Moore's Blue Boxes -- Thorax

Front 1

Chest Pain (p.77)

Back 1

most important symptom of cardiac disease

may also indicate intestinal, gallbladder, musculoskeletal, or pulmonary disorders

exam:
serious <------------------------->minor causes

*cardiac: freq. described as crushing substernal pain that does not disappear with rest

Front 2

Rib Fractures (p.79)

Back 2

1st rib rarely fractured b/c of protected position
->>> frac. leads to risk of brachial plexus and subclavian vessel damage

frac. result from blows or crushing injuries; weakest part is anterior to angle

*danger of damage to lung or spleen from broken end

diaphragmatic hernia -- tear in diaphragm 2` to rib fracture

painful 'cause broken parts move during respiration

Front 3

Flail Chest (p.80)

Back 3

multiple rib fractures allow segment of t. wall to move freely

moves paradoxically to respiration

Front 4

Thoractotomy (p80.)

Back 4

surgical creation of an opening through thoracic wall to access pleural cavity

lateral approach gives best access; fully abduct arm, access as high as 4th intercostal space

removal of rib allows entry through periosteal sheath, spares intercostal muscles

*bone may be used as a graft in reconstruction procedures -- will regenerate in periosteal sheath

Front 5

Supernumerary Ribs (p.81)

Back 5

usually have 12 ribs on each size

can have too many C / L ribs; or failure of 12th pair to form

*can confuse identification/numbering of levels on radiographs

Front 6

Protective Function and Aging of Costal Cartilages

Back 6

c.c. provide resilience to t. cage; prevent blows from fracturing sternum/ribs

chest compression can cause injury w/out fracture

in elderly, costal cart. lose elasticiy; become brittle and calcify --> radiopaque

Front 7

Ossified Xiphoid Process (p.84)

Back 7

normal in mid 40s to discover a hard lump in "pit of stomach"

patients may fear it's a tumor such as stomach cancer; just calcification at epigastric fossa

Front 8

Sternal Fractures (p.84)

Back 8

not common

can occur from crush trauma (ex. forced into steering column in crash)

usually "comminuted fracture" -- several pieces; at sternal angle

*concern of possible heart damage; mortality ~25-45%

ALL patients w/ sternal injury should be evaluated for visceral trauma

Front 9

Median Sternotomy (p.84)

Back 9

to gain access to mediastinum (ex. for CABG, removal of superior lobe tumors), divide sternum in median plane and retract

rejoin w/ wire sutures

Front 10

Sternal Biopsy (p.84)

Back 10

sternal body often used for bone marrow needle biopsy

+ breadth and subcut. position

obtain specimens for transplant or for detection of metastatic cancer and blood dyscrasias

Front 11

Sternal Anomalies (p84)

Back 11

sternal halves may not fuse in fetus --> Sternal Cleft

repair in infancy w/ direct apposition and fixation of cartilaginous sternal halves

*sternal foramen due to incomplete fusion of plates (not clinically significant, except for misinterpretation on medical image as a bullet wound)

Front 12

Thoracic Outlet Syndrome (p.85)

Back 12

Anatomists: superior thoracic aperture ~ thoracic inlet

...non-circulating substances (air and food) can ender only through this aperture

Clinicians: superior thoracic aperture ~ thoracic outlet

... arteries and T1 spinal nerves emerge trough aperture to enter lower neck and upper limbs

TOS implies thoracic location, obstruction is in root of the neck, manifestations of syndrome variably involve upper limb

Front 13

***

Dislocation of Ribs (p.91)

Back 13

displacement of a costal cartilage from sternum (or dislocation of sternocostal joint) or the displacement of the interchondral joints

common in contact sports; may damage nearby nerves, vessels, and muscles

interchondral joints -- usually unilaterally, involves 8,9, 10
produces lumb at displacement site

Front 14

***

Separation of Ribs (p.91)

Back 14

refers to dislocation of a costochonral jxn between rib and its costal cartilage

if occurs in 3 - 10, usually tears perichondrium and periosteum;

rib moves superiorly, overriding rib above it and causes pain

Front 15

Paralysis of the Diaphragm (p.91)

Back 15

hemidiaphragm paralysis as result of injury to phrenic nerve supply (each dome has separate nerve supply)

will move paradoxically when paralyzed

Front 16

Dyspnea: Difficulty Breathing (p.98)

