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three ways to access thorax: needle, larger incisions, pre-existing holes: esophagus, veins
makes up the wall of the thorax?: skin, superficial tissue (breast), muscle layers (external intercostals, internal intercostals, pectoralis major and minor, innermost intercostals
where do the vessels in the thorax travel?: between the innermost intercostals and the internal intercostals
main properties of the thorax?: rigid, mobile, elastic, jointed
properties of the thorax allow?: breathing, protection of viscera, attachments for arms, support for breasts, prevention of access to outside and vice-versa
what shape (in cross section) generally, does the thorax have early in life, and later in life: eliptical when young, flattens when growing.
components of the thoracic cage: bony rib cage, (12 ribs: 7 true, 5 false Â– two of which are floating), bony front (manubrium/sternum/xiphoid), bony back (vertebrae) spaces between ribs (intercostal spaces), costal cartilages
structures of thoracic inlet?: first ribs, first thoracic vertebra, manubrium of the sternum
significance of junction areas such as the thoracic inlet?: small area in which many tubes pass through... potential space for problems if structures that arenÂ’t supposed to be there take up room meant to be occupied by structures supposed to be there Â– think of trachea, etc. passing through thoracic inlet, plus other tubes that could be crushed if a tumour were present.
other junction area is significant near the thoracic inlet?: the triangular area formed by the first rib, the clavicle, and the scapula.
if the superior vena cavae was blocked?: - blood from head etc. couldnÂ’t drain through blocked SVC, would use multiple alternate pathways to bypass blockage: collateral pathways. flow of blood in IVC could cause blood flow to reverse there. blood would instead go through anterior chest, abdominal walls, enlarging the vessels.
normal distribution of breast tumours in areas of the breast?: 60% occur in the axillary tail, 12% in superomedial, 10% inferolateral, 6% inferomedial, and 10% peri-alveolar.
breasts composition?: modified sweat glands (glandular tissue is fairly constant Â– just amount of fat that varies), fibrous tissue to support breast
Why are most malignancies found in the axillary tail?: This is where most of the glandular tissue is. (note that tumours arise in the glandular tissue Â– NOT IN FAT.)
what is carcinoma?: tumour that arises from the skin
name given to distant spread of carcinoma?: metastasis
where do tumours arise in the breast?: from the epithelium that lines the ducts of the breast
when does calcification occur in breast epithelium?: when a woman is not lactating
mammograms detect what?: abnormal patterns of calcification
name given to cancer that is spread via the blood?: hematogenis spread (FATAL)
three letters used in the international cancer classification system, and what do they mean?: TNM: Tumour, Nodes, Metastasis.
importance of this international classification system?: international sharing of information using common system of classification to develop and/or assess treatments
difference between a lumpectomy and a mastectomy: lump removal versus whole breast removal, including surrounding tissue.
why is lumpectomy preferable?: less mutilating, less invasive, less scarring.
why are mastectomies still performed when lumpectomy has been proven to be as effective?: Drs. not following guidelines, not believing study, no monitoring nationally to see if guidelines followed, fear-based choices: women influence choice, thinking more radical option Â“safer.Â” radiation not available everywhere for required lumpectomy followup.
when should a mastectomy be done?: only when the first line of treatment has not worked (i.e. lumpectomy and radiation.)
what are the three main methods of spread of cancer?: direct, lymphatic, vascular
two superficial signs of breast cancer?: nipple retraction (cancer effecting the suspensory ligaments) Â– changes contour of breast; peau dÂ’orange (orange peel skin) local lymphatics are effected Â– being clogged by malignant cells, lymphatics canÂ’t drain,dermis swells (odema). causes swelling between sweath glands and hairs, making the skin look like Â“orange peel.Â”
most likely progression of breast cancer?: tumour in breast, cells spread to local lymphatics, spread to regional nodes and deeper direct spread, followed by distant spread (bone, liver, elsewhere)
correct treatment for breast cancer: remove lump plus tissue around lump Â– ensure no reoccurence of tumour. tissue sample of lymph nodes in area. if more extensive, can remove lymph nodes from arm, plus radiation, chemotheraphy, hormone or gene therapy treatment on nodes.
