Anatomy Flashcards
1
Q
What is contained within the hilum of the lung?
A
PA
PVs x 2
Main bronchus
Pulmonary lymphatics and bronchopulmonary lymph nodes
Pulmonary visceral afferents and autonomic motor nerves
2
Q
What is the path of the phrenic nerves?
A
From C3-C5 descends across the lateral borders of the pericardium to the diaphragm
3
Q
Describe the positions of the phrenic and vagus nerves in relation to the hilum
A
Phrenic nerve anterior to hilum
Vagus nerve posterior to hilum
4
Q
What internally lines the fibrous pericardium?
A
Lined internally by parietal serous pericardium
5
Q
What covers the anterior surface of the heart?
A
Epicardium
6
Q
What does the epicardium secrete?
A
Pericardial fluid lubricant
7
Q
Where is the pericardial cavity?
A
Located between the 2 layers of the serous pericardium - parietal and visceral
8
Q
What is haemopericardium and what does it lead to?
A
When pericardial cavity fills with blood, increasing pressure around heart and can prevent contraction = cardiac tamponade
9
Q
What does the pericardial cavity contain?
A
Pericardial fluid
10
Q
What is pericardiocentesis?
A
Drainage of fluid from the pericardial cavity
11
Q
Where is the needle inserted in a pericardiocentesis?
A
Into ‘bare area of pericardium’ via infrasternal angle and directed superoposteriorly, aspirating continuously
12
Q
Where is the bare area of the pericardium?
A
Below the sternal angle and costal cartilages
13
Q
Describe the transverse pericardial sinus
A
A space within the pericardial cavity, posterosuperiorly, lies posterior to the ascending aorta and pulmonary trunk
14
Q
What vessels are enclosed within the pericardium
A
The most proximal segments of the ascending aorta and pulmonary trunk
15
Q
How does the pericardium close around the ascending aorta and pulmonary trunk
A
Blends with their adventitia
16
Q
Why is the transverse pericardial sinus clinically important?
A
Cardiac surgeons use this sinus to identify and isolate the great vessels in order to commence cardiopulmonary bypass (for open heart surgery)
17
Q
Where does a surgeons finger emerge from the TPS?
A
Anterior to the SVC
18
Q
What are the three surfaces of the heart?
A
Anterior (sternocostal) surface,
Base (posterior) surface, inferior (diaphragmatic) surface
19
Q
What are the borders of the heart? What chambers are at these borders?
A
Right - RA
Left - LV
20
Q
What surface of the heart is in contact with the diaphragm? What chamber covers most of this surface?
A
Inferior
RV
21
Q
What vessel of the heart can only be visualised posteriorly?
A
Left atrium - on posterior surface
22
Q
Where can the apex beat normally be felt?
A
5th left intercostal space in the midclavicular line (mitral area)
23
Q
What does cardiac enlargement do to the heart?
A
Cardiomegaly- often shifts the apex beat to the left
24
Q
What does the coronary groove indicate?
A
Surface marking for the tricuspid valve (boundary between right atrium and right ventricle)
25
What does the anterior interventricular groove indicate?
The boundary between the 2 ventricles
| Holds LAD artery (branch of left coronary artery)
26
What combines to form the brachiocephalic veins? What combines to form the brachiocephlic trunk?
Bilateral internal jugular and subclavian veins
| RIGHT CCA and RIGHT subclavian arteries (unilateral)
27
What combines to form the SVC?
Brachiocephalic veins
28
What is the right auricle?
(ear like structure) Extension of the right atrium
29
What is the left auricle?
Extension of the left atrium
30
Where does the right coronary artery travel?
Within the coronary groove
31
What is the coronary sinus?
Short venous conduit which receives deoxygenated blood from most of the cardiac veins
32
Where does the coronary sinus drain into?
Right atrium
33
Where does the coronary sinus travel?
Within the atrioventricular groove posteriorly
34
What does the posterior interventricular groove contain?
Posterior interventricular artery (branch of right coronary artery) and posterior interventricular vein
35
What does the posterior interventricular groove indicate?
The boundary between the 2 ventricles
36
What is the first branch off the aorta?
Coronary arteries
37
What connects the left and right coronary arteries?
