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SSN Anatomy #1 - KEY

Abby Pease (arp2002) & Matthew Maserati (mbm2004)

September 25, 2002

FEELING, BREATHING, PUMPING


1. ORGANIZATION OF THE SPINAL CORD AND ASSOCIATED STRUCTURES
On the following diagram, label and draw in pathways for somatic afferent, visceral afferent,
somatic efferent, parasympathetic, and sympathetic nervous systems. Be sure to label:
dorsal / lateral / ventral horns, dorsal / ventral roots, dorsal root ganglion, white / gray rami
communicantes, sympathetic chain, paravertebral ganglion, prevertebral ganglion,
splanchnic nerve, and spinal nerve.

2. MOTOR INNERVATION OF LUNGS AND HEART


Complete the following table:
Innervation /function Lungs

Heart

Sympathetic

THORACIC SPLANCHNIC BRANCHES


FROM SYMPATHETIC CHAIN.

CERVICAL SPLANCHNIC N.,


THORACIC SPLANCHNIC N.

Symp. Function

VASOCONSTRICTION, SECRETOMOTOR
ACTIVITY OF BRONCHIAL GLANDS

ACCELERATE HEART RATE,


INCREASE STROKE VOLUME

Parasympathetic

VAGUS N.

VAGUS N., RECURRENT LARYNGEAL


BRANCHES

Parasymp. Function

BRONCHIAL SM. MUSC, RESPIRATORY


REFLEX AFFERENTS

SLOW HEART RATE AND REDUCE


STROKE VOLUME

Finish the sentence. Sympathetic innervation is (adrenergic/cholinergic), and


parasympathetic innervation is (adrenergic/cholinergic)
Adrenergic (uses noradrenaline); cholinergic (uses acetylcholine)

3. What is REFERRED PAIN?


Pain felt at a specific dermatome that is of visceral origin. It is referred to the somatic
dermatome associated with the particular spinal level that received the visceral
afferent nerve.
Where is it possible to have referred pain as a result of pleurisy (inflammation of the lung
pleura)? [hint: what innervation does the diaphragm receive?]
C3-C5 dermatomes (neck & shoulder). Early in development, part of the diaphragm
forms in the neck region. Later, when it descends into the abdomen, it drags its
innervation (the phrenic nerve) with it. Intercostal nerves T6-T11 innervate the
diaphragm at the costal margin, and pain is referred to these dermatomes too.
4. What is the significance of LANGERS LINES?
Connective tissue bundles in the dermis have a prevailing directionality. Cut parallel
to them minimal scarring. Cut perpendicular to them gaping wound.
5. LYMPHATICS
Complete the following tables:
Portion of breast
Lateral / inferior (75% of breast tissue)
Medial
Superior
Superficial
Organ
Bronchi, Trachea
Hilus of Lung
Esophagus
Posterior IC Spaces
Anterior IC Spaces

Lymphatic Drainage
AXILLARY NODES
PARASTERNAL NODES
SUPRACLAVICULAR NODES
CONTRALAT. BREAST / ANT. ABDOMINAL WALL

Nodal Drainage

Entrance into Systemic Venous Circulation

BRONCHOMEDIASTINAL
HILAR
PRE-AORTIC
PARA-AORTIC
PARASTERNAL

(R/L) BRACHIOCEPHALIC VEIN


(R/L) BRACHIOCEPHALIC VEIN
THORACIC DUCT L BRACHIOCEPHALIC V.
THORACIC DUCT L BRACHIOCEPHALIC V.
(R)R LYMPHATIC DUCT, (L)THORACIC DUCT

6. MUSCLES OF RESPIRATION
Complete the following table:
Type of breathing
Muscles responsible
Relaxed Inspiration

EXTERNAL INTERCOSTALS, INTERCHONDRAL PORTION OF INTERNAL


INTERCOSTALS, DIAPHRAGM (Externals Elevate the ribs)

