Anatomy review Part 1. Thorax and Abdomen

1. Anatomy reviewPart 1. Thorax and Abdomen Anatomy in clinical context Read clinical boxes in anatomy text

2. Heart and Lungs Surface anatomy Origin of great vessels Coronary arteries Auscultation of valve sounds Thoracocentesis and Chest Tubes Muscles of Respiration Referred Pain

3. Position of Heart, Great Vessels, etc. in the Thorax and Mediastinum • Heart is about the length of • the body of the sternum: • -- ribs 2-6 • -- from sternal angle • to xiphoid process • Sternal angle is at T4-5 level. It marks: • Origin of great vessels • Bifurcation of trachea Downloaded from: StudentConsult (on 6 May 2008 02:36 PM) © 2005 Elsevier

4. Superior : trachea, thymus, brachiocephalic vein, aortic arch, esophagus thoracic duct Middle: heart, ascending aorta, pulmonary trunk and veins, phrenic nerves Posterior: esopahagus vagus nerves, descending aorta, thoracic duct, sympathetic trunks Anterior: fat, connective tissue, thymus in child

5. Which of the following statements is true of the trachea? • It descends behind the esophagus • Its posterior surface is convex • It ends at the level of the sternal angle • During inspiration, its bifurcation ascends • It contains O-shaped bars of cartilage • All of these structures occupy the superior mediastinum EXCEPT the • Heart and pericardium • Thymus • Aortic arch • Trachea • Esophagus

6. Brachiocephalic veins Anterior Schematic Left pulmonary artery Superior vena cava Pulmonary veins Aorta R. pulmonary artery Pulmonary trunk Left ventricle is the left margin Right atrium is the right margin of the heart Right ventricle is anterior Left atrium is posterior against esophagus. Inferior vena cava Grant’s Atlas of Anatomy, Williams & Wilkins, 9th ed., 1991 Descending aorta

8. 36 yo male complains of general weakness and shortness of breath. He also relates rapid, throbbing pulse after climbing a flight of stairs. Cardiac auscultation reveals a diastolic rumbling murmur attributable to the mitral valve. The mitral valve is best heard: • Fifth intercostal space; left side of midline. • Second intercostal space; right of midline • Second intercostal space left of midline • Fourth intercostal space left of midline • Fifth intercostal space; right of midline

9. Coronary Arteries :They run in the atrio-ventricular and interventricular grooves . Left coronary artery SA node Circumflex branch Right coronary artery Anterior Interventricular LAD AVnode Marginal branch Grant’s Atlas of Anatomy, Williams & Wilkins, 9th ed., 1991 Posterior interventricular

11. apex Costal surface Mediastinal surface Diaphragmatic surface base Costodiaphragmatic recess

12. An elderly woman visits the hospital emergency room with the recent onset of grotesque swelling of the right arm, neck, and face. Her right jugular vein is visibly engorged and her right brachial pulse is diminished. On the basis of these signs, her chest x-rays might show which of the following? A. A left cervical rib B. A mass in the upper lobe of the right lung C. Aneurysm of the aortic arch D. Right pneumothorax E. Thoracic duct blockage in the posterior mediastinum

14. Anatomy of the Intercostal Space Vein Artery Nerve Immediately below rib Intercostal Space

15. Superior lobar Rt. Superior lobar Middle lobar Inferior lobar Inferior lobar Secondary (lobar) bronchi MAIN Tertiary bronchi—one for each BPS Inhaled objects generally are found in right bronchus due to straighter pathway

16. Muscles of Respiration Scalenes & SCM Pec minor Serr. Ant. Int. intercostal Ext. intercostal Diaphragm C3-5 phrenic nerve abdominals Expiration Inspiration

17. Referred pain from angina radiates down medial side of arm Ventricular sensory fibers enter the stellate ganglion (Heart sensation is from mid cervical to mid thoracic levels.) T1 is the lowest ventral ramus of the brachial plexus (C5-T1).

