Thorax

Anatomy: 1st Year

Short Essay Questions
Clinical Cases in Anatomy

Total Marks: 35 Time Allowed: 35 minutes

Roll No. _____________________________________ Name _____________________________________

Pericardial Effusion

A 35-year-old man with past history of dengue fever came with complaints of fatigue, dyspnea and
sweating on mild exertion. He complained of palpitation on and off. On auscultation, the physician
heard pericardial rub over the left sternal border and upper ribs. On investigating him, the chest
radiograph and 2D echocardiography showed pericardial effusion.

1. What is pericardial effusion?

The inflammation of serous pericardium is called pericarditis. It causes accumulation of
serous fluid in the pericardial cavity which is called pericardial effusion.*

2. What is cardiac tamponade?

The excessive accumulation of serous fluid in the pericardial cavity compresses the thin-
walled atria and interferes with filling of the heart during diastole and consequently the
cardiac output is diminished. This condition is called cardiac tamponade.*

3. What is pericardial friction rub?

The roughening of the parietal and visceral layers of serous pericardium by inflammatory
exudates causes friction between the two layers which is known as pericardial friction rub.*

4. At what site is paracentesis done to remove pericardial fluid?

Paracentesis is done by inserting a needle in the left costoxiphoid angle and passing it in an
upward and backward direction at an angle of 45° to the skin.*
Myocardial Infarction

A 62-year-old man was admitted to the casualty ward for sensation of pressure in the chest on the left
side. He complained of sweating, shortness of breath and vomiting. The pain radiated to the left side of
the arm, forearm and hand. He said that these symptoms occurred when he was reading the newspaper
and started about 1 hour back. After taking an ECG, the physician diagnosed the condition as myocardial
infarction. He was advised coronary bypass surgery.

1. What is myocardial infarction?

A sudden block of one of the larger branches of either coronary artery usually leads to
myocardial ischemia followed by necrosis of the myocardium. This condition is known as
myocardial infarction.*

2. Why did the pain radiate to the left side of the arm and forearm?
The afferent pain fibers from the heart reach the upper four to five spinal segments through
the cardiac branches of the sympathetic trunks usually on the left side. Therefore, the pain is
referred in the left precordium (T4 and T3 dermatome), medial side of the arm (T2 dermatome)
and medial side of the forearm (T1 dermatome).*

3. Why did the patient complain of nausea and vomiting?

Myocardial infarction involving the inferior wall or diaphragmatic surface of the heart gives
rise to discomfort in the epigastrium causing nausea and vomiting. This is because afferent
pain fibers from the heart ascend in the sympathetic trunks and enter the spinal cord through
the posterior roots of thoracic spinal nerves 7,8 and 9 thereby giving rise to referred pain in
T7, T8 and T9 dermatomes in the epigastrium.*

4. What is coronary bypass surgery? Which blood vessels are used in this surgery?
In coronary bypass, a segment of an artery or a vein is connected from the ascending aorta to
the to the coronary artery distal to the stenosis. Blood vessels involved in this surgery are the
great saphenous vein, internal thoracic arteries and radial artery.*
Pleural Effusion

A 35-year-old man visited a chest physician for severe pain on the right side of his chest for the last 10
days and difficulty in breathing. He also complained that the pain radiated to the anterior abdominal
wall. On examination, the chest physician noticed the absence of breath sounds over the lower lobe of
his right lung. The PA radiograph of his chest revealed blunting of the right costophrenic angle and line
of fluid level. The chest physician told the patient that he had fluid in the chest cavity and it had to be
drained.

1. What is this condition called?

Pleural effusion*

2. Enumerate the recesses of the pleura.

Costodiaphragmatic and costomediastinal*

3. In which intercostal space will the chest physician insert a needle to drain the fluid?
9th intercostal space in the midaxillary line during expiration to avoid the inferior border of the
lung.*

4. What are the layers pierced by the needle during pleural tapping?
The layers pierced are skin, fascia, serratus anterior, external intercostal, internal intercostal,
innermost intercostal, endothoracic fascia and parietal pleura.*

5. What is the anatomical basis of radiation of pain to the anterior abdominal wall?
The lower part of the costal parietal pleura receives sensory innervation from the lower five
Intercostal nerves which also innervate the skin of the anterior abdominal wall.*

Angina Pectoris

A 55-year-old man visited the physician complaining of a feeling of tightness on the left side of his chest
on climbing stairs and profuse sweating. He also complained that the pain radiated along the medial
side of his left arm and forearm. He told the doctor that the symptoms disappeared after rest. The
physician diagnosed his condition as angina pectoris.

