratified columnar w/out
goblet cells
 Olfactory sensory cells are bipolar nerve
cells w/ olfactory vesicles and olfactory
hairs(receptors for smell)
 Small bundles of olfactory nerves, the “fila
olfactoria” in the lamina propria
 Presence of serous tubulo-acinar glands of
Bowman serving as a solvent for odoriferous
substances
*RESPIRATORY PORTION (Schneiderian
Membrane):
 Lined by pseudostratified columnar ciliated
with goblet cells
UST FMS MEDICAL BOARD REVIEW 2019
HISTOLOGY
JOSEPHINE M. LUMITAO, MD
 Thick basement membrane
 Abundant venous sinuses
 Serous and mucous tubulo-acinar gland in
the tunica propria
NASOPHARYNX:
 Pseudostratified columnar ciliated epithelium
with some goblet cells
 Abundant lymphatic tissue comprising the
pharyngeal tonsil
LARYNX:
 Two types of lining epithelium: Stratified
squamous nonkeratinizing in the true vocal
cords and pseudostratified columnar ciliated
with goblet cells in false vocal cords
 Two types of cartilage: Hyaline in the larger
cartilages and Elastic in the epiglottis and
smaller cartilages
 Rich in elastic fibers and presence of tubulo-
acinar mixed glands
 Intrinsic muscles of the larynx are skeletal in
variety
TRACHEA:
 Pseudostratified columnar ciliated epithelium
with goblet cells
 D-shaped lumen in transverse section
 Thick basal lamina rich in elastic fibers
 Presence of glands, mainly mucous with
ducts that open into the lumen
 Presence of 16-20 C-shaped hyaline
cartilages in its antero-lateral walls
 Interlacing bundles of smooth muscle fibers
(trachealis muscle) located posteriorly,
attached to the cartilages
LUNGS:
6 | HISTOLOGY
 HISTOLOGY
JOSEPHINE M. LUMITAO, MD

BRONCHUS with Cartilages plate INTEGUMENT (SKIN)

 Presence of three coats: Mucosa,
Submucosa, and outer fibro-cartilagenous
layer
 Folded mucosa lined by pseudostratified
columnar ciliated epithelium w/ goblet cells
 Muscularis mucosa made up of smooth
muscle fibers in deeper part of the tunica
propria
 Submucosa contains blood vessels, ducts of
glands, mucous and serous glands, and
lymphoid tissue
 Irregular, crescent-shaped hyaline cartilages
surround the tube
 Pulmonary artery and vein in its outer wall
 Consists of two main layers: Epidermis and
BRONCHIOLE:
Dermis or Corium
 Formed when the bronchus is about 1 mm in
 Epidermis from the base (Keratinocytes)
diameter
*Stratum malphigii: Stratum basale +
 Lining of the larger bronchioles is the same as
Stratum spinosum (intercellular
the bronchi; in smaller bronchioles, it changes
bridges/desmosomes)
into simple columnar ciliated epithelium with
*Stratum granulosum –keratohyalin granules
goblet cells
*Stratum lucidum (eleidin droplets)
 Muscularis mucosa is thicker
*Stratum corneum
 Cartilage plates, glands and lymphoid tissue
 Presence of cells of Langerhans (antigen
disappear
responsive cells in contact dermatitis);
 Only the pulmonary artery is seen in the
Melanocytes producing melanin protecting
outermost coat
skin from harmful effects of sun and Merkel
cell, rapidly adapting mechanoreceptors in
RESPIRATORY BRONCHIOLE
stratum basale
 First segment of respiratory division of
 Dermis (cutis vera or true skin)
pulmonary tree
*Composed of dense irregular CT
 Lined by cuboidal cells and Clara cells or
*Subdivided into two strata:
bronchiolar epithelial cells for synthesis of some
- Superficial papillary layer
components of surfactant and serving as basal
- Reticular layer
cells
 Hypodermis (subcutaneous layer) is not
 Initial appearance of alveolar buds
considered to be part of the skin; consists of
adipose tissue, large blood vessels, nerves
and encapsulated end-organs