18. 3 3 2 1 Major Lymphatic Pathways of the Lung

19. Lymph Drainage of Breast 1. Upper lateral breast to axillary nodes (75%) 2. To opposite breast 3. Parasternal nodes deep to body wall 4. Superficial inguinal nodes.

20. A mammogram of a woman, age 48, reveals macrocalcification within the right breast, indicating the need for biopsy….. Blah, blah, blah…. At surgery for mastectomy, the surgeon carries the dissection along the major pathway of lymphatic drainage from the mammary gland. The major lymphatic channels parallel which of the following? A. Subcutaneous venous networks to the contralateral breast and abdominal wall B. Tributaries of the axillary vessels to the axillary nodes C. Tributaries of the intercostal vessels to the parasternal nodes D. Tributaries of the internal thoracic (mammary) vessels to the parasternal nodes E. Tributaries of the thoracoacromial vessels to the apical (subscapular) nodes

21. Abdomen Hernias 3D Relationships of organs (CT) Arterial supply to gut Portal-Caval anastomoses Visceral autonomic pathways Bile duct system

22. DIRECT INDIRECT

24. A pediatrician notices a mass in the right inguinal region of a 4 yo boy. The mass extends from just above the midpoint of the inguinal ligament to a point above and medial to the pubic tubercle. Which of the following best describes what the physician has found? A) Enlarged lymph node B) Undescended testicle C) Direct inguinal hernia D) Femoral hernia E) Indirect inguinal hernia

26. Allen is a 30-year-old bachelor who frequents "singles" bars. He has a large palpable structure in the left upper abdomen indicated by the asterisk in the accompanying radiograph. It is?

27. Celiac trunk =foregut P: vagus S: thoracic splanchnics Superior mesenteric =midgut P: vagus S: thoracic splanchnics Inferior mesenteric =hindgut P: pelvic splanchnic S: lumbar splanchnics

28. A patient complained of severe abdominal pain on several occasions, but no cause could be identified. ………..On her arteriogram there is a tortuous vessel indicated by the arrow. What is this vessel?

29. Important Sites of Portal-Caval Anastomosis Esophageal veins– azygous system (hemorrhage) Inferior vena cava (“caval” systemic venous return) Para-umbilical veins– superficial epigastric veins (caput medusa) Portal system of veins from GI capillaries to liver sinusoids Superior rectal veins— branches of internal iliacs (hemorrhoids)

30. In a patient with cirrhosis of the liver, venous hypertension would be expected in • the renal vein • the hepatic veins • the suprarenal veins • the short gastric

31. Anal Canal Note: -- Anal glands opening into crypts -- Pectinate line at bottom of columns (site of cloacal membrane) -- White line where epithelium changes -- Three parts (colored) of external sphincter (subcutaneous, superficial, deep) White line Clinical Symposia, Vol. 37, No. 6, CIBA-Geigy, 1985

34. PARASYMPATHETIC SYMPATHTETIC Vagus foregut thoracic splanchnics Vagus midgut thoracic splanchnics hindgut Pelvic splanchnic lumbar splanchnics

35. King & Showers, Human Anatomy & Physiology, 6th ed., Saunders, 1969 Spinal cord segments for visceral sensory innervation of the gut. Note: -- Thoracic splanchnics do foregut and midgut -- Lumbar (and pelvic splanchnics) do hindgut/ pelvis -- Few spinal segments for all of small intestine T1 T7-9 L1 T10 L5

36. Areas of referred pain

37. While moving furniture, an 18-year-old teenager experiences excruciating pain in his right groin. A few hours later he also develops pain in the umbilical region with accompanying nausea. Examination reveals a bulge midway between the midline and the anterior superior iliac spine, but superior to the inguinal ligament. On coughing or straining, the bulge increases and the inguinal pain intensifies. The bulge courses medially and inferiorly into the upper portion of the scrotum and cannot be reduced with the finger pressure of the examiner. Nausea and diffuse pain referred to the umbilical region in this patient most probably are due to which of the following? A. Compression of the genitofemoral nerve B. Compression of the ilioinguinal nerve C. Dilation of the inguinal canal D. Ischemic necrosis of a loop of small bowel E. Ischemic necrosis of the cremaster muscle

