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331 Cards in this Set
- Front
- Back
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What is thoracic outlet syndrome (TOS)?
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Compression of neurovascular structures due to narrowed thoracic outlet - "Costoclavicular Syndrome" is a form of this
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What are the symptoms of thoracic outlet syndrome?
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1) pain in neck/shoulder
2) numbness/weakness in arm and hand 3) diminished radial pulse |
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What are the risk factors for thoracic outlet syndrome?
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Trauma, postural distortions, heavy lifting/throwing, congenital anomalies (cervical rib), working in static positions
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What is the sternal angle?
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A landmark to locate 2nd rib and 2nd intercostal space
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Where is the costal groove and what is located there?
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It is on inferior margin of rib and passes in between the inner two layers of intercostal muscles - includes vein, artery, and nerve (VAN - superior to inferior)
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What are the three layers of intercostal muscles?
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External, internal, innermost intercostal
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What is the orientation and action of external intercostal muslces?
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Muscle fibers pass down and in - active during inspiration to elevate ribs
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What is the orientation and action of internal intercostal muscles?
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Muscle fibers pass down and out - active during expiration to depress ribs
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Where are the innermost intercostal muscles located and what is their orientation and action?
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Typically located in lateral thoracic wall - muscle fibers pass vertically and they act with internal intercostal muscles
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What intercostal muscles attach at the sternum?
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Internal intercostal muscles - external intercostal muscles do not, but rather have an external intercostal membrane at the sternum
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What intercostal muscles attach at the vertebra?
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External intercostal muscles - internal intercostal muscles do not, but rather have an internal intercostal membrane at the vertebra
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What is the location, innervation, and action of subcostal muscles?
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L: Internal surface of posterior ribs
I: Intercostal nerves A: Depress ribs |
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What is the location, innervation, and action of transverse thoracis muscles?
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L: Extend from lower sternum and xiphoid process to costal cartilages 2 - 6
I: Intercostal nerves A: Depress costal cartilages |
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What is the location, innervation, and action of levatores costarum?
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L: Segmental muscles of the back
I: Dorsal rami A: Elevate ribs |
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What is an intercostal nerve and its 4 components?
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Ventral rami of thoracic spinal nerves - somatic motor, general sensory, visceral motor, and visceral sensory
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What does intercostal nerve T1 do?
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Contributes to brachial plexus
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What does intercostal nerve T2 do?
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Intercostobrachial nerve - lateral cutaneous branch
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What do intercostal nerves T3 - T6 do?
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Typical intercostal nerves
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What do intercostal nerves T7 - T11 do?
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Innervate abdominal wall
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What does T12 nerve do?
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Subcostal nerve
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Where is the T4 dermatome?
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Level of nipples
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Where is the T10 dermatome?
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Level of umbilicus
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What is the preferred site for an intercostal nerve block?
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Posterior aspect of thoracic cage (angle of rib)
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What is the preferred site for needle decompression?
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2nd or 3rd intercostal space, midclavicular line or 5th intercostal space at midaxillary - insert needle well below the neurovascular bundle of the costal groove and slightly above the collateral bundles that run above the inferior rib
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Where are the intercostal arteries and what is their purpose?
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Pass between ribs in intercostal spaces - supply thoracic wall
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What are the divisions and origins of the intercostal arteries?
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1) Anterior - from internal thoracic artery and musculophrenic artery
2) Posterior - superior thoracic artery and thoracic aorta |
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What is the origin and major branching of the internal thoracic artery?
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Originates from subclavian artery - major branches are:
1) Anterior intercostal arteries 1 - 6 2) Superior epigastric artery 3) Musculophrenic artery |
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Describe the venous drainage of the thoracic wall?
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Venous drainage parallels arterial supply - intercostal veins drain into azygos system posteriorly and internal thoracic veins anteriorly
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What are the boundaries of the mediastinum?
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Interpleural space - sternum, thoracic vertebrae, superior and inferior thoracic apertures
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What are the contents of the superior mediastinum?
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Thymus, great vessels, trachea, esophagus, nerves
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What are the contents of the inferior mediastinum?
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1) Anterior - thymus, fat, small vessels, lymph nodes
2) Middle - aka pericardial sac/cavity - heart, pericardium, origin of great vessels, smaller vasculature and nerves 3) Posterior - aorta, thoracic duct, azygos veins, esophagus and plexus, sympathetic trunkcs, splanchnic nerves |
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What are symptoms and potential causes of anterior mediasatinal masses?
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Retrosternal pain, cough, dyspnea, SVC syndrome, choking sensation
1) Thymoma 2) Thyroid mass 3) Teratoma 4) Lymphoma |
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What are the symptoms and potential causes of middle mediastinal masses?
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Retrosternal pain, cough, dyspnea, SVC syndrome, choking sensation
1) Lymph nodes 2) Aortic aneurysm 3) Vascular dilation 4) Cysts |
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What is the pericadium and its components?
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Double-walled fibroserous sac that encloses heart and roots of great vessels
-External sac: fibrous pericardium -Internal sac: serous pericardium |
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What are the two components of the serous pericardium?
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1) Parietal layer - lines the inner surface of the fibrous pericardium
2) Visceral layer (epicardium) - adheares to the heart and forms outer covering |
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What attaches to the fibrous pericardium?
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Central tendon of diaphragm and sternum
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What supplies blood to the fibrous pericardium?
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1) Internal thoracic (pericardiacophrenic and musculophrenic) arteries
2) Inferior phrenic arteries 3) Aorta |
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What conveys sensory information from the fibrous pericardium?
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General sensory fibers of phrenic nerve
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What is the pericardial cavity?
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A "potential space" between the visceral and parietal layers of the serous pericardium - this is where blood accumulates in cardiac tamponade
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What is the transverse pericardial sinus?
