The intercostal arteries can become enlarged, since the anastomoses of the anterior intercostals from the internal thoracic artery with the posterior intercostals can circumvent the narrowing. Aortic coarctation is more common in some genetic conditions such as Turner syndrome but also can be associated with congenital abranditemities of the aortic valve such as a bicuspid aortic valve.
Valvular Insufficiencies The mitral valve is the heart valve most frequently affected by disease. It can be caused by endocarditis, myocarditis, rheumatic heart disease, or lupus erythematosus, or can result from a developmental abranditemity.
The diseased mitral valve allows reversal of blood flow from the left ventricle to the left atrium mitral regurgitation. It is characterized by a high pitched murmur, loudest over the apex of the heart.
Narrowing of the pulmonary valve stenosis is caused by fusion of the valve cusps. It can result from a developmental abranditemity or diseases such as rheumatic fever or endocarditis. Stretches from the thoracic inlet to the diaphragm and from the sternum to the bodies of the thoracic vertebrae posteriorly. Its contents include the heart, trachea, esophagus, great vessels of the heart, lymph nodes, nerves, and fat.
Superior mediastinum contains the superior vena cava arch of the aorta and its branches trachea phrenic nerves thoracic duct esophagus vagus nerves left recurrent laryngeal nerve thymus Inferior mediastinum is subdivided into anterior mediastinum middle mediastinum posterior mediastinum The anterior mediastinum contains fat and the remnants of the thymus gland The middle mediastinum contains the heart surrounded by the pericardium and the roots of the great vessels.
Thymus gland plays a central role in the development of the immune system lies posterior to the manubrium receives blood from the internal thoracic and anterior intercostal arteries is gradually replace by adipose tissue after puberty b. Heart and pericardial sac Section Thorax-Heart c. Superior vena cava Formed by the union of two brachiocephalic veins Returns blood to the heart from all structures above the diaphragm except the heart and lungs Descends vertically and terminates in the right atrium Lies to the right of the ascending aorta and to the left of the right phrenic nerve Receives azygous veins before piercing fibrous pericardium d.
Brachiocephalic veins Are formed in the root of the neck posterior to the sternoclavicular joints by union of the internal jugular and subclavian veins. Right brachiocephalic vein receives lymph from the right lymph duct.
Left brachiocephalic vein is twice as long as the right runs obliquely down and behind the manubrium crosses the roots of the three major branches of the aorta receives lymph from the thoracic duct e. Aorta Ascending begins at the aortic orifice ascends to the 2nd right sternocostal joint Arch Begins at the 2nd right sternocostal joint and arches superiorly and to the left Anterior to the right pulmonary artery and bifurcation of the trachea Passes over the root of the right lung Ends at the body of the T4 vertebra Descending thoracic begins at the body of T4 vertebra descends on the left side of the bodies of T vertebrae, posterior to the root of the left lung and the pericardium enters the abdomen through the aortic hiatus at the T12 vertebral body has a number of branches: bronchial pericardial twigs superior phrenic 1 pair esophageal 2 posterior intercostal 9 pairs subcostal 1 pair f.
Vascular supply arterial: esophageal branches of the thoracic aorta venous: azygos, hemiazygos and accessory azygos veins h. Azygos venous system Drains blood from the back and thoracoabdominal walls Is highly variable Is composed of an unpaired azygos vein and its main tributary, the hemiazygos vein.
Phrenic nerves Supply motor and sensory fibers to the diaphragm Enter the superior mediastinum between the subclavian artery and brachiocephalic vein on either side Pass anterior to the roots of the lungs, unlike the vagus nerve The right phrenic nerve descends on the right side of the inferior vena cava to the diaphragm The left phrenic nerve crosses the arch of the aorta descends anterior to the root of the left lung and along the pericardium over the left atrium and ventricle pierces the diaphragm to the left of the pericardium 1.
Surgery, injury, or disease affecting the contents of superior mediastinum can damage either or both recurrent laryngeal nerves, reducing the voice to a hoarse whisper. The left recurrent laryngeal nerve passes beneath the arch of the aorta and ascends to the neck between the trachea and the esophagus.
