Overview Introduction Standard: C5, C6, C7, C8, T1 – 77% of patients Prefixed: Prefixed (contributions from C3, C4) – 22% Postfixed (roots caudal to T1) – 1% COMPOSITION: “Robert Turner Drinks Cold Beer” Roots (5): ventral rami of C5-T1, superior and posterior to subclavian dorsal scapular nerve (C5): through levator scapula to supply levator scapula, rhomboid major & minor long thoracic nerve (C5, 6, 7): posterior to plexus onto thoracic wall to supply serratus anterior Trunks (3): emerge from triangle formed by anterior scalene, middle scalene, first rib superior (C5,6 roots) suprascapular nerve (C5, 6): through suprascapular notch to supraspinatus, infraspinatus, AC and glenohumeral joints nerve to subclavius (C5, 6) Erb's palsy tear of upper trunk (C5-C6 roots) that is usually caused by traction during delivery or trauma later in life leads to difficulty with abduction, lateral rotation, and flexion/supination middle (C7) inferior (C8, T1) Divisions (6): 3 anterior, 3 posterior (each trunk gives 1 anterior and 1 posterior division) Cords (3): Posterior Cord: formed from 3 posterior division upper subscapular nerve (C5, 6): subscapularis lower subscapular nerve (C5,6): subscapularis, teres major thoracodorsal nerve (C6, 7, 8): latissmus dorsi Lateral Cord: ant divisions of superior & middle trunks (C5, 6, 7) lateral pectoral nerve (C5, 6, 7): supplies medial aspect of pectoralis major, communication with medial pectoral nerve Medial Cord: anterior division of inferior trunk (C8, T1) medial pectoral nerve (C8, T1): pierces pec minor; supplies pec minor and lateral aspect of pec major medial brachial cutaneous nerve (T1) medial antebrachial cutaneous nerve (C8, T1) Branches (6) – 2 terminal branches from each cord Posterior cord: axillary nerve (C5, 6): through quadrilateral space to teres minor, deltoid, major nerve supply to glenohumeral joint, superior lateral brachial cutaneous nerve radial nerve (C5 – T1): runs with long head of triceps (triangular space) into radial groove on posterior humerus; supplies elbow & forearm extensors, supinator; posterior brachial cutaneous, inferior lateral brachial cutaneous, posterior antebrachial cutaneous, superficial radial (post. radial hand) Lateral cord: lateral cord of median nerve (C5 – C7): joins medial cord anterior to axillary artery then travels with artery: wrist flexors (except FCU, ulnar ½ FDP), pronators, radial two lumbricals, OP, APB, superficial head FPB); sensory distribution in hand musculocutaneous (C5, 6, 7): most superficial branch, pierces coracobrachialis (1.5-9 cm from origin) to supply biceps, coracobrachialis, brachialis, ends as lateral antebrachial cutaneous nerve Medial cord: medial cord of median nerve (C8, T1): see above ulnar nerve (C8, T1) : FCU, ½ FDP, adductor pollicus, deep head FPB, hypothenar, intrinics (except radial 2 lumbricals), sensory to hand
QUESTIONS 1 of 5 1 2 3 4 5 Previous Next Lab Values Blood Hematologic Cerebrospinal Sweat, Urine, and BMI Blood, Plasma, Serum Reference Range ALT 8-20 U/L Amylase, serum 25-125 U/L AST 8-20 U/L Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL Calcium, serum (Ca2+) 8.4-10.2 mg/dL Cholesterol, serum Rec: < 200 mg/dL Cortisol, serum 0800 h: 5-23 μg/dL //1600 h: 3-15 μg/dL 2000 h: ≤ 50% of 0800 h Creatine kinase, serum Male: 25-90 U/LFemale: 10-70 U/L Creatinine, serum 0.6-1.2 mg/dL Electrolytes, serum Sodium (Na+) 136-145 mEq/L Chloride (Cl-) 95-105 mEq/L Potassium (K+) 3.5-5.0 mEq/L Bicarbonate (HCO3-) 22-28 mEq/L Magnesium (Mg2+) 1.5-2.0 mEq/L Estriol, total, serum (in pregnancy) 24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL 28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL Ferritin, serum Male: 15-200 ng/mLFemale: 12-150 ng/mL Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL Female: premenopause: 4-30 mIU/mL midcycle peak: 10-90 mIU/mL postmenopause: 40-250 pH 7.35-7.45 PCO2 33-45 mmHg PO2 75-105 mmHg Glucose, serum Fasting: 70-110 mg/dL2-h postprandial:<120 mg/dL Growth hormone - arginine stimulation Fasting: <5 ng/mLProvocative stimuli: > 7ng/mL Immunoglobulins, serum IgA 76-390 mg/dL IgE 0-380 IU/mL IgG 650-1500 mg/dL IgM 40-345 mg/dL Iron 50-170 μg/dL Lactate dehydrogenase, serum 45-90 U/L Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL Female: follicular phase: 5-30 mIU/mL midcycle: 75-150 mIU/mL postmenopause 30-200 mIU/mL Osmolality, serum 275-295 mOsmol/kd H2O Parathyroid hormone, serume, N-terminal 