Lab test for Thorax, Abdomen, & Pelvis Flashcards
acromion
off of spine, articulates with clavicle, prominence of shoulder, proximal point at which clinicians measure the length of the upper limb
anterior, posterior intercostal a.
part of the intercostal VAN that anastomose from internal thoracic and descending aorta, respectively. The IMAs/ITAs give off anterior intercostal arteries to each space. The posterior intercostal arteries arise from the descending aorta. Lower rib and intercostal arteries blood supply lateral
auscultation points of heart
aortic R parasternal ICS [intercostal space] 2, pulmonic L parasternal 2-5 (2-3 L intercostal); tricuspid lower R (L possible too) sternal border near origin of xiphoid process; mitral around cardiac apex ICS 5, 8-10 cm L of midsternal line. These listening points are placed wide apart, and blood carries the sound in the direction of the flow (aortic and mitral are deep, so listen to where blood nearer chest wall): Aortic valve (A): 2nd intercostal space to right of sternal border, Pulmonary valve (P): 2nd intercostal space to left of sternal border, Tricuspid valve (T): near left sternal border in 5th or 6th intercostal space, Mitral valve (M): apex of heart in 5th intercostal space in midclavicular line
breast, nipple, areola (
areola, pigmented region around nipple. (mammary gland) develops as a branching ingrowth of (approximately twenty) lactiferous ducts and gland lobules into the subcutaneous tissue. Note that there is a bit of a bursa/retromammary space between breast and pectoralis major muscle, but otherwise, the breast is not encapsulated. The mammary gland (breast) will develop as an ectodermal thickening in a mammillary ridge/milk line. This helps to explain polythelia. Developmental milk ridge in mammals- primates have two other mammals have more and may have something else on midclavicular line as third nipple. Breasts are the most prominent surface features of the anterior thoracic wall, especially in women. Their flattened su- perior surfaces show no sharp demarcation from the anterior surface of the thoracic wall; however, laterally and inferiorly, their borders are well defined. The anterior me- dian intermammary cleft is the cleavage between the breasts. The nipple in the midclavicular line is surrounded by a slightly raised and circular pigmented areaÑthe areola. The color of the areolas varies with the womanÕs complexion; they darken during pregnancy and retain this color thereafter. The nipple in men lies anterior to the 4th intercostal space, about 10 cm from the anterior median line. The position of the nipple in women is inconstant and so is not reliable as a surface landmark.
cephalic v.
same one as ant. lat. surface of armˆ axillary v.
clavicle with clavipectoral (deltopectoral) triangle
first bone to ossify; most commonly broken; lung apex projects 2-4 cm above. The triangle is where pectoralis, deltoid, and clavicle define where the cephalic vein penetrates. lie subcutaneously, forming bony ridges at the junction of the thorax and neck. They can be palpated easily throughout their length, especially where their medial ends articulate with the manubrium.
coracoid process (scapula)
superior to glenoid cavity, ant. lat. (associated with pect. minor)
costal cartilage
cartilage between rib and sternum, can be inflamed with costochondritis (inflammation of costal cartilage) most commonly radiates to right shoulder or ulnar aspect of right hand.
costal groove
show separate rib piece, VAN (sup. to inf.) nerve not totally covered by rib where. neurovascular bundle is hanging out of the intercostal vein, artery, nerve will run through that space. Pain, broken rib, or shingles, set up by costal groove in nerve artery pain pattern can infiltrate region close but not too close to impact nerve. Collateral branch on top of ribs. Nerves underneath costal groove larger than below. shingles is a classic condition demonstrating the dermatome. Herpes zoster virus invades and becomes latent in its home of sensory neuron cell bodies in the dorsal root ganglion, and upon reactivation, will skin involvement along that dermatome.
external intercostal m.
fibers in same direction as external oblique m. of abdomen; help to elevate ribs in inspiration. slanting in the same direction as the more-familiar external oblique muscles of the abdomen, will help to pull up the rib cage with forced inspiration,Ê
intercostal v., a., n.
ant. intercostals send branches through intercostal mm to supply pectoral region. Intercostal veins drain into the azygos vein. The nerves are ventral rami of T1-11 (T12 subcostal n). Note the schematic of the neurovascular bundle of vein, artery, nerve (VAN) traveling in the costal groove, with smaller collateral branches on the superior part of the rib. The intercostal nerves help to delineate the segmental nature of the thoracic dermatomes. Note that a dermatome represents the sensory fibers from one dorsal root (and so, one dorsal root ganglion). Superior intercostal veins go anteriorly. Posterior intercostal veins hit the Azygous (unpaired vein) into superior vena cava. internal thoracic veins will drain the anterior intercostal veins
internal intercostal m.
more like internal oblique mm., more expiratory in function. (the deep transverse muscle layer of the innermost intercostal muscles is mostly fascial in the rib region). with their slant in the same direct as the internal oblique muscles, will tend to pull down the ribs with forced expiration.