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Separates arteries from veins
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What is the oblique pericardial sinus?
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Formed by reflection onto the pulmonary veins of the heart
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What are potential causes of cardiac tamponade?
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1) Trauma
2) Bleeding from weak muscle following a MI 3) Bleeding after cardiac surgery |
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What are signs of cardiac tamponade?
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1) JVD
2) Muffled heart sounds 3) Narrowing pulse pressure |
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Where does the breast extend and where is the nipple located?
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- Ribs 2 - 6
- Niple around 4th intercostal space - Axillary process extends laterally |
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What are the primary tissues of the breast?
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1) Glandular (mammary glands)
2) Adipose 3) Connective tissue septa |
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What is the areola?
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Heavily pigmented area around the nipple - has areolar glands made up of sebaceous and sweat glands
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What makes up the glandular tissue?
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10 - 20 individual lobes with its own lactiferous duct that opens on the nipple at the lactiferous sinus
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What is a lactiferous sinus?
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Dilated segment of the lactiferous duct - where the nipple opens on the nipple
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What is the retromammary space?
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Layer of loose connective tissue between the breast and underlying deep fascia
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What is significant about a breast cancer tumor in the retromammary space?
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Indicates a more advanced carcinoma
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What are suspensory ligaments?
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They provide a firm attachment for the mammary glands to the overlying dermis - displacement of these by a tumor can cause deformities in the nipple
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What are the primary arteries that supply the breast?
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1) Internal thoracic artery
2) Axillary artery 3) Intercostal arteries |
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What are the primary veins that drain the breast?
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1) Axillary
2) Internal thoracis 3) Intercostal |
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Where is most of the lymph of the breast collected?
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75% drains laterally and superiorly into the axillary nodes - most of the remaining lymph goes to the parasternal lymph nodes or opposite breast - some also goes into the abdominal nodes
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What are the three nodes the breast empties into?
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1) Axillary nodes (75%)
2) Parasternal lymph nodes 3) Abdominal nodes |
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What groups are the 20 - 30 axillary lymph nodes divided into?
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1) Pectoral (anterior)
2) Humeral (lateral) 3) Subscapular (posterior) 4) Central 5) Apical |
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What is unique about the apical nodes?
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They receive lymph from all of the other axillary lymph nodes
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What is the progression of lymph from the axillary nodes?
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Specific axillary node -- apical node -- right lymphatic duct or thoracic duct
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What drains into the pectoral lymph nodes?
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(Anterior) - Majority of lymph from breast tissue
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What drains into the humeral nodes?
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(Later) - Upper limbs
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Wat drains into the subscapular nodes?
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(Posterior) - Back and shoulder
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Where are the central nodes located?
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Embedded with the axillary fat
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What causes edema and an "orange peel" appearance during breast cancer?
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Tumors can block the superficial lymphatic vessels
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What nerve can be damaged during a mastectomy?
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Long thoracic nerve
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What is the coronary sulcus?
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(Atrioventricular) - encircles heart, dividing atria and ventricles
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What are the anterior and posterior interventricular sulci?
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Separate the two ventricles
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What are the three branches of the right coronary artery?
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1) Branch to SA node
2) Marginal branch (acute) - along inferior part of right ventricle 3) Posterior interventricular artery |
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What are the three branches of the left coronary artery?
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1) Anterior interventricular artery (LAD)
2) Circumflex branch 3) Marginal branch (obtuse) - courses inferiorly along posterior portion of left ventricle |
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What are some vessels used for a CABG?
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Great saphenous vein, internal thoracic artery, radial artery
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Where is the great cardiac vein?
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Along the left side of the coronary sulcus
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Where is the small cardiac vein?
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Along the right side of the coronary sulcus
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Where is the middle cardiac vein?
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Along the posterior interventricular sulcus
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What is the function and components of the tricuspid valve?
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- An AV valve with papillary muscles and chordae tendinae to prevent eversion of valves
- Has anterior, posterior, and septal divisions |
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What are the three cusps of semilunar valves?
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Left, anterior, and right
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What are the two cusps of the mitral valve?
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Anterior and posterior
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What is hypertrophy?
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Non-tumerous increase in size of organ - no increase in cell number
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What causes LVH?
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Typically hypertension and aortic/mitral valvular disease
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What is the difference between a white infarct and a red infarct?
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White - caused by arterial occlusion in heart, spleen, or kidney
Red - RBCs leak into necrotic area as in lung and GI |
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What is a transmural infarct?
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Traverses entire ventricular wall from endocardium to epicardium
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What is a subendocardial infarct?
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Limited to interior 1/3 of ventricular wall
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What is the cardiac skeleton?
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Collection of fibrous connective tissue in the form of four rings that provide attachment sites for cusps of valves
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Where is the pulmonary valve auscultated?
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Left 2nd intercostal space just lateral to sternum
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Where is the tricuspid valve auscultated?
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Lower part of sternum
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Where is the aortic valve auscultated?
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Right 2nd intercostal space just lateral to sternum
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Where is the mitral valve auscultated?
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Left 5th intercostal space away from sternum
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What is the cardiac plexus?
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Collection of sympathetic and parasympathetic nerves located at bifurcation of trachea, just superior to the heart
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Where do the sympathetic nerves of the heart come from?
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They come from the sympathetic chain:
1) Superior, middle, and inferior cardiac nerves 2) Thoracic cardiac nerves |
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Where do the parasympathetic nerves of the heart come from?
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Vagus (Cranial nerve X)
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What are the nine regions of the abdomen?
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R/L hypochondriac, epigastric, R/L lumbar, umbilical, R/L inguinal, pubic
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What are the layers of the abdominal wall? (7)
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Skin, superficial fascia (Camper's=fatty, Scarpa's=membranous), abdominal muscles and deep fascias, transversalis fascia, extraperitoneal fascia, parietal peritoneum
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Where do the fibers of the external oblique run?