APPENDAGES OF THE SKIN:

 Hair follicles
 Sebaceous glands (simple/branched saccular
and holocrine)
 Ordinary Sweat glands (convoluted tubular
and meroccrine/eccrine) ; Odoriferous sweat
glands in axillary are apocrine
 Arrectores pili muscle attached to base of
hair follicle (goose-flesh phenomenon)
 Nails

PULMONARY ALVEOLI w/ Lining cells

 Thin-walled polyhedral and hexagonal sacs
where gas exchange takes place
 Types of cells:
1. Pneumocytes Type I or Small alveolar cells
2. Pneumocytes Type II or Great alveolar cells
or “Surfactant” cells- shows lamellar bodies

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“THICK” SKIN:
 Found in the palms, fingers, soles
 Thick epidermis with prominent stratum
corneum
 Abundant sweat glands
 No pilo-sebaceous units
 Taller, numerous dermal papillae with
grooves and ridges visible (fingerprints)
 Numerous arterio-venous anastomoses in
the dermis and hypodermis
“THIN’ SKIN:
 Thin epidermal layer
 Small or moderate number of sweat glands
and pilo-sebaceous follicles
 Absence of ridges and grooves forming only
a small checkered network of lines
LYMPHOID SYSTEM
LYMPH NODE:
 Presence of a fibro-elastic capsule and
trabeculae
 Only organ that filters lymph
 Outer cortex and inner medulla
 Subcapsular, cortical and medullary sinuses
 Lymphatic nodules with germinal centers
(predominance of B lymphocytes) in the
cortex and lymphatic cords in the medulla
 Deeper cortical regions contains more T
lymphocytes
 In medulla, the B lymphocytes transform
into plasma cells and produce antibodies
TONSILS:
 Lined by stratified squamous, non-
keratinizing epithelium with a thin capsule
 Presence of tonsillar crypts with migratory
lymphocytes called “salivary corpuscles”
 Aggregates of lymph nodules in the tunica
propria
 NO lymph nor blood sinuses but a rich
supply of blood capillaries
PEYER’S PATCHES (Agminate or Aggregate
nodules):
 Aggregations of lymph nodules in the tunica
propria of the ileum
 Nodules are dome-shaped directed towards
the lumen
 Absent or few intestinal glands in the area
of the Peyer’s patches
 Can enlarge in typhoid fever and TB
UST FMS MEDICAL BOARD REVIEW 2019
HISTOLOGY
JOSEPHINE M. LUMITAO, MD
SPLEEN:
 Largest lymphatic organ
 Presence of a fibro-muscular capsule
containing elastic fibers
 Functions to filter blood through blood
sinuses
 Splenic nodules containing arterioles with
PALS (periarterial lymphoid sheaths) and
represent the typical lymphatic tissue or
WHITE pulp
 RED pulp (atypical lymphatic tissue)
consists of: 1) Billroth cords and 2)Venous
sinuses lined by “littoral” cells which are
phagocytic in function
 Open (capillary opens into the interstices of
Billroth cords) Closed (capillary opens into
lumen of venous sinus) and Compromise
theory of splenic circulation
THYMUS:
 Fibro-elastic capsule divides it into thymic
lobules, situated behind the upper sternum
 Primary lymphoid organ that undergoes
“age involution” at puberty
 Dark-staining peripheral cortex and lighter
staining inner medulla
 Consists of thymocytes and reticular cells
 Medulla contains “HASSALL’S bodies” or
thymic corpuscles; where self-reactive T
cells are removed by clonal deletion
 “Blood-Thymus” barrier inhibits
macromolecules from entering the cortex to
protect the developing T lymphocytes
MALE REPRODUCTIVE SYSTEM
TESTIS:
SEMINIFEROUS TUBULES
 Tubules are lined by a complex stratified
epithelium composed of several layers of
spermatogenic cells and supporting Sertoli
cells
 Presence of groups of acidophilic polygonal
cells in the angular interstices of the
8 | HISTOLOGY

