Chapier-4 Qu: Explain the lymphatic drainage of lungs and pleura. (Annual 2008) solution: peep lymph plexus (Travel along the branch) Superficial lymph plexus (lies breath , visceral pleura) drain lungs, bronchial tree, pulmonary vessel (Drain over surface lung to hilar g connective tissue septa) Deane s | pulmonary nodes . v ‘ ee nodes (hilum) Tracheo ee nodes v Broncho-mediastinal nodes A . ; Broncho-cephalic vein (may in to right lymphatic trunk or thoracic duct) Reference: Snell review 4" ed, P#. KLM 9"ed, P#, Lymphatic drainage of pleura: | Internal lymph nodes 2 Internal mammary lymph nodes 3 Posterior mediastinal lymph nodes . + Diaphragmatic nodes References« eributi f arteries supplyin, and distribution 0 8 the ¢ course and Ch teries in Ora. ; r rcostals arteries in coarctatio, Nagy esp importance of Inte 7 Of aang wall, &*1 : Solution: : teries: rercostal a __ 7 jor intercostals arteries e Anter! : ostals arteries = one In each space two in each space Posterior interc i ‘teries: jor intercostals ar" : : z ae eu Upper six space arteries > from internal thoracic from subclavian artery e ppel 7" 19 9" space arteries > from musculophrenic arteries > from intern thoracic arteries intercostal arteries run in intercostals space along with vein & nerve (from superior to inferior (VAN) - vein-artery & nerve iy intercostals groove) between internal & iner most intercostals muscles > terminates by anastomosing with the posterior intercostals arteries q costochondral junction Posterior intercostals arteries: © 1° & 2" posterior intercostals arteries > from superior intercostals arteries 9 from costocervical trunk 3 th wei . 5 5 * 3" to 11" posterior intercostals arteries > from descending thoracic aorta. Role of intercostals arteries in coarctation of aorta: In Coarctation of aorta, instercostal arteries act as collateral & supply the effected structures & maintain blood supply. Reference: BD ed, P#.275 KLM 9"ed, Pi.95 Q3. Give the nery © supph oe ‘ Samii (Supple: 2008) pericardium, What do you understand by cardi a lon: Nery, Nerve supply Of pericardium: * Fibrous & par > Parietal pericardia = Pericardia = by > phrenic nerve (pain sensitive)- Si rat : Epicardiaum > by = autonomic nerve (vagus + symphathetic trunk) > insensitive to pain c temponade: tetve oF fluid in the pericardial cavity is referred to as pericardial effusion or ponade. cardia Col cardia’ tem Ree . . jr can be drained by puncturing the left 5" or 6" intercostals space just lateral to the m or in the angle between the xiphoid process & left costal margin with needle i em d upwards, backwards & to the left. direct preference: pp 4"ed, P#.239 Qd.a) What are the sites of oesophageal constrictions (supple 2008) b) What is the clinical importance of these constrictions? Solution: a) Sites of esophageal contrictions: |- Atits beginning. 15cm from incisor teeth. 2. Where it is crossed by arch of aorta, 22.5cm from incisor 3- Where it ig crossed by left bronchus, 27.5em from incisor 4. Where it pierces the diaphragm, 37.5cm from incisor b) Cl importance of constrictions: Constrictions are of clinical interest because of slower passage of substances at hese sites."The constrictions ifdicate where swallowed foreign objects are most likely to odge & where a stricture may develop after accidental drinking of caustic liquid. Reference: Snell review 5" ed, P#.180 BD 4" ed, PH.268 Qs y i ) Define pericardium and name its layers with their nerve supply. What is Pericardial cavity? i i i ch nerves are involved in transmission of pain from heart and pain of Pericarditis? (Annual 2009) oaae art and roots of great vesselg ac containing he: Solutio Eee a) Pericardium it !S Layers: : 1, Fibrous perica 2, Serous pericardi 5; i ve ‘etal layer > (phrenic nen a bronches of lymphathetis trunks and vagus nerves, adouble walled s dium: (supply by phrenic nerves) jum: a. b, Visceral layer 7 Pericardial cavity: \ 0 layers of serous pericardium arouy It is the potential s the heart. pace formed between tw b) Phrenic nerve Q.6. a) Write the origin and course of left coronary artery and its branches. b) Which areas of heart will undergo ischemic changes in sudden occlusion of th artery lying in the posterior inventricular groove? (Annual 2010) © Solution: Origin: From left posterior aortic sinus Course: i Pass forwards & to left & emerges between pulmonary trunk & left auricle & give Sie artery here, There further continuation of left coronary artery! one ee artery. The anterior interventricular runs downwards in’ the groove ¢ posteriorly by anastomosing with posterior inter-ventricular artery. Branches: 1. Anterior inter-ventricular artery 2. Circumflex artery C) Areas undergo ischemic chai inges / istributi Pate ah ges / area of distribution: 2- Ventricles Anterior interventricular septum 4- Lefi-branch bundle blocknce? nD 4" ed, Pi#. 