Describe how the thoracic aorta, subclavian a. & v., brachiocephalic a. & v., SVC, IVC, internal thoracic a., intercostal a. & v., azygos v. and hemiazygos v. course through the thoracic wall.
A 22 year old female comes to the emergency department complaining of dyspnea and chest pain after a car accident. Her chest radiograph is shown below. What is causing her symptoms?
A deceleration injury to great vessels at base of the heart. Note the widened mediastinum. Because the heart swings and the descending aorta is fixed you often get tearing away of the aorta at the ligamentum arteriosum.
A 19 year old female comes to the ED with left sided chest pain and dyspnea. Upon auscultation you hear decreased breath sounds on the left side. You also note tracheal deviation. She denies any trauma in her history. What caused her to have this condition?
This is a spontaneous pneumothorax that can occur in people 17-24 years old from a congenital "bleb" on the surface of the lung that ruptures, allowing air from the lung to escape into the pleural space.
A 61 year old male comes to your clinic complaining of hemoptysis. In 95% of cases, where is the blood originating from and how does it get coughed out?
It originates in the segmental bronchi, traveling up to the lobar bronchus, into the main stem bronchus and out the trachea.
Label the structures indicated below.
Right lung. 1 = Posterior. 2 = Apical. 3 = Anterior. 4 = Lateral. 5 = Medial. 6 = Superior. 7 = Medial basal. 8 = Anterior basal. 9 = Lateral basal. 10 = Posterior basal.
Label the structures indicated below.
Left lung. 1 = Apical-posterior. 2 = Anterior. 3 = Superior lingular. 4 = Inferior lingular. 5= Superior. 6 = Anterior-medial basal. 7 = Lateral basal. 8 = Posterior basal.
A 55 year old male comes to your clinic complaining of chest pain that is worsened by breathing and lying down. Heart sounds are decreased and pulses are weak. His history reveals an acute MI one week ago. How do you help this patient?
Pericardiocentesis. He is suffering from cardiac tamponade and you must relieve pressure on the heart from fluid accumulation in the pericardial sac. You can do this by entering from the left of the xiphoid process or next to the sternum at the 5th or 6th LICS where the cardiac notch should be.
Why are patients with some type of lymphoma at high risk for pneumothorax?
The thoracic duct can get blocked up and cause leakage of chyle into the thoracic cavity, causing a chylothorax.
An 11 year old boy put a quarter in his mouth when his mom told him to give it to her. In the struggle of trying to keep it in his mouth while his mom wrestled him, he aspirated it. Where is the first place you will look on a chest radiograph to find the aspirated coin? Why?
The right main stem bronchus and right lower lobe. The left bronchus makes a sharp angle at the carina because it is angled over the pulmonary vessels, whereas the right main bronchus is a straight shot down from the trachea.
In the image below, label the sulcus terminals, sinus venarum, interatrial septum, fossa ovalis, pectinate muscles and crista terminalis.
In the image below, find the papillary muscles, moderator band, chordae tendinae, tricuspid valve, trabeculae carnae, infundibulum, and interventricular septum.
In the image below, find the chordae tendinae, papillary muscles, trabeculae carnae and mitral valve.
Identify the lunules, nodules and coronary sinuses in the aortic valve shown below.
Identify which region of the heart is at risk for ischemic injury when the artery indicated below is occluded.
LCA (LA, LV, IVS, & AV node), LAD (LV, RV & anterior 2/3 of IVS), LCX (LA & LV), LT marginal (LV), RCA (RA, posterior IVS, SA, and AV nodes), Sinuatrial (Pulmonary trunk & SA node), RT marginal (RV & apex), posterior interventricular (RV, LV and posterior 1/3 of IVS).
What is a thrill?
A superficial vibration you can feel over an area of turbulence in the cardiovascular system.
Why is the sulcus terminalis a significant embryologic landmark? What embryologic structure was covered by the fossa ovalis?