tubules, consisting of the endocrine portion
of the organ (Leydig cells)
 Presence of primary spermatogonia at base
of seminiferous tubule with mature cells,
spermatids and spermatozoa in the lumen
 “Blood-testis” barrier (tight junction between
the Sertoli cells) protects the developing
cells against noxious substances
DUCTULI EFFERENTES:
 Irregular lumen lined by alternating tall and
low cells
 Epithelium is mostly columnar resting on a
thin basal lamina
 Possesses the ONLY motile cilia in the entire
ductal system
 Contains circularly disposed muscle
EPIDIDYMIS:
 Highly tortuous tubules forming a head,
body and tail about 4-5 m. long
 Lined by pseudostratified columnar
epithelium w/ stereocilia appearing as
microvilli on E/M
 Principal storage of the spermatozoa is in
the tail
 Organ where the spermatozoa acquire
motility
DUCTUS (VAS) DEFERENS:
 Three distinct coats: Mucosa, muscular and
fibrous coats
 Narrow and irregular lumen
 Low mucosal folds lined by pseudostratified
columnar later becoming non-ciliated
 Muscular layer is the thickest coat with 3
smooth muscle layers
SEMINAL VESICLE
 Elongated convoluted sacs w/ numerous
diverticula
 Complicated and anastomosing mucosal
folds forming honey-combed pattern
 Lined by simple columnar w/
pseudostratified columnar non-ciliated
variety
 Yellow lipochrome pigment granules in lining
cells
 Produces a thick yellowish secretion rich in
globulin, Vitamin C and fructose
UST FMS MEDICAL BOARD REVIEW 2019
HISTOLOGY
JOSEPHINE M. LUMITAO, MD
PROSTATE GLAND:
PROSTATE gland w/ Corpora amylacea (CA)
USTFMS MEDICAL BOARD REVIEW 2019
 Irregular folds lined by Tall columnar cells
and basal cells
 Mucosa drawn into irregular projections into
the lumen dividing it into compartments that
communicate w/ each other
 Fibromuscular stroma
 Presence of “corpora amylacea” or “prostatic
concretions” in lumen of the alveoli
 BPH occurs predominantly in Transition zone
while malignant change occurs in the
peripheral zone
 Thin white secretion rich in citric acid
FEMALE REPRODUCTIVE SYSTEM
OVARY:
Left- GRAAFIAN follicle; Right- ANTRAL follicle
 Presence of an outer cortex and inner
medulla; cortex contains a dense
fibrocellular CT stroma
 Ovarian follicles in various stages of
development (primary, secondary and
mature Graafian follicles) embedded in
cortical stroma
 Corpus luteum and corpus albicans seen
after puberty
 Hilar region contains clusters of large,
epithelioid cells similar to the Leydig cells
(Berger or hilus cells)
UTERUS:
 Consists of 3 layers: Endometrium,
myometrium and perimetrium (serosa)
 Epithelium is simple low columnar, some
ciliated, some non-ciliated
 Tunica propria is embryonal CT
 Endometrial glands are branched tubular
9 | HISTOLOGY