internal thoracic a., v.
supply breast, ITA (IMA; internal mammary artery) turns into superior epigastric a. past xiphoid process underneath rectus abdominus w/in rectus sheath. Breast tissue is supplied by internal thoracic, intercostal, and lateral thoracic arteries, with paralleling veins, although most of the venous drainage is to the axillary vein. breast material have lateral thoracic supply, branches of superior intercostal. Most of the blood supply medial supply internal thoracic or mammary arteries, several vascular avenues to the breast. Auxiliary palpation driven by tail of Spence because of overall involvement of vessels of auxiliary arteries supply breast along with the lymph nodes draining along that direction. Looking for concern of micrometastasies because of extensive vascular and lymphatic supply to the breast.
jugular notch (suprasternal notch, sternal notch)
easily found landmark in the superior manubrium
lactiferous duct (
drainage for each lobule (about 14-20) of breast. lobules of mammary glands- smaller than in someone who is lactating. Female breast as gland, adipose, suspensory tissue, ductwor and glands.Ê
pectoralis major m.
medially rotate, adduct, flex humerus (more details with upper extremity)
pectoralis minor m.
O anterior of ribs 3-5, I coracoid process, N medial pectoral n, A protracts and depresses glenoid end of scapula
retromammary space (bursa)
potential space between breast and pectoralis muscles, such that breast tissues is not formally encapsulated. Breast embedded in skin might be a bit of a bursa (thin synovial sac should be fairly large but is flattened) between it and pectoralis
rib, head, neck
3 contact points, T5, T4, transverse T5; all synovial joints, articular cartilage, etc. Note the articular facets on the head for articulation with the vertebral body. bony thorax or rib cage protects the heart, lungs, and great vessels of the thoracic cavity. Articular components of the ribs and the sternum allow for expansion/contraction of the thoracic wall in respiration
serratus anterior m.
protracts scapula and holds it against thoracic wall; winging with limb abduction when paralyzed
sternal angle
bifurcation of trachea at this level; 2nd rib joins in here. In addition, the sternal angle will help to highlight the start of the aortic arch and the location of the mainstem bronchi. aortic arch, mainstream bronchi
sternoclavicular joint
strongly supported articulation between upper extremity and axial skeleton, assists in shoulder movement
sternum, manubrium, body, xiphoid process
Rib 1 travels deep to the clavicle at the manubrium. Rib 2 junction at the sternal angle. Body a possible marrow source for biopsy; xiphoid process a target to place your hand superior to for CPR. also lies subcutaneously in the anterior median line and is palpable throughout its length. The manubrium of the sternum ¥ Lies at the level of the bodies of T3 and T4 vertebrae ¥ Is anterior to the arch of the aorta, ¥ Has a jugular notch that can be palpated between the promi-nent sternal ends of the clavicles, ¥ Has a sternal angle where it articulates with the sternal body at the level of the T4ÐT5 intervertebral (IV) disc. The sternal angle is a palpable landmark that lies at the level of the second pair of costal cartilages. The main bronchi pass inferolaterally from the bifurcation of the trachea at the level of the sternal angle. The sternal angle also demarcates the division between the superior and inferior mediastina and the beginning of the arch of the aorta. The superior vena cava passes inferiorly deep to the manubrium, projecting as much as a fingerbreadth to the right of this bone. The body of the sternum lies anterior to the right bor- der of the heart and vertebrae T5ÐT9. The xiphoid process lies in a slight depression (the epigastric fossa) where the converging costal margins form the infrasternal angle. The costal margins, formed by the medial borders of the 7thÐ 10th costal cartilages, are easily palpable where they extend inferolaterally from the xiphisternal joint. This articulation, often seen as a ridge, is at the level of the inferior border of the T9 vertebra.
suspensory (Cooper) ligaments of breast (
reach from deep fascia to dermis, defining the lobes (and shaping the breast). enlarged versions of skin ligaments.Ê
true rib, false rib, floating rib
ribs 1-7 directly connect to the sternum, hence are true, with ribs 8-12 more indirectly or not connected or false ribs, Ribs 11-12 are floating or vertebral ribs without any cartilaginous connection to the sternum.. ribs 1-7 true, 8-10 false, 11-12 floating, angle pt of greatest curvature and hence most likely to break there, note the facets on the tubercle for articulation with the transverse process.
tubercle of rib, body, angle
The 1st rib cannot be palpated because it lies deep to the clavicle; thus, count the ribs and intercostal spaces anteriorly by sliding the fingers laterally from the sternal angle onto the 2nd costal cartilage. Start counting with rib 2 and count the ribs and spaces by moving the fingers inferolaterally. The 1st intercostal space is inferior to the 1st rib; likewise, the other spaces lie in- ferior to the similarly numbered ribs.