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Inferomedially
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Where do the fibers of the internal oblique run?
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Superomedially
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Where do the fibers of the transversus abdomins run?
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Transversely
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Where do the fibers ot the rectus abdominis run?
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Up and down
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What is the rectus sheath and its layers?
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An aponeurotic tendinous sheath formed by unique layering of the external/internal oblique and transversus abdominis - has anterior layer (covers entire surface of rectus abdominis) and posterior layer (covers upper 3/4)
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What is the arcuate line?
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Arch of fibers where aponeurotic rectus sheath transitions entirely to the anterior side of rectus abdominis
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What forms the inquinal ligament?
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Lower border of the external oblique aponeurosis
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What is the processus vaginalis?
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Peritoneal outpouching that passes through various layers of abdominal wall during decent of gonads
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What is the gubernaculum?
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Extends from inferior border of the gonads to the labioscrotal swellings - guides the processus vaginalis
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What is the remnant of the gubernaculum in women (and its counterpart in men)?
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Round ligament of the uterus (spermatic cord in men)
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What are the contents of the inguinal canal in men? (Women?)
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Spermatic cord and ilioinguinal nerve (round ligament of the uterus and iliolinguinal nerve)
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Superficially, what makes up the inguinal canal?
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Anterior wall by external oblique, medial floor by inguinal ligament, rolled-under part by aponeurosis of external oblique
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Deeply, what makes up the inguinal canal?
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Posterior wall by transversalis fascia, room by the internal oblique and transversus abdominis
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What is the conjoint tendon and what is its purpose?
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Combined insertion of transversus abdominis and internal oblique - reinforces medial part of posterior wall of inguinal canal
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What borders the superficial inguinal ring?
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Below is the inguinal ligament and medial is the inferior epigastric vessles
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What does the deep inguinal ring give rise to?
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External spermatic fascia
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What does the superficial inguinal ring give rise to?
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Internal spermatic fascia
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Where does the external spermatic fascia come from?
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Arises from the external oblique - attached to margins of superficial inguinal ring
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Where does the cremasteric fascia come from?
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Arises from internal oblique (middle layer)
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Where does the internal spermatic fascia come from?
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Arises from transversalis fascia - attached to margins of deep inguinal ring
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What are the layers of the scrotum?
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Skin, superficial fascia, external spermatic fascia, cremaster muscle and fascia, internal spermatic fascia, parietal layer of tunical vaginalis, epididymis, testis covered by visceral layer of tunica vaginalis
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What does the internal oblique turn into at the level of scrotum?
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Cremasteric fascia
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What does the transversus abdominis turn into at the level of the scrotum?
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It does not project into scrotum
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What is a hydrocele?
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Accumulation of residual peritoneal fluid in tunica vaginalis
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Where does the ilioinguinal nerve originate?
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L1 of the lumbar plexus
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What does the ilioinguinal nerve innervate?
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Transversus abdominis and internal oblique (as it pierces them) and the anterior scrotum/labia and anterior thigh
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How does the ilioinguinal nerve inter the inguinal canal?
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It pierces the transversus abdominis and internal oblique
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Where does the genitofemoral nerve originate?
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L1-L2
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Where does the genital branch of the genitofemoral nerve enter the inguinal canal and what does it innervate?
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Enters through the deep inguinal ring and as it exits the superficial ring it innervates the cremasteric muscle and fascial layers
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Where does the femoral branch of the genitofemoral nerve travel and what does it innervate?
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Travels under inguinal canal and innervates skin of femoral triangle
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What is the falciform ligament?
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Attaches the liver to the anterior body wall
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What is the ligament teres hepatis?
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"Round ligament of the liver" - along free edge of falciform ligament - divides left side of liver into medial and lateral halves (remnants of umbilical vein)
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What is an indirect inguinal hernia?
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Congenital - parietal peritoneum and viscera protrude into deep inguinal ring, lateral to epigastric vessels, travel through canal and emerge through superficial inguinal ring into scrotum
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What is a direct inguinal hernia?
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Acquired - parietal peritoneum and viscera protrude through a weak area of posterior wall of inguinal canal, medial to epigastric vessels, rarely enters scrotum
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What encloses a direct inguinal hernia?
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Hernial sac formed by transversalis fascia
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What is the nature of the oblique aponeurosis above the arcuate line? And below?
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It splits to enclose the rectus abdominis - Below line, the aponeurosis of the external oblique, internal oblique, and transversus abdominis all pass anterior to the rectus abdominis
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Where do indirect inguinal hernias originate relative to the epigastric vessels?
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Laterally
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Where do direct inguinal hernias originate relative to the epigastric vessels?
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Medially
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What is Richter's hernia?
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Antimesenteric wall of intestine is trapped and strangulation can occur without intestinal obstruction
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What is a sliding hernia?
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Occurs when an organ comprises a portion of the wall of the hernia sac
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What is an external hernia?
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Protrudes through all layers of the abdominal wall - vs. internal which protrudes through a defect in the peritoneal cavity
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What is the most common type of hernia regardless of gender?
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Indirect inguinal hernia
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What is the most common hernia in females?
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Indirect inguinal hernia
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In what gender are femoral and umbilical hernias more common?
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Females - but indirect inguinal hernia is still most common
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What is a common characteristic of the location at which abdominal wall hernias usually occur?
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Sites where aponeurosis and fascia are not covered by striated muscle
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Where do inguinal and femoral hernias typically occur and why?
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On the right - delay in atrophy of processus vaginalis after slower descent of right testis and more femoral hernias on right due to tamponading effect of the sigmoid colon on the left femoral canal
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What is the hernia defect and sac?
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The defect is the neck or orifice and is located at the innermost musculoaponeurotic layer, whereas the hernia sac is lined by peritoneum and protrudes from the neck
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What is the myopectineal orifice?
