THORAX MUST KNOW CONCEPTS

DONNIE GUNBOSS SSGFL1@GMAIL.COM

BUT BEFORE THAT LETS SEE HOW WE SHOULD STUDY ANATOMY!

Knowing anatomical terminology (eg. Superior, lateral, deep, coronal, saggital) is absolutely fundamental****

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ANYWAYS, LETS START WITH THE BREAST. CHEST WALL (LYMPH DRAINAGE OF BREAST)

FYI: suspensory ligaments and coopers ligaments are synonymous

CONCEPT CHECK
After axillary lymph node biopsy, the test for cancer is positive. From which site did it most likely spread? a) Superior half of breast b) Inferior half of breast c) Lateral half of breast d) Medial half of breast

After axillary lymph node biopsy, the test for cancer is positive. From which site did it most likely spread? a) Superior half of breast b) Inferior half of breast c) Lateral half of breast d) Medial half of breast

CONCEPT CHECK
A woman experiences an infection on the areola of her breast. To which lymph nodes did the infection most likely spread? A)supraclavicular B)parasternal C) axillary D)pectoral

A woman experiences an infection on the areola of her breast. To which lymph nodes did the infection most likely spread? A)supraclavicular B)parasternal C) axillary D)pectoral

CONCEPT CHECK
A woman is diagnosed with right medial side breast cancer. Where else should the doctor check for cancer a)Lateral side of right breast b)Medial side of left breast c)Axillary region next to right breast d)Lateral side of left breast

A woman is diagnosed with right medial side breast cancer. Where else should the doctor check for cancer a)Lateral side of right breast b)Medial side of left breast c)Axillary region next to right breast d)Lateral side of left breast

CONCEPT CHECK
Dimpling of the skin is observed in a woman with breast cancer, giving it the appearance of an orange peel (Peux dorange) What structure its responsible for this dimpling?
A) B) C)

D)

Inguinal ligaments Lactiferous ducts Gland lobules Suspensory ligaments

Dimpling of the skin is observed in a woman with breast cancer, giving it the appearance of an orange peel (Peux dorange) . What structure its responsible for this dimpling? A) Inguinal ligaments B) Lactiferous ducts C) Gland lobules D) Suspensory ligaments

LUNG DEVELOPMENT

CONCEPT CHECK
A woman is undergoing breast implantation, she says she wants to enlarge her breasts by two cup sizes. From what part of the gut tube do the lungs arise? A)Foregut B)Midgut C)Hindgut D)Anus

A woman is undergoing breast implantation, she says she wants to enlarge her breasts by two cup sizes. From what part of the gut tube do the lungs arise? A)Foregut B)Midgut C)Hindgut D)Anus

CONCEPT CHECK
A baby is born with difficulty feeding. Her food somehow ends up in her respiratory system. The embryological explanation is: A) failure of respiratory diverticulum to evaginate B) failure of tracheoesophageal fold to fuse C) Failure of lung buds to proliferate D) failure of tracheoesophageal septum to form E) B and D

A baby is born with difficulty feeding. Her food somehow ends up in her respiratory system. The embryological explination is: A) failure of respiratory diverticulum to evaginate B) failure of tracheoesophageal fold to fuse C) Failure of lung buds to proliferate D) failure of tracheoesophageal septum to form E) B and D

THE BONY FRAMEWORK

T4 is the level of the sternal angle. Take this fact

to the grave. ON RIB # 2

CONCEPT CHECK
A Harvard resident was having a problem finding the correct intercostal space when he was auscultating for the mitral valve. Along came a CMU student and told him that by palpating the Angle of Lewis (sternal angle) he could find: A) fourth rib B) third rib C) second rib D) first rib

A Harvard resident was having a problem finding the correct intercostal space when he was auscultating for the mitral valve. Along came an CMU student and told him that by palpating the Angle of Lewis he could find: A) fourth rib B) third rib C) second rib D) first rib

INTERCOSTAL SPACES

CONCEPT CHECK
A new resident performed a nerve block on a patient and the patient came back complaining of a strange sensation on his skin. Which of the following is true of intercostal spaces A)From superior to inferior in costal groove: nerve, artery, vein, in between the internal and external intercostal muscle B) From superior to inferior in costal groove: vein, artery nerve, in between the internal and innermost intercostal muscle C) From superior to inferior in costal groove: nerve, artery, vein, in between the internal and external intercostal muscle D) From superior to inferior in costal groove: vein, nerve, artery, in between the internal and innermost intercostal muscle

A new resident performed a nerve block on a patient and the patient came back complaining of a strange sensation on his skin. Which of the following is true of intercostal spaces A)From superior to inferior in costal groove: nerve, artery, vein, in between the internal and external intercostal muscle B) From superior to inferior in costal groove: vein, artery nerve, in between the internal and innermost intercostal muscle C) From superior to inferior in costal groove: nerve, artery, vein, in between the internal and external intercostal muscle D) From superior to inferior in costal groove: vein, nerve, artery, in between the internal and innermost intercostal muscle

