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Table of Contents

Abstract

Saved as global. Used in LMH 523.

abstract

Teaching is one of the core components of the professional identity of a physician. During this week, we will re-introduce you to the world of health professions education, discussing the science behind learning and teaching, using the help of some frameworks. We will also briefly review how curricula are developed.

Accordions

(Toggles are preferred, but I’m using both terms here.) See also Advanced Tabs widget.

When to use an Accordion/Toggle or a Tabs widget? It’s a judgement call.

    • If the header is very long, use the Accordion/Toggle.
    • If you want to use icons and they aren’t included in the Advanced Tabs icon, do it manually using Accordion/Toggle.

I used these in the Gross Anatomy book. There’s an en space between the icon and the titles. They’re mostly Pacific blue, but I took advantage if there were easy opportunities to include color (it also drew attention to them in what was otherwise a pretty consistent/repetitive list).

  • Many small branches of nearby arteries—renal, gonadal, and aorta (abdominal part); common/internal iliac and uterine arteries (pelvic part).
  • Anterior: Pubic bones and pubic symphysis. The retropubic space filled with subperitoneal connective tissue is between the bladder and bone.
  • Superior: Peritoneum; vesico-uterine pouch in females.
  • Posterior: Ductus deferentes, seminal vesicles, and rectovesical pouch (male); cervix of uterus and vagina (female).
  • Inferior: Prostate (male); pelvic diaphragm (female).

The empty bladder (rarely the case in the living body) is shaped like an inverted pyramid, and its anatomic parts are described in its empty state. The actual position and shape of the bladder vary according to the amount of urine it contains and the age of the person.

  • Superior surface (dome of the bladder) is covered by peritoneum. The other surfaces of the bladder are subperitoneal.
  • Posterior surface is called the base or fundus of the bladder.
  • Apex of bladder: Connects the bladder to the anterior abdominal wall via a fibrous cord called the median umbilical ligament (urachus).
  • Neck of bladder: Points inferior. This is where urine leaves the bladder and enters the urethra. In the male, the neck rests on the prostate and is fused to it.
  • Figure 20.3 NETTER, ATLAS OF HUMAN ANATOMY, PLATE 313.
    The mucosa of the empty bladder is folded and loose, except in an area at the base called the trigone, where it is smooth and firmly tacked down to the underlying muscle.
  • The trigone is defined by three orifices = two internal ureteric orifices and the internal urethral orifice. The trigone is at the base of the bladder.
  • The trigone may be elevated in males = this is called the uvula of the bladder. It can become quite prominent in older males when the underlying prostate enlarges.
  • The smooth muscle in the bladder wall is called the detrusor (Latin = “to drive away”). It contracts to squeeze out the urine. The detrusor is the juicer! In the neck, smooth muscle forms the involuntary internal urethral sphincter.
  • Ureterovesical junction (UVJ): The ureters pass through the wall of the bladder at an oblique angle. This is the intramural part of the ureter. As the bladder fills and distends, the intramural part closes to prevent backflow of urine from bladder into ureter. This valve mechanism doesn’t work so well in children because the intramural part of the ureter is short and there is not enough bladder musculature. Reflux of urine is a common cause of urinary tract infections in kids.
  • A rest-and-digest function, regulated by parasympathetic innervation. It is under voluntary control but may occur as a reflex involving the micturition center in the brainstem, as in children not “toilet-trained” or when one has an intense fight-fright-flight emergency response.
  • As the bladder fills, stretch receptors communicate fullness to the brain, causing reflex contraction of the detrusor muscle and relaxation of the internal urethral sphincter.
  • This reflex can be overcome by contraction of the voluntary external urethral sphincter in the deep perineal pouch (if you are toilet trained!), preventing flow of urine in the urethra.
  • Conscious relaxation of the pelvic diaphragm and external urethral sphincter allows urine to flow. When you can’t relax (as in a crowded public restroom), tense muscles and sympathetic closure of the internal urethral sphincter results in an unfortunate inability to micturate.

 

This site has a nice description of neural control of micturation.

