S2014 Thorax Exam

Front 1

A. Anterior median (midsternal) line

Back 1

1. vertical line through sternum in mid-saggital plane

Front 2

B. Midclavicular lines (MCLs)

Back 2

1. vertical through midpoints of the clavicles, parallel to median line

Front 3

C. Anterior axillary line

Back 3

1. vertical line along anterior axillary fold (formed by pec major)

Front 4

D. Mid axillary line

Back 4

1. vertical line though apex of axilla (armpit)

Front 5

A. Posterior axillary line

Back 5

1. vertical line through posterior axillary fold (formed by latissimus dorsi and teres major)

Front 6

A. Posterior median (midspinal or midvertebral) line

Back 6

1. vertical line through spinous processes of vertebrae in mid-saggital plane

Front 7

A. Scapular lines

Back 7

1. vertical lines that pass through inferior angles of the scapula, line is parallel to posterior median line

Front 8

I. Thoracic Wall
A. Bones of the thoracic wall =
B. Function –

Back 8

A. Bones of the thoracic wall = ribs, thoracic vertebrae and sternum

B. Function – protect thoracic content…heart, lung, blood vessels, esophagus, etc

Front 9

I. Ribs - #?
A. Classification
1. True (?-?) –
2. False (?-?) –
3. Floating (?-?) –

Back 9

12
1. True (1-7) – attach “directly” to sternum
2. False (8-10) – attach “indirectly” to sternum
3. Floating (11-12) – do not attach to the sternum

Front 10

A. Typical vs Atypical Ribs

Back 10

1. Typical ribs = 3-9
2. Atypical ribs = 1,2 10-12

Front 11

A. Landmarks of Typical Ribs (ribs ?-?)
1. Head –
2. Neck
3. Tubercle –
4. Shaft –

Back 11

1. Head – have facets that articulate with two vertebrae
2. Neck
3. Tubercle – articulates with transverse process
4. Shaft – thin, flat, “curves”….costal angle = MC site of rib fracture, weakest point of the rib

Front 12

I. Thoracic Vertebrae
A. Unique features…

Back 12

1. costal facets along vertebral bodies (2 on each side except lower 3 thoracic vertebrae)
2. costal facets along transverse processes (except lower 2-3 thoracic vertebrae)

Front 13

I. Sternum
A. Composed of three segments…

Back 13

manubrium, body and xyphoid process

Front 14

B. Manubrium

Back 14

1. jugular (suprasternal) notch
2. articulations with clavicle and 1st rib

Front 15

C. Body of Sternum

Back 15

1. articulates with the manubrium…forms sternal angle

2. sternal angle is helpful clinical landmark
a. bifurcation of trachea (carina = bifurcation into R/L primary bronchi)
b. beginning and ending of the aortic arch
c. palpation of sternal angle is location for 2nd rib

Front 16

D. Xiphoid Process

Back 16

1. might be cartilaginous or ossified
2. site of subcostal (infrasternal) angle

Front 17

I. Articulations of the Thoracic Wall
A. “Major” Articulations

Back 17

1. Costovertebral joints
a. includes articulation with vertebral (and TP where appropriate)
2. Costochondral joints
3. Sternocostal – articulation between costal cartilage and sternum
4. Sternoclavicular joint (“SC joint”) – contains disc…critical for shoulder girdle function

Front 18

I. Articulations of the Thoracic Wall
B. Other articulations…

Back 18

1. Interchondral joints – “articulation” between costal cartilage of lower ribs
2. Manubriosternal joint – “sternal angle”…see above
3. Xiphosternal – junction of xiphoid and sternum
4. Also….Intervertebral (IV) Joints of the thoracic spine

Front 19

I. Movement of the Thoracic Wall
A. Inspiration –

Back 19

increase in AP and transverse diameter of rib cage d/t “bucket handle” motion of ribs

Front 20

I. Breasts
A. Men

Back 20

clinical landmark…nipple lies at approximately 4th intercostal space (between ribs 4 and 5)