PROLIFERATIVE Phase
 Endometrium is thin with narrow tubular
glands
 Concurrent with follicular growth and
estrogen secretion
ENDOMETRIUM: with “Subnuclear” vacuoles
 Post-ovulatory secretory changes showing
possessing “subnuclear” and supranuclear
vacuoles progressing to tortuous pattern in
late secretory phase
MENSTRUATING UTERUS:
 Desquamation of the functional layer of the
endometrium
 Glands and arteries appear collapsed
CERVIX:
Endo- andEcto-CERVIX
(J- Squamo-columnar JUNCTION)
UST FMS MEDICAL BOARD REVIEW 2019
HISTOLOGY
JOSEPHINE M. LUMITAO, MD
 Endocervix lined by simple columnar epith
while ectocervix lined by stratified squamous
non keratinizing epith
 Presence of true mucous-secreting cervical
glands in the endocervical portion
 Branching folds in the mucosa
(plicapalmatae or arbor vitae)
 Squamo-columnar junction or
“transformation zone” is site of predilection
for cervical cancer
FALLOPIAN TUBE/OVIDUCT:
X-sec. of Ampullary portion, OVIDUCT
 Complicated mucosal folds esp. at the
region of the ampulla
 Lined by simple columnar cells with cilia
 Tunica propria cellular and vascular but NO
glands; thin muscular layer
 Presence of non-ciliated columnar secretory
cells, called “peg” cells
 Serosa with abundant blood vessels
 Site of fertilization is in the AMPULLARY
region of the tube; also it is the most
common site for ectopic pregnancy due to
its complicated mucosal folds
VAGINA:
 Mucosa is thrown into folds or rugae
 Lined by stratified squamous, non-
keratinizing epithelium with accumulation of
glycogen within the cells
 Loose areolar CT in tunica propria containing
several blood sinuses
 Absence of glands; abundant venous
sinuses
 Abundant elastic fibers in the outer fibrous
coat
Resting Lactating Milk Secretion
10 | HISTOLOGY

RESTING MAMMARY GLAND:
 Abundant CT stroma with numerous adipose
cells
 Loose and cellular intralobular CT
 Absence of true secretory alveoli
 Prominent duct system with clusters of cells
at their ends
LACTATING MAMMARY GLAND:
 Scanty CT stroma, appearing as thin strands
between the alveoli
 Few or absent fat cells in the stroma
 Highly developed ductal system with more
branches
 Abundant widely dilated secretory alveoli w/
secretions in the lumen
 Compound saccular in morphology
URINARY SYSTEM
KIDNEY:
RENAL CORPUSCLE in Cortex
 Presence of cortex and medulla
 Pars convoluta and Pars radiata or cortical
rays or medullary rays of Ferrein in the renal
cortex
 Phagocytic mesangial cells serve for support
of the glomerulus and for maintenance of
the GBM
 Unit of structure is the NEPHRON: made up
of :
o Renal corpuscle (Malphigian body)
consists of the Bowman’s capsule
and the renal glomerulus. Bowman’s
capsule is made up of parietal layer
lined by simple squamous epith
while visceral layer is lined by
podocytes; Glomerulus is made up
3-4 fenestrated capillaries without a
diaphragm coming from an afferent
arteriole and emptying into an
efferent arteriole
o Renal tubules made up of Proximal
convoluted tubules with abundant
microvilli where major reabsorption
takes place; Distal convoluted
tubule- where sodium and water re-
absorption takes place due to
aldosterone; Collecting tubules with
intercalated cells secreting H+ to
maintain acid base balance;
UST FMS MEDICAL BOARD REVIEW 2019
HISTOLOGY
JOSEPHINE M. LUMITAO, MD
o Collecting ducts where sodium and
water reabsorption takes place
when ADH is released by posterior
pituitary.
 Filtration barrier consist of the:
a)Fenestrated endothelium of glomerular
capillary b) GBM c)Slit pores between the
pedicels of podocytes and
 d) Subpodocyte space
 Juxtaglomerular apparatus: made up of
Juxtaglomerular cells, macula densa of DCT
and the lacis cells at angles between the
afferent and efferent arterioles
 Lacis or extraglomerularmesangial cells for
tubulo-glomerular feedback
 Renin- secreted by the JG cells
 Macula densa serve as osmoreceptors
RENAL MEDULLA
RENAL Medulla: Collecting tubules
 Made up of 8 to 18 conical subdivisions
called renal pyramids
 Contains only the straight portions of the
uriniferous tubules together w/ the loops of
Henle and blood vessels, and the straight
collecting ducts
 Proximity of vasa recta and the ascending
and descending loops of Henle provides
osmotic gradient essential for concentrating
urine.
URETER:
X- section of the URETER
 Presence of an irregular stellate-shaped
lumen
 Transitional lining epithelium
 Absence of glands
11 | HISTOLOGY
 HISTOLOGY
JOSEPHINE M. LUMITAO, MD

