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Chapter 3: Thorax

Sternal Angle

Located at the horizontal plane intersecting the T4 & T5 vertebrae

Sternal Angle (3 Clinical Corr)

1)Trachea bifurcates into right and left primary bronchi 2) Arch of aorta 3) Azygous vein drains into superior vena cava

Rib Fractures

Commonly occur just anterior to the angle of the rib (weakest point of rib) & may cause a pneumothorax

Hiccups

Due to irritative lesion of phrenic nerve that cause involuntary contractions of diaphragm

Destructive lesion of phrenic nerve

May result in paralysis and paradoxical movement of one half of the diaphragm--> paralyzed dome is forced superiorly by increase in intra-abdominal pressure

Breast adenocarcinomas (2)

1)lactiferous duct carcinomas 2) Begin as painless masses in upper lateral quadrant

Late Stage Adenocarcinomas

May cause retraction and fixation of nipple and dimpling of skin due to invasion of suspensory ligaments

Metastasis of Adenocarcinomas (2)

1) These tumors mainly metastasize to axillary lymph nodes 2) also metastasize to parasternal nodes, opposite breast, and nodes of the anterior abdominal wall

Radical Mastectomy (2)

1) Breast, pectoralis major and minor muscles, axillary lymph nodes and vessels, and tributaries of axillary vein are removed 2) May cause damage to long thoracic nerve (winged scapula due to weakness in protraction & upward rotation) or thoracodorsal nerve (weakness in extension, adduction, & medial rotation of arm at glenohumeral joint)

Pleuritis

Inflamed visceral or parietal pleura--> become rough and the 2 layers may adhere

Pleurisy

Inflamed visceral or parietal pleura--> become rough and the 2 layers may adhere

Pleural Rub

Sound heard during respiration due to friction between adhering pleura (due to pleuritis or pleurisy)

Costal Pleurisy

Sharp pain experienced over adhesion site in pleurisy--> pain increases with inspiration

Mediastinal or Diaphragmatic Pleurisy

Pain referred over C3-C5 dermatomes in supraclavicular region

Thoracentesis

1) Needle used to sample/withdraw fluid from a costodiaphragmatic recess 2) Insert into inferior part of 9th intercostal space to avoid intercostal nerves

Pneumothorax

Pain and difficulty breathing associated with air in pleural cavity due to partial/complete atelectasis (collapse)

Open Pneumothorax

1) Penetrating wound pierces costal or cervical pleura-->pain from stimulation of intercostal nerves 2) Heart and mediastinal structures shift away & compress opposite lung 3) Air is expelled through wound during expiration

Tension Pneumothorax

1) Penetrating wound creates valve effect in pluera 2) Lung collapses; heart and other mediastinal structures shift and compress other lung 3) Cardiac Output, Venous return, and respiratory function are compromised

Pleural Effusion

Fluid accumulates in pleural cavity due to 1)obstruction of veins or lymphatic vessels draining the thorax 2) Inflammation of structures near pleura

Hemothorax

Blood accumulates in pleural cavity from hemorrhage of anterior or posterior intercostal vessels or internal thoracic vessels

Chylothorax

Lymph accumulates in a pleural cavity as a complication of mediastinal surgery or trauma that injures the thoracic duct

Breath Sounds from superior lobe

May be auscultated on the anterior and superior aspects of the thoracic wall

Breath Sounds from inferior lobe

May be auscultated on the posterior and inferior aspects of the back

Breath sounds from middle lobe

May be auscultated on the anterior chest wall near the sternum, inferior to the right fourth costal cartilage

Aspirated Foreign Body

More likely to enter the right main bronchus because it is shorter, wide, and more vertical than the left main bronchus

Aspirated Foreign Body (in Sitting/Standing Patient)

More likely to become lodged in the posterobasal segment of the inferior lobe of the right lung

Emphysema

Respiratory tissue is destroyed-->permanent abnormal enlargement & increased radiolucency of affected air spaces and formation of blebs or bullae

Spontaneous Pneumothorax

Emphysematous bleb ruptures-->air introduced into pleural cavity through visceral pleura-->similar to open or tension pneumothorax; most common in visceral pleura of the superior lobe of a lung

Bronchogenic Carcinomas

Tumors that may metastasize through lymph channels or pulmonary veins (which would eventually enter systemic circulation)

Supraclavicular lymph nodes

Sentinel nodes that indicate presense of malignancy

Enlarged right supraclavicular lymph nodes

Indicate malignancy in thorax

Enlarged left supraclavicular lymph nodes

Indicate malignancy in thorax, abdomen, or pelvis because all lymph below the diaphragm is returned to the venous system on left via thoracic duct

Pancoast carcinoma

Tumor that develops in the apical part of the superior lobe of either lung and may cause thoracic outlet syndrome

Thoracic Outlet Syndrome (2)