Anastomoses
38
What is the septum between the 2 atria called and indicated by on the surface?
Interatrial septum- interatrial groove
39
What is the septum between the 2 ventricles called and indicated by on the surface?
Interventricular septum- interventricular groove
40
What can an atrial or ventricular septal defect cause?
Hypoxaemia due to mixing of atrial and venous blood
41
What does the mixing of arterial and venous blood do?
Reduces the oxygen content of systemic arterial blood in the aorta
42
What does the crista terminalis separate
Rough and smooth textures
43
Where is the tricuspid valve?
Between right atrium and right ventricle
44
Where is the pulmonary valve?
Between the right ventricle and pulmonary trunk
45
Where is the mitral (bicupsid) valve?
Between the left atrium and left ventricle
46
Where is the aortic valve
Between the left ventricle and the aorta
47
Describe the pulmonary valve
Has anterior right and left cusps
48
Describe the aortic valve
Has right, left and posterior cusps and sinuses (spaces within cusps)
49
Describe the tricuspid valve
Has anterior, posterior and septal cusps
50
Describe the mitral valve
Has anterior and posterior cusps
51
What attached the valve leaflets to papillary muscles?
Tendinous chords
52
What causes the first heart sound?
Mitral and tricuspid valves closing closing
53
What causes the second heart sound?
The closure of the aortic and pulmonary valves
54
What are the sinuses within the aortic valves for?
The coronary arteries
55
What are semilunar valves?
Cusps look like half moons; pulmonary and aortic
56
What are leaflet valves ?
Have valve leaflets held down with teninous chords which attach to papillary muscles, prevent reflux, mitral and tricuspid
57
What does the fibrous skeleton do to the valves?
Provides them with stability
58
What does a moderator band do?
Carries fibres of right bundle branch to the papillary muscle of the anterior cusp (shortcut for electrical activity to make sure all cusps contract and close tricuspid at same time)
59
What is a foetal remnant that can be seen in the right atrium?
Foramen ovale
60
Where do you auscultate for the aortic valve?
2nd right ICS sternal edge
61
Where do you auscultate for the pulmonary valve?
2nd left ICS sternal edge
62
Where do you auscultate for the tricuspid valve?
4th left ICS sternal edge (lower left sternal edge)
63
Where do you auscultate for the mitral valve?
5th left ICS midclavicular line
64
Describe diastole
Blood returns via vena cave to RA and pulmonary veins to LA
Tricuspid & mitral valves open so blood drains into RV & LV
Impulse originates at SA node and spreads across atria
Atrial contraction completes ventricular filling
65
Describe systole
Impulse spreads across ventricles
Ventricles begin to contract – once pressure in ventricles > pressure in atria tricuspid & mitral valves snap shut
Ventricles continue to contract – once pressure in ventricles > pressure in PT & aorta pulmonary and aortic valves forced open and blood ejected into great arteries
Impulse spreads across ventricles
Ventricles begin to contract – once pressure in ventricles > pressure in atria tricuspid & mitral valves snap shut
Ventricles continue to contract – once pressure in ventricles > pressure in PT & aorta pulmonary and aortic valves forced open and blood ejected into great arteries
66
How does autonomic innervation and visceral afferent nerves reach the heart?
Via cardiac plexus
67
What are the two components of the visceral afferent nerves?
```
Pain fibres travel to spinal cord alongside sympathetic nerves(visceral)
Reflex afferents (e.g. from baroreceptors) travel mainly in the vagus nerve (some in CN XI)
```
68
What do pain fibres travel to the spinal cord in?
Cardiopulmonary splanchnic nerves and cardiopulmonary plexus
69
Where is the cardiac plexus located?
Behind the great vessels of the heart
70
What connects the CNS to the ganglion (synapse)?
Presynaptic fibre/ preganglionic fibre
71
What connect the ganglion to the organ?
postsynaptic fibre
72
What is a ganglion?
Collection of nerve cell bodies outside the CNS
73
What are the neurotransmitters of the sympathetic ganglion and post synaptic fibres?
Ganglion=acetyl choline
| PSF= noradrenaline
74
How do sympathetic signals leave the CNS?