apex of lung
round, tapered superior end of lung, above clavicle. projects 2 to 4 cm above the medial clavicle, and so are potentially vulnerable to be punctured in that area
bronchopulmonary segments (I will not require memorization of the separate ones)
While not for anatomy, look for an example of tertiary bronchi and the surrounding material; useful to know for extensive thoracic work, e.g., CXR, cardiothoracic surgery.
costodiaphragmatic pleural recess
not occupied in quiet respiration parts, potential spaces for fluid accumulation, e.g., hemothorax.
hilum of lung
where the root is attached to the lung. e entrance of pulmonary arteries and bronchi, as well as the exit of pulmonary veins
horizontal fissure
separates superior and middle lobe in R lung
lobar (secondary) bronchus (bronchi)
so 2 on L, 3 on R.
lobes of lung (name them)
surrounded by visceral pleura, a sub lung with a secondary bronchus (tertiary bronchi have bronchopulmonary segments not separated by the folds of visceral pleura). Right lung with superior, middle, inferior lobes; left lung with superior and inferior lobes. The lobes of the lungs (three in the right, two in the left) are further divided into bronchopulmonary segments as the vessels and airways continue to branch out. Branching into lobar and broncholobar segments> pulmonary veins to left atria coming into 4 veins coming back into it.
lung
fills pleural cavity. Pleura and Lungs- The cervical pleurae and apices of the lungs pass through the superior thoracic aperture into the root of the neck superior and posterior to the clavicles. The anterior borders of the lungs lie adjacent to the anterior line of reflection of the parietal pleura between the 2nd and 4th costal cartilages (Fig. SA1.4). Here, the margin of the left pleural reflection moves laterally and then inferiorly at the cardiac notch to reach the level of the 6th costal cartilage. The anterior border of the left lung is more deeply indented by its cardiac notch. On the right side, the pleural reflection continues inferiorly from the 4th to the 6th costal cartilage, paralleled closely by the anterior border of the right lung. Both pleural reflections pass laterally and reach the midclavicular line at the level of the 8th costal car- tilage, the 10th rib at the midaxillary line, and the 12th rib at the scapular line, proceeding toward the spinous process of the T12 vertebra. Thus, the parietal pleura extends approximately two ribs inferior to the lung. The oblique fissure of the lungs extends from the level of the spinous process of the T2 vertebra posteriorly to the 6th costal cartilage anteriorly, which coincides approximately with the medial border of the scapula when the upper limb is elevated above the head (causing the inferior angle to be rotated laterally). The horizontal fissure of the right lung extends from the oblique fissure along the 4th rib and costal cartilage anteriorly.
oblique fissures
separates inf/sup lobes of L lung, and inf lobe of R lung from middle, superior lobes
parietal pleura
adherent to thoracic wall (separable by thin layer of endothoracic fascia), diaphragm, and pericardium. lining the body wall aspect of the pleural cavity would be innervated by intercostal nerves
pleural sacs (cavities)
lung is surrounded by a pleural sac, pleural cavity a closed, potential space containing pleural fluid. two pleural cavities and a pericardial cavity. The parietal pleura lining the body wall aspect of the pleural cavity would be innervated by intercostal nerves, in contrast to the visceral pleura covering the lungs. This overall pattern is generated by the formation of the lungs embryologically Òbudding offÓ inferior to the pharyngeal arches into the developing cavity, if you remember the image from head and neck embryology. The pleural cavities are separated from each other via the mediastinum.
primary (main) bronchus, l. and r.
R is wider, more vertical than L, so aspirated material there
pulmonary a
., v. 2 pulm veins each side, superior, inferior
segmental (tertiary) bronchus (bronchi)
those bronchi supplying bronchopulmonary segments
visceral pleura
closely adherant to all of the lung, continuous with parietal pleura at root of lung
anterior interventricular branch of l. coronary a. or left anterior descending a. (LAD, but write out for a lab practical)
in interventric groove, supplying ant. septum and ant. LV wall
aortic semilunar valve
thicker valves than pulmonary valves; just superior to the valves are the origins of the coronary a. have cusps
apex vs. base of heart
apex is blunt, formed by LV, L 5 ICS, medial to L MCL [mid clavicular line]; base is posterior, mostly LA (think of the body in a supine position to help orient for that). NOTE the inferior surface of the heart is diaphragmatic. The heart developmentally rotates to the left, so note that the apex of the heart is dominated by the left ventricle and aiming anterolaterally. The apex beat is an impulse that results from the apex being forced against the anterior thoracic wall when the left ventricle contracts. The location of the apex beat (mitral area) varies in position; it may be located in the 4th or 5th intercostal spaces, 6Ð10 cm from the midline of the thorax. In contrast, the base of the heart would be posterior, and is dominated by the left atrium. The diaphragmatic surface of the heart would be dominated by the inferior aspect of the left ventricle. heart developmentally rotates to the left, so note that the apex of the heart is dominated by the left ventricle and aiming anterolaterally. In contrast, the base of the heart would be posterior, and is dominated by the left atrium.
ascending aorta, arch
R-L, brachiocephalic trunk dividing into left and right common carotid arteries, L common carotid, L subclavian a. off of the arch
atrial branch of r. coronary a.*
supplying right atrium.Ê
atrioventricular groove (coronary sulcus)
where the RCA runs through, encircles superior part of heart, separates atria from ventricles
atrioventricular node position
interatrial septum on the ventricular side of the coronary sinus orifice
chordae tendineae
threads from papillary mm, prevent cusp inversion in systole
circumflex branch of l. coronary a. (l. circumflex a.)