  • Superior rectal artery (from inferior mesenteric) and middle rectal artery (from internal iliac).
  • Venous drainage: A submucosal rectal venous plexus drains to the superior rectal vein (portal drainage) and middle rectalveins (systemic drainage = IVC).
  • Split: Upper rectum to inferior mesenteric nodes along aorta; lower rectum to internal iliac and sacral nodes.
  • Sympathetic: From upper lumbar segments of spinal cord to pelvic plexus via the hypogastric nerves—this is vasomotor,but may also relax smooth muscle to inhibit peristalsis and constrict the internal anal sphincter.
  • Parasympathetic: From pelvic splanchnic nerves—stimulates peristalsis; relaxes internal anal sphincter.
  • Afferent: Carry information concerning stretch and fullness to the sacral spinal cord via pelvic splanchnic nerves. Most of the rectum is below the pelvic pain line, so pain is referred to sacral dermatomes and is poorly localized in the pelvic region.
  • The rectum fills slowly during the day, the feces being delivered by peristalsis in the descending and sigmoid colons.
  • The urge to defecate is initiated by mucosal receptors in the ampulla. This induces the relaxation of the internal anal sphincter (smooth muscle) and increases rectal peristalsis.
  • Reflex stimulation of the external anal sphincter (skeletal muscle) resists the pressure produced by peristalsis—maintaining fecal continence.
  • Relaxation of the voluntary sphincter and puborectalis muscle and initiation of the Valsalva maneuver (“bearing down”) with continued peristaltic activity empties the rectum.
  • Posterior to the base of the bladder.
  • The upper blind ends of the vesicles are adjacent to the rectovesical pouch.
  • Just above the prostate, their ducts join the ductus deferentes to form the ejaculatory ducts.
  • Figure 20.24 GRAY’S ANATOMY FOR STUDENTS, FIGURE 5.47.
    This can be confusing, since anatomists and urologists use different terms, and they are often mixed and matched. The passage of the urethra and ejaculatory ducts through the prostate divides it into anatomic lobes and clinical zones.
  • Anterior lobe (isthmus) is anterior to the urethra—also known as the fibromuscular zone. There is no glandular tissue here.
  • Left and right lobes are lateral to the urethra and meet posteriorly in a shallow groove. These lobes together constitute the peripheral zone, the posterior portion of which is palpated in a rectal exam. This zone is the most common location of prostate cancer.
  • Median lobe is the tissue surrounding the ejaculatory ducts. Also called the central zone.
  • The transitional zone is sandwiched between the three zones just described. It encircles the urethra in the core of the prostate, below the bladder. This is the region affected by benign hyperplasia.
  • Figure 20.19 NETTER, ATLAS OF HUMAN ANATOMY, PLATE 341.
    Ovarian ligament (proper ligament of ovary): Ovary to cornu of uterus.
  • Suspensory ligament of the ovary (infundibulopelvic ligament): A peritoneal curtain over the ovarian vessels that extends upward over the pelvic brim.
  • Figure 20.14 GRAY’S ANATOMY FOR STUDENTS, FIGURE 5.54.
    The typical orientation of the uterus is described as anteflexed and anteverted. Flexion refers to orientation of the uterine body with respect to the uterine cervix. Version refers to the orientation of the entire uterus compared to the vagina.
    • When anteflexed, the body of the uterus is bent anteriorly upon the cervix.
    • When anteverted, the entire uterus is tilted forward on the vaginal canal—the uterus and vagina thus have a profile shaped like the number “7” in a lateral view.
  • Parametrium: Outermost, composed of visceral pelvic fascia.
  • Myometrium: Middle layer, thick smooth muscle, branches of the uterine vessels are in this layer.
  • Endometrium: Inner layer, mucous membrane with uterine glands.Undergoes monthly renewal and degeneration—being cyclically prepared by hormones for implantation of the embryo.

Advanced Tabs widget

Used in Gross Anatomy, EKG, Global Health, and Virtual Neurology. It’s a judgement call re having it open on page load; same re putting the tabs on top or on the side. Use icons only if it can be done for all of the tabs. Otherwise, see Accordions/Toggles.

For students interested in Global Health who would like additional references on the field, here are some references and organizations of interest that are not specifically linked to individual modules in the course:

    1. First, Do No Harm: A Qualitative Research Documentary. This video is highly recommended for students planning to engage in short-term international experiences at some point during their training or career.
    1. Kidder T. Mountains Beyond Mountains. Random House Trade Paperbacks; 2004.
      • In many ways, Dr. Paul Farmer popularized the field of global health and provided an example to a generation of what can be done to address inequality. This biography provides a excellent anchor to the life and work of Paul Farmer, which may be helpful as an ‘overview’ in addition to reading some of Dr. Farmer’s publications.
    1. Farmer P, Saussy H. Partner to the Poor: A Paul Farmer Reader. (Saussy H, ed.). University of California Press; 2010. doi:10.1525/9780520945630
      • A collection of essays and excerpts from Dr. Farmer’s publications
    1. Consortium for Universities in Global Health.
      • A professional organization for universities around the world engaged in addressing global health challenges. Opportunities for students and trainees to be on working groups, present at conferences, and connect to other institutions involved in global health. There are several free educational programs available.
    1. Reasoning without Resources. For students who plan to participate in direct patient care in an international and low/low-middle income country, consider reviewing some of the case studies in Reasoning without Resources as an introduction to how you might need to adjust your clinical approach in areas without the diagnostic and therapeutic interventions you are used to.
    2. Considering a career in Global Health? Check out this webinar recording from the CDC: “The Landscape of Global Health.”
    3. Marantz DE. African Friends and Money Matters: Observations from Africa. 2nd ed. Summer Inst Linguistics; 2015.
      • An interesting examination of many of the common cultural experiences and friction that arise when Westerners are living/working in African through the lens of economic structure and its relation to human behavior.
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An organ consisting of an outer layer called the epidermis and a tough connective tissue layer beneath it called the dermis.

The skeletal elements underlying the thoracic body wall consisting of ribs, costal cartilages, the sternum, and thoracic vertebrae.

  • Paravertebral muscles: As the name implies, these are located adjacent to the vertebral column in the back. We won’t be discussing them much in this course, but you should be aware of them, as they form an easily palpable longitudinal mass alongside the vertebral column.
  • Body wall muscles: Three layers in both thoracic and abdominal regions:

    1. External layer
    2. Internal layer
    3. Innermost layer

Authors and co-authors

Authors

Keely Coxon, MD
Dawn DeWitt, MC, MSc, MACP, FRACP

Basic Gallery widget samples

In addition to the general gender analysis questions, key legal and rights-based subject areas to consider are:

In addition to the general gender analysis questions, the difference in women’s and men’s capacity for power and decision-making in the following areas should be considered:

Book Widgets iFrame

See also examples under Icon Boxes.

Carousel

Used on the Anatomy of a Case Report page. I used a gray rule around the whole thing to visually unite the highlighted image and the thumbnails below.

This could be a good choice in place of the Slides widget (see the Case Studies example below)—Carousel images can be clicked to enlarge.

Case studies

Ideally, the words Case Studies would be in crimson, like it (usually) is in on CBL covers.

Slides widget for cases

See also the Carousel widget for different functionality that would still look cohesive to the reader.

Case Study: Sam

Sam is a 45-year-old who presents to inquire about their breast cancer risk and when to begin mammography. She has no known family history of breast or ovarian cancer. Menarche was at age 13. Her first child was born when she was 27, and she was briefly on hormonal birth control for three years at age 20. She drinks alchohol 2–3 times a week, usually one glass of wine per sitting. She denies radiation exposure. Her BMI is 34.

Sam Pre-Question
Which risk factors does Sam have that may increase her risk of breast cancer?
a. Age, family history, age at menarche.
b. Radiation exposure, age at first child, and hormonal contraception.
c. Gender, hormonal contraception, BMI.
d. Family history, age at first child, alcohol use.
Sam Pre-Question
According to the U.S. Preventative Task Force, which of the of these screening tools is evidence based to reduce death from breast cancer?
a. Breast self-exam.
b. Screening mammography.
c. Breast ultrasound.
d. Clinical breast exam by provider.
Sam Pre-Question
According to the U.S. Preventative Task Force, when should Sam begin screening mammography, and how often should she be screened?
a. Now, every year.
b. Age 50, every other year.
c. Now, every other year.
d. Should have started at age 40, every year.
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Flip Box widget for case

(from Virtual Neurology) Case Study: Mitch—Unresponsive at a bus stop

Tap the image to view the case.

Case Study: Steve

A 55-year-old man comes to see you for recent onset of right-sided headaches which he refers to as “migraines.” He has some nausea with his headaches. He has no other symptoms with the headaches.

Another case option from Virtual Neurology (for longer, multi-paragraph cases)

Tap the arrow to view the case.
A 78-year-old male with a history of metastatic lung cancer, migraines, DVT, DM, HTN, and hyperlipidemia presented to the ED yesterday with new onset aphasia. His wife reports that, at dinner time last night, he was confused, not making sense, smacking his lips, and trying to eat dog food.

In the ED, the patient was not oriented to person, place, or time. He was stringing words together that did not make sense and did not follow commands. NIH Stroke Scale was 8. Bilateral LE extremity strength is 4/5. Overnight, he had urinary incontinence.
This morning, the patient’s aphasia has resolved, and he is oriented 4. He states that he vaguely remembers not being able to speak and thinks that he may have intermittently lost consciousness. Neurological exam shows 5/5 motor strength and intact sensation. He is currently taking Atorvastatin, Metformin, and Warfarin. Labs show hyponatremia of 130. Head CT and CT angio was unremarkable. MRI is pending. Patient refuses treatment for his lung cancer and wanted to stay at home with his family rather than pursue hospice care.
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Question

Which of the following is the most likely diagnosis?