It is the junction between the embryonic primitive atrium and the sinus venosus. (as is the crista terminalis). The fossa ovalis covered the embryonic foramen oval.
What is the difference between a direct and indirect inguinal hernia?
Direct = medial to inferior epigastric vessels and through peritoneum/transversalis fascia. Indirect = lateral to inferior epigastric vessels and through deep inguinal ring.
What structure must still exist in patients with hydrocele of the spermatic cord or testis?
A persistent processus vaginalis. Whether it is in the spermatic cord or testis is determined by how far the persistent processus vaginalis extends.
A patient comes to see you with a severely swollen and painful left testicle. What should you rule out first?
Torsion. This is a surgical emergency because pathological death of the testicle will occur if the artery and vein remain closed for a long period of time.
Which side does nutcracker syndrome occur and why?
The left. It is here the renal vein gets compressed between the abdominal aorta and the SMA. Compression of the left renal artery also results in back up into the testicles because the left testicular vein drains into the left renal vein.
Which tunic gives rise to the tunica vaginalis? Internal spermatic fascia? The cremaster fascia? The external spermatic fascia?
Tunica vaginalis = peritoneum. Internal spermatic fascia = transversalis fascia. Cremaster fascia = internal abdominal oblique fascia. External spermatic fascia = external abdominal oblique fascia.
A 23 year old first lieutenant sustains a gunshot wound to the abdomen. During your FAST exam, you note fluid drainage from the omental bursa and accumulation in what space?
Hepatorenal recess. (Morison's pouch).
What are the potential spaces surgeons can use in the pelvic region?
Retropubic space and retrorectal space.
How does the stomach change during development?
It originally starts up and down, then the left side becomes the anterior portion and the right side becomes the posterior portion (LARP). This explains why the vagus nerves become anterior and posterior instead of left and right.
A mother brings her new baby in to see you complaining of vomiting after feeding. She describes the vomit as clear. How can you help this baby out?
This child has congenital hypertrophic pyloric stenosis. It can be fixed by cutting the muscle and releasing the stenosis.
How does the pancreas produce back pain?
Adenocarcinomas of the pancreas invade the muscles and nerves of the posterior abdominal wall.
How does blood flow to and from the liver?
To the liver: portal vein and hepatic artery. From the liver: right, middle and left hepatic veins going to the IVC.
Why is it important to locate the root of the mesentery during an operation?
It holds the SMA and all of its branches and you really don't want to cut it.
A 66 year old male comes to the clinic with sever upper abdominal pain. His history only reveals long standing high blood pressure and a DVT. If he has a clot blocking his SMA, what portions of the bowel are at risk for ischemia and death?
The SMA supplies the entire small intestine, the ascending and transverse colons. These areas are all at risk with blockade of the SMA.
Identify the splenic, left gastric and common hepatic arteries in the image below.
Where do the adrenal glands get their blood supply from superiorly? In the middle? Inferiorly?
Superiorly: Inferior phrenic a. Middle: Abdominal aorta. Inferiorly: Renal artery
At what point on the duodenum does it become the jejunum?
The ligament of Treitz. This is where the suspensory ligament on the ascending portion of the duodenum connects with the portion of the diaphragm's right crus.
How does lymphatic drainage travel from the kidney?
Kidney -> Lumbar nodes -> Cisterna chyli
How does drainage differ between the left and right adrenal veins?
Left: drains into left inferior phrenic vein -> left renal vein -> IVC. Right: drains straight into IVC.
How does the ureter travel in relation to nearby blood vessels in males and females?
Males: over the external iliac and under the testicular artery and vas deferens. Females: in with the internal iliac, posterior to the ovarian artery and beneath the uterine artery.
Define the urogenital triangle. What makes up the pelvic diaphragm?
Diaphragm = coccygeus and levator ani muscles.
A patient comes to the ED because part of his small intestine is leaking and he is in terrible pain. How would his perceived pain location travel from the time of leakage to the time you see him in the ED?