L border of heart to poster. surface, commonly anastomosing with RCA, so LA and left surface of heart
coronary sinus
main vein of heart post. part of coronary groove, other cardiac v. drain into this.
crista terminalis
lymphoid organ, not from gut tube, removes abnormal RBCs, stores Fe from recycled RBCs, and initiates immune responses. Worry about rupture with L thoracoabdominal injuries, esp. if already enlarged, e.g., mononucleosis.
diastole
ventricular filling once the AV valves open as the pressure in the ventricles drop, with a final contraction of the atrium for the last filling. Blood goes from point of low to high pressure so in diastole as relaxing and letting ventricles fill pressure drop semilunar valves, AV valves open allowing blood to fill w/ a finally squeeze 20% of blood from atrial contraction. P wave indicates the electrical stimulation before the atrial contraction that finishes diastole.
fossa ovalis
remnant of the fetal foramen ovale, directionally “in line” with blood entering from IVC. Fossa ovaliis remanant of foramen ovale that allowed us to bypass blood when we were in utero. Musculature different so much of atrial wall smooth, once in ventricles of heart loglike meaty appearance with traveculae carnae squeezing more of th eblood out.Ê
great cardiac v.
travels with LAD, then L circumflex a. to reach coronary sinus
inferior vena cava
drains inf. body. Before birth, IVC valve aimed towards foramen ovale (valve on inf side, nonfunctional after birth).
interventricular grooves, anterior and posterior
separates ventricles
interventricular septum and membranous septum with a thin membranous component superiorly. The ventricular walls are dominated by broken up trabeculae carneae.
contains conduction system; membranous portion is where VSDs more likely to occur, superior towards aortic valve. a thin membranous component superiorly. with a thin membranous component superiorly. The ventricular walls are dominated by Òbroken upÓ trabeculae carneae.Ê
left atrium
auricle primitive part, 4 pulmonary v. enter. Oxygenated blood through pulmonary veins will return to the heart into the left atrium. softer walled lower pressure affecting them, right ventricle thinner than left. auricles of the atria will have pectinate muscles, but much of the atrium has a smooth surface
left border of heart
LV on CXR. corresponds to a line connecting the left ends of the lines representing the superior and inferior borders.
left coronary a.
between L auricle and pulm trunk to reach coronary groove. Supplies most of LV and LA and IV septum (including AV bundles). Blood supply to heart: in general, coronary arteries form an upside-down “crown” around the heart, with the coronary arteries lying in grooves or sulci. Both left and right coronary arteries arise from small openings in the aortic sinuses just above the semilunar valve cusps. anterior interventricular (left anterior descending) branch, and circumflex branch, supplying most of left ventricle. arise from small openings in the aortic sinuses just above the semilunar valve cusps.
left marginal a.
off of circumflex, to follow left heart border and lateral left ventricle
left ventricle
thick-walled to generate pressures for systemic circulation. Diastole: ventricular filling once the AV valves open as the pressure in the ventricles drop, with a final contraction of the atrium for the last filling Systole: ventricular contraction, with the AV valves closing to prevent eversion of blood into the atria, and when pressure is high enough, opening of the semilunar valves, which will then shut as the pressure drops in the ventricle with relaxation. P wave indicates the electrical stimulation before the atrial contraction that finishes diastole. QRS complex: the depolarization of the ventricles before they contract, with S1 indicating that the AV valves are closing. T wave: ventricular repolarization, then the ventricle relaxes, setting up the semilunar valve closure of S2. Also note the fibrous skeleton of the heart, to help anchor the valves as well as insulate between the atria and ventricles so that electrical activity normally goes through the AV node. Electrical activity prior to mechanical activity. P wave squeeze of diastole. Ventricular depolarizzation first valves to shut and mechanical traction across heart and subsequent wave fo repolarization, T wave, as thatÕs happening relaxation of mechanical activity of ventricles dub quick sharpr sound of aortic and pulmonic valve. Fibrous ring supporting valve- electrically preferntially drive all activity through AV node so atria depolarize AV node giving time to fill and then have ventricular depolarization. Blood goes from point of low to high pressure so in diastole as relaxing and letting ventricles fill pressure drop semilunar valves, AV valves open allowing blood to fill w/ a finally squeeze 20% of blood from atrial contraction. Inceasing our pressure within ventricle into systolic chordae tendinae preventing from everting into atrium. Pressure rises until pressure overcomes those
ligamentum arteriosum
remnant of ductus arteriosus in fetus. From pulm art to descending aorta. Often a site near coartaction; also a potential tethering site of aorta in trauma and subsequent rupture.
