Check List 3 PBL Anatomy Class

Gray’s Anatomy for Students Pages 167-251

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Important stuff:
Remember, Dr. Raja loves his nerve innervations. Make sure to pay special attention to those. - F

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1. Lungs—base, apex, root of the lungs

 Base: Sits on the diaphragm
 Apex: projects above rib I and into the root of the neck.
 Root: short tubular collection of structures that together attach the lung to structures in the
mediastinum
 covered by a sleeve of mediastinal pleura that reflects onto the surface of the lung as visceral
pleura.
2. Blood supply, nerve supply, and innervation of the lung
a. Blood supply:

Right & Left pulmonary arteries carries deoxygenated blood to lung from RV

Right & Left pulmonary veins carries oxygenated blood from lung to LA

Pulmonary trunk bifurcation: left of middle and inferior to T4&5

Bronchial arteries and veins: originate from thoracic aorta

b. Nerve supply – vagus nerve pass through posterior to root, phrenic nerve pass through
anterior to root
c. Innervation - anterior and posterior pulmonary plexus, the posterior is bigger. Branches
from these plexus distribute along the branches of the airways and vessels.
i. Visceral afferent and efferent
ii. Vagus nerve (parasympathetic) and sympathetic system
3. What is the role of sympathetic and parasympathetic on the bronchial diameter:
Parasympathetic stimulation causes bronchoconstriction (Vagus Nerve): decrease D &
airflow, increase resistance

Sympathetic stimulation causes bronchodilation: increase D & airflow; decrease resistance

4. Pleura, parietal and visceral pleura (similar to Q10 Checklist #1)

Pleura is mesothelium (single layer of cells) that lines the thorax

Visceral Pleura covers the lungs

Parietal Pleura is the outer membrane, surrounds thoracic cavity

5. Differences between left lung and right lung

Left lung is two lobed, one lobe, smaller, houses the heart (Cardiac Notch due to heart). Oblique
fissure separates inferior and superior lobes. Aortic arch (T IV/V Level) and thoracic aorta near left
lung.

Right lung is three lobed, larger, two fissures, likelier to received aspirated objects. Oblique fissure
separates the inferior, superior, and middle lobes. Horizontal lobe separates superior and middle
lobe. Vena Cava and Azygos vein near right lung.

6. Trachea, Bronchi(primary, secondary, and tertiary)

Trachea is a flexible tube from CVI to TIV/V, bifurcates at the mediastinum (T4/5). Mainly smooth
muscle. Passage for air.

Right main bronchus is wider than left main bronchus. (primary bronchi)

Main bronchi divide within the lung as Lobar Bronchi (secondary bronchi), each supplying a lung’s
lobe.

Lobar Bronchi divide into Segmental Bronchi (tertiary bronchi), supplying bronchopulmonary
segments. (tributary in between each bronchopulmonary segment)

7. Bronchopulmonary segments and their clinical importance

A bronchopulmonary segment is the smallest functionally independent region of a lung and the
smallest area of lung that can be isolated and removed without affecting adjacent regions. Supplied
by tertiary/segmental bronchi. Some fuse in the left lung.

Left: 8 bronchopulmonary segments

 Right: 10 bronchopulmonary segments

8. Pulmonary arteries and pulmonary veins

Left/Right Pulmonary Arteries originate from the pulmonary trunk, carry Deoxygenated blood to
the lungs, from the right ventricle of heart.

Superior/Inferior Pulmonary Veins carry Oxygenated Blood from the lungs to the heart (LA).

9. Mediastinum, division and contents of each mediastinum (similar to Q8, Checklist 1)

 Mediastinum is a thick, midline partition, flexible soft tissue partition
o Separates the pleural cavities
o Divisions: separated by sternal angle
 Superior mediastinum
 Inferior Mediastinum
1. Anterior mediastinum
a. Between the sternum and the pericardium
b. Includes the thymus gland
2. Middle mediastinum
a. Pericardium and heart
3. Posterior mediastiunum
a. Between the pericardium and thoracic vertebrae
o Contents
 Heart, Esophagus, thymus, trachea, Major nerves, Major systemic vessels
 Thymus gland, pericardial sac

10. Pericardium, fibrous, serous pericardium

Pericardium is a fibro serous sac surrounding the heart and the roots of the great vessels.
Fibrous pericardium is tough connective tissue, defines boundary of middle mediastinum.

*Serous Pericardium is thin and composed of Parietal layer (lines fibrous pericardium, it is a
continuation of visceral/epicardium) and Visceral layer (epicardium – covering of the heart)

11. Blood supply and nerve supply of the pericardium

Internal thoracic, pericardiophrenic, musculophrenic, and inferior phrenic arteries, and the
thoracic aorta supply blood to the pericardium.

Veins from the pericardium enter the azygos system of veins and the internal thoracic and
superior phrenic veins.

Vagus nerve (CN X) is the primary innervation of pericardium. (Sympathetic trunk and Phrenic
nerve also help in innervation).

Innervation of pericardium by vagus nerve, phrenic nerve, and sympathetic.

12. Pericardial effusion, constrictive pericarditis, and cardiac tamponade

Pericardial effusion is excess fluid between the visceral and parietal pericardium (between
heart/pericardium).

Cardiac tamponade is the result of accumulation of excess fluid within the pericardial sac, thus
compressing the heart, resulting in biventricular failure. *(Due to pericardial effusion)

Constrictive Pericarditis is the abnormal thickening of pericardial sac, involving only the Parietal
Pericardium, impairing heart function and may result in heart failure. (Diagnose by reading the
jugular venous pulse on neck, pulse should drop upon inspiration. Opposite occurs (pulse jumps
during inspiration) called Kussmaul’s Sign) Diastolic phase of cardiac cycle is restricted severely.