251 expiet a. what are the m > explain, rstand by “ coron’ b. what do you unde ' used in coronary by enumerate the vi of commonly used vess Solution: a) 1. Left anterior descending artery of LCA = (40-50 2. RCA (30-40%) ECA (15.209 3. Cireumflex branch of LCA (15-20%) : b) Coronary arteries does not anastomosis frankly with each other that’s why they ag called end arteries. Their occlusion cause infarction of heart ©) Vessel used in bypas I- Great Saphenous vein Radial artery Internal mammary artery Great Saphenous is most commonly used because: I- has diameter to orgreater than that of coronary arteries. 2 Can be easily dissected from the lower limb 3 Offers relatively lengthy portions wit i latively 1 ns with a minim currence branching um occurrence of value ¢ Reference: KLM 6"ed, P#.155, 156 Q.16. a) Plain how the antero- thoracic cage are altered du b) Give the nei 4) Thoracic w, Posterior transye ring quie "Ve supply of differe all Movements; TSC and verti t respiration, nt parts of ple diameters of the (Annual 2016) 0 Ura, wvVARS 3S TST EAL meee mye KEY TO UHS Solved UQS & MCQ@s 89 mp handle movements: rs pu joposterior (AP) dimension of “AnterioPo of the thorax increases w i muscles contact seo taieale of the ribs (primarily 2™ -6") 4 eae und an axis passing rough the neck of the ribs causes the anteri cee ‘that is called pump handle movements. interior end of the ndle movements: ibs (0 ris ucket hal dimension of th it ‘The transverse ¢ thorax also increases sli es - s slightly when the inter muscles contract, raising middle (lateral most parts) ofthe ie that i aie ta raovements s that is called bucket Nerve supply of pleura: Parietal pleural: Develops from the som; i : atopleuric layer of mesoderm & supplied by Somatic nerves (Intercostal and nee ae Pain sensitive ee Pulmonary/Visceral pleura: develops from splanchnopleuric layer of the lateral plate mesoderm & supplied by autonomic nerves (Sympathetic nerves from 2 to 6" spinal segments & parasympathetic from vagus nerve) .... Pain insensitive Reference: QuTa) b) What are the a) KLM, B.D Write the source, branches and distribution of arterial supply of Heart. 02,02 two most common sites of Coronary Artery Occlusion? (Supple 2016) ol Heart is supplied by right coronary Right coronary artery: Source: RCA arises from anterior aortic sinus and left coronary artery Course: It first passes forwards and to the the root of pulmonary trunk and rig! anterior coronary sulcus to the junction of ri Winds around the inferior border to reach Here it runs backward and to the left in right p Posterior intervemtricular groove. It terminal coronary artery, Bi Branches: rae branches: 1) Marginal 2) Posterior interventricular mall braches: 1) Nodal in 60 % 2) Right atrial 3) Infundibul right to emerge on the surface of the heart b/w ht auricle. It then runs downwards in the right ight and inferior borders of the heart. It the diaphrgamtic surface of the heart. osterior coronary sulcus to reach the tes by anastomosing with the left jar 4) TerminalArea of Distribution: 1. Right atrium 2. Ventricles 3. Posterior part of interventricular septum eee 4. Whole conducting system except left branch of Left coronary artery: See above Most common sites of occlusion: 1. Lefi anterior descending artery of LCA = (40-50%) 2. RCA (30-40%) 3. Circumflex branch of LCA (15-20%) Reference: KLM & BD Qu8 a) Needle thoracostomy, had Pneumothorax to allow lungs to re. needle if it is to be inserted in 2"! a) What precaution should be taken to avoid injury to intercostals nerves and vessels? 