Relaxed Expiration

NONE (PASSIVE RECOIL OF RIB CAGE AND PULMONARY COMPLIANCE


OF LUNGS)

Forced Inspiration

ALL MUSCLES OF RELAXED INSPIRATION + PECTORALIS


MAJOR/MINOR, STERNOCLEIDOMASTOID, SCALENES

Forced Expiration

INTERNAL INTERCOSTALS, TRANSVERSUS THORACIS, QUADRATUS


LUMBORUM (stabilizes 12th rib), ABDOMINAL MUSCLES

MUSCLES OF RESPIRATION (Continued)


Fill in the blanks: (see diagram in April, p.247)
Synergist muscles act on the same side of the axis of rotation or are perpendicular to
each other on the opposite side of the axis of rotation. Antagonist muscles act on the
opposite side of the axis of rotation or are perpendicular to each other on the same
side of the axis of rotation.
7. MECHANICS OF INSPIRATION
Complete the following table:
Aspect of inspiration
Increase in which diameter (transverse or anteroposterior)?
Bucket-handle effect

TRANSVERSE THORACIC

Pump-handle effect

ANTERIOR-POSTERIOR

Rotation effect

TRANSVERSE THORACIC

The bucket-handle effect is due to elevation of the ribs as they rotate upwards in
inspiration. The pump-handle effect is due to elevation of the sternum as a result of
upward rotation of the crossed axes. The rotation effect is due to rotation of the ribs
(which are concave on their interior surface) on inspiration.
8. BREATHING DIFFICULTIES
Why is breathing more difficult for the elderly? How do they (and children) compensate for
this?
Calcification of costal cartilages reduced thoracic compliance.
Both elderly and children tend to breathe diaphragmatically (vs. costal breathing).
What type of breathing do obese people favor and why?
Obese people, persons wearing girdles or corsets, and women in advanced
pregnancy cannot effectively contract the diaphragm and therefore favor costal
ventilation.
If a patient is bed ridden and having difficulties breathing, name one simple, non-invasive
procedure you could perform to help. Why is this procedure so successful?
Sit her up in bed. Gravity will pull down on abdominal organs, decreasing resistance
on diaphragm.

9. PLEURAL RECESSES
What are pleural recesses and name the two of them?
Potential spaces between the parietal and visceral pleura filled by a thin layer of fluid.
Costomediastinal and L&R costodiaphragmatic.
What might you find in them in a pathological situation?
Air (pneumothorax), Blood (hemothorax), Lymph (chylothorax), Pus (pylothorax)
Where do you tap a patient with hemothorax to sample the fluid and why?
Posterior to midaxillary line above ICS 9 (to avoid liver) but 1-2 ICSs below fluid level
and just above superior surface of rib (to avoid neurovascular bundle).
Complete the following table:
Type of
Symptoms
pneumothorax

Consequences

Sucking

Mediastinal
flutter

Lung collapse b/c fluid monolayer gone vent/perfusion of


lung in affected side cyanosis

Tension

Mediastinal shift

Same as above but vent/perfusion of both lungs since air


that enters pleural space doesnt leave pressure
compression of unaffected lung

10. STRUCTURE OF THE LUNG AND CLINICAL CONSEQUENCES


Contrast the size and shape of the Right and Left Lung.
R: 3 lobes (vs. 2 on left), greater capacity, wider and shorter (b/c of liver, and more of
heart being on left side)
What are the differences in shape and position of the left and right main stem bronchi and
what clinical significance does this have?
The right main stem bronchus is shorter, wider, and MORE VERTICAL than the left. It
is the probable resting place for large aspirated objects. Specifically, the right lower
lobar bronchus is the most vertical division of the right main stem bronchus, and
small aspirated objects will likely rest here.
What section of the lung is most likely to be involved in aspiration pneumonia (Mendelsons
syndrome)?
Superior segmental bronchi of both lobes because they face posteriorly when a
person is lying down.

