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SURFACE MARKINGS - GMC KADAPA

Complete Exam Guide

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LUNGS - BORDERS

Apex

• Rises 2.5 cm above the medial 1/3 of clavicle (or 2.5 cm above the sternal end of clavicle)

Anterior Border

• Right lung: Passes behind right sternoclavicular joint → down to midline at sternal angle → vertically down to 6th costal cartilage at the right border of sternum
• Left lung: Same as right down to 4th costal cartilage → deviates left (cardiac notch) → reaches 6th costal cartilage in the midclavicular line

Inferior Border (Lower Border)

• Runs from 6th costal cartilage → crosses 6th rib in MCL → 8th rib in midaxillary line → 10th rib posteriorly at the lateral border of erector spinae
• Rule of 6-8-10: 6th rib MCL, 8th rib MAL, 10th rib posteriorly (lung); pleura = 8-10-12

Posterior Border

• Runs from apex downward along the vertebral column lateral to the spine, from C7 to T10

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1. BORDERS OF HEART

1. Upper right: 3rd right costal cartilage, 1 cm lateral to sternal border
2. Lower right: 6th right costal cartilage, 1 cm lateral to sternal border
3. Upper left: 2nd left costal cartilage, 1 cm lateral to sternal border
4. Lower left (apex): 5th left ICS, 9 cm from midline (midclavicular line)

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2. APEX BEAT

• Located in the 5th left intercostal space in the midclavicular line (9 cm from midline)
• Formed by the left ventricle
• Lowermost and outermost point of cardiac impulse

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3. VALVES OF HEART

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5. PLEURA - REFLECTIONS (Costomarginal)

Costal Pleura (Anterior Reflection)

• Both sides: Start at the sternoclavicular joint → converge behind the manubrium at the sternal angle
• Right: Runs vertically down behind the sternum to the 6th costal cartilage
• Left: Diverges at 4th costal cartilage (cardiac notch) → reaches 6th costal cartilage at the MCL

Lower (Costodiaphragmatic) Reflection

• Rule of 8-10-12: 8th rib in MCL, 10th rib in MAL, 12th rib posteriorly (2 ribs below the lung)

Costomediastinal Recess (left)

• Behind 4th-6th costal cartilages along the left sternal border

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6. INGUINAL CANAL

• Length: 4 cm
• Direction: Downward, forward, and medially
• Deep (internal) ring: 1.25 cm above the midpoint of the inguinal ligament (midpoint between ASIS and pubic tubercle)
• Superficial (external) ring: Just above and lateral to the pubic tubercle
• Inguinal ligament: From ASIS to pubic tubercle

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7. McBURNEY'S POINT

• Junction of the lateral 1/3 and medial 2/3 of a line drawn from the right ASIS to the umbilicus
• Corresponds to the base of the appendix / site of maximum tenderness in acute appendicitis

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8. HESSELBACH'S TRIANGLE (Inguinal Triangle)

• Site of direct inguinal hernia (medial to inferior epigastric vessels)
• Floor: Transversalis fascia + conjoint tendon

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9. LIVER

• Upper border: Right side at 5th ICS in MCL; left side at 5th ICS in left MCL (left lobe)
• Right border: From 5th right ICS → down to the right costal margin at the 10th rib
• Lower border: Right costal margin from 10th rib → crosses midline at the transpyloric plane (L1) → left 5th ICS
• Notch: Palpable below xiphisternum in the midline between xiphoid and umbilicus

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10. SPLEEN

• Long axis: Along the 10th rib
• Poles: Between 9th and 11th ribs posteriorly
• Anterior border: Does NOT cross the MCL in normal state
• Surface marking: 9th, 10th, 11th ribs, between posterior and midaxillary lines on the LEFT
• Extends from T10 to L1 vertebral levels

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11. PANCREAS

• Head: In the C-loop of duodenum, at the level of L2
• Neck: At the transpyloric plane (L1), overlying the superior mesenteric vessels
• Body and Tail: Extends obliquely upward and to the left, tail touching the hilum of the spleen at T12
• Lies retroperitoneally across vertebral bodies L1-L2
• Surface: Behind the stomach, anterior to aorta and IVC

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12. DUODENUM

• 1st (Superior) part: At L1, from the pylorus (transpyloric plane) → runs to the right and backward
• 2nd (Descending) part: Runs vertically from L1 to L3, on the right side of vertebral column
• 3rd (Horizontal) part: Runs horizontally at L3 from right to left, crossing the aorta
• 4th (Ascending) part: At L3-L2, ascends to the duodenojejunal flexure at L2 on the left, marked by the ligament of Treitz
• C-shaped loop surrounding the head of pancreas