Front 21

B. Female breast

Back 21

1. circular base extends from
a. sternum to MAL (mid-axillary line)
b. ribs 2-6
2. glandular (approximately 15 –20 lobes that drain into ducts)and adipose tissue
3. axillary tail of the breast…extends along inferior border of pec towards the axilla
4. understanding of the anatomy is critical for optimal clinical examination/assessment of potential CA
a. documentation in quadrants...upper inner, lower inner, lower outer, upper outer
5. lymph drainage
a. approximately 75% of breast drain lateral into axillary lymph nodes and then eventually flow back to the axillary drainage system
b. lymphadema of upper extremity is potential secondary complication following surgery for breast CA

Front 22

II. Thoracic apertures
A. Superior aperture

Back 22

– contains esophagus, trachea, nerves & blood vessels that supply the head, neck and UE

Front 23

II. Thoracic apertures
B. Inferior aperture –

Back 23

allows the esophagus, IVC (inferior vena cava) and aorta to pass inferior

Front 24

A. External intercostals - function?

Back 24

inspiration

Front 25

B. Internal intercostals - function

Back 25

expiration

Front 26

1. Innermost intercostals …function?

Back 26

elevate?…not completely understood,

Front 27

2. Transversus thoracis
-function? located?

Back 27

a. expiration (depress ribs), located along internal ribs
b. located on internal anterior thoracic cage

Front 28

3. Subcostal muscles

-function? located?

Back 28

a. inspiration (elevate ribs), located on internal portion of the ribs
b. located on internal posterior thoracic cage

Front 29

4. Levator costarum -function? located?

Back 29

a. inspiration (elevate the ribs), attach to ribs and transverse processes (TPs) of C7 – T11
b. located on external posterior thoracic cage

Front 30

5. Serratus posterior superior –function?

Back 30

inspiration (elevates the ribs),

Front 31

6. Serratus posterior inferior – function?

Back 31

expiration (depresses the ribs)

Front 32

B. Diaphragm

Back 32

1. innervated by phrenic nerve (C3-5)…provides motor and sensory components of diaphragm
2. major muscle of INSPIRATION
3. contraction will “flatten” the diaphragm…increasing thoracic volume..pressure changes cause increase of air into the lungs
4. central tendon
5. regions of diaphragm – sternal, costal lumbar

Front 33

A. Intercostal Spaces

Back 33

1. contain 3 layers of musculature (external, internal and innermost intercostals muscles)
2. neurovascular bundle (intercostal VAN = vein, artery , nerve)
a. intercostal vein, artery and nerve

3. Intercostals nerve gives off lateral and anterior cutaneous branches

Front 34

A. Intercostal Spaces
a. Clinical note:

Back 34

Herpes zoster (“shingles”) – very common in thoracic region,
 dormant virus in single segmental nerve will become active
 painful, red, vesicular lesion in dermatome pattern
 Shingles is not limited to thoracic region….will see in head/face and LE

Front 35

A. Inspiration

Back 35

1. rest = diaphragm
2. exercise = diaphragm + external intercostals
3. extreme exercise = above + accessory muscles (SCM and scalenes)..pecs can assist also
a. clinical…patients with COPD and other pulmonary disease may display this type of breathing pattern

Front 36

B. Expiration

Back 36

1. rest = elastic recoil of the lungs
2. exercise = recruit the internal intercostals + abdominal mm (rectus abdominis, int/ext oblique)

Front 37

A. Two major sources of blood supply to rib cage

Back 37

(descending aorta and R/L subclavian arteries)

Front 38

1. Descending aorta –

Back 38

provides blood to segmental branches known as posterior intercostals arteries

Front 39

a. Posterior intercostals arteries

Back 39

 Travel anteriorly between ribs (along with intercostals vein and intercostals nerve – “VAN”)

Front 40

2. Subclavian arteries –

Back 40

provide blood to R/L internal thoracic arteries

Front 41

a. Internal thoracic arteries

Back 41

 Descend along anterior wall of internal rib cage
 Anterior intercostals arteries originate from descending internal thoracic artery
(i) Anterior intercostals travel between ribs and anastomose with posterior intercostals arteries

Front 42

1. Azygos vein

Back 42

a. Located right posterior internal rib cage, drains into SVC

Front 43

2. Hemiazygos and accessory hemiazygos vein

Back 43

a. Located on left posterior internal rib cage
b. Hemiazygos drains
c. drain segmental portions of thorax