2,5 to be done in a patient with Tension ~expand. What structures are pierced by the intercostal space at anterior axillary line? b) Enlist the Posterior relations of a) Structures pierced by the needle: 1. Skin - 2.5 (Annual 2017) 2. Superficial fascia ‘ 3. Serratus anterior muscle : 4. External intercostals muscle WEN 5. Internal intercostals muscle AUB 6. Inner most intercostals muscle a Endothoracic fascia 8. Parietal Pleura Precaut er Of the thing s Subcostal ree ae Tib to avoid 7 the u “1 TVe in the , 10 avoj Stal g, b) Posteri é n ) Posterior relations o thoracic pary 4 UNE the deg side of ~ Vertebral column Sesophagus. the recess,Chapter-4 — ct Aygo yen wth ae terminal parts of the hemiazygos veins ‘thoracic aorta - Right pleural recess 7 Diaphrag™ the parts of pericardium with nerve supply. 1.5 qs.) Nam ical significance? 2 Name te Pericardial sinuses. What is their cli i what is Cardiac Temponade? Give its reason and effects on heart functions. 1s (Supple 2017 held in 2018) m parts and their nerve supply: ardium consists of fibrous pericardium & serosal pericardium. v Peric Y The outer layer of parietal pericardium is fused with the fibrous pericardium. The inner layer or the visceral pericardium, or epicardium is fused to the heart except s, where it is separated from the heart by bteod vessels. along the cardiac groove ‘The pericardium is innervated by thovagus, together with phrenic nerves and the sympathetic trunks. ¥ Fibrous and parietal pericardia are supplied by the Pherenic nerve. ¥ The Epicardium is supplied by autonomic nerves of the heart. b) pericardial sinuses & their clinical significance: assageways formed the unique way in wl .yPericar re The pericardial sinuses are p: hich the pericardium folds around the great vessels. + The oblique pericardial sinus is a blind ending passageway (‘cul de sac’) located on the posterior surface of the heart. “. The transverse pericardial sinus is found superiorly on the hear It can be used in coronary artery bypass grafting ihe location of the transverse pericardial sinus is: iL Posterior to the ascending aorta and pulmonary trunk. ii Anterior to the superior vena cava. iii, Superior to the left atrium In this position, the transverse pericardial sinus sep’ dul y . ey trunk) and the venous vessels (superior vel arates the arterial vessels (aorta. na cava, pulmonary veins) of the This can be used to identify and subsequently ligate (to tie off) the arteries of the heart Juri ing coronary artery bypass grafting.ose Awwus TeRANSVE aor ' PULNONARY TRUNK, Cardiac temponade: Collective of uid in the candiae temponade, R Pericanlal cavity is referred 10 as pericardial effusion or can be drained by stemum o4 the ar directed upwards, by puncturing the left 5 gle between the xiphoid aickwards & to the lett, oF 6" intereostat rocess & left cost \ Space just lateral to the al margin y ith needle Reference: BD 4%ed, P#.230 (220. a) Why are coronary arteries fermed as tunctionay end by What is the role of the SOMOMAEY collateral cinenyge eT "Explain, Myocardial Infarction? Mion in “Velopment of ©) What is the functional vatue of coronary collateral cireul, 4. Coronary arteries ag functional end arteries: ation? Mual 297 | Because they are the only source of blood SUPPIY to the myo, Ardiy imF 1 Role of the coronary collateral circulation: Coronary collateralcirculationprovides an alternate source of blood in case of plockage of a branch of a coronary artery. nctional yalue of coronary collateral circulation: Coronary collateral anastomosis is of little practical value. They are not able to. rovide an alternate source of blood in case of blockage of a branch of a coronary. Blockage of arteries or coronary thrombosis usually leads to death of myocardium, The condition is called myocardial infarction Qu. a) Name the various parts of parietal pleura. (Supple 2018 held in 2019) b) Explain the two pleural recesses, What is pleural effusion? a) Parts of parietal pleura: The parietal pleura is thicker than the pulmonary pleura, and is subdivided into the following four parts: 1. Costal 2. Diaphragmatic 3. Mediastinal * 4. Cervical b) Pleural recesses: There are two recesses of parietal pleural, which act as ‘reserve spaces’ for the lung to expand during ing Costomediastinal recess: It lies anteriorly, behind the sternuiiand costal cartilages, between the costal and mediastinal pleura, particularly