Clinical Correlations Interval 3

Question 1

Stabbing in 4th intercostal space, just left of sternal border, distended neck

Answer 1

Cardiac Temponade

Question 2

Kussmaul’s Sign

Answer 2

Distention of veins of the neck during inspiration

Question 3

Atherosclerosis: what is it and where do coronary arteries anastamose?

Answer 3

Artery wall thickens due to accumulation of fatty materials

End-arteries: arteries that do not anastamose. Abstruction of these would cause necrosis

RCA and LCX anastamose
PDA and LAD anastamose (LAD travels around apex)

Question 4

Fracture of the 10th rib: what organ was likely affected

Answer 4

Spleen! Sits at ribs 9-11. 10th rib lies along the long axis of the spleen

Question 5

A chronic duodenal ulcer might rupture which artery?

Answer 5

Gastroduodenal artery, which decends posterioraly to the 1st part of the duodenum

Question 6

What is a common site for ischemic bowel infarction?

Answer 6

Splenic flexure (point where transverse colon becomes the descending colon)

Ischemic bowel infarction means that the blood supply was cut off. The splenic flexure is where the middle colic and left colic arteries anastamose

Question 7

Where is McBurney’s point and what is it’s significance?

Answer 7

McBurney’s point is 1/3 of the way from the ASIS to the umbilicus. It is where there is pain due to appendicitis.

There is also pain at the lower splanchnic T10 dermatome: the umbilicus

Question 8

Name two types of problems that can cause appendix pain

Answer 8

1. Fecalith: stool obstructs the appendix (adult)

2. Hyperplasia of the lymphatic tissue (kids)

Question 9

Name the boarders of the heart

Answer 9

Right border: right atrium, SVC, IVC

Left border: left ventricle and left auricle

Inferior border: juncture between anterior surface and diaphragmatic surface. Mainly right ventricle

Superior border: left and right atria and the ascending aorta, pulmonary trunk and SVC

Question 10

Where would you put your fingers on a person to approximate the normal surface projection of the heart and pericardial sac

Answer 10

Place your fingers on the sternal angle, the xiphisternal joint and the apex impulse

Question 11

Myocardial infarction

Answer 11

Myocardial infarction (heart attack) results from localized avascular necrosis of cardiac muscle cells caused by prolonged ischemia

Usually due to LAD occlusion. Less commonly the RCA and LCX occlusion

Symptoms:
Sudden, severe pain beneath the sternum

Treatment:
Open up the stenosed vessel ASAP

Question 12

AV block

Answer 12

In complete block, atria and ventricular contraction become dissociated and these chambers beat independently

Question 13

Angina Pectoris

Answer 13

Severe chest pain

-T1-T4/5 refer pain to left arm and thorax

Question 14

What is Beck’s Triad?

Answer 14

1. Hypotension
2. Muffled heart sounds
3. Increased central venous pressure

Suggests cardiac tamponade

Question 15

What is the anatomic reason trans-esophageal echocardiography can provide excellent cardiac images?

Answer 15

This can image the great vessels, heart valves, both atria, atrial septum and coronary arteries

The thoracic esophagus is located directly behind the left atrium and is separated from the heart only by pericardium. Thus, the ultrasound beam only has to go a few mm, instead of through your entire chest

Question 16

Where in the chest wall should you place a stethoscope to hear valve sounds?

Answer 16

Aortic: right 2nd intercostal space at the sternal margin

Pulmonic: left 2nd intercostal space at the sternal margin

Mitral: left 5th intercostal space at the cardiac apex

Tricuspid: left 5th intercostal space at the sternal margin

Question 17

What anatomic structures are currently used to bypass obstructed coronary arteries?

Answer 17

Saphenous vein segments (superficial veins in the leg)

Right and left internal thoracic arteries

Radial arteries (on arm)

Question 18

What physiologic aberrations can occur if papillary muscle rupture occurs after an acute myocardial infarction?

Answer 18

Mitral or tricuspid regurgitation

Question 19

At what point in the cardiac cycle the 2 coronary ostia receive blood?

Answer 19

Coronary ostia are the aortic sinuses that mark the beginning of the coronary artery ???????

During diastole, when the aortic valves are closed

Question 20

Danger of tachycardia

Answer 20

Tachycardia is a fast heart rate, it impinges on diastole, shortening the time of coronary flow

Question 21

What is the significance of accessory spleens?

Answer 21

10% of the population has accessory spleens

In the surgical removal of the spleen, an accessory spleen may enlarge and result in failure of the primary splenic issue to resolve. These must be removed along with the primary spleen

These are often found in the hilum of the spleen or adjacent to the pancreatic tail, in the gastrosplenic ligament, greater omentum, or splenorenal ligament

Question 22

What is a Kocher maneuver?

Answer 22

The point is to expose structures in the retroperitoneum behind the duodenum and the pancreas

1. Peritoneum is incised at the right edge of the 2nd portion of the duodenum
2. The 2nd portion of the duodenum and the head of the pancreas are reflected left

• this exposes structures in the retroperitoneum
  3. The duodenum and pancreatic head are moved, allowing for surgery on a bleeding ulcer (for example)

Question 23

What is the surgical significance of the marginal artery of Drummond?

Answer 23

The marginal artery is formed when the ascending and descending branches of the SMA and IMA anastamose

This is an important source of collateral blood supply to the colon if the SMA, IMA or their branches are blocked

Question 24

What is the anatomic usefulness of the coronary sinus in biventricular cardiac pacemakers?

Answer 24

The RV, LV and RA are paced due to dysynchronos contraction due to heart failure

Introduce a lead transvenously into the coronary sinus and advance the tip into the epicardial vein on the lateral wall of the LV to pace the heart

Question 25

Bradycardia

Answer 25

Leads to decreased perfusion of vital organs (ventricles beat slowly)

Question 26

What is cardiac temponade?

Answer 26

Fluid in the pericardiac cavity that compresses the chambers of the heart

Consequences:

1. Decreased venous return and reduced cardiac output
2. Heart chambers are compressed
3. Neck veins are distended
4. Thin-walled atria cannot fill

Treatment:
1. Pericardiocentesis at the left xiphocostal angle

Question 27

Danger of surgical appendix removal? (appendectomy procedure)

Answer 27

The iliohypogasatric nerve may be lesioned. This would cause a weakening of the anterior abdominal wall, causing a direct hernia

Question 28

Atrial Fibrillation

Answer 28

Chaotic atrial heart beat

This can cause a clot within the left atrium