CONCEPT CHECK
A doctor informs his colleagues to insert a catheter in patient at the seventh intercostal space, which of the following is the correct insertion point of the probe: a) Just above seventh rib b) Just below seventh rib c) Just above the eighth rib d) Just below the eighth rib

A doctor informs his colleagues to insert a catheter in patient at the seventh intercostal space, which of the following is the correct insertion point of the probe: a) Just above seventh rib b) Just below seventh rib c) Just above the eighth rib d) Just below the eighth rib

BLOOD SUPPLY

CONCEPT CHECK

Upon radiograph examination of the thorax, the doctor noticed that the patients ribs were unusually thin (rib notching). He also had strong radial pulses but a diminished pulse in the lower limbs Which of the following was most likely responsible: A) aorta obstruction proximal to Major branches B) aorta obstruction distal to Major branches C) subclavian artery obstruction D) common carotid artery obstruction

Upon radiograph examination of the thorax, the doctor noticed that the patients ribs were unusually thin (rib notching). He also had strong radial pulses but a diminished pulse in the lower limbs Which of the following was most likely responsible: A) aorta obstruction proximal to Major branches B) aorta obstruction distal to Major branches C) subclavian artery obstruction D) common carotid artery obstruction

MUSCLES OF RESPIRATION
>>Inspiration: -

Diaphragm
(contracts) -External IC (hands in pocket) -INTERCHONDRAL part of internal intercostal Accesory:(forced insp.) Sternoceidomastoi d -Scalenes >>Expiration: (usually passive) but when forced:

CONCEPT CHECK
A patient runs into the hospital complaining of dyspnea(shortness of breathe). He complains that breathing in air is difficult. Which of the following is a muscle of inspiration? A)Rectus abdominus B)Internal intercostals C)Innermost intercostals D)Interchondral part of internal intercostals

A patient runs into the hospital complaining of dyspnea(shortness of breathe). He complains that breathing in air is difficult. Which of the following is a muscle of inspiration? A)Rectus abdominus B)Internal intercostals C)Innermost intercostals D)Interchondral part of internal intercostals

CONCEPT CHECK
Same patient comes in the next day Complaining that he has difficulty breathing out? Which of the following is primarily responsible for expiration? A)Diaphragm B)Scalenes C)SCM D)External intercostal

Same patient comes in the next day Complaining that he has difficulty breathing out? Which of the following is primarily responsible for expiration? A)Diaphragm (The relaxation of it) B)Scalenes C)SCM D)External intercostal

DIAPHRAGM OPENINGS

PHRENIC NERVE

CONCEPT CHECK
Which of the following embryological components become the crura of the diaphragm? A)septum transversum B)pleuroperitonel folds C)dorsal mesentery D)body wall

Which of the following embryological components become the crura of the diaphragm? A)septum transversum B)pleuroperitonel folds C)dorsal mesentery D)body wall

CONCEPT CHECK
A patient presents with a sudden but severe dyspnea. Upon radiographic examination, the Doctor found that the left thoracic cavity was decreased in volume. He was diagnosed with: A)Right hemidiaphragm paralysis B)Left hemidiaphragm paralysis C)Left hemothorax D)Hiatal hernia

A patient presents with a sudden but severe dyspnea. Upon radiographic examination, the Doctor found that the left thoracic cavity was decreased in volume. He was diagnosed with: A)Right hemidiaphragm paralysis B)Left hemidiaphragm paralysis C)Left hemothorax D)Hiatal hernia

CONCEPT CHECK
The patient above was actually diagnosed with Hiatal hernia. At what level is the hernia protruding through the diaphragm? A)T4 B)T8 C)T10 D)T12

The patient above was actually diagnosed with Hiatal hernia. At what level is the hernia protruding through the diaphragm? A)T4 B)T8 C)T10 D)T12

CONCEPT CHECK
A patient was diagnosed with peritonitis(the peritoneum is a structure in the abdomen). Given that it is in contact with the diaphragm, where would you expect the patient to feel pain? A)Over medial aspect of arm B)Over area of upper back C)Over shoulder region D)Over chest region

A patient was diagnosed with peritonitis(the peritoneum is a structure in the abdomen). Given that it is in contact with the diaphragm, where would you expect the patient to feel pain? A)Over medial aspect of arm B)Over area of upper back C)Over shoulder region D)Over chest region

SO WE TALKED ABOUT DEVELOPMENT OF LUNGS, LETS TOUCH UP ON THE PLEURA. WTF IS THE PLEURA??