Front 44

II. Thoracic Cavity and Viscera
A. 3 compartments

Back 44

1. 2 pulmonary cavities – contains lungs and pleura
2. mediastinum - contains heart, great vessels, trachea, esophagus, thymus and lymph

Front 45

I. Pleurae
A. Each lung is invested by pleural sac

Back 45

B. 2 layers of continuous, thin, serous membranes…layers are “enfolded” on each other during embryonic development

Front 46

C. visceral pleura (pulmonary pleura) –

Back 46

invests the lungs

Front 47

D. parietal pleura –

Back 47

lines the thoracic wall and diaphragm

Front 48

E. parietal cavity –

Back 48

potential space between the two pleural layers, lubricated by serous pleural fluid…allows 2 layers to glide smoothly

Front 49

F. costodiaphragmatic recesses –

Back 49

pleural recesses that can accumulate fluid with various conditions , lateral and posterior removed via thorencentesis (hypodermic needle inserted through intercostal space)

Front 50

G. costomediastinal recesses –

Back 50

smaller pleural recesses located posterior to the sternum

Front 51

1. Pneumothorax –
2. Pleural effusion –
3. Hemothorax –
4. Pleuritis –

Back 51

1. Pneumothorax – air enters pleural cavity, partial or complete collapse of lung

2. Pleural effusion – abnormal accumulation of fluid from pathology within pleural cavity, potential compression of lung

3. Hemothorax – blood accumulates in the pleural cavity, potential compression of lung

4. Pleuritis – inflammation of pulmonary pleura, lung sounds “friction rub”

Front 52

A. Ventilation =

Back 52

mechanical movement of air in/out of lungs

Front 53

1. inspiration…increase in volume of thorax creates

Back 53

negative pressure in lungs/pleural cavity causes air to be “sucked in”

Front 54

spirometry

Back 54

a. static lung volumes (total lung capacity, tidal volume, inspiratory reserve capacity, etc..)
b. dynamic lung measures – examples…
 FEV1 (forced expiratory volume) = amount of air expired in 1st second of expiration,
 minute ventilation – amount of air expired in one minute

Front 55

B. Respiration =

Back 55

gas exchange that occurs in lungs (at alveolar/capillaries) and throughout the body (at target tissue /capillaries)

Front 56

a. Pulse oximeter –

Back 56

measures arterial saturation of oxygen, ideal 96 - 100%

Front 57

D. Hilum or root of each lung…
1. site where

Back 57

the lung becomes covered by visceral pleura

Front 58

D. Hilum or root of each lung…
2. contains..

Back 58

a. primary bronchus
b. 2 pulmonary veins (superior and inferior)
c. 1 pulmonary artery – eventually supply pulmonary capillaries for gas exchange
d. bronchial vessels – supply the lung tissue and pleurae
e. pulmonary nerve plexus - autonomic nerves and sensory nerves
f. lymph vessels

Front 59

E. Right lung

Back 59

1. 3 lobes separated by oblique fissure and horizontal fissure
2. superior, middle and inferior lobe
3. right lung eventually divide into 10 bronchopulmonary segments (2 – superior lobe, 3 – middle lobe and 5 inferior lobe)

Front 60

F. Left lung

Back 60

1. 2 lobes separated by oblique fissure
2. superior and inferior lobes
3. lingula – “similar” to middle lobe of right lung
4. left lung eventually divide into 10 bronchopulmonary segments (5 – superior lobe and 5 inferior lobe)

Front 61

G. Bronchial tree

Back 61

1. trachea…bifurcation at level of sternal angle, known as carina
2. R/L primary bronchi (enter the hilum)
3. divide into lobar bronchi (secondary bronchi)
4. further divide into segmental bronchi – supply the 10 bronchopulmonary segments
5. continue to divide into 20 – 25 generations of smaller divisions of bronchioles
6. eventually end as terminal bronchiole (no gas exchange yet…)
7. terminal bronchioles give rise to respiratory bronchioles which supply the aveoli (gas exchange)

Front 62

Pulmonary embolism (PE)