Bronchogenic or esophageal carcinoma or an aneurysm of the arch of the aorta can thus affect this nerve. Chylothorax Surgical procedures involving the posterior mediastinum can injure the thoracic duct, which is hard to identify because it has a thin wall and is usually colorless.
Injury to the thoracic duct can lead to leakage of lymph into the thoracic cavity at a volume of up to mL per hour. Lymph is called chyle when it is carrying chylomicrons fat droplets from the digestion of food in the gastrointestinal system. If lymph from the thoracic duct enters the pleural cavity, the resulting condition is called a chylothorax and may require removal by thoracocentesis.
Mnemonics Memory Aids To remember the spinal nerve contributions to the phrenic nerve: C3,4,5 keeps the diaphragm alive T8-Site at which inferior vena cava pierces the diaphragm TSite at which esophagus pierces the diaphragm TSite at which aorta pierces the diaphragm Memory Aids SAT for major contents of the superior mediastinum : Superior vena cava, Arch of aorta, and Trachea Turkeys Blow Eggs: Trachea lies Behind the Esophagus page page Memory Aids Relationship of Thoracic Duct to Esophagus and Azygos Vein "The duck lies between two gooses.
Is the largest cavity in the body and is continuous with the pelvic cavity. Lined with parietal peritoneum, a serous membrane Bounded superiorly by the diaphragm Has a concave dome Spleen, liver, part of the stomach, and part of the kidneys lies under the dome and are protected by the lower ribs and costal cartilages. Lower extent lies in the greater pelvis Between the ala or wings of the ilia Ileum, cecum, and sigmoid colon thus partly protected Anterior and lateral walls composed of muscle Viscera in these areas are more likely to be damaged by blunt force and penetrating injuries.
Posterior wall comprised of vertebral column, the lower ribs, and associated muscles Protect the abdominal contents. All the rest of the organs are peritoneal Lie within the peritoneal cavity Covered by a layer of visceral peritoneum Visceral peritoneum is continuous with the parietal peritoneum lining the cavity via a mesentery. These planes create nine abdominal regions: Right and left hypochondriac regions, superiorly on either side Right and left lumbar flank regions, centrally on either side Right and left inguinal groin regions, inferiorly on either side Epigastric region superiorly and centrally Umbilical region, with the umbilicus as its center Hypogastric or suprapubic region, inferiorly and centrally Descriptive quadrants and regions are essential in clinical practice Each area represents certain visceral structures Allow correlation of pain and referred pain from these areas to specific organs.
Appendicitis: inflammation of the appendix. Pain first presents in the epigastric region, moves to the umbilical region and then localizes in the right lower quadrant. Rupture of the appendix leads to peritonitis inflammation of the peritoneum. This presents with severe pain, fever, and abdominal rigidity. Muscle-splitting incision of McBurney : used to access the appendix. Each muscle layer is split in the direction of the fiber orientation. The incision must not go too far laterally or the ascending branch of the deep circumflex iliac artery may be severed.
Clinical Points Grey-Turner's sign Local right flank redness or bruising ecchymosis Indicates a retroperitoneal hemorrhage Usually takes 24 to 48 hours to appear Can be predictive of severe hemorrhagic pancreatitis, abdominal injury, or metastatic cancer page page Clinical Points Cullen's sign Discoloration ecchymosis around the umbilicus Aresult of peritoneal hemorrhage Mnemonics Memory Aids Causes for abdominal expansion protuberance : Remember the five Fs: Fat Feces Fetus Flatus Fluid. Transversalis fascia endoabdominal fascia Athin membranous sheet lining most of the abdominal wall Lies deep to the transversus muscles and the linea alba Endoabdominal fat separates the transversalis fascia from the parietal peritoneum Muscles Functions Protect the viscera Help maintain posture Can compress the abdominal contents, thus raising intra-abdominal pressure, such as in sneezing, coughing, defecating, micturating, lifting, and childbirth Four paired muscles make up the anterolateral abdominal wall Three flat muscles Asingle vertical muscle.
Three flat muscles include The external abdominal oblique a. Largest and most superficial b. Fibers run inferiorly and medially and end in aponeurosis that contributes to the rectus sheath. Inferior border of its aponeurosis forms the inguinal ligament, where it thickens and folds back on itself d. Innervated segmentally by T6-T12 spinal nerves and subcostal nerve The internal abdominal oblique a. Athin muscular layer b. Fibers run inferiorly and laterally and end in an aponeurosis that contributes to the rectus sheath c.