Question

Which of the following is the most likely diagnosis?

Table 16.1. Table title

Column header

Column header

   
   
   
   
   
   
   

Checkbox

checkbox

checkbox text

item

item

item

Goals

See Learning Goals.

Gross Anatomy Style Guide

I’ve worked all of the widgets from that page into this one. Let me know if there are any questions about how/where they are used.

Hero images

Add a vector-based image as a Featured Image (in WordPress, size 1200px x 628px) if it is going on the main textbook LP. The same image should be used in the hero.

If it is going on a sub-LP, it does not need a featured image.

Use JPG for featured image and PNG (transparent background) for hero image.

Icons

Lots more icon examples

Purely sensory

I
II
VIII

Mainly motor

III
IV
VI
XI
XII

Mixed

V
VII
IX
X

Functions

Olfaction (smell)—special sensory

Skull opening

Olfactory (cribriform) foramina.

Attachments to CNS

Nucleus of origin/destination in CNS

Bipolar neurons of olfactory nerves synapse on secondary olfactory neurons in olfactory bulbs.

Details

  • Anatomy is a visual science.

    The best way to learn it is to be able to recall it visually and be able to describe it based on what you see in your “mind’s eye.”

  • Sketch! Sketch! Sketch!

    Do little sketches, flow-charts, or even stick-drawings.

Meetings and trainings

Health services

Political processes

Work

Social spaces

Six-pack review

Icon boxes

Complete anatomy

Gross Anatomy dissector

Chalk Talk

Gross Anatomy textbook

alert header

Alert text

A note about this session

Gross Anatomy textbook

Note

Gross Anatomy textbook

Question

Gross Anatomy textbook

Downloads

Change icon if it's not a PDF download.

David Conley

Conley's clues

Gross Anatomy textbook

Mnemonic

Gross Anatomy textbook

An important concept

Gross Anatomy textbook

Clinical correlation: extra info

Gross Anatomy

Clinical correlation

Gross Anatomy

Second paragraph

Figure 2.19. LARSEN’ S HUMAN EMBRYOLOGY, 5TH ED., FIG. 4-13. See also Figure 2.20.

interactive

Embryonic and extraembryonic structures of Week 2. Can you identify these? (Tap to open; use your Apple Pencil to draw and make notes.)

HAND-DRAWN CONLEY- GRAM.

Draw on me/interactive

(Tap to open; use your Apple Pencil to draw.)

Learning objectives

Use the term ‘learning goals’ (lowercase) rather than objectives . . . unless it is a full year 4 course (such as Global Health).

Point students to objectives on E.Flo MD using the icon widget below. We want to avoid having objectives on the Learning site because E.Flo MD is the source of truth and we don’t want to risk two sets of information that don’t match.

Learning goals

We used the red bullets in LMH, but we’re moving away from that because it’s tedious to create each line one by one, and it looks dorky if the line is more than two long.

We use this in the Dissector:

  1. Identify the boundaries and contents of the axilla.

  2. Learn the architecture of the brachial plexus.

  3. Identify the muscles, nerves, and vessels of the arm.

Lists (Alternatives to bulleted lists)

See also Tables, Icon List

1

The outer layer is the visceral layer of serous pericardium or the epicardium, a serous membrane. It contains a variable amount of fatty tissue deep to the mesothelium.

2

The thickest portion of the heart is the middle layer, the myocardium. This layer consists of cardiac muscle tissue.

3

The smooth, inner layer of the heart is the endocardium. It is continuous with the endothelium, the simple squamous epithelium lining the blood vessels that enter and leave the heart.

Gestation

The period of intra-uterine development of the human.

Trimester

A period of three calendar months. Clinicians divide the gestation period into three trimesters. The most dramatic and critical stages of development occur during the 1st trimester.

Gestational (menstrual) age

Using the last normal menstrual period as the reference point. Gestation lasts 40 weeks using this calendar.

Fetal period

Fetus is the term used to describe the developing human after the completion of the embryonic period. The fetal period therefore is between the ninth week and birth.