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13. MORRISON'S PARALLELOGRAM (Pouch)

• Also called the hepatorenal recess - the most dependent part of the peritoneal cavity in the supine position
• Boundaries: Between the liver (right lobe) and right kidney
• Surface marking: In the right flank, approximately between the 10th and 12th ribs in the posterior axillary line
• Clinically important for fluid collection (ascites, hemoperitoneum drains here first)

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14. PAROTID GLAND

• Anterior: Extends to the masseter muscle (anterior border of masseter)
• Posterior: To the mastoid process and SCM
• Superior: To the zygomatic arch
• Inferior: To the angle of the jaw
• Wedge-shaped, occupies the retromandibular fossa

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15. PAROTID DUCT (Stensen's Duct)

• Length: 5 cm
• Course: From the anterior border of the parotid gland → runs horizontally on the masseter along a line drawn from the tragus of ear to the midpoint of the philtrum (or to just above the corner of the mouth)
• Turns medially at the anterior border of masseter → pierces the buccinator → opens opposite the upper 2nd molar tooth
• Surface line: 1 finger-breadth below the zygomatic arch, parallel to it

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16. FACIAL ARTERY

• Origin: External carotid artery (in carotid triangle)
• Course on face: Winds around the lower border of mandible at the anterior border of masseter (pulse felt here) → ascends tortuously to the medial angle of eye
• Surface marking: From the lower border of mandible at the anterior border of masseter → angle of mouth → side of nose → medial angle of the eye (becoming angular artery)

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17. FACIAL NERVE IN FACE (VII)

• Exits stylomastoid foramen → enters parotid gland → divides into 5 terminal branches
• Mnemonic: Ten Zulus Bore My Cat (Temporal, Zygomatic, Buccal, Marginal mandibular, Cervical)

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18. SUPERFICIAL TEMPORAL ARTERY

• Terminal branch of the external carotid artery
• Pulse point: Felt anterior to the tragus of the ear (in the preauricular region)
• Course: Emerges from upper border of parotid → crosses the zygomatic arch → divides into frontal and parietal branches above the zygoma

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19. CAROTID TRIANGLE

• Common carotid bifurcation at the level of the upper border of thyroid cartilage (C3-C4)

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20. AXILLARY ARTERY

• Continuation of subclavian artery from the outer border of the 1st rib to the lower border of teres major
• Surface marking: Arm abducted 90°; draw a line from the midpoint of the clavicle to the medial epicondyle - the upper 1/3 of this line represents the axillary artery
• Divided into 3 parts by pectoralis minor

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21. BRACHIAL ARTERY

• Continuation of axillary artery from lower border of teres major to the cubital fossa (neck of radius)
• Surface marking: Line from the medial epicondyle to the midpoint of the cubital fossa, with arm slightly abducted
• Pulse: Felt medial to biceps tendon in the cubital fossa
• Divides into radial and ulnar arteries at the neck of radius

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22. AXILLARY NERVE

• From the posterior cord of brachial plexus (C5, C6)
• Course: Passes through the quadrilateral space (bounded by teres minor above, teres major below, long head of triceps medially, surgical neck of humerus laterally)
• Surface marking: A point 5 cm below the tip of the acromion (surgical neck of humerus)
• Supplies deltoid and teres minor; cutaneous branch = upper lateral cutaneous nerve of arm

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23. MEDIAN NERVE

• Formed by medial and lateral roots from the medial and lateral cords (C6-T1)
• In arm: Lateral to brachial artery in the upper arm → crosses to the medial side at mid-arm
• In forearm: Between FDS and FDP
• Surface marking: From the axilla → along the medial border of biceps (with brachial artery) → midpoint of the cubital fossa (just medial to brachial artery) → midline of forearm → enters palm through carpal tunnel at the wrist
• Wrist: Between palmaris longus and FCR tendons

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24. RADIAL NERVE

• From the posterior cord (C5-C8, T1)
• Surface marking: From the axilla → winds in the spiral groove of the humerus (posterior aspect) → pierces lateral intermuscular septum → appears in front of the lateral epicondyle → divides into superficial (sensory) and deep (posterior interosseous) branches
• Key point: Posterior to the medial epicondyle in the axilla → lateral epicondyle anteriorly