Innervated segmentally by the ventral rami of T6-T12 spinal nerves The transversus abdominis a. Innermost of the three flat muscles b. Fibers run transversely and medially and end in an aponeurosis that contributes to the rectus sheath. Innervated segmentally by the ventral rami of T6-T12 spinal nerves Linea alba a.
Tendinous raphe running vertically in the midline b. Formed by the union of the aponeuroses of the flat muscles on either side c. Largely avascular d. Nerves and vessels are transversely oriented and segmental Nerves Thoracoabdominal nerves Anterior cutaneous branches of the ventral primary rami of T7-T11 a.
T7-T9 supply skin above the umbilicus b. T10 supplies skin around the umbilicus c. Subcostal nerves T12 supply skin below umbilicus e. Iliohypogastric and ilioinguinal nerves terminal branches of L1 supplies skin below umbilicus Vascular supply Arteries Anterior and collateral branches of posterior intercostal arteries Branches of the internal thoracic arteries a.
Superior epigastric b. Musculophrenic Inferior epigastric from external iliac Branches of the femoral artery a. Superficial epigastric b. Superficial circumflex iliac Veins Venous drainage is via venae comitantes veins corresponding to the arteries listed Blood drains away from the umbilicus Venous drainage to the caval system Lymphatics Superficial lymphatics above the umbilicus lymph drains to the axillary nodes Superficial lymphatics below the umbilicus drain to the superficial inguinal nodes Deep lymphatics a.
Accompany deep veins b. Gives off inferior epigastric and deep circumflex arteries b. Exits under the inguinal ligament as the femoral artery c. Its tributaries follow branches of aorta Exceptions: a. Left gonadal vein drains to left renal vein b.
Ventral primary rami of T12 b. Arise in the thorax c. Run inferiorly on surface of quadratus lumborum d. Supply external abdominal oblique and skin of anterolateral abdominal wall Lumbar nerves a. Dorsal and ventral primary rami of lumbar spinal nerves b. Dorsal rami supply muscles and skin of back c. Ventral rami pass into substance of psoas major muscle and form lumbar plexus Nerves of lumbar plexus Ilioinguinal and iliohypogastric nerves L1 a.
Enter abdomen posterior to medial arcuate ligament b. Pierce transverse abdominus near anterior superior iliac spine ASIS c. Emerges from anterior surface of psoas muscle b. Runs inferiorly deep to fascia c.
Emerges from lateral aspect of psoas muscle b. Runs inferiorly on iliacus c. Emerges from medial border of psoas b. Descends through pelvis to obturator canal c. Supplies muscles and skin of medial thigh Femoral nerve L2-L4 a.
Emerges from lateral border of psoas b. Innervates iliacus c. Passes beneath inguinal ligament on surface of iliopsoas muscle d. Descends over ala of sacrum into pelvis b. Joins in formation of sacral plexus Autonomic nerves Thoracic splanchnic nerves a. Convey presynaptic sympathetic fibers to celiac, superior mesenteric, and aorticorenal sympathetic ganglia Lumbar splanchnic nerves a.
Rise of abdominal sympathetic trunks b. Three to four in number c. Convey presynaptic sympathetic fibers to inferior mesenteric, intermesenteric, and superior hypogastric plexuses Prevertebral sympathetic ganglia a. Celiac b. Superior mesenteric c. Inferior mesenteric d. Aorticorenal Parasympathetic fibers a. Preganglionic b. Contain preganglionic sympathetic and parasympathetic fibers, postganglionic sympathetic fibers, sympathetic ganglia prevertebral , and visceral afferent fibers b.
Some named for major blood vessels periarterial : celiac, superior mesenteric, inferior mesenteric, intermesenteric, aorticorenal c. Located 1.
Direct inguinal hernias protrude through the layers of the wall in Hesselbach's the inguinal triangle, medial to the epigastric vessels. The hernial sac consists of peritoneum containing a portion of a viscus usually small or large bowel Indirect hernias which leave the abdomen lateral to the epigastric vessels, entering the inguinal canal through its deep ring. The hernial sac consists of peritoneum containing a portion of a viscus usually small or large bowel and is covered by the layers covering the spermatic cord.