Navigation

If the posts widget will cooperate:

If not, it's manual:

previous

Pleura, pleural sacs, and lungs

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Pleura, pleural sacs, and lungs

Optional reading

(Or similar—used in Gross Anatomy and Molecular Bio)

  • Clinically Oriented Anatomy, 8th ed., Overview of Thorax section through The bottom line: Muscles and neurovasculature of thoracic wall.

3.2.4 Review of bones of the thorax.

  • 3.2.1 The bones of the thorax.

  • 3.2.3 First rib and clavicle.

  • 3.2.2 Costovertebral joints. (The ligaments can be skipped.)

  • 3.2.7 Muscles of inspiration. (Just external intercostals; actions are in chapter 7.)

  • 3.2.8 Muscles of expiration. (Just internal intercostals; actions are covered in chapter 7.)

  • 3.2.14 Nerves of the thorax. (Intercostal nerves section only, which is only a few seconds long.)

Overall table of contents

Used in Gross Anatomy, Virtual Neurology, EKG.

Posts widget

Uses H3, so it shows up in the TOC. Example: LP of Virtual Neurology. Saved as global.

Uses <p>, so it doesn’t show up in the TOC. Example: The Brain. Saved as global.

Pull quote

While this knowledge check is “open book,” the best way to learn is to practice spaced-repetition “free recall,” so try to answer these without looking.

I want to thank you for your beautiful work on the Microaggressions module. It’s BEAUTIFUL! The faculty I work with in IPE were blown away. Thank you for creating such an interactive module for students.

Quiz samples

Quiz samples are on a separate page.

Recommended resource/reading

Table alternative

Gestational ageBefore conception
Read More

Recommended testing/screening

  • Rubella titer
  • Varicella titer

Recommended immunization(s)

  • Rubella
  • Varicella

Recommended counseling/anticipatory guidance

  • Smoking cessation
  • Prenatal Vitamins
Gestational ageAt every visit
Read More

Recommended testing/screening

  • Weight
  • BP
  • FHR
  • Fundal height (starting at 20 wga)
  • +/–Urinalysis

Recommended immunization(s)

  • Influenza (pending season)
  • COVID-19 (pending season)

Recommended counseling/anticipatory guidance

  • Nutrition/exercise, weight gain
Gestational ageAt first appointment
Read More

Recommended testing/screening

  • BMI
  • Blood type/Rh
  • Hgb/Hct
  • Rubella titer
  • CT/GC
  • Hep BsAg
  • Hep C Antibody
  • Syphilis
  • +/– Varicella titer
  • Urine culture
  • HIV
  • Pap +/– HPV (if due based on history/age)
  • NIPS (if desired starting at 10 WGA)
  • Carrier Screening (if desired)
  • Early 1 hour GTT (if high risk)

Recommended counseling/anticipatory guidance

  • Intimate Partner Violence
  • Depression
Gestational age10–12 WGA
Read More

Recommended testing/screening

  • NT/sequential/integrated screen (if desired and NIPS declined)

Recommended risk-reduction treatments

  • Low-dose aspirin for Preeclampsia prevention if high risk (13–36 wga)
Gestational age15–20 WGA
Read More

Recommended testing/screening

  • AFP optional for fetal oNTD screening
Gestational age24–28 WGA
Read More

Recommended testing/screening

  • Rh (if neg)
  • Gestational diabetes screening (if not currently diagnosed with diabetes)
  • CBC

Recommended risk-reduction treatments

  • Rhogam if Rh negative

Recommended immunizations

  • TdaP (27–32 weeks)
Gestational age35–37 WGA
Read More

Recommended testing/screening

  • GBS
  • Check fetal presentation
  • Check cervix (optional)

Recommended risk-reduction treatments

  • HSV prophylaxis starting at 36 weeks-delivery if history of genital HSV lesions

Recommended immunizations

  • RSV if 32–36 wga and due September–January (the vaccine should be administered during weeks 32–36 weeks of pregnancy from September through January)
Gestational agePostpartum
Read More

Recommended testing/screening

  • Pap +/– HPV (if due based on history/age)

Recommended risk-reduction treatments

  • Rhogam (if patient Rh negative and infant Rh positive)

Recommended immunizations

  • Rubella (if non-immune)
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Next
Gut tube (= inner tube) and its derivatives = air tubes of lungs, liver, gall bladder, and pancreas
Read More
  • From splanchnic mesoderm and endoderm
  • “Visceral” type of innervation from autonomic nervous system
  • Pain from these organs is often referred to somatic body parts.
Body wall (= outer tube)
Read More
  • From somatic mesoderm and ectoderm
  • “Somatic” type of innervation from peripheral nerves
  • Pain from these areas is usually sharp and well-localized.
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