So as you can see this is the lowest point in the pleural cavity. Its called the Costodiaphragmatic recess. Since its the lowest, gravity will pull fluid down to this recess. This

IN ORDER TO DRAIN THE PLEURA, WE HAVE TO KNOW WHERE THE LUNG SITS IN RELATION TO THE PLEURA.

Mid clavicular line line *remember, the intercostal spaces are numbered with respect to the rib ABOVE them. Ex. Under the first rib is

mid axillary line

paravertebral B/c the examiner mite as the question between which ribs? or may ask in what intercostal space is the needle inserted to drain.

Why the hell do we need to know that?

CONCEPT CHECK
A patient presented with hemothorax. The doctor feels that he is most comfortable draining the pleura at the mid axillary line. In what intercostal space should the needle be inserted? A)7th B)8th C)9th D)10th

A patient present with hemothorax. The doctor feels that he is most comfortable draining the pleura at the mid axillary line. In what intercostal space should the needle be inserted? A)7th B)8th C)9th D)10th oh but I thought that it can also be done in the eighth because the PLEURAL cavity at the midaxillary line is between the eight and tenth ribs. Well yeah you are right, but you forgot to think that since the ninth intercostal space is lower than the eighth, there is a LESS LIKELY chance that youll pierce or damage the lung. Thats why ninth is the answer. I hope you guys are seeing that critical thinking is the trick to the trade.

ENOUGH ABOUT THE PLEURA, LETS DO THE LUNGS

CONCEPT CHECK
An CMU student, who was trying to be gangster, decided to brawl at a bar. He ended up with a laceration in the right fourth intercostal space around the midclavicular line. Which lobe is most likely damaged? A)upper lobe B)middle lobe C)lower lobe D)ear lobe

An CMU student, who was trying to be gangster, decided to brawl at a bar. He ended up with a laceration in the right fourth intercostal space around the midclavicular line. Which lobe is most likely damaged? A)upper lobe B)middle lobe C)lower lobe D)ear lobe

LYMPH OF LUNGS

CONCEPT CHECK
A patient present with symptoms of a lung infection. The doctor sees that the infection is a the tracheobronchial nodes. He knows that this collects lymph from both the superficial and deep structures. In order to find out if it came from superficial or deep structure, which nodes should he biopsy in order to confirm. A)Tracheobrionchial B)Bronchopulmonary C)Pulmonary

A patient present with symptoms of a lung infection. The doctor sees that the infection is a the tracheobronchial nodes. He knows that this collects lymph from both the superficial and deep structures. In order to find out if it came from superficial or deep structure, which nodes should he biopsy in order to confirm. A)Tracheobrionchial B)Bronchopulmonary

HEART DEVELOPMENT

CONCEPT CHECK
The Bulbus cordis becomes which of the following in the adult: A) truncus arteriosus B) trabeculated part of Arteries C) conus arteriosus D) sinus venarum

The Bulbus cordis becomes which of the following in the adult: A) truncus arteriosus B) trabeculated part of Arteries C) conus arteriosus D) sinus venarum

CONCEPT CHECK
A pediatric cardiologist was performing heart surgery on a neonate. He cut open the Right atrium and noticed the Smooth part (sinus venarum). This reminded him that the embryonic origin of this was: A)bulbus cordis B)sinus venosus C)truncus arteriosus D)primitive atrium

A pediatric cardiologist was performing heart surgery on a neonate. He cut open the Right atrium and noticed the Smooth part (sinus venarum). This reminded him that the embryonic origin of this was: A)bulbus cordis B)sinus venosus C)truncus arteriosus D)primitive atrium

FETAL CIRCULATION

CONCEPT CHECK
In the developing fetus, Which of the following provides a bypass from portal circulation: A)ductus venosus B)ductus arteriosus C)foramen ovale D)umbilical vein

In the developing fetus, Which of the following provides a bypass from portal circulation: A)ductus venosus B)ductus arteriosus C)foramen ovale D)umbilical vein

CONCEPT CHECK
Which of the following is a remnant of a structure that allowed bypass from pulmonary circulation in the developing fetus? A)ligamentum teres B)ligamentum venosum C)ductus arteriousus D)ligamentum arteriosum

SEPTUM FORMATION OF THE HEART WILL BE DISCUSSED VERBALLY AS IT IS A CONCEPT DIFFICULT TO SOLELY EXPLAIN IT ON SLIDES. THE NEXT FEW SLIDES WILL JUST BE PICTURES OF DEFECTS THAT I WILL EXPLAIN AS WE GO ALONG

MEDIASTINUM

EVENTS AT T4 (ANGLE OF LEWIS/LOUIS)

Angle of Louis
2nd

rib articulates with the sternum aortic arch begins and ends trachea bifurcation at the carina demarcation of inferior border of superior mediastinum thoracic duct passes from Right to Left