230-630 pg/mL Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L Phosphorus (inorganic), serum 3.0-4.5 mg/dL Prolactin, serum (hPRL) < 20 ng/mL Proteins, serum Total (recumbent) 6.0-7.8 g/dL Albumin 3.5-5.5 g/dL Globulin 2.3-3.5 g/dL Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h Thyroxine (T4), serum 5-12 μg/dL Triglycerides, serum 35-160 mg/dL Triiodothyronine (T3), serum (RIA) 115-190 ng/dL Triiodothyronine (T3) resin uptake 25%-35% Urea nitrogen, serum 7-18 mg/dL Uric acid, serum 3.0-8.2 mg/dL Hematologic Reference Range Bleeding time 2-7 minutes Erythrocyte count Male: 4.3-5.9 million/mm3Female: 3.5-5.5 million mm3 Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/hFemale: 0-20 mm/h Hematocrit Male: 41%-53%Female: 36%-46% Hemoglobin A1c ≤ 6 % Hemoglobin, blood Male: 13.5-17.5 g/dLFemale: 12.0-16.0 g/dL Hemoglobin, plasma 1-4 mg/dL Leukocyte count and differential Leukocyte count 4,500-11,000/mm3 Segmented neutrophils 54%-62% Bands 3%-5% Eosinophils 1%-3% Basophils 0%-0.75% Lymphocytes 25%-33% Monocytes 3%-7% Mean corpuscular hemoglobin 25.4-34.6 pg/cell Mean corpuscular hemoglobin concentration 31%-36% Hb/cell Mean corpuscular volume 80-100 μm3 Partial thromboplastin time (activated) 25-40 seconds Platelet count 150,000-400,000/mm3 Prothrombin time 11-15 seconds Reticulocyte count 0.5%-1.5% of red cells Thrombin time < 2 seconds deviation from control Volume Plasma Male: 25-43 mL/kgFemale: 28-45 mL/kg Red cell Male: 20-36 mL/kgFemale: 19-31 mL/kg Cerebrospinal Fluid Reference Range Cell count 0-5/mm3 Chloride 118-132 mEq/L Gamma globulin 3%-12% total proteins Glucose 40-70 mg/dL Pressure 70-180 mm H2O Proteins, total < 40 mg/dL Sweat Reference Range Chloride 0-35 mmol/L Urine Calcium 100-300 mg/24 h Chloride Varies with intake Creatinine clearance Male: 97-137 mL/minFemale: 88-128 mL/min Estriol, total (in pregnancy) 30 wks 6-18 mg/24 h 35 wks 9-28 mg/24 h 40 wks 13-42 mg/24 h 17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 hFemale: 2.0-8.0 mg/24 h 17-Ketosteroids, total Male: 8-20 mg/24 hFemale: 6-15 mg/24 h Osmolality 50-1400 mOsmol/kg H2O Oxalate 8-40 μg/mL Potassium Varies with diet Proteins, total < 150 mg/24 h Sodium Varies with diet Uric acid Varies with diet Body Mass Index (BMI) Adult: 19-25 kg/m2 Calculator ( ) xy AC 7 8 9 ÷ 4 5 6 × 1 2 3 - 0 . = + Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (M1.AN.54) A 56-year-old woman is referred to a plastic surgeon for breast reconstruction approximately 18 months after undergoing right modified radical mastectomy for breast cancer. Physical exam demonstrates atrophy of the lower lateral pectoralis major muscle. Damage to which of the following nerves during mastectomy is the most likely cause of her atrophy? Review Topic QID: 106360 1 Long thoracic 32% (29/91) 2 Intercostobrachial 4% (4/91) 3 Medial pectoral 20% (18/91) 4 Lateral pectoral 34% (31/91) 5 Lateral intercostal 4% (4/91) M1 Select Answer to see Preferred Response PREFERRED RESPONSE 3 (M1.AN.39) A 39-year-old male who recently presented with acetaminophen overdose was admitted to the MICU, where several attempts were made at obtaining intravenous access without success. The decision was made to place a right axillary arterial line, which became infected and was removed by the medical student while the patient was still intubated. It was later noticed that he had substantial swelling and bruising of the upper extremity. Given his sedation, a proper neuro exam was not performed at that time. Several days later, after the patient's liver function improved, he was successfully extubated. On exam, he complained of lack of sensation over the palmar and dorsal surface of the small finger and half of the ring finger, as well as weak digit abduction, weak thumb adduction, and weak thumb-index finger pinch of the affected extremity. What is the most likely cause and corresponding location of the injury? Review Topic QID: 106246 FIGURES: A 1 Needle injury to ulnar nerve secondary to blind line placement 34% (35/102) 2 Needle injury to median nerve secondary to blind line placement 8% (8/102) 3 Compression of ulnar nerve secondary to coagulopathy 42% (43/102) 4 Compression of median nerve secondary to coagulopathy 5% (5/102) 5 Stretch injury to ulnar nerve secondary to frequent repositioning 5% (5/102) M1 Select Answer to see Preferred Response PREFERRED RESPONSE 3
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