STRUCTURE OF THE LUNG AND CLINICAL CONSEQUENCES CONTINUED


What is a Pancoast tumor and what are its clinical sequelae?
A lesion of the upper lobe of either lung. It may compress:
a) Subclavian or brachiocephalic vein ipsilateral venous engorgement / edema
of face/arm
b) Subclavian artery diminished pulse in ipsilateral arm
c) Phrenic nerve compression results in paralysis of a hemidiaphragm
d) Recurrent laryngeal nerve compression results in vocal horseness
e) Sympathetic chain compression results in Horners syndrome (miosis,
pseudoptosis, anhydrosis)
What structures would be found at the hilus of the lung?
Main stem bronchus, pulmonary artery, pulmonary veins, bronchial lymphatics,
bronchial arteries, hilar lymph nodes.
What are the main components of a bronchopulmonary segment?.
Segmental bronchus, segmental artery, intersegmental veins.
11. JOINTS
Joint Type

Movement (Y/N)

Examples

Synarthrosis

No

Sagittal suture, tibiofibular joint

Amphiarthrosis

Yes (limited)

Pubic symphisis, intervertebral discs

Diarthrosis

Yes (free)

Shoulder, elbow, wrist joints

12. DIAPHRAGMATIC HIATUS


Complete the following table:
Hiatus
Structures transmitted

Location

Aortic

Aorta
Thoracic duct
Azygos vein

Midline, between crura (T12)

Esophageal

Esophagus
Left & right vagus nerves

Slightly left of midline (T10)

Caval

Inferior vena cava


Branches of right phrenic nerve

On right, in tendinous portion (T8)

13.

CARDIAC CYCLE

14. FETAL CIRCULATION


Complete the following table:
Prenatal
Shunts blood
Circulatory
from:
Anatomy

Shunts blood
to:

Umbilical Veins

MOTHER VIA
UMBILICUS

Ductus Venosus
Foramen Ovale
Ductus
Arteriosus
Umbilical
Arteries

UMBILICAL VEIN
R. ATRIUM

PORTAL V./
DUCTUS
VENOSUS
INF. VENA CAVA
L. ATRIUM

L. PULMONARY
ARTERY

AORTA

L/R INTERNAL
ILIAC ARTERIES

MOTHER VIA
UMBILICAL
ARTERIES

13. CARDIAC MALFORMATIONS


Complete the following table:
Defect
R Auricular
Appendage
L Auricular
Appendage
Cardiac

Homologous adult structure


LIGAMENTUM TERES
LIGAMENTUM VENOSUM
FOSSA OVALIS (PULMONARY SHUNT)
LIGAMENTUM ARTERIOSUM (PULMONARY
SHUNT)
PROXIMAL: SUPERIOR VESICULAR
ARTERIES (TOP OF BLADDER)
DISTAL: MEDIAL UMBILICAL LIGAMENTS

Vascular Pathology

Sequelae

POTENTIAL SITE OF THROMBI


FORMATION

PULMONARY EMBOLISM

POTENTIAL SITE OF THROMBI


FORMATION

SYSTEMIC, CEREBRAL
EMBOLISM

Atrial Septal Defect

PATENT FOSSA OVALIS

Small VSD

INCOMPLETE INTERVENTRICULAR
SEPTUM
INCOMPLETE INTERVENTRICULAR
SEPTUM AND PULMONARY
ARTERY STENOSIS
A. VSD ALLOWS
INTERVENTRICULAR
COMMUNICATION
B. PRESSURE IN LV
TRANSMITTED TO RV CAUSING
RV HYPERTROPHY
C. HYPERTROPHY OF
SUPRAVENTRICULAR CREST
CAUSES PULM. STENOSIS AND
FORCES BLOOD THROUGH TO
THE LV

VSD w/ pulmonary
artery stenosis
Ventricular
Septal
Tetralogy of Fallot

ASYMPTOMATIC: LR
SHUNT B/C L ATRIAL
PRESSURE > R ATRIAL
PRESSURE
ASYMPTOMATIC LR
SHUNT
RL SHUNT LEADING TO
CYANOSIS
THE FUNCTIONAL
OCCLUSION OF THE
PULMONARY OUTFLOW
TRACT FORCES A RL
SHUNT SENDING
DEOXYGENATED BLOOD
TO THE LV AND THEN
INTO THE AORTA.