 Coat of smooth muscle arranged in inner THYROID GLAND

longitudinal, outer circular layers in upper
2/3rd becoming 3 layers in lower 3rd
URINARY BLADDER:
 Transitional epithelium and cells w/ tight
junctions that prevent urine seepage
through its wall
 Presence of dome cells with asymmetrical
unit membrane to adjust to increased
volumes of urine without injury to bladder
epithelium
 Lining cells exhibit elasticity
 No glands in the tunica propria
 Thick muscular layer consisting of
THYROID Follicles filled w/ colloid
interlacing bundles of smooth muscle
URETHRA:  Presence of varying sizes of thyroid follicles
 Lined by 3 types of epithelium: Transitional, containing colloid in lumen
Pseudostratified columnar and Stratified  Follicular epithelium, the principal cells, are
squamous, non-keratinizing simple cuboidal w/ regularly arranged dark
 Lumen is V-shaped in the male; crescentic spherical nuclei; secrete T3 and T4 which
in the female regulate basal metabolic rate
 Mucous glands of Littre in the tunica propria  Presence of parafollicular cells(C-cells) or
are more abundant in the male calcitonin cells in the interfollicular spaces;
 Thicker muscular wall in the female urethra secretes Calcitonin which lower blood
calcium through increased activity of
ENDOCRINE SYSTEM osteoblasts.
PITUITARY GLAND:
PARATHYROID GLAND
 Small brown, oval bodies lying in the
posterior surface of the thyroid, covered by
a thin capsule
 Contain two types of epithelial cells:
1) Chief or principal cells- smaller and
more numerous cells that secrete
parathormone and
2) Oxyphils or acidophils- fewer in number
 Parathormone is important to increase
calcium levels in blood by increasing the
activity of the osteoclasts
ADRENAL GLAND

 Cellular anterior lobe (pars distalis)

containing acidophils, basophils and
chromophobes
 Fibro-reticular CT stroma richly w/ sinusoidal
blood vessels
 Acidophils secrete growth hormone and
prolactin
 Basophils secrete trophic hormones (ACTH,
TSH. LH, FSH, ICSH)
 Intermediate lobe contains colloid; produces
MSH ADRENAL CORTEX and MEDULLA
 Posterior lobe composed of pituicytes and
neuroglia; less cellular and fibrous looking in  Presence of 3 zones in the cortex: Zona
appearance glomerulosa, fasciculata, and reticularis
 Herring bodies (accumulation of  Presence of fatty cells (spongiocytes) in the
neurosecretory material) abundant in the zona fasciculata
infundibular process  Zona glomerulosa produces
 Hormones released from posterior pituitary mineralocorticoids, zona fasciculata
(oxytocin and vasopressin) are from produces glucocorticoids and zona reticularis
supraoptic and paraventricular nuclei of secretes sex steroid hormones
hypothalamus passing through the predominantly.
hypothalamo-hypophyseal tract  Large central vein and sympathetic ganglion
cells in the medulla

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 HISTOLOGY
JOSEPHINE M. LUMITAO, MD

 Adrenal medulla produces adrenaline and

noradrenaline
 Pheochrome reaction of the cells in the
medulla due to the presence of chromaffin
granules

PANCREAS:

IL

IL – Islets of Langerhans
 Richly vascularized small masses of pale-
staining endocrine cells, arranged as
irregular anastomosing cords
 Types of cells that can be distinguished
within the islets:
1) Beta cells – most numerous found
centrally; secrete insulin
2) Alpha cells- at periphery of islets;
secrete glucagon
3) Delta cells
4) Non-granular or C-cells-progenitor
of the Alpha cells
PINEAL GLAND
 Made up of cluster of cells called
pinealocytes and neuroglia cells
 Produces melatonin, an endocrine
transducer which influences body
biorhythms; secretion increased during dark
and decreases with sunlight
 Corpora arenacea or brain sand – basophilic
bodies made up of calcium and magnesium
phosphate - in old age

