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1. Revisit to EMEs Reflective Learning Session Conducted by Dr. R. Rajavarman

2. Questions from EMEs Upper Limb

3. HB 06: UPPER LIMB PART II – STRUCTURED ESSAY QUESTIONS Briefly describe how the thumb is anatomically adapted to optimize the function of the hand. (50 Marks) A patient complained that after she had a radical mastectomy her scapula stuck out like a wing when she pushed open a door. She later found difficulty in reaching the top shelves too. Explain the anatomical basis of her clinical presentations. (20 Marks) A first-year medical student slipped on the wet pavement and injured his right arm while walking to his classroom. Radiographic images show a midshaft fracture of the humerus. State two neurovascular structures that would be injured in his arm. (10 Marks) Explain the consequences of the nerve injury and the loss of its functions.(20 Marks)

4. Briefly describe how the thumb is anatomically adapted to optimize the function of the hand . (50 Marks) Function of the hand – handling objects and precise works. Role of the thumb is giving firm grip when holding objects by movements towards other fingers. The following anatomical features or adaptation the thumb has Orientation of the thumb. away from other fingers. facilitates movements of the thumb in different direction. First metacarpal bone is strongest metacarpal bone in the hand . MCPJ is synovial multiaxial joint based on axis of other fingers.

5. Briefly describe how the thumb is anatomically adapted to optimize the function of the hand. (50 Marks) The following anatomical features or adaptation the thumb has Special group of muscles move the thumb . Thenar muscle – Abduction, flexion, and opponens . Adductor muscles Extensor muscle from forearm Blood supply : having its own blood supply from radial artery – Princeps pollicis artery. Innervation: by three nerves such as, median, ulna and radial nerves . Movements Adduction – Mainly adductor pollicis – Ulnar nerve Abduction – (Palmar abduction) by Abductor pollicis brevis Flexion – mainly by Flexor pollicis longus and brevis Extension – (Radial abduction) mainly by extensor pollicis longus and brevis Opponens - Opponens pollicis by ulnar nerve

6. A patient complained that after she had a radical mastectomy her scapula stuck out like a wing when she pushed open a door. She later found difficulty in reaching the top shelves too. Explain the anatomical basis of her clinical presentations. (20 Marks) Radical mastectomy is surgical removal of a breast with axillary clearance of lymph nodes . This risks the long thoracic nerve (C5,6 &7) as it lies in the lateral wall of the chest. This nerve supplies serratus anterior muscle . The serratus anterior pull the scapula forward and assist to rotate the scapula in abduction of the arm. To reach the top shelf, she has to bring the arm vertical beside the head and requires scapular rotation that makes the glenoid fossa face upwards. Scapular rotation is performed by trapezius and serratus anterior. It causes paralysis of serratus anterior muscle and the action no longer possible. Action of trapezius is not adequate to perform scapular rotation . Therefore, inability to raise her right arm above the head and pull the scapula causing Winging of scapula.

7. A first-year medical student slipped on the wet pavement and injured his right arm while walking to his classroom. Radiographic images show a midshaft fracture of the humerus. State two neurovascular structures that would be injured in his arm. (10 Marks) Right radial nerve Right profunda brachi artery

8. A first-year medical student slipped on the wet pavement and injured his right arm while walking to his classroom. Radiographic images show a midshaft fracture of the humerus. Explain the consequences of the nerve injury and the loss of its functions.(20 Marks) Unable to extend his wrist and metacarpophalangeal joints including thumb result in wrist drop Wrist drop is a condition caused by the inability of the forearm extensor muscle to produce the extension of the wrist joint. The wrist extensors are extensor carpi radialis longus, extensor carpi radialis brevis, extensor digitorum, extensor digiti minimi , & extensor carpi ulnaris which are supplied by the radial nerve and its deep branch. Injury to the radial nerve at the spiral groove level affects the extensors of the wrist. Therefore, the extension of the wrist is impaired, and the flexors of the forearm flex the wrist joint and produces the wrist drop. Sensory loss is minimal and usually confined to a small area overlying the first dorsal interosseous, Unable to perform a power grip due to the unavailability of the movement of three thumb muscles (abductor pollicis longus, extensor pollicis brevis and extensor pollicis longus) and extensor indicis .