Back 62

1. obstruction of a pulmonary arterial blood flow
2. embolus may travel from periphery (classically the veins of the legs) back to the right side of the heart
3. right side of the heart pumps it through the pulmonary trunk to pulmonary artery and gradually into smaller diameter vessels where it will eventually will obstruct blood flow
4. obviously a large embolus could be disastrous – acute respiratory distress/failure…potential for death

Front 63

I. Mediastinum

Back 63

A. Region between the pleural cavities

Front 64

B. Borders of mediastinum

Back 64

1. superior – superior thoracic aperture
2. inferior – diaphragm
3. anterior – sternum and costal cartilages
4. posterior – thoracic vertebrae

Front 65

C. Divisions and contents of the mediastinum

Back 65

1. horizontal line through sternal angle to T4-5 disc space divides mediastinum into superior and inferior divisions

2. Superior division – thymus in children (remnants in adults), arch of aorta/great vessels, trachea, esophagus

3. Inferior division
a. Anterior – internal thoracic vessels, fat, few lymph nodes
b. Middle – pericardium, heart, roots of great vessels
c. Posterior – esophagus, descending (thoracic) aorta, thoracic duct, lymph nodes

Front 66

I. Heart

Back 66

A. Heart is located in the middle mediastinum
B. Heart is enclosed in double walled, fibroserous sac known as pericardium

Front 67

C. Pericardium
1. Outside sac =

Back 67

fibrous pericardium

a. attaches to diaphragm via pericardiacophrenic ligament

b. also attaches to the sternum via sternopericardial ligament

Front 68

2. Inside sac =

Back 68

serous pericardium

a. Similar to pleura of lungs…heart invests in on the serous pericardium forming two layers…
 parietal layer
 visceral layer – “becomes” the outer layer of the heart known as the epicardium

Front 69

b. pericardial cavity -

Back 69

potential space between parietal and visceral layers, smooth fluid allows heart to “move” freely within pericardial sac

Front 70

A. Wall of the Heart

Back 70

1. epicardium – visceral serous pericardium….see above
2. myocardium – cardiac muscle
3. endocardium – thin, smooth endothelial layer that lines the heart and valves

Front 71

B. External anatomy of the heart
1. fibrous skeleton of the heart

Back 71

a. four fibrous rings, surround the orifices of the valves
b. function
 provides attachments for myocardium of atria and ventricles
 provide attachment for cardiac valves
 provide electrical insulation between atria and ventricles

Front 72

2. apex of the heart
a. formed by
b. located approximately

Back 72

formed by the tip of the left ventricle

located ~ between left ribs 5 and 6 (5th intercostal space)…just medial to midclavicular line

Front 73

c. clinical anatomy: apex of heart

Back 73

 might visible in some patients..”apical impulse”
 sometimes helpful to have patient lay on left side to help palpate or visualize
 obesity, pregnancy, excessive muscular development, anomalies, etc. may limit ability to locate apical impulse
 if location is lateral to midclavicular line may suggest displacement or cardiac enlargement

Front 74

1. base of the heart

Back 74

a. posterior side of heart as it sits in vivo
b. formed by the left atrium….(technically some right atrium included)

Front 75

2. Describe each of the borders of the heart.
a. Right border – right atrium, extending between SVC and IVC
b. Left border – primarily left ventricle and some left atrium
c. Inferior border – primarily right ventricle and some left ventricle
d. Superior border – junction where great vessels enter and leave the heart

Back 75

a. Right border – right atrium, extending between SVC and IVC
b. Left border – primarily left ventricle and some left atrium
c. Inferior border – primarily right ventricle and some left ventricle
d. Superior border – junction where great vessels enter and leave the heart

Front 76

3. Name and describe the surfaces of the heart.

Back 76

a. Sternocostal (anterior) surface – mostly right ventricle
 Clinical anatomy
(i) The right ventricle can be examined along the left sternal border (3 – 5th intercostal spaces)

b. Diaphragmatic (inferior) surface – mostly left ventricle and partially right ventricle

c. Pulmonary (left) surface– mostly left ventricle

Front 77

a. right atrium

Back 77

 SVC/IVC openings
 Opening coronary sinus
 Fossa ovalis
 Tricuspid valve

Front 78

b. right ventricle

Back 78

 tricuspid valve
 papillary muscle/chordae tendineae
 pulmonary valve

Front 79

c. left atrium

Back 79

 Foramen ovale
 4 openings of pulmonary veins

Front 80

d. left ventricle

Back 80

 Bicuspid valve
 papillary muscle/chordae tendineae
 Aortic valve

Front 81

a. Superior vena cava (SVC) –

Back 81

returns blood back to right atrium from areas superior to diaphragm (except from heart and lungs)

