Anatomy

LA
- features

- mostly smooth
- 4 x pulmonary veins
- valve of foramen ovale
- some pectinate muscle

Thymus
- location
- function

- superior-anterior mediastinum
- educates T lymphocytes to recognize self antigens & then involutes (peak mass of 35 g @ puberty)

Fibrous pericardium

- attached to the diaphragm, heart moves up and down with each breath.

Superior and inferior mediastinum:
- separated by?

line connecting from jugular notch→ T4 /T5

Sulci
- coronary sulcus

also known as atrioventricular; separates atria and ventricles
→ RCA (right coronary artery)

Apex of the heart
- formed by
- location

formed by LV, 7- 9 cm left of midline, 5th intercostal space.

sulci
- how many
- what does it separate

3;
one separating A/V (coronary sulcus)
two separating the ventricles (anterior and posterior inter-ventricular sulci)

RA
- features (6*)

- pectinate muscle (derived from primitive atrium)
- sinus venarum (smooth; derived from sinus venosus)
- fossa ovalis
- openings for coronary sinus /SVC/IVC
- crista terminalis
- Koch's triangle --> AV node

Aortic valve
- # cusps

3 cusps (left, right, posterior);
posterior is non coronary w /right and left giving off branches of coronary arteries

Right lung vs. left lung

R lung has 3 lobes, L lung has 2 lobes

Topography of the lungs
Superior:

- apices extend 2.5 cm above the clavicle to vertebrae prominens (C7)

Topography of the lungs
Inferior:

- depends upon the line of the axis
Mid clavicular - Rib 6
Mid axillary - Rib 8
Paravertebral - Rib 10

Borders of the mediastinum
anterior:

sternum

Divisions of the mediastinum
- separated by

line connecting jugular notch → T4/T5

Inferior mediastinum
- subdivisions

anterior, middle, posterior

Superior mediastinum
- contents

trachea, esophagus, & thymus (anterior)

Middle mediastinum (inferior)
- contents

pericardium, heart, initial segments of great vessels

Posterior mediastinum (inferior)
- contents

esophagus continued & primary bronchi

Where to auscultate the aortic valve

R 2nd intercostal space

Where to auscultate pulmonic valve

Left 2nd intercostal space

Where to auscultate the right AV valve

Left 4th intercostal space

Where to auscultate the left AV valve

Left 5th intercostal space

RV
- features

- trabeculae carneae (muscular ridges)
- papillary muscles
- chordae tendinae

LV
- features

- trabeculae carneae
- papillary muscles
- chordae tendinae

Surfaces of the heart:
anterior/sternocostal

RA, RV, part of LV & L auricle

Surfaces of the heart:
base

receives pulmonary veins, SVC & IVC

Surfaces of the heart
- Apex

formed by LV, 7-9 cm left of midline, 5th intercostal space

Pulmonic valve (more anterior)

3 cusps (anterior, right, left)

Aortic valve

3 cusps (left, right, posterior); posterior is non coronary w/ right and left giving off branches of coronary arteries

Borders of the mediastinum:
Posterior

T1 - T12

Borders of the mediastinum
Superior

jugular notch --> T1

Surfaces of the heart:
right pulmonary

RA

Surfaces of the heart:
left pulmonary

LV, part of LA

Surfaces of the heart:
diaphragmatic

RV & LV

Sulci
- Anterior IV

separates ventricles anteriorly
--> LCA (left coronary artery)

Sulci
- Posterior IV

separates ventricles posteriorly
--> circumflex & RCA (right coronary artery)