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It is the site of groin hernias (direct, indirect, and femoral) - the inguinal ligament, spermatic cord, and femoral vessels also pass through this area
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What is Hesselbach's triangle?
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It is where direct inguinal hernias protrude and is bound by:
Medially - lateral margin of rectus sheath (linea semilunaris) Superolaterally - the inferior epigastric vessels Inferiorly - the inguinal ligament |
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What kind of hernias protrude into the inguinal canal lateral to Hesselbach's triangle?
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Indirect hernias
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Where do femoral hernias occur?
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Belowe the inguinal ligament into the femoral canal
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What are the peritoneal layers?
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Perietal layer, peritoneal cavity, visceral layer, mesentary, blood supply
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Where does the parietal peritoneum get its blood supply?
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Blood vessels of abdominal wall
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Where does the visceral peritoneum get its blood supply?
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Blood vessels of the viscera
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What are the intraperitoneal organs?
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Stomach, duodenum (1st part), liver, pancreas tail, spleen, jejunum, ileum, transverse colon, sigmoid colon
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What are the retroperitoneal organs?
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Kidneys, ureters, bladder, aorta, inferior vena cava, esophagus, duodenum (2nd-4th parts), pancreas (except tail), ascending colon, descending colon, rectum (except lower 1/3 is extraperitoneal)
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What does "secondarily retroperitoneal" mean?
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1) Intraperitoneal organ rotates and fuses with posterior body wall
2) Peritoneal layers fuse and organ is covered with parietal peritoneum, resulting in a retroperitoneal organ |
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What is peritonitis and what causes it?
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Inflammation of peritoneum resulting in ascites - caused by trauma or infection
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What is the greater omentum?
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A reflection of the peritoneum that suspends from greater curvature of stomach and covers abdominal viscera
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What is the lesser omentum and what is it composed of?
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Double layer of peritoneum from the lesser curvature of the stomach to the liver - composed of hepatogastric and hepatoduodenal ligaments
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What ligaments compose the lesser omentum?
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Hepatogastric and hepatoduodenal
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What is the greater sac?
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Makes up most of the peritoneal cavity and spans from the diaphragm to the lower aspect of abdominal cavity
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What are the two divisions of the greater sac?
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Supracolic and infracolic compartment
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What are the main recesses of the greater sac?
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1) Subphrenic (suprahepatic)
2) Subhepatic - hepatorenal (Morison's pouch) 3) Paracolic (gutters) |
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What is the subphrenic recess?
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Recess of the greater sac - located suprahepatically
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What is the subhepatic recess?
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Recess of the greater sac - located in hepatorenal area on right side (aka Moroison's pouch)
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What is the paracolic recess?
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Recess of the greater sac - located at "gutters"
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What is the lesser sac?
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"Omental Bursa" - small part of the peritoneal cavity, an irregular space behind liver, lesser omentum, and stomach
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What are the recesses of the lesser sac?
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Superior, splenic, inferior
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What is the omental foramen and its other name?
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Natural opening between lesser sac and greater sac - aka epiploic foramen of Winslow
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What are the boundaries of the omental foramen?
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Caudate lobe of liver, first part of duodenum, hepatoduodenal ligament, inferior vena cava
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What is the epiploic foramen of winslow?
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Omental foramen
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What is the clinical significance of the omental foramen?
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1) Fluid may accumulate here after perforation of the posterior stomach or an injured pancreas
2) A loop of intestin may herniate through it into the omental bursa 3) If cystic artery is severed during gall bladder removal, a Pringle maneuver may stop bleeding |
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What makes up the portal triad and where is it located?
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Found within the hepatoduodenal ligament:
1) Common bile duct 2) Portal vein 3) Proper hepatic artery |
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What is the hepatoduodenal ligament?
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Connects the liver to the duodenum - houses the portal triad
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What are the mesenteries?
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Double layer of peritoneum that reflect off body wall and enclose viscera, suspending organs and connecting them to each other - blood vessels travel between the two layers
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What are mesentery roots?
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Location on the posterior body wall where parietal pertoneum reflects and forms the double layer of mesentery (typicall refers to the root of the small intestine)
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What are peritoneal ligaments?
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Double layers of peritoneum between organs (ex. gastrolienal, lienorenal) - a subdivision of mesenteries
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What is the gastrolienal ligament?
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Connects stomach to spleen
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What is the lienorenal ligament?
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Connects spleen to left kidney
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What is the falciform ligament?
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Connects liver to diaphragm and abdominal wall
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What is the coronary ligament?
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Composed of two triangular ligaments - encloses bare area of liver
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What is the ligamentum teres hepatis?
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"Round ligament of liver" - Lies in free margin of falciform ligament and ascends from umbilicus to inferior liver
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What is the ligamentum venosum?
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Remnant of ductus venosus
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What are the main trunks that come off the abdominal aorta and their level?
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1) Celiac trunk (T12) - foregut
2) Superior mesenteric artery (L1) - midgut 3) Inferior mesenteric artery (L3) - hindgut |
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What are the main branches of the celiac trunk?