Back 16

when people w/ resp. problems (ex. asthma, CHF,...) struggle to breath, they may use accessory respiratory muscles to assist expansion of t. cavity

leaning on chair or knees can "fix" pectoral girdle so these accessory muscles are better able to act on rib attachments

Front 17

Extrapleural Intrathoracic Surgical Access (p.99)

Back 17

endothoracic fascia is a natural cleavage plane in surgery

separate costal parietal pleura from the thoracic wall --> access to lymph nodes

*can place instruments without risking opening of potential space of pleural cavity surrounding lungs

Front 18

Herpes Zoster Infection of the Spinal Ganglia (p.101)

Back 18

shingles

causes red, vesicular rash confined to a dermatome; sharp burning pain in affected region

(1` sensory, can prod. muscle weakness)

freq. a reactivation of VZV (varicella-zoster)

Front 19

***

Intercostal Nerve Block (p.102)

Back 19

injecting a local anesthetic near intercostal nerves between paravertebral line and area of desired anesthesia

*each area of skin gets innervation from two adjacent nerves --> overlapping dermatomes; must block several intercostal nerves for complete anesthesia

Front 20

Changes in the Breasts (p.106)

Back 20

branching of the lactiferous ducts may occur during menstruation or pregnancy

Colostrum -- creamy white premilk; starts in 3rd trimester; rich in prot, Ig, growth factors

breasts increase in size w/ multiple pregnancies

breasts decrease in size w/ age and loss of fat / atrophy of glands

Front 21

Breast Quadrants (p.106)

Back 21

radial coordinate system to refer to location of tumors or cysts in breasts

divide into 4 equal quadrants, nipple as center reference point

Front 22

Carcinoma of the Breast (p.109)

Back 22

lymph drainage important; usually pass 2 or 3 sets of nodes before reaching venous drainage

lymphedema, peau d'orange sign, dimples; breast elevation w/ pec contraction (if invading muscle)

usually adenocarcinomas (from epithelial cells of lactiferous ducts)

Front 23

lymphedema

Back 23

edema or excess fluid backup in breast upon blockage of lymph drainage by cancerous mass

Front 24

peau d'oragne sign

Back 24

prominent / puffy skin between dimples pores

results from lymph backup in cancerous breast

Front 25

Mammography (p.109)

Back 25

radiographic breast examination

carcinoma appears as large jagged density

Front 26

Polymastia, Polythelia, and Amastia (p.110)

Back 26

supernumerary breasts, or accessory nipples -- occur superior or inferior to normal on mammary ridge

usually rudimentary -- easily mistaken for mole until they change color during pregnancy

both sexes can lack breasts

Front 27

Breast Cancer in Men (p.111)

Back 27

accounts for 1.5% of breast cancers

usually metastasizes to lymph nodes (also to bone, pleura, lung, liver, and skin)

presents with visible or palpable subareolar mas or nipple secretion; tends to invade pectoral fascia

Front 28

Gynecomastia (p.107)

Back 28

male breast hypertrophy after puberty -- quite rare

may be age or drug related; or imbalanc ebetween estrogenic and androgenic hormones

treat as a symptom, check suprarenal and testicular cancer and cirrhosis

*40% Klinefelter's (XXY) have gynecomastia

Front 29

Injuries to the Cervical Pleura and Apex of Lung (p.117)

Back 29

cervical pleura and apex of lung project through opening of the superior thoracic aperture into the base of the neck, just posterior to inferior attachment of sternocleidomastoid

*risk of pneumothorax with penetrating wounds at base of neck;

children are especially vulnerable

Front 30

Injury to Pleurae (p.117)

Back 30

p. descend inferior to costal margin; abdominal incision may enter pleural sac

1) right part of infrasternal angle
2) right costovertebral angle
3) left costovertebral angle

2/3) angles of 12 ribs posterior to superior poles of kidneys -- surgical incision could induce pneumothorax

Front 31

***

Pulmonary Collapse (p.117)

Back 31

lungs ~ inflated balloon; inherent elasticity can cause collapse

pressure in pleural cavities in subatmospheric (-2mmHg, during inspiration: -8mmHg)

w/ penetrating wound, air will be sucked into pleural cavity; breaks surface tension adhearing visceral to parietal pleura --> collapse

ex. -- in open-chest surgery, maintain inflation w/ positive-pressure pump

Front 32

***

Pneumothorax, Hydrothorax, Hemothorax (p.118)