The hernia may continue through the superficial ring and into the scrotum. Clinical Points Psoas Abscess Usually caused by the spread of lumbar vertebral tuberculosis to the psoas sheath.
The sheath becomes thickened and pus accumulates beneath it Pus tracks inferiorly within the sheath, deep to the inguinal ligament, surfacing in the superior part of the thigh.
Should pus track to the adjacent iliac fascia, a recess may form-the iliacosubfascial fossa. The large bowel can become trapped in this fossa, with resulting severe pain. Involvement of parietal peritoneum leads to well-localized, sharp abdominal pain with tenderness on palpation. Ascites Accumulation of fluid in the peritoneal cavity May form secondary to peritonitis or a variety of other pathological conditions Abdomen may become grossly distended as many liters of fluid accumulate Paracentesis may be undertaken both for diagnostic purposes and for draining the ascitic fluid.
Usually performed under local anaesthesia. Thick, circular middle layer of muscularis externa b. Controls passage of chime into duodenum c. The right arm of the H is formed by the inferior vena cava and the gall bladder. The left arm is formed by the fissure for the ligamentum teres hepatis and the fissure for the ligamentum venosum.
Clinical points page page Gallstones cholelithiasis Stone-like deposits are commonly seen in the gallbladder If they obstruct the cystic duct, can cause pain in the right upper quadrant RUQ , especially after consumption of a fatty meal. Pain typically comes and goes biliary colic and may be associated with nausea and vomiting. Secondary inflammation of the gallbladder leads to constant pain, and is often the trigger to seeking medical attention. If the gallstones pass further down, they may obstruct the biliary system causing jaundice, or the pancreatic duct causing pancreatitis.
Splenic rupture Spleen is the most commonly damaged abdominal organ, despite being protected by the ribcage. Trauma causing rib fracture or sudden increases in intra-abdominal pressure such as being impaled against a steering wheel in a road traffic accident may result in rupture of the spleen.
Bleeding is typically profuse owing to its thin capsule and soft parenchyma. Subphrenic abscess Subphrenic recess is a common site for pus to accumulate. Right-sided abscesses are more common owing to the incidence of perforation of an inflamed appendix. Pus usually tracks into the hepatorenal recess in the supine position, and is best drained inferior to the 12th rib avoiding puncture of the pleura.
Left gastroepiploic: supplies left side of greater curvature of stomach, anastomoses with right gastroepiploic b. Short gastric arteries: supply fundus of stomach Common hepatic artery Extends retroperitoneally to the right to reach hepatoduodenal ligament Divides into gastroduodenal and proper hepatic arteries Gastroduodenal artery branches: a.
Superior pancreaticoduodenal supplying the head of pancreas and proximal duodenum b. Right gastroepiploic artery supplying right side of greater curvature of stomach Proper hepatic branches: a. Right gastric artery to right portion of lesser curvature of stomach c. Cystic artery usually from the right hepatic artery supplies the gallbladder and cystic duct Superior mesenteric artery SMA Arises at L1 Supplies the gut from the second part of duodenum as far as the distal one third of the transverse colon Major branches include: Inferior pancreaticoduodenal a.
Supplies duodenum distal to entry of bile duct , pancreas, and spleen b. Anastomosis with superior pancreaticoduodenal Jejunal and ileal branches a.
Form anastomotic loops arterial arcades Fewer large loops in jejunum Many shorter loops in ileum b. Loops give off vasa recta straight arteries Longer in jejunum Shorter in ileum Ileocolic artery: a.
Supplies caecum and some of the ascending colon b. Resistance to portal blood flow may occur due to intrahepatic obstruction fibrosis of the liver from cirrhosis Resistance may also occur as a result of posthepatic obstruction such as heart failure or Budd-Chiari syndrome or prehepatic obstruction. Each plexus has sympathetic and parasympathetic input, both with motor and sensory divisions. Motor control governs glandular secretion, smooth muscle activity, and vascular tone.
Afferent nerves mediate distension of organs and tension on mesenteries. Embryologically, the kidneys develop in the pelvis and ascend to their abdominal position. In doing so, they acquire successively more superior vessels from the aorta and IVC, whereas inferior vessels degenerate.