Great vessels & cardiac chambers that receive or issue from them
- aorta

Left ventricle --> aorta

Great vessels & cardiac chambers that receive or issue from them
- pulmonary arteries

right ventricle --> pulmonic valve --> pulmonary trunk --> 2 pulmonary arteries

Great vessels & cardiac chambers that receive or issue from them
- pulmonary veins

lungs send oxygenated blood back to heart --> left atrium

Great vessels & cardiac chambers that receive or issue from them
- SVC

SVC --> right atrium

Great vessels & cardiac chambers that receive or issue from them
- IVC

IVC --> right atrium

Origin of and branches off the RCA
- supplies

RCA comes off the right aortic valve cusp
RCA rides along AV/coronary sulcus
- Right marginal artery (anterior)
- Posterior descending artery or PDA (posterior IV sulcus) * right dominant pattern

Supplies
- RA, RV, SA node

Right dominant pattern
- artery in posterior IV sulcus
- frequency in population

PDA
70-80%

Origin of and branches off LCA
- supplies

LCA comes from left cusp of aortic valve, short course before it branches off
- LAD (anterior IV sulcus)
- LCx (posterior IV) ** left dominant pattern

Supplies
LA, LV, IV septum

Left dominant pattern
- artery in posterior IV sulcus
- frequency in population

LCx
8-10%

Widowmaker

Left anterior descending artery
- supplies the left atrium and left ventricle

Balanced or codominant coronary circulation

PDA in posterior IV sulcus
LCx also supplying the back of the heart

Great cardiac vein
- location
- drains into

anterior IV sulcus
coronary sinus

Middle cardiac vein
- location
- drains into

posterior IV sulcus
coronary sinus

Small cardiac vein
- location
- drains into

right lateral inferior heart
coronary sinus

** follows course of right marginal artery

Anterior cardiac veins
- location
- drains into

Origin: along right ventricle
Drains directly into left atrium

Venae cordis minimae

runs deep with muscle tissue

Koch's triangle
- boundaries
- significance

Todaro's tendon
Ostium of coronary sinus
Base of septal cusp

Location of AV node

Foregut derivates

Lungs and pulmonary airways
Esophagus
Stomach
Proximal duodenum
Liver and biliary apparatus
Pancreas

Regions of parietal pleura
- thorax

Costovertebral/costal
Diaphragmatic
Cervical
Mediastinal

Recesses of pleural membranes

all are potential spaces
- Costodiaphragmatic
- Costomediastinal
- Vertebromediastinal

Thoracentesis
- procedure
- indications

usually enter the costodiaphragmatic space by inserting the needle just above rib #10 along mid axillary line

pleural effusions, HF, lung infections, tumors

Trachea
- begins at
- bifurcates at
- length

C6
T4/5
10-11 cm

# rings in trachea

incomplete rings with opening posteriorly
- 16 - 20

Carina and differences between primary bronchi

trachea bifurcates at T4/5 --> right and left main bronchi
Right: wider and more vertical (more likely to receive a FB)

Layers of the trachea

Inside --> out
Mucosa: epithelium
Tunica mucosa/submucosa: glands
Cartilaginous/fibromuscular: trachealis muscle
Adventitia: connective tissue coat

1', 2' & 3' Bronchi differences in R/L lungs

1': right and left
Right: 3 secondary or lobar bronchi --> 10 tertiary or segmental bronchi
Left: 2 lobar --> 8 segmental bronchi

Bronchi --> bronchioles

Key features of left lung (not the fissures or lobes)

Lingula - located on superior lobe @ inferior angle
Cardiac notch - also superior lobe

Lobes and fissures of left and right lobes

Right
- Horizontal fissure separates superior and middle lobes
- oblique fissure separates middle and inferior lobes

Left
- oblique fissure separates superior and inferior lobes

Hilum of the lungs
- Key features

Pulmonary ligament
Gateway into and out of the lung
Different vessel/airway orientation based on laterality

Right lung
- pulmonary artery location

pulmonary artery anterior to main bronchi

RALS

Left lung
- pulmonary artery location

pulmonary artery is superior to main bronchi
RALS

Bronchopulmonary segments

R: 10
L: 8
Own artery and septa
Supplied by 3' bronchi

Pulmonary acinus

supplied by terminal bronchiole
- houses alveolar sacs

Pulmonary acinus
Arterial ramifications ___ branching patterns of bronchioles

Arterial ramifications follow branching patterns of bronchioles

Pulmonary acinus
Pulmonary veins are located __

Pulmonary veins are located peripherally

Parts of esophagus

cervical
thoracic (most extensive)
abdominal (after passing esophageal hiatus of diaphragm)