14. VALVE DEFECTS


Complete the following table:
Type of Valve Pathology
Atypical Sounds

Pitch

Atrioventricular

INSUFFICIENCY

SYSTOLIC MURMUR

LOW PITCHED

Atrioventricular

STENOSIS

DIASTOLIC MURMUR

LOW PITCHED BEFORE 1ST HEART SOUND

Semilunar

INSUFFICIENCY

DIASTOLIC MURMUR

Semilunar

STENOSIS

SYSTOLIC MURMUR

HIGH PITCHED

15. CORONARY CIRCULATION


Complete the following table.
Variation
Balanced (60-65% of the population)
Left Preponderant (10-15%)

Right Preponderant (20-25%)

Arterial Supply
RCA gives off posterior descending
branch, supplying the septum but not
significantly supplying the left ventricle.
Circumflex artery gives rise to the posterior
descending branch, so that both arteries
supplying the septum arise from the same
stem lower chance of survial w/infarct
RCA reaches into typical distribution of the
circumflex artery, supplying a substantial
portion of the left ventricle.

15. CLINICAL QUICKIES AND OTHER QUICKIES


What spinal nerve innervates the nipple?

T4

The umbilicus? T10 .

How can you diagnose a breast tumor by observation only?


Breast will dimple due to compression of suspensory ligaments of Cooper, which
connect skin to Scarpas fascia and separate lobes.
What happens to the costal groove with coarcation with the aorta?
Narrowing of descending aorta leads to decreased blood flow through aorta and
posterior intercostals arteries, which must be compensated for by increased blood
flow through the internal thoracic artery and anterior intercostals arteries. Therefore,
scalloping of ribs occurs due to expansion of intercostals arteries.
What are the two routes used to perform pericardiocentesis?
Subcostal: needle into sternocostal angle (rib/xiphoid), angle up at 45 and L. (avoid
marginal br. of RCA and avoids pleural cavities.
Parasternal: into L 4th or 5th ICS adjacent to sternum, avoiding Int. Thoracic Artery,
Ant. Interventricular Artery, and pulmonary pleura (cardiac notch).
What are the first arteries off the aorta, and when does blood flow through them?
R/L Coronary arteries. Only during diastole.
What veins of the heart DO NOT drain into the coronary sinus?
Anterior Cardiac Veins (directly into RA), Thebesian (least cardiac) Veins (into closest
chamber of heart.)
What is the function of the papillary muscles?
Tighten chordae tendinae to prevent eversion of valve cusps (NOT to close valves.)
What is the Bundle of Kent and what is its clinical significance?
Abnormal muscle bridge (modified cardiac tissue) electrically connecting the atria
and the ventricles. Excitatory impulses bypass the A-V node disrupting the normal
synchonry of the heart.
The Left brachiocephalic artery
Does not exist.
Esophageal varices are often associated with what condition?
Portal hypertension caused by diseased liver.
Finish the sentence. Cervical spinal nerves exit just (above/below) the corresponding
vertebrae; thoracic spinal nerves exit just (above/below) the corresponding vertebrae.
Cervical spinal nerves exit just above the corresponding vertebrae, i.e. 3rd cervical
spinal nerve emerges through the intervertebral foramen between cervical vertebrae 2
& 3. One exception is the 8th cervical spinal nerve, which exits between the 7th
cervical vertebra and the 1st thoracic vertebra. Thoracic spinal nerves exit just below
the corresponding vertebrae, i.e. 3rd thoracic spinal nerve emerges through the
intervertebral foramen between thoracic vertebrae 3 & 4.