Back 32

Air, Water, or Blood in the pleural cavity

air -- from penetrating wound
fluid -- from from pleural effusion
blood -- injury to a major intercostal/internal thoracic vessel

Front 33

***

Thoracentesis (p.118)

Back 33

insertion of hypodermic needle through intercostal space into pleural cavity to sample fluid / remove blood or pus

*needle should be just superior to rib to avoid neurovascular bundle

*fluid accum. (when sitting) in costodiaphragmatic recess; thus insert needle at 9th intercostal space to avoid lung (& point up to avoid liver)

Front 34

***

Insertion of a Chest Tube (p.119)

Back 34

placed for removal of large amounts of air, blood, fluid, or pus

incision in 5th/6th intercostal space in midaxillary line

direct superior -- remove air
direct inferior -- drain fluid

*connect outside end of tube w/ underwater drainage sys w/ controlled suction (prevent backflow)

Front 35

Thoracoscopy (p.119)

Back 35

diagnostic/therapeutic procedure for examination of pleural cavity

incisions in intercostal space allow placement of scope (take photos, biopsies; disrupt adhesions or remove plaques)

Front 36

Pleuritis (Pleurisy) (p.119)

Back 36

normal inspiration/expiration produces no detectable noise from pleurae

inflammation --> rough surfaces

friction --> "pleural rub"; audible w/ steth.

*acute can come w/ sharp, stabbing pain on exertion

Front 37

Pleurectomy / Pleurodesis (p.120)

Back 37

obliteration of pleural cavity by disease / surgery does not impair fxn; can come w/ pain during exertion

can induce adhesion of oposing layers of pleura w/ irritating powder (makes scar tissue, prevents recurring collapse)

Front 38

Variations in the Lobes of the Lung (p.123)

Back 38

can have extra fissure or one may be absent

azygos lobe -- most common accessory lobe, appears in RL; azygos vein arches over apex, not hilum, creating new lobe in medial part of apex

Front 39

Appearance of the Lungs and Inhalation of Carbon Particles and Irritants (p.123)

Back 39

lungs are light pink in children, non-smokers in clean environment

commonly dark / mottled in adults in urban / agricultural areas as a result of inhaled particles {--> smoker's cough}

*lymph carries "dust cells" that phogocytose particles and deposit in "inactive" CT -- allows absorption of large amounts of C w/out fxn impairment

Front 40

***

Auscultation of the Lungs and Percussion of the Thorax (p.123)

Back 40

listening w/ steth; tapping to detect sounds

A: asses airflow

P: establishes state of underlying tissue -- air filled (resonant), fluid (dull), or solid (flat)

*some places should be flat b/c of bone struc; always include root of the neck (apicies); base of lung refers to inferoposterior part, listen at T10

Front 41

Lung Cancer and Mediastinal Nerves

Back 41

involvement of phrenic nerve may paralyze diaphragm

apical cancers may involve recurrent laryngeal nerve; presents as hoarseness due to paralysis of vocal cored

Front 42

Aspiration of Foreign Bodies (p.126)

Back 42

R bronchus is wider, shorter, and runs more vertically than L

--> foreign bodies tend to lodge in the R bronchus or one of its branches

*dentists may insert a rubber dam in oral cavity to prevent aspiration during procedures

Front 43

Bronchoscopy (p.126)

Back 43

carina (keel) -- ridge seen between orifices of main bronchi; lays in sagital plane and has definite edge

carina will be distorted w/ enlarged lymph nodes in angle -- morphologic changes important for diagnosis of cronchoscopy

mucus membrane covering carina assoc. w/ cough reflex

Front 44

Lung Resections (p.128)

Back 44

can surgically remove diseased segments; tumors or abscesses often localize to a given segment

surgical options include removal of lung (pneumonectomy), a lobe (lobectomy), or a bronchopulmonary segment (segmentectomy)

Front 45

Segmental Atelectasis (p.128)

Back 45

blockage of segmental bronchus prevents air from reaching supplied segment

air will be gradually absorbed and segment will collapse (does not require compensating space in pleural space; adjacent segments expand)

Front 46

Pulmonary Embolism (p.131)

Back 46

embolus forms when blood clot, fat globule, or air bubble travels to lung

may block artery or one of it's branches
--> PE leads to partial or complete obstruction of blood flow --> acute respiratory distress

right side of heart may become dilated (inc. venous return
collateral circ. can compensate for PE in younger people