38. Bile and Pancreatic Duct System Left and right hepatic ducts Common hepatic duct Cystic duct (Common) bile duct Main pancreatic duct from ventral bud Gall stones lodge at sphincter Of Oddi/major duodenal papilla

39. A woman presents with gallstones and no jaundice…..…….The entire duct system is carefully probed for stones, one of which is found to be obstructing a duct. In view of her symptoms, where is the most probable location of the obstruction? A. The bile duct B. The common hepatic duct C. The cystic duct D. Within the duodenal papilla proximal to the juncture with the pancreatic duct E. Within the duodenal papilla distal to the juncture with the pancreatic duct

40. Branches of descending arota?

41. During the visit of a 73-year-old man to your office for ongoing control of his hypertension (155/90). ……You palpate his abdomen and note that there is a midline pulse, which you had initially mistaken for a heartbeat, but it is slightly delayed. You grow quite concerned about this pulsating abdominal mass and send him for an abdominal CT with intravenous contrast because you think that he has which of the following? A. A hiatal hernia B. Splenomegaly C. Cirrhosis of the liver D. An aortic aneurysm E. A horseshoe kidney

43. A couple comes to your office because they have been unable to conceive a child after 1 year of trying. You examine the man and notice a darkish mass and fullness of the left scrotum/spermatic cord compared to the smaller right scrotum/spermatic cord. You suggest he follow up with an urologist because you suspect which of the following? A. Undiagnosed cryptorchidism of the right testicle B. Acquired varicocele C. Acquired left femoral hernia D. Acquired right direct femoral hernia E. Congenital absence of the pampiniform plexus on the right side

44. Pelvic Organs Kidney stones Urogenital diaphragm Pelvic diaphragm

45. Common sites for kidney stones to lodge: Renal pelvis Common iliac vessels Entrance to bladder Clinical Symposia, Vol. 38, No. 3, CIBA-Geigy, 1986

46. rectouterine rectovesical

47. A 50-year-old multiparous woman comes to your office to rule out cancer. She reports a growing mass or fullness on the anterior wall of her vagina. Upon physical examination you detect a soft, bulging, and a very compressible mass on the anterior surface of the vagina. When you push on the bulging mass she feels the need to urinate. You order a CT because you suspect which of the following? A. Rectocele B. Cystocele C. Cervical cancer D. Didelphic uterus E. Indirect inguinal hernia

48. Male bladder, urethra, superficial and deep perineal pouches

49. A 6-year-old boy badly bruised his perineum on the horizontal bar of his bicycle as he was learning to ride a bike. Blood extended into his scrotum, and onto the anterior abdominal wall from 3 in. below his umbilicus to just anterior to his anus, but did not pass into his thigh. Which anatomical layers most likely explain the distribution of extravasated blood? A. Superficial membranous fascia and Camper's fascia B. Superficial membranous fascia and transversalis fascia C. Dartos fascia and the perineal membrane D. Superficial membranous fascia and the perineal membrane E. Deep perineal fascia and inferior fascia of the pelvic diaphragm

50. Injury to urethra ABOVE the perineal membrane (fracture of pelvic girdle) results in blood/urine accumulating in the DEEP PERINEAL POUCH AND IN THE LOWER PELVIC CAVITY Injury to the urethra BELOW the perineal membrane (straddle injuries) result in blood/urine accumulating in the SUPERFICIAL PERINEAL POUCH, SCROTUM, AND DEEP TO SCARPA’S FASCIA BUT NOT INTO THE THIGH OR ANAL TRIANGLE