middle cardiac v.
travels with posterior interventricular a. to coronary sinus
mitral (bicuspid) valve
AV valve on left side, the valve most commonly affected by rheumatic fever (RF). AV valves have striking w/ large leaflets parachute chords (chorae tendinae) with papillary muscles holding it into place. Three valves on right similar to three lobes of lung on left. Two on right for both heart and lung.Ê
moderator band (septomarginal trabecula)*
crosses from IV septum to ant. papillary mm., carries some of R branch of AV bundle
nodal a. (sinus node a.)*
supplies SA node in majority of people–off of RCA and its atrial branch
papillary m.
conical projections mentioned above with bases attached to wall of ventricle
parietal pericardium (
part of serous pericardium, underneath fibrous pericardium (inelastic and protective electrically preferntially drive all activity through AV node so atria depolarize AV node giving time to fill and then have ventricular depolarization. ). The pericardiacophrenic a. (off of internal thoracic a.) and vein travel with the phrenic n.
pectinate m.
anterior part with rough mm. edges, smooth part (sinus venarum) where the sinus venosus has grown in, developmentally speaking
pericardial cavity
potential space with some serous fluid; cardiac tamponade as a concern. Pericardial cavity- media stinum. Pleura little thin simple squamous epithelium of lungs (visceral) compared to the side of the body wall (parietal) different pleura. To innervate body wall have innercostal nerves, will be able to identify pretty tightly. If something more visceral more indirect and less innervated- throbbing hurting type pain. Superficial to deep: pericardium, the sac that covers the heart, consists of two parts: outer fibrous pericardium, inelastic and protective; inner serous parietal pericardium. pericardial space (cavity), with lubricant serous fluid (normally 15-50 mL). Heart covered with visceral (hard to tell pain), pericardial sac more parietal (phrenic nerve tell you pain coming from there) slippery layer so visceral and parietal side are not rubbing too much up against eachother. with lubricant serous fluid.
posterior interventricular branch of right coronary a. (posterior descending a.)
the largest branch of RCA, supplies both ventricles in that region
pulmonary semilunar valve
ant., right, left cusps.
pulmonary trunk and artery
R, L pulm arteries, with branches to lobar and segmental branches
pulmonary v.
open to post. aspect of LA (bronchial veins of lung tissue into azygos system for comparison)
right atrium
primitive RA is the auricle. Deoxygenated blood collected here. Right ventricle thinner in contrast to left (120/80), lungs have much lower blood pressure even if same amount of blood is going through at the same time. auricles of the atria will have pectinate muscles, but much of the atrium has a smooth surface. the right atrium, note the fossa ovalis, a remnant of the foramen ovale.
right border of heart
RA, e.g., on CXR [chest x-ray). corresponds to a line drawn from the 3rd right costal cartilage to the 6th right costal cartilage; this bor- der is slightly convex to the right.
right coronary a.
found in AV groove, supplies right side of heart and nodes (see separately listed branches). Overall, RCA supplies RA, RV; SA and AV nodes (in most people). runs in coronary groove between right auricle (part of atrium), with a marginal branch and posterior interventricular (descending) branch. The RCA supplies both (over half of population) the sinoatrial node (sinuatrial node, SA node) and (for most of population) the atrioventricular (AV) node. arise from small openings in the aortic sinuses just above the semilunar valve cusps.
right ventricle
tapers into conus arteriosus before pulm. Trunk, generates lower pressures than RV. The right ventricle will pump deoxygenated blood through pulmonary arteries into the pulmonary circulation around the alveolar sites of gas exchange. This is a low pressure system, with a systolic/diastolic of ~ 25/8 mm H. Right ventricle thinner in contrast to left (120/80), lungs have much lower blood pressure even if same amount of blood is going through at the same time.
right marginal branch of r. coronary a. (right marginal a.)
to supply R wall.
sino(u)atrial node position
lateral RA where SVC enters, near muscle ridge
small cardiac v.
paralleling right marginal artery and diaphragmatic RCA to drain into coronary sinus
superior vena cava
superior vena cava returns blood from superior part of body forelimbs, head, neck, and most of abdominal and thoracic body wall, with contributing tributaries of azygos and brachiocephalic veins. SVC receives inputs from brachiocephalic veins and from azygos vein.