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1) Common hepatic artery
2) Splenic artery 3) Left gastric artery |
|
|
What are the branches of the common hepatic artery?
|
1) Proper hepatic artery
2) Right gastric artery 3) Gastroduodenal artery |
|
|
What are the branches of the splenic artery?
|
Curvy artery:
1) Short gastric artery 2) Left gastroepiploic |
|
|
What is function of left gastric artery?
|
- Smallest branch of celiac trunk
- Runs along lesser curvature of stomach, supplies distal esophagus and stomach |
|
|
What are the main branches of the superior mesenteric artery?
|
1) Jejunal and ileal branches
2) Middle colic artery 3) Ileocolic artery |
|
|
What are the main branches of the inferior mesenteric artery?
|
1) Left colic
2) Sigmoid 3) Superior rectal |
|
|
What can an ultrasound of the RUQ show with chest/abdominal trauma?
|
Fluid in Morison's pouch
|
|
|
What is Morison's pouch?
|
Area between liver and right kidney - "subhepatic recess"
|
|
|
What is the Pringle maneuver?
|
1) Place finger through the omental foramen (epiploic foramen of Winslow) and lift the hepatoduodenal ligament
2) Clamp the proper hepatic artery |
|
|
How much space do the lungs occupy in the chest?
|
From T1 - T12, there is lung above the clavicle and below the xiphoid
|
|
|
Where is the heart located in the chest?
|
Superiorly - to the 2nd intercostal space
Inferiorly - to the xiphoid and 5th rib space Laterally - to midclavicular line |
|
|
What are the differences between open, closed, and tension pneumothoracies?
|
Open - air enters pleural cavity from outside
Closed - air enters pleural cavity from lung Tension - air enteres pleural cavity on each inspiration but cannot leave |
|
|
Where are chest tubes placed and aimed?
|
Anterior axillary line at 4th, 5th, or 6th intercostal space - aim anteriorly for air, posteriorly for fluid
|
|
|
What are the somatic structures of the body?
|
Skin, skeletal muscles, tendons, joints
|
|
|
What are the visceral structures of the body?
|
Mucous membranes, glands, smooth muscle, cardiac muscle
|
|
|
What are the four general nerve types and which one is a two neuron system?
|
General motor, general sensory, visceral motor, visceral sensory - visceral motor is a two neuron system
|
|
|
What are the origins of the divisions of the autonomic nervous system?
|
Sympathetic - thoracolumbar
Parasympathetic - craniosacral |
|
|
What kind of fibers make up the autonomic nervous system?
|
Visceral motor fibers
|
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|
Where is the origin of the sympathetic nervous system?
|
Thoracolumbar - T1-L2
|
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|
What is the preganglionic to postganglionic cell length in the sympathetic nervous system?
|
Short:long
|
|
|
Where are the synapses of the sympathetic nervous system located?
|
Paravertebral and prevertebral ganglia
|
|
|
What is the postsynaptic neurotransmitter of the sympathetic nervous system?
|
Norepinephrine (except sweat glands)
|
|
|
Where is the origin of the parasympathetic nervous system?
|
Craniosacral (S2 - S4 and brainstem: CN III, VII, IX, and X)
|
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|
What is the preganglionic to postganglionic cell length in the parasympathetic nervous system?
|
Long:short
|
|
|
Where is the typical synapse location in the parasympathetic nervous system?
|
Wall of organ
|
|
|
What is the postsynaptic neurotransmitter of the parasympathetic nervous system?
|
Acetylcholine
|
|
|
What is the sympathetic and parasympathetic innervation and ganglion of the heart and trachea/bronchi?
|
Symp: T1 - T4
Para: Vagus (CN X) Gang: Cardiac plexus / Pulmonary plexus |
|
|
What is referred pain?
|
When the CNS cannot distinguish between visceral pain (ex. the heart) and the somatic pain associated with that dermatome (ex. T1-T4=left arm)
|
|
|
What is the sympathetic and parasympathetic innervation and ganglion of the foregut?
|
Symp: T5 - T9
Para: Vagus (CN X) Gang: Celiac |
|
|
What is a celiac ganglia block?
|
Percutaneous block of celiac ganglia to control pain in patients with severe abdominal pain from malignancy
|
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|
What is the sympathetic and parasympathetic innervation and ganglion of the midgut and kidney?
|
Symp: T10 - T11
Para: Vagus (X) Gang: Aorticorenal and Sup. Mes. Ganglion |
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|
What is the sympathetic and parasympathetic innervation and ganglion of the hindgut?
|
Symp: L1 - L2
Para: S2 - S4 Gang: Inferior mesenteric ganglion |
|
|
What is Hirschsprung's disease?
|
When nerve cells (ganglia) do not develop in the wall of the large intestine - it prevents peristalsis by not allowing the muscles to relax which leads to trapped stool, inflammation, and infection
|
|
|
What innervates the suprarenal gland?
|
Symp: T5 - T8
Para: NONE |
|
|
Where are the two areas of ganglia in the abdomen?
|
Paravertebral - collateral
Prevertebral - around aorta |
|
|
What are two organs not innervated by the parasympathetic nervous system?
|
Skin and suprarenal medulla
|
|
|
What is the difference between visceral and somatic pain?
|
Visceral - dull and difficult to localize
Somatic - sharp and easy to localize |
|
|
What are the sympathetic splanchnic nerves?
|
Cervical, thoracic, and lumbar
|
|
|
What are the parasympathetic splanchnic nerves?
|
Pelvic splanchnic nerves
|
|
|
Where is the synapse for a splanchnic nerve that exerts its influence in the thorax?
|
Sympathetic chain
|
|
|
Where is the synapse for a splanchnic nerve that exerts its influence in the abdomen?
|
Prevertebral ganglion
|
|
|
What is the dividing line for where a nerve exerts its effect and where the ganglion is located?
|
Above diaphragm - sympathetic chain
Below diaphragm - prevertebral ganglion |
|
|
What is duodenal obstruction?
|
"Double bubble" - Caused by failure of duodenum to recanalize or extrinsic compression (atresias, annular pancreas, volvulus)
|
|
|
What is malrotation?
|
When there is a failure of the small intestine to rotate properly as it comes back from the umbilicus - large intestines end up on the left and small intestines end up on the right
|
|
|
What is volvulus?
|
Can occur from malrotation - when the blood supply to the small intestine (supplied by superior mesentery artery) is occluded - leads to ischemia, infarction, necrosis of tissue
|
|
|
What is the typical presentation of Hirschsprung's disease?