1) Results from compression of the sympathetic trunk at the level of the stellate ganglion, inf trunk of brachial plexus in root of neck, subclavian vessels, or the recurrent laryngeal nerve 2) May cause Horner's Syndrome, Decreased radial pulse, hoarseness and dysphagia, paresthesia ( due to compression of the C8 and T1 ventral rami in brach plexus)

Horner's Syndrome (2)

1)May be caused by compression of the sympathetic trunk or inferior trunk of bra plexus 2)Signs and symptoms include anhydrosis (loss of sweating on corresponding side of the face), ptosis, and miosis (constriction of the pupil)

Decreased radial pulse in upper limb

Caused by compression of the subclavian artery and vein

Hoarseness and dysphagia

Due to compression of a recurrent laryngeal nerve

Primary Carcinomas

Tumors that develop in other organs commonly metastasize to the lungs

Thymoma (2)

1) Often seen in patients with myasthenia gravis 2) Signs & symptoms include an obstructed left brachiocephalic vein and chest pain

Superior Vena Cava Syndrome (2)

1) Vein compressed by enlarged lymph nodes due to metastasis from a bronchogenic carcinoma or due to the carcinoma itself 2) Patients experience headache, edema of head and neck, prominent superficial veins, and cyanosis; veins of upper limbs fail to empty when lifted above the heart

Anastomoses of the Superior Vena Cava (2)

1) Between thoracic veins and superficial epigastric veins 2) Between superior epigastric veins and inferior epigastric veins

Coarctation of the Aorta (3)

1) Constriction of the aorta just proximal (infantile) or distal (adult) to ligamentum arteriosum 2) Blood pressure reduced in lower limbs and elevated in head, neck, and upper limbs 3) Anastomoses provide collateral circulation: anterior (branches of int. thoracic art) and posterior (branches or aorta) intercostal arteries--> blood flows in retrograde direction through posterior intercostal arteries into the descending aorta

Notching of the ribs

Due to resorption of ribs caused by dilation of anterior and posterior intercostal arteries in coarctation of the aorta

Carcinomas of the esophagus

Tumors develop at one of the 3 sites of constriction in the mediastinum

Swallowed foreign Body

May become lodged at one of the three sites of constriction of the esophagus in the mediastinum

Aneurysm of the arch of the aorta (2)

1) May compress the trachea, esophagus, and left recurrent laryngeal nerve 2) Trouble breathing, swallowing, and hoarseness

Cardiac Tamponade (2)

1) Results from accumulation of fluid in the pericardial cavity that compresses the chambers of the heart 2) Decreased venous return and reduced cardiac output

Kussmaul's Sign

A distension of the veins of the neck on inspiration due to pericardial effusion

Hemopericardium

Accumulation of blood in the pericardial cavity (may be due to acute tamponade resulting from wound or myocardial infarction that weakens the wall of the heart)

Pericardiocentesis to relieve a tamponade

Needle is passed through parietal pericardium at the left xiphocostal angle to aspirate blood from the pericardial cavity

Pericarditis (2)

1) Causes a stiffening and reduced compliancy of serous pericardium 2) ventricles may not fill completely & cardiac output may be reduced because of a pericardial effusion

Small Patency

Asymptomatic probe patency in the upper part of fossa ovalis in interatrial septum; blood shunted from left atrium to right atrium

Large Patency

Symptomatic atrial septal defect due to patency in the fossa ovalis; blood shunted from left atrium to right atrium

Ventricular Septal Defect

Large postnatal defect in interventricular septum (membranous part) results in shunt of blood from the left ventricle into the right ventricle; pulmonary hypertension may result causing congestive heart failure

Heart Murmur

Abnormal sound resulting from vibrations produced by the turbulent flow of blood; in valvular heart disease, due to valves not being fully closed (insufficient or incompetent valve) or from a decrease in valve diameter (stenoic valve)

Systolic Valvular Defects

Mitral valve should be closed and aortic valve should be open; includes mitral insufficiency and aortic stenosis

Diastolic Valvular Defects

Mitral valve should be open and the aortic valve should be closed; includes mitral stenosis and aortic insufficiency

Angina Pectoris

Chest pain from transient ischemia brought on by exercise; due to narrowing of coronary artery

T1-T5 Dermatomes

Sites of referred pain in patients with Angina Pectoris

Myocardial Infarction

Results from localized avascular necrosis of cardiac muscle cells due to prolonged ischemia; onset marked by sudden, severe pain beneath the sternum; most commonly due to occlusion in LAD

Atrioventricular Block

aka Heart Block; Conduction is slowed through the AV node (no impulses transmitted in a complete AV block) ; Atria beat 70times/min and ventricles may receive impulses from pacemaker in the AV bundle initiating contraction at a rate of 30-40times/min

Complete AV Block

Contractions of the atria and ventricles become dissociated and chambers beat independently

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