Heart Anatomy
Compare and contrast the function, vasculature, innervation, and striations of the external, internal and innermost intercostals
For the vasculature, what are the route and terminal branches for the artery?
External: Elevate ribs, inspiration, inferoanterior
Internal: Depress ribs, expire, inferoposterior
Innermost: Depress ribs, expire, inferoposterior
All 3: Innercostal nerves (T1-T11)
Anterior: Subclavian --> Internal Thoracic/Mammaryh --> Anterior Intercostal (1-6) --> Musculophrenic (7-9)
Posterior: Thoracic Arch (or subclavian) to Posterior Intercostal (1-11)
What are some differences between the Right and Left Lung anatomy?
3 for full credit
Pulmonary Artery is anterior to bronchus on the right, superior on the left
3 lobes vs. 2
Wider more vertical vs. narrower and more horizontal
10 segments vs. 8-10 on left (some fuse)
What's the story behind the pleuroperitoneal canals?
What problem do they pose? How is this solved?
Bonus 100: What's it called when these canals do not close in development
Holes formed in septum transversum, lead to an open communication b/w thoracic cavity and abdominopelvic region, fixed by pleuroperitoneal membranes/folds. \
Congenital Diaphragmatic Hernia
Describe the difference in the course of the left recurrent laryngeal arch and right laryngeal arch.
What is the reason behind this?
Left: Aortic Arch
Right: Right subclavian
6th aortic arch persists on the left side, but not on the right. The last arch that persists on the right side is the 4th, which forms the right subclavian artery
6 month old baby won't stop crying. Imaging shows a complete vascular ring surrounding both the trachea and esophagus. What is this? What causes it?
Double aortic arch caused by persistence of the 5th RIGHT aortic arch.
Where would referred be felt for pericarditis versus ischemia/heart attack? Which nerve roots affected in each?
The nerve for one of these regions also has another key function, what is that?
Pericarditis: Top of shoulders, upper lateral arm
Myocardial problems: Mid-left chest (pec area), medial arm
Fibrous Pericardium is inn by phrenic nerve, phrenic nerve is tasked with sensory and motor to diaphragm, allowing it to ascend and descend during expiration and inspiration, respectively.
Name the Airway pathway
Nasal / oral cavities → pharynx → larynx → trachea → main bronchi → secondary bronchi → tertiary bronchi → terminal bronchioles → respiratory bronchioles → alveoli
The intraembryonic cavity gives rise to which two ventral body cavities? Which two sub cavities within those?
What is the thick plate of visceral mesoderm between the thoracic and abdominal cavity?
100 each
Thorax and Abdomen
Thorax: Pericardial and pleural
Abdomen: Abdominal and Pelvic
Septum transversum
For each embryonic structure, say its adult derivative:
Truncus Arteriosus
Bulbus Cordis
Primordial Ventricle
Primordial Atria
R horn of sinus venosus
L horn of sinus venosus
TA: Ascending aorta + pulmonary trunk
BC: Smooth outflow tracts of each ventricle
PV: Rough parts of both ventricles
PA: Rough parts of both atria (also auricles and pectinate muscles)
R Horn SV: Sinus venarum of RA, SVC IVC entry
L Horn SV: Coronary Sinus
Tetralogy of Fallot, Transposition, and Persistent Truncus are referred to as the 3 T's.
What do they have in common?
What is the primary phenotype seen in these disorders that is not seen in the alternative form?
Why?
All Right to Left shunts
ToF: RV to LV because septum didn't fuse,
Transposition: pulm trunk & aorta switched, spiral septum doesn't spiral
Persistent Truncus: 1 common arterial trunk (mixing of blood)
Cyanosis
Right to Left Shunts bypass the lungs, so deoxygenated blood is circulated around the body
Bonus 100 if you can say the position of the pulm trunk vs. aorta before and after normal spiraling.
What are the AV valves? SL valves? When are the AV valves open vs. closed? SL?
Where is the best place to auscultate each?
Differentiate between Mitral Valve Prolapse and Mitral Valve Stenosis. Which is associated with Jugular Vein Distention, Edema, and Cool Limbs?
(100 points each)
AV: Tricuspid and bicuspid (mitral) // SL: Pulmonary and Aortic
Aortic: Right 2nd intercostal // Pulm: Left 2nd/3rd Intercostal // Tricuspid: 4th Intercostal // Mitral: 5th Intercostal
Prolapse: Regurgitation due to flappy leaflets valve. Due to wear and tear, or structural weakness of chordae tendineae
Stenosis: Thickening of valve, permanent narrowing due to calcification. **Assoc w/ symptoms
JVD and Swelling due to: backflow blocked, LA overload, Lung congestion (traveling backwards), RV failure, Pressure backs up into neck or lower limbs
Cool limbs: Underfilled pumping chamber, less CO, fatigue weakness and cool limbs
Pericardium filling with some sort of fluid is referred to as __
What's the treatment?
What's a potential cause?
Why is all this bad?
75 points each
Cardiac Tamponade
Pericardiocentesis (or technically surgical window)
Gunshot wound, CV rupture, inflammation by infection, cancer
Lowers cardiac output
What structure is an outgrowth from the ventral foregut that leads to development of this system?
What is the structure that eventually separates this from the foregut?
What physiologic structure of the trachea is important to allow it to be positioned ___ to the esophagus?
100 each
Respiratory Diverticulum
Tracheoesophageal Ridges
These ridges eventually fuse to form a tracheoesophageal septum with an anterior trachea and posterior esophagus. Trachea has C-shaped cartilage that allow the esophagus to exist, expand, and contract behind it.
Daily Double! Keep in mind, this is probably the hardest question in the whole jeopardy.
In some cases, you actually want to keep the ductus arteriosus open. What is one of these cases and why would you want to keep it open?