|
Distension and failure to pass meconium (usually dx'ed within first 6 weeks)
|
|
|
What is cloaca?
|
When the urinary, reproductive, and/or anal cavities are all in one
|
|
|
What is midgut volvulus and it's worrisome presentation?
|
It is when the blood supply to the entire small intestine is occluded - green vomit should make you worry
|
|
|
What are the two ways to get to the pancreas surgically?
|
1) Cut the greater omentum and lift the stomach to expose the pancreas
2) Go through the omental foramen (epiploic foramen of winslow) |
|
|
What is the primary blood supply to the pancreas and what are its major branches to the pancreas?
|
The splenic artery - dorsal, inferior, and anterior pancreatic arteries as well as artery to tail of pancrease
|
|
|
What are the roots, function, and location of the phrenic nerve?
|
Roots: C3 - C5 "C3,4,5 keep diaphragm alive)
Function: Somatic motor innervation to diaphragm, general sensory innervation from central diaphragm, pleura, pericardium Location: Between parietal pleura and pericardium |
|
|
What provides sensory innervation of the diaphragm?
|
Central: phrenic nerve
Peripheral: intercostal nerves |
|
|
What are the muscles of inspiration?
|
Primary: external intercostals, diaphragm
Accessory: sternocleidomastoid, scalenes (ant, mid, post) |
|
|
What are the muscles of expiration?
|
Quiet: passive recoil of lungs and ribs
Active: Internal intercostals, abdominal muscles |
|
|
What are the types of pleura that make up the plearal cavities and their innervation?
|
Parietal: walls of the pleural cavity (general sensory nerves, so sensitive to pain)
Visceral: adheres to lungs (visceral sensory, so insensitive to pain) |
|
|
What are the different areas of the parietal pleura referred to?
|
Costal, diaphragmatic, mediastinal, cervical
|
|
|
What is the hilum of the lung?
|
Where the mediastinal pleura reflects off the mediastinum, encloses the airway and vessels as the root of the lung, and reflects onto lung as the visceral pleura
|
|
|
What is the root of the lung?
|
Short, tubular collection of structures that attach lung to mediastinum (artery, veins, bronchus, bronchial vessels, nerves, lymphatics)
|
|
|
What are pleural recesses?
|
Areas at the bases and costomediastinal area of the pleural cavities which are not completely filled by the lung - results in recesses where two layers of parietal pleura become opposed
|
|
|
What is a simple pneumothorax?
|
When air enters pleural cavity (open: air enters from outside, closed: air enters from lung)
|
|
|
What is anthracosis?
|
"Coal miner's lung" - extensive deposition of black carbon pigment and fibrotic central region of lung
|
|
|
What are the five characteristics of emphysema?
|
1) Permanent enlargement of airspaces and destruction of bronchiole walls by inflammation
2) Elastic recoil of lung decreases 3) Airways collapse during expiration 4) Expiration is difficult so patients try to force out air 5) Leads to hypertrophy of intercostal muscles and barrel-chested appearance |
|
|
Where does squamous cell carcinoma originate?
|
Bronchus
|
|
|
Where does adenocarcinoma originate?
|
Intrapulmonary bronchi
|
|
|
What is idiopathic pulmonary fibrosis?
|
Chronic restrictive lung disease - causes chronic inflammation, fibrosis, and need for higher pressure to inflate stiffened lungs
|
|
|
What is the progression of the bronchial tree?
|
1) Trachea
2) Main bronchus (left and right) 3) Lobar bronchus 4) Segmental bronchus 5) Bronchioles |
|
|
What is a bronchopulmonary segment and where are the veins located?
|
Area of lung supplied by segmental bronchus and accompanying pulmonary artery branch (smallest, functionally independent region of lung) - veins located between segments
|
|
|
What are the bronchopulmonary segments of the right lung? (10)
|
Superior: (apical, posterior, anterior)
Middle: (lateral, medial) Inferior: (superior, medial basal, anterior basal, lateral basal, posterior basal) |
|
|
What are the bronchopulmonary segments of the left lung? (8)
|
Superior: (apicoposterior, anterior, superior lingular, inferior lingular)
Inferior: (superior, anteromedial basal, lateral basal, posterior basal) |
|
|
What are signs of lesser degree pumonary embolism?
|
Tachypnea, anxiety, dyspnea, vague substernal pressure (although 60% are "silent" and don't have symptoms)
|
|
|
What are signs of massive PE?
|
Acute cor pulmonale (right heart failure), circulatory collapse
|
|
|
What supplies the bronchial arteries?
|
Branches of aorta or its branches (posterior intercostal arteries)
|
|
|
Where do the bronchial veins drain?
|
Primarily into the azygos system
|
|
|
What innervates the lungs and where are they located?
|
Pulmonary plexus - located at bifurcation of trachea
|
|
|
What is the path of lymph drainage from the lungs?
|
Superficial and deep lymphatics of lung -- tracheobronchial lymph nodes (roots of lobar and main bronchi, sides of trachea) -- bronchomediastinal trunks
|
|
|
What is located in the posterior mediastinum?
|
Aorta, thoracic duct, azygos and hemiazygos veins, espophagus and its plexus, sympathetic trunks, splanchnic nerves
|
|
|
What are the three main parts of the azygous venous system?
|
1) Azygos vein - travels on right side, receives right intercostal veins, empties into SVC
2) Hemiazygos vein - travels on left side, receives lower 4 posterior intercostal veins 3) Accessory hemiazygos vein - travels on left side, receives middle 4 left posterior intercostal veins |
|
|
Where is the thoracic duct located and where does it empty?
|
Between aorta and azygos vein - empties into junction of left internal jugular vein and subclavian vein
|
|
|
What areas of the abdomen does the thoracic duct collect lymph from?
|
RLQ, LLQ, LUQ - right lymphatic duct drains RUQ
|
|
|
What are the thoracic splanchnic nerves?