Front 47

Lymphatic Drainage after Pleural Adhesion (p.132)

Back 47

lymphatic vessels in lung and visceral pleura drain to axillary lymph nodes

presence of C particles is evidence of pleural adhesion

Front 48

Bronchogenic Carcinoma (p.132)

Back 48

usually squamous or small-cell carcinoma arising from bronchus (now refers to any lung cancer)

main cause: cigarette smoking

most arise in mucosa of large bronchi; present w/ persisten, prouctive cough

metastises to blood, bone, lymph, adrenal

Front 49

Pleural Pain

Back 49

visceral pleura is insensitive to pain, but parietal pleura is extremely sensitive

-- innervated by intercostal and phrenic nreves

pain refereed to dermatomes of same posterior root ganglia
*costal / peripheral diaphragmatic pleura ~ thoracic and abdominal walls
*mediastinal / central diaphragmatic pleura ~ C3-C5 dermatomes

Front 50

Mediastinoscopy and Mediastinal Biopsies

Back 50

used to conduct minor surgical procedures

biopsy lymph nodes to test for bronchiogenic carcinoma

Front 51

***

Widening of Mediastinum

Back 51

often observed after trauma from lacerated great vessels ~ serious hemorrahge

also indicates:
malignant lymphoma
enlargement of heart (hypertrophy) w/ CHF

Front 52

Surgical Significance of Transverse Pericardial Sinus

Back 52

must ligate these vessels during cardiac surgery (i.e. CABG)

Front 53

***

Pericarditis

Back 53

inflammation of pericardium

--> chest pain

Front 54

Pericardial Friction Rub

Back 54

inflammation causes friction along roughened surfaces

sounds like rustle of silk, hairs rubbing togethers

Front 55

***

Pericardial Effusion

Back 55

leaky pericardial capillaries or pus accumulation during inflammation

also occurs during CHF w/out inflammation

Front 56

***

Cardiac Tamponade

Back 56

heart compression caused by prevention of full expansion of heart (poss. from pericardial effusion)

limits amt of blood heart can recieve --> decrease CO

Front 57

Pneumopericardium

Back 57

air from pneumothorax dissecs percardial sac

Front 58

***

Pericardiocentesis

Back 58

drainage of fluid from pericardial cavity

insert needle in L 5th or 6th intercostal space near sternum
("bare area of pericardium")

Front 59

Positional Abnormalities of the Heart

Back 59

dextrocardia : apex directed right instead of left

*mirror image positioning of great vessels

Front 60

Percussion of the Heart

Back 60

use to define density and size

percuss at 3rd, 4th, and 5th intercostal spaces from left anterior axillary line to right

*change from resonance to dullness indicates edge of heart

Front 61

Atrial Septal Defects

(ASDs)

Back 61

large ASDs shunt O2 rich blood from LA to RA

--> hypertrophy of RA and RV; overloads pulmonary vascular system

Front 62

Ventricular Septal Defects

(VSDs)

Back 62

commonly on membranous part of interventricular septum

*25% of all forms of congenital heart dx

LV-->RV shunt of blood increases pulmonary blood flow (hypertension) and may cause cardiac failure

-much less common for the muscular part of the septum to remain open (usually closes in childhood)

Front 63

Stroke / CVA

Back 63

"cerebral vascular accident"

thrombi detach and pass into systemic circulation, occluding peripheral arteries

occlusion of an artery supplying brain --> CVA

*affects vision, cognition, and/or motor fxn

Front 64

***

Valvular Heart Disease

Back 64

stenosis = valve cannot fully open

insufficiency / regurgitation = valve cannot fully close

*both result in increased workload, produce audible turbulence (murmurs or thrills)

can replace valves w/ artificial valve prostheses (synthetic or xenografted)

Front 65

Mitral Valve Insufficiency / Prolapse

Back 65

blood regurgitates back into LA, produces a characteristic murmur

*freq. present w/out clinical significance

Front 66

Pulmonary Valve Stenosis

Back 66

~narowed central opening

-infundibular pulmonary stenosis : conus arteriosus is underdeveloped and results in back rush of blood into RV during diastole

Front 67

Aortic Valve Stenosis

Back 67

most frequent valve abnrmality

often results in LV hypertrophy

used to be caused by rheumatic fever(now <10% cases);

freq. degenerative calcification, appears after 60 y/o

Front 68

Aortic Valve Insufficiency

Back 68

produces a heart murmur and collapsing pulse (a forcible impulse that rapidly diminishes)

