close

Вход

Забыли?

вход по аккаунту

?

Anatomy review Part 1. Thorax and Abdomen

код для вставкиСкачать
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)
В© 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
Anterior Schematic
Left pulmonary
artery
Superior
vena cava
Aorta
R. pulmonary
artery
Right atrium
is the right
margin of the heart
Pulmonary
trunk
Right ventricle
is anterior
Inferior vena cava
Descending aorta
Pulmonary veins
Left ventricle is the
left margin
Left atrium is
posterior against
esophagus.
Grant’s Atlas of Anatomy,
Williams & Wilkins, 9th ed., 1991
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
Grant’s 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
Superior lobar
Rt. Superior lobar
Middle lobar
Inferior lobar
MAIN
Inferior lobar
Tertiary bronchi—one for
each BPS
Inhaled objects generally are found in right bronchus due
to straighter pathway
Muscles of Respiration
Scalenes & SCM
Pec minor
Serr. Ant.
Int. intercostal
Ext. intercostal
Diaphragm
C3-5 phrenic
nerve
Inspiration
abdominals
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
2
1
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)
Direct (Acquired)
Follows path of processus
vaginalis through inguinal canal
NOT through the inguinal
canal
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 lateral to inferior
epigastric artery.
Medial to inferior epigastric
artery
20x more in males
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)
Para-umbilical
veins–
superficial
epigastric veins
(caput
medusa)
Esophageal veins–
azygous system
(hemorrhage)
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
Vagus
Vagus
SYMPATHTETIC
foregut
thoracic splanchnics
midgut
thoracic splanchnics
Pelvic splanchnic
hindgut
lumbar splanchnics
King & Showers,
Human Anatomy &
Physiology, 6th ed.,
Saunders,
1969
Spinal cord segments for
visceral sensory innervation
of the gut.
Note:
T1
-- Thoracic splanchnics do
foregut and midgut
T7-9
-- Lumbar (and pelvic
splanchnics) do hindgut/
pelvis
-- Few spinal segments for
all of small intestine
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 SCARPA’S 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
Gonads, uterine tube, fundus of uterus
Internal Iliac
Anal canal (above pectinate line)
Inferior rectum
Base of bladder
Lower uterus
Upper vagina, cervix
Prostate
External Iliac
Superior bladder
Mid-uterus
Superficial Inguinal
Lower limb
Perineum—scrotum
Anal canal below pectinate line
Glans
Deep inguinal
Документ
Категория
Презентации
Просмотров
17
Размер файла
6 618 Кб
Теги
1/--страниц
Пожаловаться на содержимое документа