|
Sympathetic nerves that originate in the thorax but travel to the abdomen where they innervate organs (greater, lesser, least splanchnic nerves)
|
|
|
Where does the esophagus enter the diaphragm?
|
Esophageal hiatus - at level of T10
|
|
|
What innervates the esophagus?
|
Anterior vagal trunk (left vagus) and posterior vagal trunk (right vagus)
|
|
|
In what abdominal regions is the stomach located?
|
Epigastric, left hypochondriac, and umbilical
|
|
|
What are the primary functions of the stomach? (3)
|
1) Acidifies
2) Converts bolus into chyme 3) Produces digestive enzymes (pepsinogen, lipase) and hormones |
|
|
What are the primary regions of the stomach?
|
Cardia: surrounds opening of esophagus
Fundus: area above level of cardial orifice Body: largest region Pyloric part: antrum and canal |
|
|
Where does adenocarcinoma of the stomach originate?
|
Malignant tumor originating from the glandular epithelium
|
|
|
What are the regions of the small intestine and their location?
|
Duodenum (epigastric)
Jejunum (LUQ) Ileum (RLQ) |
|
|
What are the 4 parts of the duodenum?
|
1st: superior (most ulcers here)
2nd: descending (major and minor papilla) 3rd: inferior or transverse 4th: ascending |
|
|
In what cavity is the duodenum?
|
Intraperitoneal proximally, becomes retroperitoneal along its course
|
|
|
Where is the junction of the foregut and midgut?
|
At the major papilla in the 2nd (descending) part of the duodenum
|
|
|
What is the significance of the major duodenal papilla?
|
1) Main pancreatic duct and common bile duct converge here and enter duodenum
2) Marks junction of foregut and midgut |
|
|
What is the significance of the 3rd (inferior/transverse) portion of the duodenum?
|
Crosses aorta under superior mesenteric artery and vein
|
|
|
What is the significance of the 4th (ascending) part of the duodenum?
|
Terminates at the duodenojejunal junction which is held in place by ligament of Treitz
|
|
|
What makes up the "nutcracker?"
|
Aorta and SMA make up handles, renal vein and duodenum (3rd part) travel through handle
|
|
|
What are characteristics of the jejunum?
|
- Proximal 2/5 of small intestine
- Mostly in LUQ - Vascularized by long vasa recta |
|
|
What are characteristics of the ileum?
|
- Distal 3/5 of small intestine
- Mostly in RLQ - Vascularized by short vasa recta - Ends in ileocecal junction |
|
|
What are diverticula?
|
Pouches or sacs branching out from a hollow organ (typicall intestine or mesenteric border) - can become inflammed = diverticulitis
|
|
|
What are the main parts of the colon?
|
1) Cecum
2) Ascending colon 3) Transverse colon 4) Descending colon 5) Sigmoid colon 6) Rectum 7) Anus |
|
|
What are the characteristics of the cecum?
|
- First part of colon
- Inferior to ileocecal opening - Blind-ended tube - Attachment point of appendix |
|
|
What is the location and function of appendix?
|
- Hollow tube connected to cecum
- Contains large aggregations of lymphoid tissue |
|
|
What cavities are the colon located in?
|
"RIRI"
Ascending: retroperitoneal Transverse: intraperitoneal Descending: retroperitoneal Sigmoid: intraperitoneal |
|
|
Where is the junction of the midgut and hindgut and what is the change in innervation/blood supply?
|
2/3 distance across transverse colon - parasympathetic innervation switches from vagus to S2 - S4 - blood supply switches from SMA to IMA
|
|
|
What are the recesses of the liver?
|
Subphrenic and hepatorenal (Morison's pouch)
|
|
|
What is the porta hepatis?
|
"Door of the liver" - serves as entry point for hepatic arteries and portal vein and exit point for hepatic ducts
|
|
|
What are the lobes of the liver?
|
Right
Left: quadrate (upper) and caudate (lower) |
|
|
What is the function of the falciform ligament?
|
Attaches liver to anterior abdominal wall
|
|
|
What is the function of the triangular ligaments and coronary ligaments?
|
Attaches liver to diaphragm
|
|
|
What is the function of the hepatogastric ligament?
|
Attaches liver to stomach, part of lesser omentum
|
|
|
What is the function of the hepatoduodenal ligament?
|
Attaches liver to duodenum, part of lesser omentum
|
|
|
What are the primary functions of the liver?
|
1) Exocrine secretion (bile)
2) Endocrine secretion (urea and plasma proteins) 3) Metabolite storage (glycogen, triglycerides, vitamens/minerals) 4) Gluconeogenesis 5) Detoxification 6) Bilirubin metabolism 7) RBC production in fetus |
|
|
What are consequences of cirrhosis of liver?
|
Increased portal venous pressure can cause esophageal varices, rectal hemorrhoids, paraumbilical venous collaterals, and splenomegaly
|
|
|
What makes up cystohepatic triangle of calot?
|
Liver, cystic duct (from gallbladder) and common hepatic duct - latter two combine to common bile duct
|
|
|
What is cholecystitis?
|
Acute inflammation of the gallbladder causing nausea, vomiting, fever, and RUQ pain
|
|
|
What is cholelithiasis?
|
Gallstones - typically cholesterol and calcium
|
|
|
Where is the pancreas located?
|
Posterior to stomach between duodenum and spleen - secondarily retroperitoneal except small part of tail
|
|
|
What are the regions of the pancreas?
|
Head, uncinate process, neck, body, tail
|
|
|
What are the primary functions of the pancreas?
|
Endocrine: trypsin, peptidases, amylases, lipases, nucleases
Exocrine: Insulin, glucagon |
|
|
What are the main arteries that supply the pancreas?
|
Celia, splenic (from celiac), and SMA
|
|
|
Where is spleen located?