in relation %4he cardiac notch of the left lung. This recess is filled up by the anterior mafgin of the lungs even during quite breathing. It is only obvious in the region of cardiac notch of the lung. Costodiaphragmatic/ costovertebral recess: It lies inferiorly between the costal and diaphragmatic pleurae. Vertically, it Measures about Sem, and extends from the eighth to tenth ribs along the midaxillary line, . During inspiration lungs expand into these recesses. So, these recesses are obvious only in expiration and not in deep inspiration. p22a) What are bronchopulmonary segments? Describe these segments in the left ng,ovements of thoracic cage during quite inspiration, (Anny, ibe the m b) Dese gments are: sey ‘Ans: The bronchopulmonary : The largest subdivisions of a lobe. shaped segments of the lung, with their apices facing the lung ro he pleural surface. Ot ay al 2019) , > Pyramidal- their bases at t ou ated from adjacent segments by connective tissue septa, Separe - Supplied independently by a segmental bronchus and a tertiary branch Of the up| pulmonary artery. talelod 5 Named according to the segmental bronchi supplying them. x Drained by intersegmental parts of the pulmonary veins that lie in th tissue between and drain adjacent segments. X ie Connective Usually 18-20 in number (10 in the right lung; 8-10 in the left lung, the combining of segments). x depending on + Surgically resectable. Segments in the left lung. [ 7 Lobes Segments A. Upper Upper division L.Apical 2.Posterior 3.Anterior Lower division 4.Superior lingular 5.Inferior lingular B. Lower . 6.Superior 7.Medial basal | 8.Anterior basal “9.Lateral basal 10. Posterior basal ©) Mavements of thoracic ea e duriifg qu * qT : . he Anteroposterior diameter of the thorax is increased by elevation of the SeCOnd to sj : 7 "xth ribs. The first rib remains fixed. inspira’| 98 Chapter-4 > The transverse diameter of the thorax is increased by elevation of the 7th to tenth ribs. > The vertical diameter is increased by descent of the diaphragm. nt with acute myocardial infarction developed sudden breathlessness. ‘A patient WIM § ‘| cian diagnosed it as Cardiac tamponade. (Supple 2019 held in 2020) 2 rhe physician what is Cardiac tamponade? ») pescribe the procedure done to relieve this condition. a Give the ‘Ans: a) Cardiac temponade: 7 Collective of fluid in the pericardial cavity is referred to as pericardial effusion or blood and nerve supply of the serous pericardium. cardiac temponade. b) Re the sternum or in the angle between the xiphoid pro gin wil van wards, backwards & 10 fe Ae process & left costal margin with needle ¢) Blood supply of the serous pericardium: Blood supply to the pericardium occurs mainly through the pericardiophrenic artery, sfough a few minor contributions also occur via the musculophrenic artery, esophageal artery, bronchial artery, and superior phrenic artery. The coronary artery is also involved, but it supplies blood only to the visceral layer. | | | | | It can be drained by puncturing the left 5" or 6" intercostals space just lateral to | | | | Nerve supply of the serous pericardium: Serous pericardium: a. Parietal layer > (phrenic nerve) b. Visceral layer ->bronches of lymphathetis trunks and vagus nerves; Q. 24 Give the origin and area of supply of right coronary artery and name its branches. What part of heart will most likely get infracted if a thrombus blocks the circumflex artery? (Annual 2020) Ans: Origin of right coronary artery: ‘Arises from the right aortic sinus of the ascending aorta Area of supply of right coronary artery: © The right atrium. se Most of right ventricle. © Part of the left ventricle ( ¢ Part of the IV septum, usually the ‘the diaphragmatic surface). posterior third.ely 60% of peor i eople). on He ‘i ql proximately 80% of P The AV node a nes of right coronary 9 tet A nodal branch : Cc] joht marginal bran : : ee interventricular brane! » AVnodal branch interventricular septal branch posterior part of hear, in and blocks the circumflex artery, left margi . > Ifa thrombu: gets infarcted. i . vhile eating. aspirated by.a man W i eae n body lodgement. Give reasons. t of the pleura is pain sensitive Q. 25. A small pie : : a) Name the bronchus more liable to foreig b) Give the innervation of