Front 82

b. Inferior vena cava (IVC) –

Back 82

returns blood back to the right atrium from areas inferior the diaphragm

Front 83

c. Pulmonary trunk –

Back 83

sends unoxygenated blood from right ventricle to lungs

Front 84

d. Right/left pulmonary veins –

Back 84

returns oxygenated blood back to the left atrium from the lungs

Front 85

e. Aorta – function

name branches

Back 85

sends blood to body from left ventricle, branches of the aortic arch include…
 Brachiocephalic trunk gives rise to right common carotid artery and right subclavian artery
 Left common carotid artery
 Left subclavian artery

Front 86

A. Tricuspid valve

Back 86

(right AV valve)

1. located between right atrium and right ventricle
2. chordae tendineae and papillary muscles anchor cusps of the valve
3. clinical
a. auscultate along left sternal border at 5th (or 4th) intercostal spaces

Front 87

B. Pulmonary valve

Back 87

(right semilunar valve)
1. located between the right ventricle and pulmonary trunk
2. clinical
a. auscultate along the left 2nd intercostal spaces

Front 88

A. Bicuspid valve

Back 88

(left AV valve)
1. located between left atrium and left ventricle
2. chordae tendineae and papillary muscles anchor cusps of the valve
3. clinical
a. auscultate along apex (left 5th intercostal space…just medial to midclavicular line)

Front 89

C. Aortic valve

Back 89

(left semilunar valve)
1. located between left ventricle and the aorta
2. clinical
a. auscultate along right 2nd intercostal space

Front 90

1. coronary arteries

Back 90

a. arise from base of aorta…”backflow” from aortic pressure creates blood flow through coronary arteries

Front 91

b. right coronary artery (RCA)

Back 91

 supplies right atrium and ventricle
 nodal branches supply SA and AV nodes
 marginal branch of RCA is portion that supplies the right ventricle
 posterior interventricular artery (right posterior descending)

Front 92

b. right coronary artery (RCA)
 nodal branches supply...?
 marginal branch of RCA supplies ...?
 posterior interventricular artery (right posterior descending)

Back 92

 nodal branches supply SA and AV nodes

 marginal branch of RCA is portion that supplies the right ventricle

 posterior interventricular artery (right posterior descending)

Front 93

a. left coronary artery (LCA)
 divides into

Back 93

anterior interventricular artery and circumflex artery

Front 94

a. left coronary artery (LCA)
 anterior interventricular artery (aka left anterior descending..LAD) supplies

Back 94

(i) R/L ventricles and majority of interventricular septum

Front 95

a. left coronary artery (LCA)
 circumflex artery (“behaves” like RCA at this point)

Back 95

(i) supplies left atrium and ventricle

Front 96

a. left coronary artery (LCA)
(i) marginal branch is portion the supplies

Back 96

left ventricle

Front 97

a. Coronary sinus

Back 97

 Most of the cardiac veins drain into the coronary sinus
 Coronary drains directly into the right atrium
 Great, middle, small cardiac veins and oblique vein of the left atrium all empty into coronary sinus
 Anterior cardiac vein and smallest cardiac veins empty directly into the right atrium

Front 98

II. Conducting System of the Heart

Back 98

A. SA node (sinuatrial)
B. AV node (atrioventricular)… 1/10 second delay…allows for atrial contraction
C. AV bundle (of His)
D. L/R bundle branch
E. Purkinje fibers

Front 99

III. Innervation of the heart
A. Sympathetic

B. parasympathetic (via CN ?)

Back 99

A. Sympathetic
1. cervical and thoracic sympathetic trunks
2. innervate atria and ventricles
3. function
a. increase HR, contractility

B. parasympathetic (via CN 10 (vagus nerve)
1. innervate atria
a. decrease HR, contractility