Anatomy Review Part 1

5/27/2018 Anatomy Review Part 1

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Anatomy review

Part 1. Thorax and Abdomen

Anatomy in clinical context

Read clinical boxes in anatomy text


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Heart and Lungs

Surface anatomy

Origin of great vessels

Coronary arteriesAuscultation of valve sounds

Thoracocentesis and Chest Tubes

Muscles of Respiration

Referred Pain


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2005 Elsevier

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

Position of Heart, Great Vessels, etc. in the Thorax

and Mediastinum


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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


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Which of the following statements is true of the trachea?

It descends behind the esophagus

Its posterior surface is convexIt 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


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Left ventricle is theleft margin

Right ventricle

is anterior

Right atrium

is the right

margin of the heart

Aorta

Pulmonary

trunk

Superior

vena cava

Inferior vena cava

Pulmonary veins

Left pulmonary

artery

R. pulmonary

artery

Descending aorta

Brachiocephalic

veinsAnterior Schematic

Grants Atlas of Anatomy,Williams & Wilkins, 9thed., 1991

Left atrium is

posterior against

esophagus.


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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 isbest 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


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Coronary Arteries :They run in the atrio-ventricular and

interventricular grooves

.

Left coronary artery

Circumflex

branch

Anterior

Interventricular

LAD

Right coronary

artery

Posterior interventricular

Marginal branch

Grants Atlas of Anatomy,

Williams & Wilkins, 9thed., 1991

SA

node

AVnode


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apex

base

Costal surface

Diaphragmatic

surface

Mediastinal

surface

Costodiaphragmatic

recess


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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 rightbrachial 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 pneumothoraxE. Thoracic duct blockage in the posterior mediastinum


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Intercostal Space

Anatomy of the

Intercostal Space

Vein

Artery

Nerve

Immediately

below rib


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MAIN

Rt. Superior lobarSuperior lobar

Middle lobar

Inferior lobarInferior lobar

Secondary(lobar) bronchi

Tertiary bronchione for

each BPS

Inhaled objects generally are found in right bronchus due

to straighter pathway


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Inspiration Expiration

Diaphragm

C3-5 phrenicnerve

Ext. intercostal

Pec minor

Serr. Ant.

Scalenes & SCM

Int. intercostal

abdominals

Muscles of Respiration


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Referred pain from angina

radiates down medial side

of arm

Ventricular sensory fibers

enter the stellate ganglion

(Heart sensation is from midcervical to mid thoracic

levels.)

T1 is the lowest ventral ramus

of the brachial plexus (C5-

T1).


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1

2

3

3

Major Lymphatic Pathways of the Lung


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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 inguinalnodes.


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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 fromthe 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 nodesE. Tributaries of the thoracoacromial vessels to the apical

(subscapular) nodes


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Abdomen

Hernias3D Relationships of organs (CT)

Arterial supply to gut

Portal-Caval anastomoses

Visceral autonomic pathways

Bile duct system


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INDIRECTDIRECT


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Indirect (Congential) Direct (Acquired)

Follows path of processusvaginalis through inguinal canal

NOT through the inguinalcanal

Passes through both deep and

superficial inguinal rings.

Passes through weakness

in abdominal wall

Distended mass is in spermatic

cord (often found in

scrotum/labia)

Mass is adjacent to

spermatic cord (rarely

enters scrotum or labia)

Mass is lateralto inferiorepigastric artery.

Medialto inferior epigastricartery

20x more in males


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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 nodeB) Undescended testicle

C) Direct inguinal hernia

D) Femoral hernia

E) Indirect inguinal hernia


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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 accompanyingradiograph. It is?


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Celiac trunk =foregut

Superior mesenteric

=midgut

Inferior mesenteric

=hindgut

P: vagus

S: thoracic splanchnics

P: vagusS: thoracic splanchnics

P: pelvic splanchnic

S: lumbar splanchnics


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A patient complained of severe abdominal pain on several occasions, but

nocause could be identified. ..On her arteriogram there is a tortuous

vessel indicated by the arrow. What is this vessel?