Initial gut pain starts in the midline, is dull, deep, achy and difficult to localize. Once the fluid makes contact with the peritoneum of the abdominal wall, the pain will become sharp and well localized. This is because the peritoneum is much more sensitive than the visceral layers of the organs.
What ligament contains the ovarian arteries? The uterine arteries?
The ovarian arteries branch off of the aorta and travel through the suspensory ligament to the ovaries. The uterine arteries branch off the internal iliac and travel through the transverse cervical (cardinal) ligament.
When performing a pelvic examination on a female patient you feel hard nodules in the area of the cardinal ligament. What could this entail?
You would then have to work the patient up for metastatic cervical cancer.
What areas are innervated by the pudendal nerve? Genitofemoral?
Genitofemoral = female: labia majora, male: cremaster, scrotum and thigh. Pudendal = perineum, rectum and glans/clitoris. Ilioinguinal =
Aorta on CT
Which chamber of the heart is most prone to anterior crush injuries?
Right ventricle is the most anterior chamber and most prone to injury because it sits right behind the sternum. LV comprises left lateral border. Left atrium is the most posterior chamber.
What are the differences in blood supply, drainage and innervation of the superior and inferior regions of the pectinate line.
Location of SA and AV node
AV - Koch's triangle (posterior leaflet of tricuspid valve, opening of coronary sinus and IV septum). SA node - junction of SVC and IVC
Large ASD heart sound?
Fixed splitting of S2
- S - Suprarenal (adrenal) gland
- A - aorta/IVC
- D - duodenum (second and third part)
- P - pancreas (except tail)
- U - ureters
- C - colon (ascending and descending)
- K - kidneys
- E - (o)esophagus
- R - rectum
What veins contribute to the portal circulation?
SMV + splenic vein + IMV
What veins contribute to the caval circulation?
Left gastric and azygos veins
IMA and its branches
Left colic, superior rectal and sigmoid arteries.
Branches off celiac artery
A 24 year old soldier comes in after a firefight complaining of difficulty breathing. His blood pressure is 90/60 mmHg. Upon auscultating his lung fields you hear muffled breath sounds, but you can hear them nonetheless. Percussion reveals dullness near the diaphragm. What is this patient most likely suffering from? How can you temporarily relieve his symptoms?
Hemothorax. Fluid still conducts sound and that is why you hear muffled breath sounds. Dull percussion reveals fluid accumulation at the base of the thorax. Decreased blood pressure indicates internal hemorrhage. You could do a thoracentesis and drain some of the accumulated blood. You would insert the needle in the 9th intercostal space in the MAL, putting your needle into the costodiaphragmatic recess.
A 37 year old male comes to the ED after a car crash. He complains of difficulty breathing. His blood pressure is 130/80 mmHg. You note absence of breath sounds of the left lung and tracheal deviation to the left side. What can you do to help this man?
This man is suffering from a pneumothorax. Laceration to the parietal pleura of the lung messed up the negative pressure that keeps the lung inflated in the chest cavity. You need to reinstate that negative pressure with a chest tube inserted at the 5th or 6th intercostal space at the MAL.
A 73 year old man on a ventilator says he is having increased difficulty breathing. His blood pressure is 90/50 mmHg. Chest x-ray is shown below. What is your diagnosis and what caused his condition?
This is a tension pneumothorax. Note the mediastinal shift. His decreased blood pressure is due to positive pressure put into the pleural cavity from the ventilator via a tear in the lung. This positive pressure decreases venous return and thus decreases his blood pressure.
How do electrical signals pass through the heart? What regions are at risk in occlusion of the RCA and the LAD?
LAD = septal branches of AV node. RCA = SA and AV nodes.
Identify the different cardiac veins seen below.
In what locations can veins anastamose to avoid the liver the case of obstruction?
Esophageal vein (caval) and the left gastric vein (portal). The epigastric vein (caval) with the para-umbilical vein (portal). The superior rectal vein (caval) and the inferior rectal vein (portal). Retroperitoneal veins (caval and portal).