procedure for checking other nodes?: auxiliary dissection Â– taking fat and lymph nodes from armpit to check for involvement of tumour Â– VERY important part of assessing breast lumps.
secondary problem could be caused by removal of breast lymph nodes?: odema of arm (arm uses lymph nodes to drain)
what else may cause swelling related to breast cancer treatment?: radiation, lymph nodes may actually be blocked causing swelling
where is odema most often seen in the hands: on the dorsum (back) of hand
purpose of lymphatics?: drain tissue fluid and return it to circulation
what lymph nodes drain the arm?: apical, central, and lateral nodes
on average, how many lymph nodes per arm?: 35.
most of the lymph from the breast drains where?: to the axillary lymph nodes (apical, humeral, central, pectoral and subscapular)
main group of nodes does the lymph drain to?: pectoral (anterior) group
other areas that must be considered? (i.e. where else could lymph drain, taking cancer cells with it?: parasternal or internal thoracic lymph nodes (not palpable), opposite breast, nodes in the abdominal wall
nerves serve the breast?: anterior and lateral cutaneous branches of 4 Â– 6 intercostal nerves
why might lymph of the breast not drain to the axillary nodes?: lymphatic drainage may not be normal, due to blockage.
why might fractures be associated with cancer?: pathological fracture (if seeing an unusual fracture) Â– indicates that something wrong with bone (tumour)
why is male breast cancer generally more fatal?: not detected as early, and not enough tissue for the cancer to work within, so generally already spread deep to muscle before detected.
regional divisions of the nervous system?: central and peripheral (CNS & PNS)
what makes up the CNS?: brain and spinal cord
two divisions of the PNS?: afferent (sensory) and efferent (motor) systems, taking information to and from the CNS.
two functional divisions of the nervous system?: somatic and autonomic.
functions of the somatic nervous system?: taking information from skin, muscles, bones and joints (afferent) to CNS, and transmitting stimuli to limb and back muscles via efferents.
functions of the autonomic nervous system?: regulating activities of viscera (heart, gut, bladder, etc.)
example of an efferent autonomic response?: making glands secrete, changing heart rate, i.e. Â“motorÂ” response
example of an afferent autonomic response: painful sensations from gut, info about heart contraction, i.e. sensory.
two divisions of the autonomic nervous system?: sympathetic and parasympathetic.
types of nerves are found in the sympathetic and parasympathetic nervous systems?: both afferent and efferent
nerves composed of?: many thousands of neurons
what causes the cervical and lumbar enlargements?: need for extra nerves to supply legs and arms
phrenic nerve innervate?: diaphragm, part of pericardium
which vessels have more nerves? veins or arteries: arteries
what is the order, from superior to inferior, of the structures that sit within the subcostal groove?: vein, artery, nerve
vein runs in the deltopectoral groove?: cephalic
vein does the cephalic feed?: axillary
external intercostal muscle form anteriorly?: anterior intercostal membrane
internal intercostal form posteriorly?: posterior intercostal membrane
how many neurons might a nerve contain, and of what type?: thousands of neurons, both afferent and efferent
classification of intercostal nerve?: ventral rami, or anterior primary rami
what is supplied by this nerve type?: ventral body wall, supplying skin, intercostal muscles, ribs, parietal pleura
what nerves supply the posterior thorax?: dorsal rami, supplying skin and back muscles
what type of nerves are in dorsal roots?: afferent sensory
what type of nerves are in ventral roots?: efferent motor
how many neurons might a spinal nerve contain?: 5000 efferent, 3000 afferent
what is a dermatome?: an area of skin supplied by a particular spinal segment
where is the best place to inject local anaesthetic to relieve pain in the thorax?: angle of the ribs. (This misses the VAN) Injecting here would be in the area where the external intercostal is still muscle (not membrane), the internal intercostal is membranous, and the innermost intercostal is present. (Runs from the angle of the rib to the costal margin.)
what factors might effect pain experience and localization of pain?: cultural, past experience, anxiety, fatigue, sensory input, descending inhibition
what is descending inhibition?: fibres in spinal cord keep pain below the level of consciousness... when less input (i.e. at night) often more conscious of pain
what is the order of the major tubes within the thorax, from anterior to posterior?: veins arteries wind and water. (remember the Â“venous planeÂ” the Â“arterial planeÂ”, the trachea, and esophagus.