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Important Sites of Portal-Caval Anastomosis

Esophageal veins

azygous system(hemorrhage)

Superior rectal veins

branches of internal iliacs

(hemorrhoids)

Para-umbilicalveins

superficial

epigastric veins

(caput

medusa)

Inferior vena cava

(caval systemicvenous return)

Portal system of veinsfrom GI capillaries to

liver sinusoids


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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


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

Anal Canal

Note:

-- Anal glands opening

into crypts

-- Pectinate line at bottom

of columns (site ofcloacal membrane)

-- White line where

epithelium changes

-- Three parts (colored)

of external sphincter

(subcutaneous,

superficial, deep) White line


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foregut

midgut

hindgut

thoracic splanchnics

thoracic splanchnics

lumbar splanchnics

SYMPATHTETICPARASYMPATHETIC

Vagus

Vagus

Pelvic splanchnic

King & Showers


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Spinal cord segments for

visceral sensory innervation

of the gut.

T1

T7-9

L1

L5

T10

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, 6thed.,

Saunders,

1969


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Areas of referred pain


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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 painintensifies. 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 canalD. Ischemic necrosis of a loop of small bowel

E. Ischemic necrosis of the cremaster muscle


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Bile and Pancreatic Duct System

Main pancreatic ductfrom ventral bud

Left and right hepatic ducts

Common hepatic ductCystic

duct

(Common) bile duct

Gall stones lodge at sphincter

Of Oddi/major duodenal papilla


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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


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Branches of descending arota?

D i th i it f 73 ld t ffi f i


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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


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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. Yousuggest 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


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Pelvic Organs

Kidney stones

Urogenital diaphragmPelvic diaphragm

C i f kid


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Clinical Symposia, Vol. 38,

No. 3, CIBA-Geigy, 1986

Common sites for kidney

stones to lodge:

Renal pelvis

Common iliac vessels

Entrance to bladder


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rectouterine

rectovesical

A 50 ld l i ffi l


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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 ofthe 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


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Male bladder, urethra, superficial and deep

perineal pouches


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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


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Injury to urethra ABOVEthe

perineal membrane (fracture of

pelvic girdle) results in

blood/urine accumulating in the

DEEP PERINEAL POUCH AND INTHE LOWER PELVIC CAVITY

Injury to the urethra BELOWthe

perineal membrane (straddleinjuries) result in blood/urine

accumulating in the SUPERFICIAL

PERINEAL POUCH, SCROTUM, AND

DEEP TO SCARPAS FASCIA BUT

NOT INTO THE THIGH OR ANAL

TRIANGLE

C t t f


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Contents of

superficial

pouch

Autonomic Innervation of Pelvic


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The sympathetic supply comesprimarily from the superiorhypogastric plexus and itscontinuation, the hypogastricnerve. A smaller contribution

comes from the sacralsplanchnic nerves arising fromthe continuation of thesympathetic trunk.

The parasympathetic supplycomes primarily from thepelvic splanchnic nerves (S2-4)

Autonomic Innervation of PelvicOrgans


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Lymphatics Lymphatic drainage of

any structure in thepelvis or perineumgenerally follows thecourse of its bloodsupply and venousdrainage.

Therefore, drainage ofpelvic organs is mainlyinto nodes distributedalong the branches ofthe internal iliac artery.

Drainage of perinealstructures may be tosuperficial or deepinguinal nodes.

How do lymphaticsfrom the testis reachthe thoracic duct?

Lymph Node Group structures


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Lymph Node Group structures

Lumbar Gonads, uterine tube, fundus of uterus

Internal Iliac Anal canal (above pectinate line)

Inferior rectumBase of bladder

Lower uterus

Upper vagina, cervix

ProstateExternal Iliac Superior bladder

Mid-uterus

Superficial Inguinal Lower limbPerineumscrotum

Anal canal below pectinate line

Deep inguinal Glans

Anatomy Review Part 1

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