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25. ULNAR NERVE

• From medial cord (C7, C8, T1)
• Surface marking: From axilla → medial side of arm (medial to brachial artery in upper arm) → passes posterior to the medial epicondyle (vulnerable here - "funny bone") → enters forearm between two heads of FCU → runs on the ulnar side of the forearm → crosses the flexor retinaculum on the radial side of the pisiform bone → enters palm (Guyon's canal)

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26. SCIATIC NERVE

• Largest nerve in the body (L4, L5, S1, S2, S3)
• Surface marking: From the midpoint between the ischial tuberosity and the greater trochanter → runs vertically downward to the midpoint of the popliteal fossa (where it divides into common peroneal and tibial nerves)
• Piriformis: Nerve usually exits below piriformis; above in 10% (anomaly)

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27. POPLITEAL ARTERY

• Continuation of femoral artery from the adductor hiatus (at the junction of middle and lower thirds of the thigh)
• Surface marking: From the adductor hiatus → vertically down through the popliteal fossa → to the lower border of popliteus muscle (bifurcates into anterior and posterior tibial arteries)
• Pulse: Felt in the popliteal fossa with knee slightly flexed, deep palpation in the midline

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28. GREAT SAPHENOUS VEIN

• Origin: Dorsal venous arch of the foot (medial end) → medial malleolus
• Course: Ascends along the medial aspect of the leg → behind the medial condyles of tibia and femur → along the medial thigh → drains into the femoral vein at the saphenous opening (4 cm below and lateral to the pubic tubercle / groin crease)
• Surface marking: From anterior to the medial malleolus → medial knee → medial thigh → femoral triangle

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29. SHORT (SMALL) SAPHENOUS VEIN

• Origin: Dorsal venous arch, lateral end → behind the lateral malleolus
• Course: Ascends up the back of the leg (between the heads of gastrocnemius) → drains into the popliteal vein in the popliteal fossa (variable - can be above or below popliteal crease)
• Surface marking: From posterior to the lateral malleolus → up the midline of the calf → popliteal fossa

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30. DORSALIS PEDIS ARTERY

• Continuation of the anterior tibial artery below the extensor retinaculum
• Surface marking: From the midpoint between the two malleoli (anterior to the ankle joint) → along the dorsum of the foot to the 1st intermetatarsal space
• Pulse felt: Between the tendons of extensor hallucis longus and extensor digitorum longus, at the level of the base of the 1st intermetatarsal space (2nd toe web)

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31. CEPHALIC VEIN

• Origin: From the dorsal venous network of the hand (radial side / anatomical snuffbox)
• Course: Winds around the radial border of the forearm → up the lateral forearm → anterior to the elbow (lateral to biceps) → ascends in the deltopectoral groove → pierces the clavipectoral fascia → drains into the axillary vein
• Surface marking: Radial side of wrist → lateral forearm → lateral biceps → deltopectoral groove → axillary vein (just below clavicle)

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32. ARCH OF AORTA

• Surface marking: Begins and ends at the level of the sternal angle (of Louis) - T4/T5 (manubriosternal junction)
• Begins as the ascending aorta → arches backward and to the left over the left bronchus → continues as the descending thoracic aorta
• Branches (right to left): Brachiocephalic trunk, Left common carotid, Left subclavian
• Highest point: Just below the midpoint of the manubrium (about 2.5 cm below the suprasternal notch)

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33. LUMBAR PUNCTURE

• Level: Between L3 and L4 (or L4-L5) spinous processes
• Landmark: Tuffier's line (intercristal/supracristal line) - a horizontal line connecting the highest points of both iliac crests - corresponds to the L4 spinous process (or L3-L4 interspace)
• Safe below L1-L2 because the spinal cord ends at L1-L2 (conus medullaris); below this is only the cauda equina
• Position: Lateral decubitus (left lateral) with full flexion, or sitting leaning forward

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34. FEMORAL ARTERY

• Continuation of the external iliac artery below the inguinal ligament
• Surface marking: From the midpoint of the inguinal ligament (midpoint between ASIS and pubic symphysis = mid-inguinal point) → to the adductor tubercle (or medial epicondyle of femur) with the knee slightly flexed and thigh abducted and laterally rotated
• Femoral triangle: Bounded by inguinal ligament (above), sartorius (lateral), adductor longus (medial)
• Pulse: Felt at the mid-inguinal point

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Quick Memory Summary Table

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