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 REVIEW TEST
JOSEPHINE M. LUMITAO, MD

Choose the best answer: 10. Which of the ff. cells secrete surfactant
and show presence of lamellar
1. Which is considered as the archive of the
bodies?
cell and the carrier of hereditary characteristics?
A. Clara cells
A. Plasma membrane
B. Pneumocytes type I
B. Nucleus
C. Pneumocytes type II
C. Mitochondria
D. Alveolar macrophages
D. Endoplasmic reticulum
11. Which part of the ovary produces
2. Which of the following does NOT possess
progesterone?
a perichondrium?
A. Theca externa
A. Fibrocartilage
B. Theca interna
B. Elastic cartilage
C. Theca lutein cells
C. Adult hyaline cartilage
D. Corona radiata cells
D. Articular hyaline cartilage
12. Which of the ff. cells contribute to the
3. Which of the following vessels is the prime
blood-brain barrier?
controller of blood pressure?
A. Microglia C. Oligodendroglia
A. Medium-sized vein
B. Astrocyte D. Ependymal cell
B. Arteriole
C. Medium-sized artery 13. In what part of the male reproductive
D. Large artery system do the sperm cells acquire motility?
A. Seminiferous tubules
4. Which histological feature is characteristic
B. Vas deferens
of the common carotid artery?
C. Seminal vesicle
A. Prominent tunica media
D. Epididymis
B. Prominent internal elastic membrane
C. Abundant elastic fibers in the tunica 14. Which of the ff. protects the developing
media sperm cells from auto-immune reaction?
D. Well-developed tunica adventitia with A. Tunica albuginea
numerous collagenous fibers B. Tunica vaginalis testis
C. Interstitial cells of Leydig
5. Which of the following cells secrete HCl?
D. Tight junctions between the Sertoli
A. Chief cells
cells
B. Parietal cells
C. Mucous neck cells 15. In what part of the renal tubule does
D. Enteroendocrine cells aldosterone exert its effect?
A. Collecting duct
6. The “abdominal tonsil” refers to the:
B. Collecting tubule
A. Peyer‟s patches
C. Distal convoluted tubule
B. Appendix
D. Proximal convoluted tubule
C. Ascending colon
D. Pylorus, stomach 16. Which of the ff. produces renin?
A. Macula densa
7. Which of the following comprise the
B. J-G cells
„Stratum Malphigii‟ of the skin?
C. Mesangial cells
A. Stratum basale and spinosum
D. Extramesangial or lacis cells
B. Stratum basale and granulosum
C. Stratum spinosum and granulosum 17. Which lymphoid organ filters blood?
D. Stratum spinosum and lucidum A. Lymph node C. Spleen
B. Thymus D. Peyer‟s patches
8. Which of the following is TRUE of “thick
skin”? 18. In what part of the thymus do the self-
A. Numerous pilo-sebaceous units reactive T cells undergo clonal deletion?
B. Numerous sweat glands A. Cortex
C. Thin stratum corneum B. Medulla
D. Scanty arterio-venous anastomosis C. Hassall‟s body
D. Blood-thymus barrier
9. In what level of the bronchial tree does
the hyaline cartilage disappear? 19. Which of these endocrine glands
A. Primary bronchus produces hormone that increases calcium in
B. Secondary bronchus blood?
C. Atria A. Adrenals C. Hypophysis
D. Bronchiole B. Thyroid D. Parathyroid

20. Which part of the hypophysis secrets the

gonadotrophic hormones?
A. Pars distalis C. Pars intermedia
B. Pars nervosa D. Pars tuberalis

UST FMS MEDICAL BOARD REVIEW 2019 | HISTOLOGY