systole
ventricular contraction, with the AV valves closing to prevent eversion of blood into the atria, and when pressure is high enough, opening of the semilunar valves, which will then shut as the pressure drops in the ventricle with relaxation. Inceasing our pressure within ventricle into systolic chordae tendinae preventing from everting into atrium. Pressure rises until pressure overcomes those from the semilunar valves of the pulmonary and aorta systolic pressure heading on out. QRS complex: the depolarization of the ventricles before they contract, with S1 indicating that the AV valves are closing. T wave: ventricular repolarization, then the ventricle relaxes, setting up the semilunar valve closure of S2. , T wave, as thatÕs happening relaxation of mechanical activity of ventricles dub quick sharpr sound of aortic and pulmonic valve
trabeculae carneae
trabeculae carneae Òfleshy little timbersÓ, anchored only at ends highlights primitive spongy characteristics of myocardium squeezes more blood out of ventricles
tricuspid valve
AV valve of the right heart
visceral pericardium (epicardium)
part of serous pericardium, superficial to myocardium
anterior vs. posterior walls of trachea
posterior wall muscular, so possibility of erosion with chronic intubation.
azygos v.
drains posterior wall of thorax on right side, drains into SVC. Internal thoracic veins will drain the anterior intercostal veins, but the unpaired posterior veins of azygos vein on the right drain the posterior intercostal vein
brachiocephalic a.
(also seen as innominate artery or brachiocephalic trunk) soon divides into r. subclavian a., r. common carotid a.
carina
keel-like ridge between the bronchal orifices, sensitive so cough reflex. Distortions seen in bronchoscopy imply disease process, e.g., from enlargement of tracheobronchial lymph nodes.
common carotid a.
left coomon carotid a. as a direct branch off of the aortic arch, with the right coming off of the brachiocephalic a.
descending aorta
in the posterior mediastinum; we will note the posterior intercostal arteries off of it. out of the left ventricle, with the brachiocephalic trunk (artery) then dividing into the right subclavian and right common carotid arteries; left common carotid artery, and left subclavian artery
diaphragm
B. Describe the layers of the abdominal wall
esophagus and lower esophageal sphincter
posterior in position in thorax, part of posterior media stinum. collapsible muscular tube, conducting food from the laryngopharynx to the stomach by peristaltic contractions. In contrast to the stomach with its simple columnar epithelium associated with protective mechanisms to minimize damage, the esophagus is lined with a nonkeratinizing stratified squamous epithelium (and so is vulnerable to damage from gastric reflux). food tube, peristalsis from pharynx down to stomach collapsible muscular tube, conducting food from the laryngopharynx to the stomach by peristaltic contractions. In contrast to the stomach with its simple columnar epithelium, the esophagus is lined with a nonkeratinizing stratified squamous epithelium. Three possible stricture sites with physiologic narrowing can correspond to common sites of damage from swallowing caustic materials, placement of feeding tubes, or cancer (with gastric reflux a large risk factor for adenocarcinoma). Veins associated can have backflow from portal hypertension and create varicoses. pharyngeal junction- pharynx to esophagus, cross over by aortic arch and left bronchus, at diaphragm- kink built in at diaphragmatic hiatus to kink it off
great radicular artery (of Adamkiewicz)*
major supply to lumbar spinal cord as it supplements the anterior spinal artery from a left posterior intercostal/lumbar a. (T8-L1 level), and so needs to be monitored, e.g., during thoracic surgery.
greater (thoracic) splanchnic n.
splanchnic n. main source of symp. nerves into abdomen. Coming from T5-9 to celiac ganglion aiming towards abdomen . Preganglionic fibers that pass via white rami comm. Greater runs medial to symp trunk to reach celiac ganglion and so supplies liver, spleen, stomach region (some visceral pain afferent fibers that pass back via rami comm to dorsal roots, so referred pain patterns accordingly). This means that the visceral pain afferents from that same epigastric region will be traveling back through them and enter the spinal cord at the T5-T9 levels. splanchnic nerves off of the chain represent preganglionic neurons extending to ganglia in front of the abdominal aorta
hemiazygos v., accessory hemiazygos v.
on left side, can be part of alternative venous drainage, there can be an accessory hemiazygos v. that is superior to that as well. hemiazygos (hemi-azygos) and accessory hemiazygos veins will be draining the posterior intercostal veins. On left side have hemiazygos more broken up on left side draining innercostal vein
mediastinum
seperates pleural and visceral cavities from eachother. space between lungs and pleurae, with heart, great vessels, esophagus, ANS (autonomic nervous system), thymus, etc. Anterior anterior to pericardium (post to sternum)ˆ the (large) thymus in youth. Superior thoracic inlet to sternal angle. Middle pericardium and heart, main bronchi, lung roots. Posterior posterior to pericardium, with esophagus and desc. thoracic aorta. is the mobile region medially positioned between the pulmonary cavities. Note four regions of the mediastinum: Localized media stinal structures. Superior, with the aortic arch and trachea, Anterior, with thymus and lymph nodes between sternum and heart, Middle, dominated by the heart, Posterior, with esophagus, thoracic aorta, azygos vein. Lymph nodes w/in lung- bronchiolar and trachea because we breath in crap and have immune survance need moist for gas exchange but not too much for pulmonary edema causing pumping to maintain it.
phrenic n., l., r.