what happens with the esophagus below the level of the tracheal bifurcation?: it becomes an anterior structure.
what is the name for air in the pleural cavity?: pneumothorax
blood in pleural cavity?: hemothorax
lymph in pleural cavity: chylothorax
how could a chylothorax occur?: thoracic duct punctured (sometimes during surgery), can leak lymph into pleura
condition: air under subcutaneous layer & symptoms: subcutaneous emphysema Â– skin swells up, feels like tissue paper underneath Â– crackles. if hole stopped up, air will be reabsorbed.
how could subcutaneous emphysema occur?: breaks in trachea, bronchi, or esophagus will allow air into medistinum Â– air bubble up into neck, bloats up tissues.
what overlies oblique fissure when arm raised overhead?: medial border of the scapula
lines fissures of the lungs?: visceral pleura
what would cause a fourth lobe in the R lung?: azygos lobe Â– during development, azygos not tightly bound to mediastinum, lung develops through a portion of it, creating separate superior lobe
how often does azygos lobe occur?: 1%
purpose of mucous in lungs?: mucous membranes line membranes, warms and moistens air, catches particulate matter
mucous cycle?: is continously produced. tips into esophagus and is swallowed.
how does mucous move & at what speed where?: beating of cilia 13 cycles per second .1mm/min in terminal bronchioles, 10 Â– 20 mm/min in trachea
name of bronchial dilation, and cause: bronchiectasis = irreversible dilation due to chronic infections / destructive inflammatory diseases.
what causes this problem?: in chronic infections, cilia donÂ’t work properly. bronchi wall not working, too much mucous, causes dilation.
kartogeners syndrome?: autosomal recessive disorder; cilia canÂ’t beat: outer dynein arms not present in ciliate structure; about 1 in 70 are carriers
kartogenerÂ’s symptoms: mucous accumulates in lungs, posterior pleural cavity
kartogeners treatment: postural drainage, rearrange person, beat them to loosen mucous, suck up excess mucous or drain.
do spinal nerves have singular or multiple roots?: many roots, both dorsal and ventral.
importance of nerve territories - anaesthesia purposes?: dermatomes overlap.
another name for an intercostal nerve in the thorax, or an anterior abdominal wall nerve?: anterior primary ramus.
types of fibres are in thoracic intercostal nerves?: both sensory and motor
nerves serve the parietal pleura?: anterior primary ramus
nerves serve the periosteum of the ribs?: anterior primary ramus
another name for the anterior primary ramus: ventral ramus
other types of nerve fibres are in intercostal nerves, other than somatic?: autonomic: sympathetic efferent
sample function: sympathetic efferent autonomic nerves?: erector pili muscle, sweat glands, blood vessels (vasodilation or constriction),
name given to a nerve that runs from the grey matter of the spinal cord to the sympathetic ganglion: a pre-ganglionic nerve
lies within ganglions: cell bodies of afferent nerves
what (specifically) lies within sympathetic trunk ganglia?: cell bodies of sympathetic autonomic nerves: vasodilation, blood vessels, erector pili muscle, sweat glands.
number of cranial nerves?: 12
number of spinal nerves, and in what segments?: 8 cervical, 12 thoracic, 5 lumbar, 5 sacral, 5 coccygeal
How many neurons might there be in a nerve like an intercostal nerve?: thousands Â– both efferent and afferent
intercostal nerves supply where?: anterior body wall, skin, intercostal muscles, ribs, parietal pleura & vertebrae
dorsal rami supply?: back, skin, back muscles.
grey Â“butterflyÂ” shaped area of the spinal cord?: the grey matter
EVERY segment of the spinal cord contains?: dorsal roots (afferent sensory)
ventral roots: efferent motor (but not exclusively afferent)
dorsal and ventral roots unite to become?: spinal nerve
spinal nerve divides into?: ventral ramus and the dorsal ramus, both of which are efferent and afferent
number of neurons in a spinal nerve (ballpark): 3000 afferent, 5000 efferent

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