How would you keep it open? Which aortic arch does ductus arteriosus come from?
Must get all for credit (partial is allowed)
Downs syndrome patient shows up with split S2 and AV valve regurgitation. Ultrasound shows that the septum primum did not fuse with the endocardial cushions. What type of septum defect is this
Why does the patient have AV valve regurgitation?
Primum type ASD
Endocardial cushions play a role in AV valve formation.
Right Auricle
Pectinate Muscle (Derived from)
Smooth Wall (Derived from?)
Crista Terminalis
Fossa Ovalis
Tricuspid Valve (What are two structures that hold it closed?)
The following are features of the ____. What are each of their functions or descriptions?
(40 pts each)
Auricle: Ear-like pouch, expanding to increase capacity of RA when blood volume or pressure spikes
Pectinate: Rough part, muscular contractions; primordial atrium
Smooth Wall: Minimize turbulence as blood is received (sinus venarum)
Crista Terminalis: Separation of rough (ant) and smooth (post) walls; also houses SA node
Fossa Ovalis: Remnant of Foramen Ovale (right to left shunt to bypass non-functional lungs)
Tricuspid Valve: Prevent backflow of blood into RA during ventricular systole. Opens during atrial systole. Papillary Muscles and Chorae Tendinae
After trying to pregame their comedy skit at the AAPI festival, both Patient X and Patient Y start coughing as they attempt to finish their drink before taking the stage. Patient X was lying down while Patient Y was standing
What's going on? Where is the fluid accumulated in each?
Aspiration
Patient X: Superior segment of right lower lobe or Posterior aspect of right upper lobe
Patient Y: Posterior basal segment of right lower lobe; near costodiaphragmatic recess
Function of Type I and Type II cells in 5 words or less
Pseudoglandular 5-17: Branching up until terminal bronchioles
Canalicular: 17-25: Respiratory bronchioles + vasculo/angiogenesis
Terminal Sac 26-Birth: Type I and II cells
Alveolar Birth - 8 years: Mature alveoli develop
Blood air barrier
Produce surfactant
How does tetralogy of Fallot arise? What are the 4 characteristics?
septum is offset to the right and doesn't fuse with muscular IV septum.
RV hypertrophy, VSD, pulmonary stenosis, overriding aorta as it receives blood from both ventricles
Patient presents with an ultra-rare disorder in which Neural Crest Cell migration is severely hindered. What do you most expect to see in the baby?
Failure of spiral septum formation, 3 T's, cyanosis, common ventricle, poor semilunar valve development
Also no division of BC and IV septum, but most important take-home point is failure of spiral septum, leading to R-->L shunt disorders = cyanosis.
Branches and what they supply for EACH branch off the Right Coronary Artery and Left Coronary Artery
Functions of SA and AV node
What is meant by "__ -sided dominance"
Occlusion of which arteries is called the widowmaker? Why?
What do the RCA and circumflex artery travel in around the heart?
(100 each)
RCA: SA nodal artery: SA node // Right Marginal Artery: RV myocardium // AV nodal artery: AV node // PDA (usually): 1/3 of IV septum, wall of both ventricles
LCA: LAD: Anterior 2/3 of IV septum, wall of LV // Left Circumflex: LV and LA
SA: Pacemaker // AV: time between contractions
Which side gives off the PDA (usually right, sometimes left, rarely co)
Left Main or LAD, supply LV which is most powerful part of heart. If occluded, can't get blood passed to body
Coronary Sulcus
Patient Q is playing in their first ever pickleball game when all of a sudden they feel a bit faint and are rushed to the emergency room. "Your lungs aren't getting enough blood supply," Dr. Muppidi said. "Good thing you came in when you did."
How is this possible when the patient's pulmonary arteries and veins are completely fine? What is the venous drainage for the lungs as well?
Pulmonary arteries bring blood to the lungs, yes, but they are not the blood supply for the lungs. That would be the bronchial arteries.
Venous drainage is bronchial veins to azygous veins
Prenatal ultrasound revealed polyhydramnios, microgastria, and a distended hydropharynx.
What does the patient likely have?
Why does each symptom arise?
Polyhydramnios: Fluid is produced but not recycled (baby can't swallow properly) --> buildup of excess fluid (esophageal blockage)
Microgastria: No communication b/w esophagus and stomach, no stomach development, appears as collapsed stomach
Distended hydropharynx: Esophageal atresia, accumulation of fluid and pressure as it becomes trapped in an upper blind pouch
What are the fates of the vitelline, umbillical, and cardinal veins (Right and Left for each)
Vitelline: Right becomes IVC, left obliterates
Umbillical: Left connects the placenta to liver as round ligament (ligamentum teres), right disappears
Cardinal: Form supra and subcadinal veins: Supra drain the posterior wall, subcardinal drain the kidneys
Bonus if you get that the IVC is made up of vitelline, subcardinal, and supracardinal veins, while the SVC is made up of the R common cardinal and R anterior cardinal
Patient X shows up with progressive shortness of breath, chest fullness, and profound fatigue over the past 3 days. On physical examination, his blood pressure is 92/54, heart rate is 132, and his jugular veins are significantly distended. Heart sounds are notably distant and muffled
What are two options that should pop into your mind as to what this could be
Assuming Dr. Patel cleaned his glasses, what imaging test should the doctors do to figure out if this is A or B
What treatment should likely be pursued regardless of if it's A or B
Where should you puncture? Why?
Pneumothorax or cardiac tamponade
To determine if air or fluid, run a CT scan. Air will show up black, fluid gray
Window or pericardiocentesis
Just above the rib below or in the inferior aspect of the intercostal space. Primary neurovascular bundles are in the superior aspect, only collateral are in the inferior aspects