Anatomy 3 - Consequences of a Chronic Cough

Question 1

What lobe of what lung do foreign bodies tend to be inhaled into in the upright patient?

Answer 1

The inferior lobe of the right lung (right bronchus has a larger diameter, more vertical orientation and a shorter length)

Question 2

What is the name of the internal aspect of the tracheal birfurcation?

Answer 2

Carina

Question 3

What is a pneumothorax?

Answer 3

The presence of air in the pleural cavity causing the lung to collapse

Question 4

What are 3 types of pneumothoraxes with explanation?

Answer 4

Spontaneous = no apparent cause (in an otherwise healthy person)Traumatic = result of an injury Tension = breach in the lung surface acts as a one way valve allowing air to move into the pleural cavity during inhalation but preventing it from moving out during exhalation

Question 5

What is a bulla?

Answer 5

A thin-walled air-filled space within the lung, arising congenitally or in emphysema

Question 6

What size is a small pneumothorax?

Answer 6

Less than 2cm

Question 7

What happens when a small amount of air enters the pleural cavity (either due to a penetrating injury to the parietal pleura or due to rupture of the visceral pleura) leading to the lung collapsing?

Answer 7

The vacuum is lost and the elastic lung tissue recoils towards the lung root (if only a small pneumothorax there will only be a

Question 8

Examination findings when a pneumothorax is present? (3)

Answer 8

Reduced ipsilateral chest expansion and breath soundsHyper-resonance on percussion

Question 9

What are the 2 features of a pneumothorax on a chest x-ray?

Answer 9

Absent lung markings peripherally and lung edge invisible

Question 10

What does the build up of air in the pleural cavity eventually lead to in a tension pneumothorax?

Answer 10

Pleural cavity applies pressure (tension) to the mediastinal structures eventually causing mediastinal shift compressing the heart and left lung

Question 11

What happens to the trachea in a tension pneumothorax?

Answer 11

Tracheal deviation away from he side of a unilateral tension pneumothorax

Question 12

Why does a tension pneumothorax lead to hypotension?

Answer 12

SVC compression reduces venous return to the heart leading to hypotension

Question 13

What is the treatment of a large pneumothorax?

Answer 13

Needle aspiration (thoracentesis)sitting of a chest drain

Question 14

Why is the a chest drain inserted in the 4th or 5th intercostal space midaxillary line?

Answer 14

This is the “safe traingle” - anterior border of latissimus dorsi and the posterior border of the pectoralis major

Question 15

When carrying out thoracentesis, where should you aim to place the needle?

Answer 15

Just above the rib below in order to keep away from the NVB

Question 16

Emergency management of a tension pneumothorax?

Answer 16

Insert a large gauge cannula (grey/orange) into the pleural cavity via the 2nd or 3rd intercostal space in the midclavicular line on the side of the tension pneumothorax

Question 17

What is the most likely consequence of a chronic cough?

Answer 17

Herniae

Question 18

What are the 2 factors usually required for the development of a hernia?

Answer 18

Weakness of one structure (usually a part of the body wall)Increased pressure on one side of the part of the wall (e.g. chronic cough)

Question 19

What are 4 examples of the body wall which have a normal anatomical weakness?

Answer 19

DiaphragmUmbilicusInguinal canalFemoral canal

Question 20

Apart from normal anatomical weakness, what other 2 factors can cause weakness of a structure?

Answer 20

Congenital abnormalities e.g. congenital diaphragmatic weaknessSurgical scars = incisional hernias

Question 21

What are 3 normal anatomical weaknesses in the diaphragm? (common arrestor hernia)

Answer 21

Attachements to xiphoid processOesophageal hiatusAt posterior attachments

Question 22

2 type of hiatus hernia?

Answer 22

Paraoesophageal hiatus hernia (herniated part of stomach passes through hiatus to become parallel to the oesophagus int he chest)Sliding hiatus hernia (herniated part of stomach slides through hiatus into chest with gastro-oesophageal junction

Question 23

Where in the inguinal canal do inguinal herniae tend to form?