from C3, 4, 5, they course anterioromedially along pericardium, with motor and sensory to central diaphragm (and sensory to pericardium)–hence, referred pain patterns of say, right shoulder pain from inflamed gallbladder. The contraction of the intercostal muscles, scalenes, and other accessory muscles raises the ribs and expands the diameter of the thorax (25% of inspiratory effort compared to the diaphragm via the phrenic nerve), with normal expiration from muscular relaxation, particularly of the diaphragm (vs. abdominal muscle contraction for forced expiration). to the diaphragm makes up a neurovascular bundle with pericardiophrenic artery and vein on the lateral aspect of the pericardium. Phrenic nerve- C3,4,5, on either side of pericardium. Gotta breath to stay alive located in the diotome.
r., l. brachiocephalic v.
also known as innominate v., they are without valves, feed into SVC, from jugular, subclavian veins. R brachiocephalic receives R lymphatic duct, L brachiocephalic v. receives thoracic duct.
rami communicantes* white
rami communicantes* white myelinated preganglionic fibers from T1-L2. Grey (unmyelinated) postganglionic fibers into spinal nerves. “The further you get from home, the dirtier you get” as a mnemonic.
recurrent laryngeal n.
, left* this hooks around ligamentum arteriosum (motor source to larynx, so hoarseness if damaged or impinged, e.g., by tumor or trauma). strikingly looping around aortic arch at ligamentum arteriosum to travel back up to larynx. right recurrent laryngeal nerve often loops around the right subclavian artery and so is typically not often affected, the left recurrent laryngeal nerve around the aortic arch can be impacted by mediastinal events, such as thoracic aneurysms.
greater (thoracic) splachnic nerve
from T5-T9 aiming towards the abdomen. The greater splanchnic nerve is of interest as this represents (preganglionic) sympathetic neurons traveling towards the celiac ganglia. This means that the visceral pain afferents from that same epigastric region will be traveling back through them and enter the spinal cord at the T5-T9 levels. Phrenic nerve surface of heart, vena cava, brachiocephalic trunk, superior vena cava (azygous vein (draining osterior intercostal veins along the way). Preganglionic running forward greater splanchic nerve, synpase spot for sympathetic system go down to abdominal aorta, celiac super and inferior mesenteric arteries preaortic ganglion (splanchic nerve- celiac artery 5-9 thoracic) visceral pain afferents from viscera traveling back and coming into spinal cord at those levels. T10 umbillicus not sure where it is causing reffered pain pattern.
subclavian a.
left off of aortic arch, with the right off of the brachiocephalic artery. From the main supply of the upper limbs, the subclavian arteries, arise the internal thoracic arteries (internal mammary arteries) just lateral to the sternum
sympathetic trunk (ganglia)
collection of neuroectodermal ganglia, paravertebral. visible on the anterolateral aspects of the vertebral bodies. Thoracolumbar outflow from T1-L2, so first leg often into a chain of ganglia into each body segment. Consisting of ascending and descending fibers. rami communicantes tying into the intercostal nerves. rami communicantes tying into the intercostal nerves. visceral afferent neurons carrying pain sensation will travel with the sympathetics.
thoracic (descending) aorta
thoracic duct, azygos v. on R side of it going through aortic hiatus of diaphragm as well. The aorta splits into common iliac arteries close to the level of the umbilicus on the left. The inferior vena cava is to the right. Internal illiac- deeper true pelvis. Celiac in vein form is superior and inferior mesenteric vein. Paired vessels drain into inferior vena cava can go along body wall into zygos system for alternate pathway. Note that there are paired vessels to paired organs, e.g., suprarenal and renal arteries, gonadal arteries, lumbar arteries, with corresponding veins. The azygos system can be an alternative pathway of drainage for the lumbar veins. In terms of unpaired arteries, the celiac, superior mesenteric, and inferior mesenteric arteries arise from the abdominal aorta, but the corresponding venous components are part of the hepatic portal system, as highlighted last week before the break.
thoracic duct
major lymphatic drainage for the body as it originates from the cisterna chyli in the abdomen. Damage to the thoracic duct can lead to chylothorax. Right lymphatic duct draining right side of head and right arm. main lymphatic duct, medial to azygos vein starts from cisterna chyli, post.; drains into L subclavian/ L int. jugular junction. lungs aim medially into pulmonary, bronchopulmonary, tracheobronchial, bronchomediastinal nodes, and so can be of consideration for lung cancer and other lung diseases.main lymphatic vessel of the body will be medial to azygos vein.
thymus*
T cell maturation, large in childhood, involutes, ant./sup. mediastinum
trachea and bifurcation
note how r. main stem bronchus is more in line and slightly wider than l. main stem bronchus, so more likely for aspirate to end up in right lung.
tracheobronchial lymph nodes
drainage around the bifurcation
vagus n. (CN X), l., r.