1. travel inferiorly within spinal cord tracts and then…
| 2. exit the spinal cord in one of T1-L2/3 spinal nerves (thoracolumbar)
75
What are the 3 most likely options for a sympathetic signal once it leaves the CNS
1. go into the ganglion of that level & synapse
2. travel superiorly in the sympathetic chain to another ganglion & synapse
3. travel inferiorly in the sympathetic chain to another ganglion & synapse
76
What do the cardiopulmonary splanchnic nerves supply?
Sympathetic nerves to heart and lung from spinal cord
77
What type of innervation will a midline organ (e.g. the heart) have?
Bilateral sympathetic innervation
78
What three types of nerve fibres make up the cardiac plexus and where do they come from?
Sympathetic fibres from the cardiopulmonary splanchnic nerves
Parasympathetic fibres from the vagus
Visceral afferent fibres (pain fibres etc)
79
What are the neurotransmitters for the ganglion and post synaptic fibres of the PS system?
Both acetylcholine
80
What are PS post sympathetic fibres very short in the innervation of the heart?
As ganglion on heart wall so PGF dont have to travel very far
81
How do PS signals reach the organs
via Cranial Nerves III, VII, IX & X
82
What is CN III?
Oculomotor nerve
83
What is CN VII?
Facial nerve
84
What is CN IX?
Glossopharyngeal nerve
85
what is CN X?
Vagal nerve
86
Describe the nerve fibres within the CN X nerve?
Presynaptic parasympathetic fibres in vagus nerve then synapse onto postsynaptic neurones (with short axons in ganglia within the walls of the organs of the chest & upper abdomen e.g. heart, lungs)
87
What does the vagus nerve supply ? What is vagal tone?
Heart and other thoracic organs
| Continuous background APs in CNX to reduce HR
88
What spinal nerves do PS also travel in?
Sacral spinal
89
What reflex afferents are in the vagus nerve?
Aortic arch baroreceptor reflex afferents in vagus nerve
90
What are the somatic causes of pain in the central chest and what is it like?
```
Muscular
Joint
Bony
Intervertebral disc
(Fibrous) pericardial nerve typically sharp, stabbing and well localised
```
91
What are the potential visceral causes for central chest pain and what is it like?
```
Heart & Great vessels
Trachea
Oesophagus
Abdominal viscera
typically more dull, aching, nauseating, poorly localised
```
92
Describe radiating pain
```
Pain felt in centre of chest
AND felt spreading from there
-Upper limbs
-Back
-Neck
```
93
Describe referred pain
Pain ONLY felt at site remote from area of tissue damage in the chest
- Upper limbs
- Back
- Neck
94
Where does sensation reach consciousness?
Cerebral cortex
95
What is stimulated in dermatomes to produce sensations?
Skin mechanoreceptors
96
Describe the path of pain
Sensory
- AP propagated centrally
- crosses spinal cord
- CNS (e.g. Anterior ramus, spinal nevre posterior root, crosses side of spinal cord and then comes into contact with cerebral cortex)
97
Why is somatic pain well localised?
Due to precisely (somatotopically) organised pathways from periphery and projections to cortex
98
What is the somatosensory part of the brain and what does it do?
Postcentral gyrus of parietal lobe
| - APs arriving here bring body wall (somatic) sensations into “consciousness”
99
What is the somatomotor part of the brain and what does it do?
Precentral gyrus of frontal lobe
| - APs originating here bring about contractions of body wall (somatic) skeletal muscle
100
What are sources of sharp, somatic central chest pain?
Herpes zoster (shingles), muscle joint and bone, parietal pleura and fibrous pericardium
101
What could cause dull, visceral central chest pain
```
Trachea- tracheitis
Aorta- ruptured aneurysm of aortic arch
Abdominal viscerae- infections
Oesophagus-oesophagitis
Heart- angina and MI
```
102
What sub division of the mediastinum are the great vessels in?
Superior
103
Where does the phrenic nerve run in relation to the hilum?
Anterior
104
Where is the vagus nerve always found on the RHS?
On surface of the trachea, passing posterior to the root of the lung then follows the oesophagus to the diaphragm
105
What does the azygous vein drain into?
