Anatomy review Part 1.

Thorax and Abdomen

Anatomy in clinical context Read clinical boxes in anatomy text

Heart and Lungs

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

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

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

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

Brachiocephalic veins Superior vena cava

Aorta

Anterior Schematic
Left pulmonary artery Pulmonary veins Left ventricle is the left margin Left atrium is posterior against esophagus.
Grants Atlas of Anatomy, Williams & Wilkins, 9th ed., 1991

R. pulmonary artery Right atrium is the right margin of the heart Inferior vena cava

Pulmonary trunk

Right ventricle is anterior

Descending aorta

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

Coronary Arteries :They run in the atrio-ventricular and interventricular grooves

. Left coronary artery

SA node

Right coronary artery

AVnode

Circumflex branch

Anterior Interventricular
LAD

Marginal branch Posterior interventricular

Grants Atlas of Anatomy, Williams & Wilkins, 9th ed., 1991

apex
Costal surface

Mediastinal surface

Costodiaphragmatic recess

Diaphragmatic surface

base

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

Anatomy of the Intercostal Space

Vein Artery Nerve

Immediately below rib
Intercostal Space

Secondary (lobar) bronchi

Rt. Superior lobar

Superior lobar

Middle lobar

MAIN

Inferior lobar

Inferior lobar

Tertiary bronchione for each BPS

Inhaled objects generally are found in right bronchus due to straighter pathway

Muscles of Respiration
Scalenes & SCM

Pec minor Serr. Ant. Ext. intercostal

Int. intercostal

Diaphragm C3-5 phrenic nerve

abdominals

Inspiration

Expiration

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 (C5T1).

3
3

Major Lymphatic Pathways of the Lung

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.

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

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

DIRECT

INDIRECT

Indirect (Congential)
Follows path of processus vaginalis through inguinal canal Passes through both deep and superficial inguinal rings. Distended mass is in spermatic cord (often found in scrotum/labia) Mass is lateral to inferior epigastric artery. 20x more in males

Direct (Acquired)
NOT through the inguinal canal Passes through weakness in abdominal wall Mass is adjacent to spermatic cord (rarely enters scrotum or labia) Medial to inferior epigastric artery

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

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?

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

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?

Important Sites of Portal-Caval Anastomosis

Inferior vena cava (caval systemic venous return)

Esophageal veins azygous system (hemorrhage)

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)

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

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) Clinical Symposia, Vol. 37,
No. 6, CIBA-Geigy, 1985

White line

PARASYMPATHETIC

SYMPATHTETIC

Vagus

foregut

thoracic splanchnics

Vagus

midgut
thoracic splanchnics

Pelvic splanchnic

hindgut

lumbar splanchnics

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

King & Showers, Human Anatomy & Physiology, 6th ed., Saunders, 1969

T1 T7-9

L1

T10

L5

Areas of referred pain

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

Bile and Pancreatic Duct System

Left and right hepatic ducts Cystic duct

Common hepatic duct

(Common) bile duct

Main pancreatic duct from ventral bud Gall stones lodge at sphincter Of Oddi/major duodenal papilla

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

Branches of descending arota?

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

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

Pelvic Organs
Kidney stones Urogenital diaphragm Pelvic diaphragm

Common sites for kidney stones to lodge:

Renal pelvis Common iliac vessels

Entrance to bladder
Clinical Symposia, Vol. 38, No. 3, CIBA-Geigy, 1986

rectouterine
rectovesical

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

Male bladder, urethra, superficial and deep perineal pouches

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

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 SCARPAS FASCIA BUT NOT INTO THE THIGH OR ANAL TRIANGLE

Contents of superficial pouch

Autonomic Innervation of Pelvic Organs

The sympathetic supply comes primarily from the superior hypogastric plexus and its continuation, the hypogastric nerve. A smaller contribution comes from the sacral splanchnic nerves arising from the continuation of the sympathetic trunk. The parasympathetic supply comes primarily from the pelvic splanchnic nerves (S24)

Lymphatics
Lymphatic drainage of any structure in the pelvis or perineum generally follows the course of its blood supply and venous drainage. Therefore, drainage of pelvic organs is mainly into nodes distributed along the branches of the internal iliac artery. Drainage of perineal structures may be to superficial or deep inguinal nodes. How do lymphatics from the testis reach the thoracic duct?

Lymph Node Group structures Lumbar Internal Iliac Gonads, uterine tube, fundus of uterus Anal canal (above pectinate line) Inferior rectum Base of bladder Lower uterus Upper vagina, cervix Prostate Superior bladder Mid-uterus Lower limb Perineumscrotum Anal canal below pectinate line

External Iliac

Superficial Inguinal

Deep inguinal

Glans