Failure of degeneration of any of these vessels may result either in branches to the poles of the kidney, or in accessory vessels at the hilum. Furthermore, the renal arteries are not infrequently divided prior to their arrival at the hilum. Clinical Points Nephrolithiasis kidney stones Renal caliculi stones may be found anywhere between the renal calices and urinary bladder Astone in the ureter can cause significant distension This results in colicky pain radiating from loin to groin as ureteric contractions try to move the stone distally In the past, an intravenous urogram pyelogram was the imaging tool to determine a filling defect in the ureter More recently, a computed tomography CT scan has become the tool of choice, because patients may have an allergic response to the dye used in the urogram.
Management is usually conservative waiting for the stone to pass , but may be surgical or involve lithotripsy sonic disruption of the stone. Renal cysts Cysts are a common finding in the kidney. They may be solitary or multiple. Solitary cysts are usually of no clinical consequence. Multiple cysts may cause gross distortion and enlargement of the kidneys, culminating in renal failure. Multiple cysts may be caused by adult polycystic kidney disease, because of an autosomal dominant gene.
Acute Urinary Retention: The bladder, if distended, may be palpated and percussed up to the umbilicus. On examination, the bladder is dull to percussion and in acute urinary retention, the patient may also complain of tenderness on palpation in the suprapubic region.
Supracristal Line: Auseful landmark when performing a lumbar puncture since it corresponds to the 4th lumbar vertebral body. Lumbar puncture in adults is performed in the lateral decubitus position in the L4-L5 interspace. This movement is prevented by the sacrospinous and sacrotuberous ligaments.
All of the ilia are less flared in men than in women, so the greater pelvis is deeper. In a stable fracture, the pelvis remains stable and there is only one break-point in the pelvic ring with minimal hemorrhage. In an unstable fracture, the pelvis is unstable with two or more break-points in the pelvic ring with moderate to severe hemorrhage.
Signs of a fractured pelvis include: pain in the groin, hip or lower back; difficulty walking; urethral, vaginal or rectal bleeding; scrotal hematoma; and shock as a result of concealed hemorrhage contained bleeding into the pelvic cavity Afracture can be confirmed on x-ray and is seen as a break in continuity of the pelvic ring.
Decubitus Ulcers Also called pressure sores Can be a partial- or full-thickness loss of skin, underlying connective tissue and can extend into muscle, bone, tendons, and joint capsules. One of the things that impressed me about Iceland is the large number of natural pools with hot springs there. The feeling of bathing in the open air surrounded by wild nature and without being cold is indescribable. I definitely recommend making a stop to enjoy one of the best hot springs in Iceland.
Do you know any other that is not on our map of Iceland? Iceland has around active and extinct volcanoes and as many glaciers. If you want to know where they are, check out the map of Iceland volcanoes and also the map of Iceland glaciers below, which are essential for enjoying the land of ice and fire.
As there are so many volcanoes and glaciers in Iceland, I have surely forgotten to include some on the map, but I would like at least those that can be visited to be included. Therefore, if you have been to a volcano or glacier that is worth visiting, leave me a comment and I will add it. Here is a map of Iceland cities and villages so that when you travel around the island, you can find cities and towns where you can stop for lunch or rest.
Map of Iceland Cities and Villages. Seeing the northern lights is one of the best things to do in Iceland if you travel in winter. However, due to light pollution, not all places are good for seeing and enjoying this phenomenon in the same way. In order for you to have a good memory and the best photographs back home, I have created a map of the best places to see northern lights in Iceland. As you will see, in addition to points with the optimal conditions to see them, I have also marked the best Northern Lights hotels in Iceland.
Here is all the information you need to see Northern Lights in Iceland. Here are my favorite Northern Lights tours from Reykjavik. It is undoubtedly the most touristy area of the island, so here is a map of the Golden Circle of Iceland so that you know all the interesting places that are worth stopping at.
Map of Iceland Golden Circle. As I mentioned at the beginning of the article, we return to the island every year to run our Iceland photo tours , so we have tried many accommodations. Here is a map of the best hotels in Iceland , although I also wrote this article about where to stay in Iceland. Are required.
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