the pleura. Which par’ and why? (Supple 2020 held in 2021) ‘Ans: a) Right principal bronchus Reasons: > The right principal bronchus is 2.5 cm long. > Itis shorter, wider and more in line with the trachea than the left principal bronchus, 7 > hale particles or foreign bodies, therefore, tend to pass more frequently to the right lung, with the result that infections are more common ight si on the left, ‘on on the right side than b) Nerve supply of pleura: Parietal pleural: © Develops from the sor m matopleuric |; by Somatic nerves (Interonstal neq he lateral Intercostal and phrenic plate me: nerve) soderm & supplied © Pain sensitive PulmonaryVisceral pleura: * Develops from splanch; i aa nopleuric layer of the late ce | eral plate Pain insensitive due to lack oe ‘ory UPplied ° Spinal segments @ information, Q26. a) Explai Explain the yen . yy ‘trdidedominancey “*#!A8e of heart, Wh, ) List six main at d i © you unde, held in 2029) characteristics of 8 bronchopul ‘ Tstang by mona y left « Y semen: a n2 These are 3-4 small ventricle and open directly 4, These are also calleg smalle inus: I corona = t V4 si is the lnrBe jor W ‘qhis | into posterior jen of heart: in of heart. It is situated in left posterior coronary sulcus. It ends by all of right atrium. ardiac yein accompanies interventricular artery and then circumflex to enter into left end of coronary sulcus. It receives left marginal vein from a ; left yentricle. Middle cardiac vein accompanies posterior interventricular artery and joins middle Part of coronary sinus ein accompanies right coronary artery in right posterior coronary mall cardiac ve! ight end of coronary sinus. Right marginal vein may drain onto sulcus and joins r this vein. . Posterior vein of left ventricle runs on diaphragmatic surface of left ventricle and ends in coronary sinus. : Oblique vein of left atrium of Marshall runs on posterior surface of left atrium and terminates in left end of coronary sinus. + Right marginal vein accompanies marginal branch of right coronary artery. jteither drains into small cardiac vein or may open directly into right atrium. ‘Anterior cardiac veins: I veins which run parallel to one another on anterior wall of right into right atrium through its anterior wall. Venae cordis minimae: st cardiac'veins. These are numerous valveless veins that are present in all 4 chambers of heart which open directly into the cavity. Left cardiac dominance: Q27. a) A 63 year old man was brought t If posterior interventricular artery arises from left coronary artery, such cases are called left cardiac dominant. In about 10 percent of hearts, right coronary artery is posterior interventricular branch. This it arises from ci Coronary artery. small and ungble to give ircumflex branch of left 0 cardiac emergency with severe chest pain radiating to left arm, profuse sweating and marked pallor. ECG confirmed myocardial Infarction. Give the anatomical basis of cardiac referred pain to ‘left arm, What is the order frequency of occlusion of coronary arteries?SAA REY ee eee , can 98 + : i y of high grade fey, ‘ with history © ep horas dle aged man visited medics fe days Examination and X-ray o,° b) A middle aj for the pas' : . ‘st ee uritic pain?Give 4 cough and pleuritic pam ia. What is the cause of ple hi confirmed bronchopneumonia. in 2022) held ii , .(Supply 2021 : . onvesth ij nerve supply leave ts PAIN: axons of pain dita irae soy BASIS OF pea ena reach TI to T5segments SAE oe aiid sensei ime sympathetic sof left side. Since these dorsal root ganglia als bath gets refered ie os from medial s *forean id upper most part of cest. Ss from medial side of arm , forearm an areas. Ie Order of frequency of obstruction of coronary arteries. I~ Anterior IV branch of LCA (40-50%) 2- Right coronary artery (30-40%.) 3- circumflex branch of left coronary artery (15-20%). b) Cause of pleuritic pain pleuritic pain is caused by the nerve involument.Pleura is Pain from the lung is directly transmii Nerve supply of pleura © Intercostal nerves rovide innervati . . . I pleura pl nervation to costal pleura and Peripheral diaphragmatic highly sensitive to pain. ited to the parietal pleura. © Phrenic nerve prov’ ide innervation to mediastj - . pleura, e ty ‘astinal pleura and central] diaphragmatic *