SVC
106
What is the path of the vagus nerve on the left hand side?
Crossing left side of aortic arch heading posterior to the lung hilum towards the oesophagus
107
Where is the thoracic duct?
Left side of upper oesophagus
108
From what side of mediastinum can the aorta be visualised?
Left hand side
109
What creates the recurrent layrngeal nerve?
Branch of left vagus nerve that cross the trachea
110
What part of the aorta lies in the posterior mediastinum?
Thoracic aorta
111
Describe the path of visceral afferent APs
Pass bilaterally to thalamus & hypothalamus then diffuse areas of the cortex
112
Alongside what do visceral pain afferents travel alongside going to the organs?
Alongside the sympathetic (motor)
113
Where do visceral pain afferents from the heart enter the spinal cord?
Via posterior roots in the cervical ganglia and T1-T5
114
How does the route visceral afferents lead to radiating chest pain?
As route visceral afferents take from heart via neck & upper thoracic regions of trunk/cord leads to radiating and referred pain from the heart
– due to lack of precision in route taken by visceral afferents to the spinal cord (cant decide between visceral or somatic as they synapse at ganglion in same place)
115
Where do somatic sensory neurons enter the spinal cord in relation to visceral afferents?
In same place (via posterior roots)
116
If pain is originating in a somatic structure the radiation of pain is where?
Along the affected dermatome(s)
117
If pain is originating from the heart where is the radiating pain and why?
Radiation is to the dermatomes supplied by the spinal cord levels at which the cardiac visceral afferents enter the sympathetic chain/spinal cord i.e. BILATERALLY to cervical and upper thoracic dermatomes
118
What is referred pain?
The sensation of pain is “felt” ONLY at a site remote from the actual area of injury or disease
119
What causes referred pain
Due to afferent (sensory) fibres from soma and afferent (sensory) fibres from viscera (visceral afferents) entering the spinal cord at the same levels
The brain chooses to believe that the pain signals coming from the organ, are actually coming from the soma
120
What is a heart attack?
Myocardial infarction (MI) – irreversible death (necrosis) of part of the myocardium due to occlusion of it’s arterial blood supply
121
What are the types of MI?
According to which SURFACE of the heart has been affected, e.g.:
Anterior MI
Inferior MI
Anterolateral MI
122
Where do the coronary arteries arise from?
Right and left aortic sinuses of the ascending aorta
123
What are common sites for coronary atheroscleorosis (narrowing and occlusion especially) (4 in order of likely hood)?
Anterior interventricular branch (LAD) of LCA
RCA
Circumflex branch of LCA
Left (main stem) coronary artery
124
What is triple vessel disease?
Narrowing or occlusion in three coronary arteries, treated by triple bypass
125
Where are coronary artery grafts anastomosed proximally?
To the ascending aorta
126
Where are coronary artery grafts anastomosed distally
To coronary artery distal to narrowing
127
What are three commonly used grafts
Radial artery/internal thoracic (mammary) artery; great saphenous vein
128
What artery is grafted in pedicle and what does this mean?
internal thoracic artery graft (by pedicle meaning a segment not cut from vessel but instead the distal end of the vessel is anastomosed distal to the narrowing leaving the proximal end in situ and receiving blood as normal via the subclavain artery
129
What happens if the blood supply to the conducting system of the heart is reduced= tissue damaged by ischaemia?
Arrhythmia
130
What blood supply feeds the SA node?
RCA near it's origin
131
What blood supple feeds the AV node?
RCA near origin of PIV artery (posterior interventricular artery)
132
What supplies blood to the interventricular septum?
dual supply;
| LAD (left anterior descending) or anterior interventricular artery and posterior interventricular artery
133
What happens is the blood supply to the interventricular septum is compromised?
Arrhythmias
134
What is right and left co dominance?
Territory supplied by left and right coronary arteries right-dominant pattern in ~70%; in up to 35% LCA is dominant and in approx. 20% there exists a co-dominance : i.e. both supply branches that run in the posterior interventricular groove)
135
Which coronary artery gives rise to the posterior interventricular artery?
Right CA
136
What is dysphagia?
Difficulty swallowing
137
What is the mediastinum?