|
Against diaphragm behind stomach in the area of ribs 9 and 10 (LUQ)
|
|
|
What are the ligaments of the spleen?
|
Gastrosplenic (gastrolienal): connects to stomach
Splenorenal (leionrenal): connects to left kidney |
|
|
What is the main function of the spleen?
|
1) Filtration of blood
2) Storage of RBCs 3) Phagocytosis of damaged and aged RBCs 4) Proliferation of B and T lymphocytes 5) Production of antibodies |
|
|
What drains through the hepatic portal system?
|
Venous drainage of the spleen, pancreas, gallbladder, and abdominal part of GI tract
|
|
|
What forms the portal vein?
|
Union of splenic, superior mesenteric, and inferior mesenteric veins - travels in portal triad
|
|
|
Where is the blood rerouted in the main complications of cirrhosis of the liver?
|
Esophageal varices: left gastric vein
Caput Medusae: paraumbilical veins Hemorrhoids: superior rectal vein |
|
|
Where is lymphatic drainage of the GI organs collected?
|
Pre-aortic lymph nodes: celia, superior mesenteric, and inferior mesnteric
|
|
|
What are the major muscles of the posterior abdominal cavity?
|
Psoas major/minor, quadratus lumborum, iliacus (located on anterior surface of ilium)
|
|
|
What components form the diaphragm?
|
Central tendon, skeletal muscle, right and left crus
|
|
|
What arteries supply the superior surface of the diaphragm?
|
Musculophrenic, pericardiacophrenic, superior phrenic
|
|
|
What artery supplies the inferior surface of the diaphragm?
|
Inferior phrenic
|
|
|
What provides sensory innervation of the diaphragm?
|
Central: phrenic nerve
Peripheral: intercostal nerves |
|
|
What are the openings in the diaphragm and their vertebral level?
|
Vena caval hiatus: T8 (IVC and right phrenic nerve)
Esophageal hiatus: T10 (esophagus, vagal trunks, esophageal branches of left gastric vasculature) Aortic hiatus: T12 (aorta, thoracic duct, azygous) |
|
|
At what vertebral level are the kidneys located?
|
T12 - L3 (ribs 11-12)
|
|
|
What are the tissues surrounding the kidney?
|
Perirenal fat (closest to capsule), renal fascia, pararenal fat
|
|
|
What are the 5 segments of the kidneys?
|
Superior, anterosuperior, anteroinferior, inferior, posterior
|
|
|
What are the major structures of the kidneys?
|
Capsule, cortext (outer region and extends into renal columns), medulla (inner region, makes up renal pyramids that have papilla at tip), minor calyx (located in sinus), major calyx, renal pelvis, ureter, hilum (renal vessesls, lymphatics, nerves, ureter enter/leave here)
|
|
|
What is polycystic kidney disease and its manifestation?
|
Inherited disorder (AD) of kidney, characterized by replacement of renal tissue by cysts - presents with HTN, hematuria, renal masses, and leads to renal failure
|
|
|
What is hydronephrosis?
|
Progressive dilation of renal pelvis and calyces - usually occurs as consequence of urinary tract obstruction due to renal stones or prostatic hyperplasia
|
|
|
What are pelvic kidneys?
|
Kidneys that fail to ascend (usually blocked by vasculature)
|
|
|
What is horseshoe kidney?
|
Kidneys that fuse together and remain in pelvis
|
|
|
How does renal cell carcinoma typically present?
|
Age 50-70, usually originates in upper pole - hematuria, palpable mass, fever, flank pain
|
|
|
What are the constrictions of the ureters? (3)
|
Ureteropelvic junction, pelvic inlet, entrance to bladder
|
|
|
What are the primary vasculature to the ureters?
|
Upper: renal arteries
Middle: aorta, gonadal, common iliac arteries Pelvic Cavity: internal iliac arteries |
|
|
What are the shapes of the suprarenal glands?
|
Right: pyramidal
Left: semilunar |
|
|
What supply the superior, middle, and inferior suprarenal arteries?
|
Inferior phrenic, aorta, and renal arteries
|
|
|
Where does right suprarenal vein drain?
|
IVC
|
|
|
Where does the left suprarenal vein drain?
|
Left renal vein
|
|
|
What levels does the abdominal aorta span?
|
T12 (aortic hiatus) to L4 (bifurcation to common iliac)
|
|
|
What are the four categories of branches of the abdominal aorta?
|
1) Unpaired branches to alimentary canal
2) Branches to paired viscera 3) Posterior branches to body wall 4) Terminal branches |
|
|
What are the unpaired branches of the abdominal aorta to the alimentary canal?
|
Celiac trunk, SMA, IMA
|
|
|
What are the abdominal aorta branches to paired viscera?
|
Middle suprarenal arteries, renal arteries, gonadal arteries
|
|
|
What are the abdominal aorta branches to the posterior body wall?
|
Inferior phrenic arteries, lumbar arteries, median sacral artery
|
|
|
What are the terminal branches of the abdominal aorta?
|
Common iliac arteries
|
|
|
How is an AAA defined and caused?
|
Considered aneurysm when 1.5x normal size - caused by atherosclerosis, HTN, penetrating wounds, and infection
|
|
|
What levels does the IVC span and what does it do?
|
L5 (uniting of two external iliac veins) to T8 (IVC hiatus) - returns blood from all structures below the diaphragm EXCEPT abdominal GI, spleen, pancreas, or gallbladder
|
|
|
What are the major nerves of the lumbar plexus?
|
1) Iliohypogastric
2) Ilioinguinal 3) Lateral femoral cutaneous 4) Genitofemoral |
|
|
What forms the lumbar plexus and what does it do?
|
Union of ventral rami (T12/L1 - L5) - provides motor and sensory innervation to lower limb, hip, and groin
|