13. Apex and base of the heart

Base of heart is quadrilateral, consists of left atrium, part of right atrium, Superior/Inferior Vena
Cava, and pulmonary veins. (no nerves/no ventricles)

Apex of the heart formed by Inferolateral part of Left Ventricle, positioned at left fifth intercostal
space.

14. Chest radiograph—Posteroanterior and lateral view—identification of trachea, arch of aorta,

pulmonary trunk, apex of the heart, left ventricle, right ventricle, clavicle, spine of the scapula,
breast shadow (in female), fundic gas/gastric bubble, and dome of the diaphragm
 Page 193 fig 3.7

During a mastectomy (removal of breast due to cancer) will not give off a breast shadow in x-ray.

15. Left and right border of the heart (pg. 192)

Right border of the heart is a long border, formed by right atrium (mainly RA) (above) and right ventricle
(below). Atrial portion is almost vertical, near the sternum. Ventricular portion is thin/sharp and near
the apex of the heart.

Left border is shorter than right border, rounded shape. Formed mostly by left ventricle, but partly from
above by left atrium. From sternal margin and convexes towards apex of heart.

16. Interatrial septum, atrial septal defect, and fossa ovalis

Interatrial Septum separates left and right atria (faces forward, towards the right)
 Fossa Ovalis is right above the Interatrial Septum, it is a depression just above the orifice of the
Inferior Vena Cava. Marks the location of the foramen ovale (embryonic), which is important in fetal
circulation. Foramen ovale allows oxygenated blood from left atrium through inferior vena cava to
pass direct through right atrium, bypassing pulmonary circulation.

Atrial Septic Defect is a hole between left/right atria (upper heart) of the heart, congenital, may
never cause problems.

17. Ligamentum arteriosus and ductus arteriosus ( pg221)

Ligamentum arteriosus is a small remnant ligament in the superior mediastinum, important for fetal
circulation (remnant of the embryonic “Ductus Arteriosus”). Connects pulmonary trunk to arch of
aorta bypassing lungs. Closes after birth.

18. Papillary muscles of the heart, ventricular septal defect. Chordae tendineae (pg 197)

Papillary muscles (trabeculae carneae) have one end attached to ventricular surface and another
end to connecting to tricuspid valve. Three are found in the right ventricle. Attach via Chordae
tendinea (tendous like fibrous cords).

1. Anterior Papillary is the largest and most constant

2. Posterior Papillary consist of 1,2, or 3 structures directly from ventricular wall.
3. Septal Papillary is most inconsistent (may be small or absent) directly from septal wall.

Ventricular septal defect is a hole in the septum that separates left/right ventricles (lower
heart).

19. Mitral valve, tricuspid valve, and semilunar valves

*** Valves prevent backflow of blood***

Mitral Valve: (lets blood go from left atrium to left ventricle)

 Also known as the left atrioventricular valve or the bicuspid valve

 Located in between the left atrium and left ventricle
 when the left atrium fills with blood, the mitral valve opens to allow blood to flow to the
left ventricle
 Has two cusps (an anterior and posterior cusp)
 Cusps secured to a fibrous ring surrounding the opening
 Cusps are continuous with each other

Tricuspid Valve: (lets blood go from the right atrium to the right ventricle)
  Right atrioventricular valve
 right atrioventricular orifice (between the R. atrium and R. ventricle) is closed during ventricular
contraction
o During filling of R. ventricle tricuspid valve is open (cusps project into R. ventricle)
 3 cusps, connected with fibrous ring which helps maintain the shape of the cusp
o Cusp names: anterior, septal, posterior
o Attached to chordae tendineae which is connected to papillary muscles
 Contraction of papillary muscle attached to cusps by chordae tendineae prevents cusps from
being everted (flipped) = compensating mechanism
o Without this mechanism the flow of blood would be forced upward back into the atrium
o These muscles keep the valve closed when it’s supposed to be closed
 Proper closing of this valve pushes blood from right ventricle into pulmonary trunk

Semilunar Valves

 Also known as the pulmonary valve

 The opening into the pulmonary trunk from the R. Ventricle is closed by semilunar valve
 3 semilunar cusps: left, right, anterior semilunar cusps
o Each cusp forms a pocket like sinus
o Free edges project upward into lumen of pulmonary trunk
o Free superior edge of each cusp has a middle, thickened part called the nodule of the
semilunar cusp
 Also has a thin lateral part = lunula of the semilunar cusp
 After ventricular contraction the recoil of blood fills these pulmonary sinuses/pockets and forces
the cusps closed
o Prevents blood in pulmonary trunk from refilling the R. Ventricle
20. Conducting system of the heart

Cardiac conduction system initiates and coordinates contraction.

Contains Sinu-Atrial (SA) Node (Pacemaker of the heart), Atrioventricular (AV) Node, AV bundle with
its left/right branches, and Purkinje Fibers (subendocardial plexus of conduction cells.

Coronary artery disease and dysrhythmia (irregular heart beat) may result in heart failure/death.

Sinoatrial node (SA) --> atrioventricular node (AV) --> bundle of his --> purkinje fibers

-----Random Facts -----

Parasympathetic decreases heart rate, reduces contraction force, constricts coronary arteries.

Sympathetic increases heart rate and increases contraction force.

Atria are upper parts of the heart (A=Above)

Ventricle are lower parts of heart

Tri before you Bi (in terms of tricuspid/bicuspid valves)