Area between the lungs
138
What divides the superior and inferior mediastinum?
Sternal angle (in between t4 and t5)
139
What structures surround the thoracic inlet?
Ribs 1, T1 vertebra and jugular notch
140
How is the mediastinum divided?
Superior, inferior; anterior, middle and posterior
141
What is the anterior mediastinum between?
Sternum and the fibrous pericardium
142
What gland in contained within the anterior mediastinum?
Thymus
143
What is the role of the thymus is children and adults?
Children- produces T lymphocytes
| Adults- replaced with adipose tissue
144
What is contained within the middle mediastinum?
Pericardium, heart, parts of the great vessels
145
What great vessels attach to the heart and pass through the middle mediastinum?
```
Inferior part of SVC,
Superior part of IVC,
Pulmonary trunk and arteries,
Pulmonary veins,
Ascending aorta
```
146
What is contained within the posterior mediastinum?
Azygous vein, vagus nerves, 2 main bronchi, thoracic aorta, oesophagus, vagal trunks, thoracic duct, sympathetic chains/ trunks
147
What is the role of the azygous vein
Conveys blood from the intercostal veins to the SVC
| Wraps around right main bronchus
148
What is the role of the thoracic duct?
Carries lymph to the left venous angle
149
What is the path of the vagal trunks?
Pass through the diaphragm with the oesophagus onto the stomach
150
What part of the aorta lies within the posterior mediastinum?
The thoracic part
151
Where does the trachea bifurcate?
At the level of the sternal angle (so in the superior mediastinum)
152
Describe how and where the vagus nerves exist
As plexus within posterior mediastinum
153
What nerves are the most lateral?
Sympathetic trunks
154
What can rupture the azygous vein?
Chest trauma
155
Describe the path of the azygous vein?
Arches anteriorly, superior to the lung root to drain into the SVC
156
Where do the intercostal veins drain into?
Drain posteriorly into the analogous vein
157
Where is the azygous vein in relation to the lung root?
Posterior and superior to it
158
When does the descending aorta become the abdominal aorta?
After it passes through the diaphragm
159
What part of the aorta do the carotids come from?
Ascending aorta
160
What are the mediastinal branches of the aorta?
1ST BRANCH: coronary arteries,
brachiocephalic trunk- common carotids and left subclavian,
posterior intercostal ateries (one for each intercostal space),
branches from the thoracic aortas anterior surface;
-bronchial arteries
-oesophageal arteries
-mediastinal arteries
-pericardial arteries
-phrenic arteries (for the diaphragm)
161
Where does the right subclavian artery come from?
Right brachiocephalic artery
162
What is the role of the bronchial arteries?
Arterial blood for the lung tissue
163
What is the aortic hiatus?
Opening in the diaphragm for the aorta
164
What drains into the right venous angle?
Right lymphatic duct
165
What drains into the left venous angle?
Thoracic duct
166
What do the lymph vessels accompany?
Veins
167
How does the lymph drain from the nodes?
Via the bronchopulmonary lymph nodes
168
Where are the bronchopulmonary lymph nodes?
Surround the main bronchus at the lung root
169
How can pulmonary malignancies metastasise?
Via the lymphatics
170
Where are the tracheo-bronchial lymph nodes?
Around the bifurcation of the trachea
171
What is the cisterna chyli?
Swollen start of thoracic duct in abdomen
172
How does the oesophagus pass through the diaphragm?
Oesophageal hiatus
173
Where is the right vagus nerve in the mediastinum?
Sits on lateral surface of the trachea and passes posterior to the root of the lung
174
The right phrenic nerve pass through the _____ with the _____ to supply the _____ from the ______ aspect
Passes through the diaphragm with the IVC to supply the diaphragm from the inferior aspect
175
Where is the left vagus nerve in the mediastinum?
Closely associated with the aorta, lies on top of it then passes posterior to root of lung
176
What is the ligamentum arteriosum?
Remnant of the ductus arteriosus
177
Where is the ligamentum arteriosum?
Between the aortic arch and pulmonary trunk
178
The right phrenic nerve pass through the _____ to supply the _____ from the ______ aspect
Left dome of the diaphragm
Diaphragm
Inferior aspect
179
What is a role of the recurrent laryngeal branch of the left vagus nerve?