Answer 23

In the medial half of the inguinal region

Question 24

When is the inguinal canal formed?

Answer 24

During embryology due to the passage of the testes or the round ligament of the uterus into the perinuem

Question 25

What does the inguinal canal contain in the adult?

Answer 25

The spermatic cord or the round ligament of the uterus

Question 26

What can add increased pressure in the inguinal canal (intra-abdominal) leading to the formation of an inguinal hernia?

Answer 26

Chronic coughChronic constipationOccupational lifting of heavy weightsAthletic effort

Question 27

Where is the inguinal (groin) region?

Answer 27

The region between the anterior superior iliac spine and the pubic tubercle

Question 28

Where do the inguinal ligaments attach between?

Answer 28

The ASIS and the pubic tubercle

Question 29

What does the medial halves of the inguinal ligaments form in terms of the inguinal canals?

Answer 29

Forms the floors of the inguinal canals

Question 30

How are the inguinal ligaments related to the external oblique aponeuroses?

Answer 30

Inguinal ligaments are the inferior borders of the external oblique aponeuroses

Question 31

What are the inguinal canals?

Answer 31

approx. 4 cm long passageways through the anterior abdominal wall in the inguinal regions

Question 32

What are the entrance and exit to the inguinal canals called?

Answer 32

Entrance = deep in (superior to the midpoint of the inguinal ligament)Exit = Superficial ring (“V” shaped defect in the external oblique aponeurosis that lies superolateral to the pubic tubercle)

Question 33

What causes the weakness in inguinal hernia?

Answer 33

The presence of the inguinal canal in the inguinal part of the anterolateral abdominal wall

Question 34

What are the layers of the anterolateral abdominal wall of the inguinal canal in men?

Answer 34

Scrotal skinSuperficial fascia of the scrotumDeep fasciaInguinal ligamentLower border of internal obliqueLower border of transverses abdomensTransversalis fasciaTesticular vein (tributary of IVC or left renal vein)Testicular artery (branch of AA)Peritoneum(the vas deference is attached inferiorly in the pelvis in the region of the developing prostate gland)

Question 35

What is the name of the out pouching of parietal peritoneum that forms as the testicle begins to descend?

Answer 35

Processus vaginalis

Question 36

What is the name of the covering transversals fascia that covers the testicle as it descends through the transversalis fascia?

Answer 36

Internal spermatic fascia

Question 37

What is the name of the covering of skeletal muscle fibres from the internal oblique that cover the testicle as it descends?

Answer 37

Cremasteric fascia

Question 38

What is the name of the covering of external oblique aponeurosis that covers the testicle as it descends?

Answer 38

External spermatic fascia

Question 39

What is the name of the remains of the processes vaginalis?

Answer 39

Tunica vaginalis

Question 40

What forms the deep ring of the inguinal canal?

Answer 40

Where the testis pushed into the transversalis fascia

Question 41

What passes through the inguinal canal with the testis?

Answer 41

The spermatic cord

Question 42

What is the spermatic cord

Answer 42

The 3 layers of “coverings” gained as the testis passes through the inguinal canal and the structures contain within (vas deferent, testicular artery and pampiniform plexus)

Question 43

What passes through the inguinal canals and females?Where do these go to?What are these?

Answer 43

Round ligaments of the uterus Labium majusFibrous embryological remnants in the adult female

Question 44

2 types of inguinal hernia?

Answer 44

Direct inguinal herniaAn indirect inguinal hernia

Question 45

How is a direct inguinal hernia formed?

Answer 45

A “finger” of peritoneum is forced through the posterior wall of the inguinal canal and directly out of the superficial ring into the scrotum

Question 46

How is an indirect inguinal hernia formed?

Answer 46

A “finger” of peritoneum is first forced through the deep ring into the inguinal canal and then out of the superficial ring into the scrotum

Question 47

How can you clinically differentiate between a direct and indirect hernia? (not a perfect test)

Answer 47

Reduce the herniaOcclude the deep ring with fingertip pressureAsk the patient to coughIf it is a direct hernia, the lump will reappear whereas if it is an indirect hernia the lump will not appear