9. HB 07: RESPIRATORY SYSTEM PART II – STRUCTURED ESSAY QUESTIONS Explain anatomical basis of followings: Trachea and the main bronchi do not collapse during the negative pressure of inspiration. (10 Marks ) Lower lobe pneumonia (infection of lung) can cause pleural inflammation (Pleuritis). Patient with lower lobe pneumonia can present with abdominal pain. (15 Marks) A man was diagnosed to have a tumor in right mediastinal pleura. Physical examination reveals that trachea and apex of the heart are shifted to left. (15 Marks)

10. Trachea and the main bronchi do not collapse during the negative pressure of inspiration. (10 Marks ) Trachea and main bronchi are initial part of the lower airway and provide conduit for air passage or ventilation during inspiration and expiration. (5) Their wall is guarded by “C” shaped incomplete fibro cartilages to maintain patency of air passage and it provide rigid structural support . (5) Therefore, this anatomical feature does not permit this conduit system to collapse when intrathoracic pressure become negative during inspiration, but bronchopulmonary segments or lungs do not have such rigid structural element and then they collapse. (5)

11. Lower lobe pneumonia (infection of lung) can cause pleural inflammation (Pleuritis). Patient with lower lobe pneumonia can present with abdominal pain. (15 Marks) Parietal pleura and chest wall have same innervation by intercostal nerves from T2 to T11 and subcostal nerve. (5) Intercostal nerves lie in the intercostal groove of the related ribs with intercostal vessels. T8 to T11 Intercostal and subcostal nerves extend and supply to abdominal wall as well. (5) In lower lobe pneumonia with pleural inflammation the lower four intercostal nerves and subcostal nerve can be inflamed or irritated (5). It results in neural pain to abdomen presenting with abdominal pain.

12. A man was diagnosed to have a tumor in right mediastinal pleura. Physical examination reveals that trachea and apex of the heart are shifted to left. (15 Marks) Mediastinum is a midline structure which lies in between the pleural sacs in the thoracic cavity, and it contains heart, root of the lungs and great vessels. (5) Root of the lungs comprise main bronchi and pulmonary vessels and nerves. (2) The aortic arch arches over to the left main bronchus. (3) A tumour arises in mediastinal pleura can shift the mediastinum to opposite site by its mass effect. (5) Therefore, trachea and apex of the heart are displaced to left in right mediastinal tumour.

13. HB 07: RESPIRATORY SYSTEM PART II – STRUCTURED ESSAY QUESTIONS What are the four main types of hypoxia? (10 marks) Show which components of the oxygen delivery equation these relate to. (10 marks) Give examples of how the different types of hypoxia can occur. (40 marks)

14. What are the four main types of hypoxia? (10 marks) Hypoxic hypoxia Anaemic hypoxia Stagnant/Ischaemic hypoxia Histotoxic/Cytotoxic hypoxia

15. Show which components of the oxygen delivery equation these relate to. (10 marks ) DO 2 = Cardiac Output (CO) x Arterial O 2 content (CaO 2 ) = CO [(1.34 x Hb x SaO 2 ) + (0.003 x PaO 2 )] Hypoxic hypoxia = Low PaO 2 thereby Low SaO 2 Anaemic hypoxia = Low Hb Stagnant/Ischaemic hypoxia = Low CO Histotoxic/Cytotoxic hypoxia = All normal. Low tissue extraction

16. Give examples of how the different types of hypoxia can occur. (40 marks)

17. Question from you

18. Defecation is an autonomic reflex. Which of the following explain it? Urge to pass stool occur when rectal pressure is about 18 mmHg. Spinal cord transection leads to fecal incontinence. Defecation can be facilitated by increasing intra-abdominal pressure. Defecation can be postponed by contraction of external anal sphincter. External and internal sphincter relax when anal pressure is about 55 mmHg

19. Intestinal movements those will help to mix the food include, Peristalsis Segmentation contractions Mass action contractions Tonic contractions Pyloric contractions

20. SEQs Explain how patients with hepatic encephalopathy benefited by keeping bowel free of micro-organisms. Metabolic disturbances owning to chronic obstruction of bile duct and their physiological basis. A middle-aged obese women underwent partial gastrectomy for the purpose of reducing body weight. She manage to loss 30% of excess weight in next six months. But she complained of frequent episodes of dizziness and palpitation following food intake. Explain physiological basis of palpitations after meal.

21. Explain how patients with hepatic encephalopathy benefited by keeping bowel free of micro-organisms.

22. A middle-aged obese women underwent partial gastrectomy for the purpose of reducing body weight. She manage to loss 30% of excess weight in next six months. But she complained of frequent episodes of dizziness and palpitation following food intake. Explain physiological basis of palpitations after meal. Role of stomach in eating habits are Reservoir and control delivery of food into small intestine Gastric signal by ghrelin trigger food ingestion Removal of part of the stomach (gastrectomy) or gastro-jejunal bypass results in loss of the gastric reservoir, patients can eat only small meals. When this patient eat larger meals -> Food reach small intestine rapidly -> R apid absorption of glucose from the intestine -> hyperglycemia -> Abrupt rise in insulin secretion -> hypoglycemic symptoms – Dizziness, palpitation, sweating and weakness (usually after two hours of ingestion) Dumping syndrome. Another cause of the symptoms is rapid entry of hypertonic meals into the intestine; this provokes the movement of so much water into the gut that significant hypovolemia and hypotension are produced.

23. Bilirubin Metabolism