1. What is angina pectoris?

It is pain in the region of the precordium that may last from 15 seconds to 15 minutes.*

2. Why did the pain occur on exertion and disappear after taking rest?
The coronary arteries are narrowed so that ischemia of the cardiac muscle occurs only on
exertion as the heart requires more blood during exertion. When the patient is resting, blood
requirement of the heart is less; therefore pain disappears after taking rest.*

3. What is the anatomical basis of pain felt in the left side of the chest and on the medial side of
the left arm and forearm.
The afferent pain fibers from the heart reach the upper four to five spinal segments through
the cardiac branches of the sympathetic trunks usually on the left side. Therefore, the pain is
referred in the left precordium (T4 and T3 dermatome), medial side of the arm (T2 dermatome)
and medial side of the forearm (T1 dermatome).*
Coronary Artery Bypass

A 65-year-old man who suffered myocardial infarction was admitted to the cardiothoracic surgery ward
for coronary bypass surgery. The surgeon used the patient’s long saphenous vein and reversed it for
bypass surgery.

1. What is myocardial infarction?

A sudden block of one of the larger branches of either coronary artery usually leads to
myocardial ischemia followed by necrosis of the myocardium. This condition is known as
myocardial infarction.*

2. What is coronary bypass surgery?

In a coronary bypass, the graft segment of an artery or vein is connected to the ascending
aorta or proximal part of the coronary artery and then to the coronary artery distal to the
stenosis.*

3. Why was the long saphenous vein used in coronary bypass surgery?
The long saphenous vein was used in coronary bypass surgery because (a) it has a diameter
which equals to or is greater than that of a coronary artery, (b) it can be easily dissected from
the lower limb and (c) it offers relatively lengthy portions with minimum occurrence of valves
or branching.*

4. Why was the implanted segment of the long saphenous vein reversed?
So that valves do not hamper the blood flow.*

5. Which other blood vessels are used in coronary bypass surgery?

Internal mammary arteries and radial artery*
Bronchogenic Carcinoma

A 65-year-old man visited a surgeon for difficulty in breathing and swallowing and hoarseness of voice.
He told the surgeon that he was a chronic smoker. On examination, the surgeon noticed engorgement
of veins in the neck. A radiograph of the chest revealed a large well-circumscribed radio-opaque shadow
in the hilar region of his right lung and widening of the mediastinum. The surgeon diagnosed this case
as bronchogenic carcinoma.

1. Why is bronchogenic carcinoma more common in chronic smokers?

Chronic smoking induces transformation of the respiratory epithelium into stratified
squamous epithelium, an eventual step in its eventual differentiation into a tumor.*

2. Why is bronchogenic carcinoma more common in the right lung?

The right bronchial tree is more exposed to carcinogens, i.e. cigarette smoke and tarry
particles, as the right bronchus is wide and more or less vertical in line with the trachea.*

3. Why did the patient complain of dysphagia, dyspnea and hoarseness of voice?
A bronchogenic carcinoma spreads to the tracheobronchial and bronchomediastinal lymph
nodes, involving the recurrent laryngeal nerve leading to hoarseness of voice, compressing
the trachea leading to dyspnea and compressing the esophagus leading to dyspnea.*

4. Trace the venous blood route through which metastasis of lung cancer cells occurs, to the brain.
The metastasis to the brain through venous blood occurs via the following route:
bronchial vein ⟶ azygos vein ⟶ external vertebral venous plexus ⟶ internal vertebral
venous plexus ⟶ cranial venous dural sinuses ⟶ brain.*

5. Trace the arterial blood route through which metastasis of lung cancer cells occurs, to the brain.
The metastasis to the brain through arterial blood occurs via the following route:
Lung capillaries ⟶ pulmonary vein ⟶ left atrium ⟶ left ventricle ⟶ aorta ⟶ internal carotid
artery ⟶ vertebral artery ⟶ brain.*
Pancoast Tumor

A 56-year-old man who is a chronic smoker visited a chest physician with complaints of persistent
cough, hemoptysis (blood in the sputum) and loss of weight. He also complained of pain along the
medial border of his arm and forearm, absence of sweating on the right side of his face and slight
drooping of the right upper eyelid. On examination, there was a diminished brachial pulse on the right
side and constriction of the right pupil. The PA view of the chest radiograph showed a mass of the right
lung and erosion of the 1st and 2nd ribs.

1. Name the clinical condition and site of lesion.

Pancoast tumor. It is the cancer of apex of the (right) lung.*

2. Why did the patient complain of pain along the medial border of the arm and forearm?
A pancoast tumor compresses the structures on the posterior aspect, i.e. ventral rami of
C8 and T1 which supply the medial border of the arm and forearm causing pain along this
region.*

3. Why was there ptosis (drooping) of the right upper eyelid and constriction of the pupil?
The tumor compresses the sympathetic chain causing Horner’s syndrome, i.e. ptosis
(drooping) of the right upper eyelid, a constricted pupil and absence of sweating on the
right side of the face.*

4. Why was there edema of the arm and a diminished brachial pulse?
The tumor compresses the subclavian vein causing edema of the arm and pressure on the
subclavian artery resulting in a diminished brachial pulse.*

5. Why was there erosion of the 1st and 2nd ribs?

The growth of the tumor erodes the 1st and 2nd ribs.*