Allows us to talk
180
What is the course of the left recurrent laryngeal branch of the left vagus nerve?
Left RLN originates from the left vagus nerve as it crosses the aortic arch.
It then passes posteriorly under the arch and the ligamentum arteriosum then travels back up to larynx
181
List the structures within the superior mediastinum from anterior to posterior
Brachiocephalic veins and SVC, arch of aorta, trachea, oesophagus, thoracic duct
182
List the structures within the superior mediastinum from lateral to medial
Phrenic nerves, vagus nerves, recurrent laryngeal nerves
183
The pressure inside which veins reflect the pressure in the right atrium?
Central veins
184
What are the central veins?
Internal jugular, subclavian, brachiocephalic, superior vena cava, inferior vena cava illiac, femoral
185
What causes the double pulsation in the JVP?
Atrial contraction and then filling of the right atrium against a closed tricuspid valve
186
How high should the JVP be normally at 45 degrees?
No more than 3cm above the sternal angle
187
What does the right recurrent laryngeal nerve hook under?
The right subclavian artery
188
Do either of the reccurent laryngeal nerves enter the chest?
no
189
What are the phrenic nerves made up of?
Combined anterior rami of the cervical spinal nerves 3, 4 and 5 ( keep the diaphragm alive)
190
What does the phrenic supply somatic motor to?
The diaphragm
191
What does the phrenic supply somatic sensory to?
Mediastinal parietal pleura, fibrous pericardium, diaphragmatic parietal pleura, diaphragmatic parietal peritoneum
192
describe referred pain from the diaphragm
Something (liver abscess/ inflammation) irritates parietal peritoneum lining the inferior surface of the diaphragm, which is supplied by the phrenic nerve (C3,4,5).
The supraclavicular nerves (c3,4) supply the dermatomes over the “shoulder tip” and enter the spinal cord at the same levels as the phrenic nerve.
Brain refers pain to skin over the shoulder tip
193
What does the vagus nerves contain?
Somatic sensory nerves, somatic motor nerves, autonomic parasympathetic nerves
194
What structures are supplied with the somatic sensory nerves within the vagus nerves?
Palate, laryngopharynx and larynx
195
What structures are supplied with the somatic motor nerves within the vagus nerves?
Pharynx and larynx
196
What structures are supplied with the autonomic parasympathetic nerves within the vagus nerves?
Thoracic and abdominal organs
197
What do the vagus nerves contain after the recurrent laryngeal branches branch off?
Only parasympathetic fibres
198
Where do the anterior intercostal arteries come from?
Thoracic artery
199
Where do the posterior intercostal arteries come from?
Thoracic arota
200
What is the superficial vein of the upper limb?
Cephalic vein
201
Where do the anterior intercostal veins drain into?
Thoracic vein
202
Where do the posterior intercostal veins drain into?
Azygous veins
203
What is the peripheral pulse in the neck and where is it found?
Bifurcation of the common carotid
| Anterior to sternocleido-mastoid muscle at level of superior border of thyroid cartilage
204
What peripheral pulses are in the upper limb and where are they found?
Brachial- medial to biceps brachii tendon in the cubital fossa
Radial- lateral to tendon of flexor carpi radialis
205
What peripheral pulses are in the lower limb and where are they found?
Femoral artery-inferior to midpoint of inguinal ligament
Popliteal artery-in popliteal fossa (immediately posterior to knee joint)
Posterior tibial artery-between the posterior border of the medial malleolus & the achilles tendon
Dorsalis pedis artery (dorsal artery of the foot) - medial to tendon of extensor hallucis longus on the dorsum of the foot
206
What are allows arterial access to the (left side) of the heart and their uses?
```
Radial artery (cannulation for ABP/ABG)
Femoral artery (intravascular interventions)
Subclavian artery (cardiac pacing wire)
```
207
What are allows venous access to the (right side) of the heart and their uses
```
Inferior jugular vein (central line)
Femoral vein (central line and intravascular interventions)
```
208
Which branch of the RCA points towards the apex?
Marginal artery
209
What are the main branches of the LCA?
LAD artery
| Circumflex artery