Layers of esophageal wall

Mucosa
Submucosa
Muscularis externa
- 2 layers (inner circular layer and outer longitudinal layer)
Adventitia/serosa

Constrictions of esophagus

- pharyngo-esophageal
- aortobronchial (right 1' bronchus)
- diaphragmatic

Diverticula

- Zenkers (pharyngo-esophageal)
- T4
- Epiphrenic T11 or T12

Geometry of esophagus

Killian's triangle
- borders include cricopharyngeus muscle between transverse and oblique fibers
- junction between pharynx and esophagus
- point of weakness --> Zenker's diverticulum

Laimer's triangle
- below Killian's

*** thoracic viscera 4

abdominal cavity is located between the ___ and the ____

abdominal cavity is located between the thoracic diaphragm and the pelvic rim (linea terminalis)

Parts of the pelvic rim

Sacral promontory
Sacral ala
Arcuate line
Pectineal line
Pubic crest

The abdominal cavity extends superiorly into the osteocartilaginous thoracic cage to about ___

5th intercostal space (supine)

anterior abdominal wall limits

superior: right and left costal margins
inferior: line connected each ASIS to the pubis
lateral: vertical line through ASIS

Vertebral level of:
Umbilicus

L3-L4 intervertebral disc

Vertebral level of:
subcostal plane

L2-L3
joins the inferior margins of the 10th costal cartilage passing thru L2/L3

Vertebral level of:
transtubercular plane

L5
through iliac tubercles

Vertebral level of:
transumbilical plane

L3-L4
through the umbilicus

Vertebral level of:
transpyloric plane

L1
usually midway between the xiphosternal joint and the umbilicus

Important structures related to transpyloric plane (6)

- pylorus of stomach
- fundus of gallbladder
- neck and body of pancreas
- hila of kidneys
- first part of duodenum
- origin of SMA

linea semilunares
extends from __ to the ___

9th costal cartilage, pubis

Linea semilunares is __ cm from the median plane

5-8 cm

Linea semilunares represents the __ border of the __ muscle

lateral border; rectus abdominis

pubic crest and tubercle: bony landmark located ___ cm ___ of the pubic symphysis

___ attaches here

2.5 cm, laterally, inguinal ligament

iliac crest extends ___ from ASIS
& can be palpated ___ cm ____ to the ASIS

posteriorly, 6 cm, posterior

Superior surface anatomy of the abdomen

xiphoid process
costal cartilages 7-10th ribs

Inferior surface anatomy of the abdomen

inguinal ligament
pubic crest and pubic symphysis

Subcostal plane
which costal cartilage
which vertebral level

10th costal cartilage
L2-L3

location of McBurneys point

R ASIS --> umbilicus
1/3 of the way from the ASIS

Fascia of the anterior abdominal wall

superficial
- Camper's (fatty superficial layer)
- Scarpa's (membranous deep layer)
deep [thin, strong layer over the superficial muscles]

Camper's fascia
continuous w/ __ ?? [thigh]

superficial fascia of the thigh

Scarpa's fascia is continuous w/ ___ of the thigh and ___ + ___

deep fascia of the thigh/fascia lata

Colle's fascia (superficial fascia of the perineum) + the fascia investing the scrotum, penis, and labia majora

Four important paired muscles of the abdominal wall

External oblique
Internal oblique
Transversus abdominis
Rectus abdominis

External oblique
- origin
- insertion
- nerve
- action

O: external surface of 5th - 12th ribs

I: linea alba, pubic tubercle, anterior 1/2 iliac crest

N: inferior 6 thoracic nerves + subcostal nerve

A: compress/support abdominal viscera; flex & rotate the trunk