Vagus nerve (CN X) is active in terms of parasympathetic innervation to the thorax and much of the abdomen. located near gut (esophagus). ÒDescendingÓ (embryologically speaking) aortic arches pull vagal fibers to gill arch mm into a loop; think of the length of a giraffeÕs l. recurrent laryngeal nerve! coming along common carotid artery.
anterior superior iliac spine
inguinal ligament starts from here, TFL (tensor fasciae latae m.), rect. femoris mm. as well. anterior superior iliac spine; one end point that along with the umbilicus helps determine McBurneyÕs point connected to the pubic crestÊ
external oblique m.
note inferior, medial slanting of fibers, flat layer end in aponeuroses
extraperitoneal fat (fatty areolar tissue)
another place to pack in fat within the layers of the abdominal wall (subserous fascia is another synonym)
four quadrants of abdomen (name them)
from median/transumbilical planes LUQ (stomach); RUQ (liver), LLQ (sigmoid colon); RLQ (appendix)
iliac crest
the tubercle is the most lateral point of (as landmarks for regions), 6 cm post. to ant sup iliac spine. useful to determine L4 level, e.g., for lumbar puncture
internal oblique m.
note superior-aiming flat slant of fibers, as they spray up from iliac crest, most inferior fibers join with trans. aponeurosis for conjoint tendon used in hernia repair.
linea alba aponeuroses
abdominal musculature ends in Tendon broad aponeuroses that connect midline as the linea alba, as well as compose the rectus sheath in which the rectus abdominis muscles reside. help stomach muscle support, compress abdominal viscera, and can help flex or roatte trunk. linea alba aponeuroses fusing in midline midline incision to avoid vessels and nerves. Aponeurosis of external oblique rolled along creating inguinal canal that spermatochord travels through beginning opening at either end of inguinal canal. ON outside of inguinal canal thatÕs covered by skin w/ gap of superficial inguinal ring through oblique aponeurosis.
medial umbilical ligaments (2)*
remnants of umbilical arteries that once fed into int. iliac arteries.
median umbilical ligament (1)*
obliterated urachus (allantois) [fetal bladder component] from bladder to navel
nine regions of abdomen (name them)
MCL, SCP (subcostal plane), TTP (transtubercular iliac tubercles on iliac crest, around L5) R, L hypochondriac, epigastric// R, L lateral/lumbar region, umbilical// R, L inguinal region, pubic or hypogastric. Major contents include thoughts such as pancreas in umbilical region and spleen in L hypochondriac
paraumbilical and superficial epigastric veins*
small vessels in superficial fascia that are involved in caput medusae
pubic symphysis
cartilaginous joint with disc
pubic tubercle
terminates pubic crest, on pubic body where inguinal ligament attaches
rectus abdominis m., rectus sheath, arcuate line
rectus element of abd. wall, surrounded by aponeurosis into rectus sheath; at the arcuate line (about 1/3 inferior from umbilicus to pubis), the rectus sheath is only anterior (so that rectus abdominis m. are backed by transversalis fascia)
skin (epidermis and dermis)
Note that a number of these abdominal wall objectives represent the layers of the abdominal wall, from superficial to deep.
superficial fascia, with fatty layer (of Camper) and membranous layer (of Scarpa)
can contain fat (see Camper’s layer) and the deeper membranous layer (of Scarpa). These distinctions become more important in the lower abdominal wall and perineum because of urinary extravasation issues where urine and blood can be trapped between the membranous layer and the deep fascia over muscles. Sagging folds in the fatty layer (panniliculi) can be noticeable in very heavy individuals.
transversalis fascia
abdominal fascia deep to body-wall mm,relatively firm and membranous, lining the transversus abdominis m.
transversus abdominis m.
horizontal flat fibers; note internally the arcuate line marking when the rectus sheath does not have the aponeurosis of trans. abd. mm. running deep to it.
conjoint tendon (inguinal falx)
fibers of internal oblique m. joining with those of tranversus abdominis m. to form a structure that attaches to the pubic crest; can be used in hernia repair. a merger of internal oblique and transversus abdominis fibers, is often used as an anchor for surgical hernia repairs
cremaster m.
from int. oblique fascia. Cremasteric mm (strands) in there. Cremasteric reflex from ilioinguinal n (L1) region (thigh) and motor to cremasters from genital branch of genitofemoral n. (L1-2). fibers reflexively draw the scrotum up through the motor innervation of the genitofemoral nerve (L1-L2).Ê
dartos fascia (and muscle)*
firmly attached to skin, gives “ridging” (wrinkling), in superficial fascia (membranous layer)
deep inguinal ring
through transversalis fascia. Indirect inguinal hernia lateral to inf. epigastric and down the (majority of inguinal hernias for both genders). through transversesalis fascia can go to conjoined tendon for anchoring a repair going on.Ê
ductus (vas) deferens
hard and cord-like in feel, a consideration for vasectomy, derived from mesonephric (wolffian) duct, carries sperm along from epididymis to the ejaculatory duct
epididymis
sup/post to testis, storage there 18-24 h gives sperm mobility.sperm maturation in high convuluted tubules.Ê
