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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