Front 69

***

Coronary Artery Disease

Back 69

leading cause of death

occlusion of major artery resulting in reduced blood supply to myocardial tissue

infarction -- vessel bloodless
leads to necrosis - pathological tissue death

common sites: Anterior IV LAD of the LCA; RCA; circumflex branch LCA

Front 70

Myocardial Infarction (MI)

Back 70

area of myocardium has undergone necrosis due to sudden occlusion of major artery

common locations:
1) LAD branch
2) RCA
3) circumflex

Front 71

Coronary Atherosclerosis

Back 71

lipid accumulations on internal walls of arteries eventually results in stenosis

collateral channels may compensate, but may not be able to provide enough O2

insufficiency of blood supply to heart --> myocardial ischemia

Front 72

***

Angina Pectoris

Back 72

transient, but moderately severe pain / tightness in thorax

caused by ischemia of myocardium

results from narrowed/hardened coronary arteries
anaerobic metabolism of myocytes produces lactic acid -- pain receptors sensitive to drop in pH

*treat w/ sublingual nitroglycerin to dilate coronary arrteries

Front 73

***

Coronary Bypass Graft

(CABG)

Back 73

segment of artery or vein connects proximal part of artery to ascending aorta, distal to blockage

great saphenous vein is often used, can also use radial artery

Front 74

***

Coronary Angioplasty

Back 74

catheter with small inflatable balloon flattens plaque against vessel wall to increase lumen size

thrombokinase -- used to dissolve blood clot
intravascular stent -- introduced to maintain dilation

Front 75

Coronary Occlusion and Heart Conduction Effects

Back 75

LAD supplies AV bundle

RCA supplies SA and AV nodes

--> heart block may occur upon occlusion of these vessels

Front 76

Artificial Cardiac Pacemaker

Back 76

implanted to induce heart contraction at a predetermined rate

electrode passed through SVC into RA, through tricuspid to RV and firmly fixed to traveculae carnae in ventricular wall

Front 77

Restarting the Heart

Back 77

CPR -- firm pressure over thorax forces blood into systemic circulation, release of pressure allows for refilling

Front 78

Fibrillation of Heart

Back 78

multiple, rapid, circuitous contractions or twitching of muscle fibers

atrial fibrillation : rapid, irregular uncontrolled twitchings of atrial walls

ventricular fibrulation : twitchings do not pump / maintain circulation
*most disorganized of all dysrhythmias; fatal if persistant

Front 79

Defibrillation of Heart

Back 79

electric shock causes cessation of all cardiac movements to induce normal beating

Front 80

Cardiac Referred Pain

Back 80

actual heart insensitive to touch, pain, or temp.

ischemia and metabolic products stimulate pain endings in myocardium, through T1-T5 axons (L side)

noxious stimuli in heart perceived as pain on superficial part of body (i.e. L upper limb)

anginal pain --> radiates from substernal and L pectoral regions to L shoulder and medial aspect of upper limb

Front 81

Age changes in Thymus

Back 81

thymus replaced by adipose tissue in adults, but continues to be important

1` source of T cells in body

Front 82

Aneurysm of Ascending Aorta

Back 82

-results from force of LV contraction and a localized dilation
-chest pain radiates to back
-aneurysm of arch of aorta may cause difficulty breathing and swallowing; impede on recurrent laryngeal nerve

Front 83

Variations in the Great Arteries

Back 83

-different branch patterns of aortic arch (in 35% of people)

- R arch over R lung OR double arch

-coarctation of aorta : abnormal narrowing, producing obstruction to blood flow
*most commonly near ligamentum arteriosum; collateralization provides many years of life

Front 84

Injury to Recurrent Laryngeal Nerves

Back 84

-supply all intrinsic muscles of larynx, except one

-affected by aneurysm of aortic arch b/c of path around it

Front 85

Laceration of Thoracic Duct

Back 85

-vulnerable to inadvertent injury during investigative / surgical procedures

-results in lymph escaping into thoracic cavity at very high rates causing chylothorax

-fluid may be removed by thoracentesis and ligation of duct may be necessary

Front 86

Alternate Venous Routes to the Heart

Back 86

azygos, hemiazygos, and accessory hemiazygos all offer alternate means of venous drainage to heart if there is obstruction of the IVC