Clinical

Ana Notes (Snell Page 80-101)

1. Pericarditis-inflammation of the serious
pericardium which can involve excessive
accumulation of pericardial fluid
->Cardiac Tamponade
Compression of the atria which can
interfere with the filling of the heart
during diastole, secondary to pericarditis
Can also occur secondary to stab/gunshot
wounds when chambers of the heart are
penetrated
Blood escapes into pericardial cavity
->Pericardial Friction Rub
Produced by roughening of visceral and
parietal layers of serous pericardium by
inflammatory exudate in acute
pericarditis
Can be felt through palpation/heard
through stethoscope
->Paracentesis
process of aspirating the pericardial fluid
when excessive amounts accumulate in
pericarditis
Needle is introduced to left of xiphoid
process in an upward and backward
direction at an angle 45 degrees to the
skin
o This site ensures that pleura and
lung are not damaged because of
the presence of cardiac notch in
the area
2. Failure of the Conduction System of the Heart
-> Sinoatrial Node- Spontaneous source of impulse
-> AV Node- Responsible of picking up cardiac impulse
from atria
AV route: Only route impulse travels from
atria to ventricle
Arrhythmia- Failure to conduct the
normal impulse result in alteration of the
rhythmic contraction of the ventricles
Complete bundle block- complete
dissociation between atrial and
ventricular rates of contraction
Atherosclerosis- Common cause of
defective conduction through the bundle
or its branches which results to a
diminished blood supply to the
conducting system
3. Commotio Cordis Caused by blunt non-
penetrating blow to the anterior chest wall over the
heart, results in ventricular fibrillation and sudden
death
->Occurs mostly in young and adolescents because of
compliant chest wall due to flexible ribs/costal
cartilage, thin underdeveloped chest muscles
->Usually sports-related: Sudden blow is frequently
produced by baseball, fists, elbow

->Timing of blow relative to cardiac cycle is critical:

ventricular fibrillation occurs during upstroke of T
wave in ECG
4. Coronary Artery Disease
->Myocardium receives blood supply from L and R
coronary arteries. Although there are anastomoses ,
the coronary arteries are essentially functional end
arteries.
-> Most cases of coronary artery blockage are caused
by acute thrombosis on top of a chronic
atherosclerotic narrowing of the lumen
-> Three ways atherosclerosis presents itself:
1. General degradation and fibrosis of the
pericardium over many years caused by gradual
narrowing of coronary arteries
2. Angina Pectoris- cardiac pain that occurs on
exertion. Coronary arteries are so narrowed that
myocardial ischemia occurs on exertion but not at
rest.
3. Myocardial Infarction- Sudden block of the
branches of the coronary arteries lead to necrosis of
the cardiac muscle. Major cause of death in
industrialized nations.
5. Cardiac Pain
-> Pain originating in the heart as result of acute
myocardial ischemia is caused by oxygen deficiency
and accumulation of metabolites.
Stimulation of the nerve endings in the
myocardium -> afferent nerve fibers ->
Sympathetic trunk -> Posterior roots of
T1-T4 -> CNS
->Pain is not felt in heart, but is referred to skin areas
supplied by T1- T4 and by the intercostobrachial
nerve (T2).
->Intercostobrachial nerve communicates with medial
cutaneous nerve of arm and is distributed to skin of
medial side of upper arm
->Pain is also sometimes felt in neck and jaw
->Myocardal infarction in diaphragmatic surface of the
heart gives rise to discomfort in the epigastrium.
Afferent pain fibers from heart->
sympathetic nerves -> Spinal Cord ->
Posterior roots of T7 to T9 spinal nerves -
> referred pain in thoracic
dermatomes(T7 to T9) in the epigastrium
Heart and thoracic esophagus have
similar afferent pain pathways = Acute
esophagitis can mimic pain of myocardial
infarction
6. Auscultation of the Heart Valves
->Lub: produces by contraction of ventricles and
closure of tricuspid and mitral valves.
->Dub: Produced by sharp closure of aortic and
pulmonary valves
-> Clinical Valve Areas
Tricuspid valve: Right half of lower enf of
body of sternum (6th ICS)
Mitral Valve: Over apex beat(5th ICS 9 cm
from midline)

Pulmonary Valve: Medial End of 2nd Left

ICS
Aortic Valve: Medial End of 2nd Right ICS
7. Valvular Disease of the Heart
-> Inflammation of valve causes edges of cusps to stick
together, then fibrous thickening occurs, followed by
loss of flexibility and shrinkage.
-> Narrowing(stenosis) and valvular
incompetence(regurgitation) results.
-> Rheumatic Disease of mitral valve: Chordae
tendinae shorten, preventing closure of cusps during
ventricular systole
8. Valvular Hear Murmurs- occurs when valve
orifices are narrowed/valve cusps are distorted and
shrunken by disease
Rippling effect would be set up, leading to
turbulence and vibrations are heard as
heart murmurs
9. Traumatic Asphyxia
-> Sudden caving in of anterior chest wall associated
with fractures of sternum and ribs causes a dramatic
rise in intrathoracic pressure
->Thinness of walls of thoracic veins and the RA cause
their collapse under high intrathoracic pressure, and
venous blood is dammed back in the veins of the head
and neck
Causes venous congestion, bulging of
eyes, swelling of lips and
tongue(cyanotic), skin of face, neck and
shoulders become purple.
10. Anatomy of Cardiopulmonary
Resuscitation(CPR)
-> Achieved through compression of the chest, blood
flows in CPS because the whole thoracic cage is a
pump, heart functions only as a conduit of blood
-> Extrathoracic pressure gradient is created by
external chest compressions
-> Pressure in all chambers within the chest cavity is
the same.. With compression, blood is forced out of
thoracic cage
-> Blood flows out the arterial side, and back down the
venous site because venous valves in IJV system
proved a useless oscillatory movement.
-> With release of compression, blood enters the
thoracic cage, down the venous side of systemic
circulation
11. Azygos Vein and Caval Obstruction
-> Obstruction of Superior/ Inferior Vena Cava
Azygos vein provide an alternative pathway for return
of venous blood to the RA
-> Possible because azygos veins and their tributaries
connect the SVC and IVC
12. Aneurysm and Coarction of Aorta
-> Aneurysm Gross dilatation of aorta that shows
itself as a pulsatile swelling in the suprasternal notch
-> Coarction of the aorta Congenital narrowing of
the aorta just proximal, opposite, or distal to the site of
the ligamentum arteriosum.

Results from unusual quantity of ductus

arteriosus in the wall of the aorta
When ductus arteriosus contracts, the
ductal muscle in the aortic wall also
contracts, and aortic lumen is narrowed.
Later, when fibrosis takes place, aortic
wall is narrowed permanently
Cardinal sign of aortic coarctation:
absent/diminished pulses in the femoral
arteries of both lower limbs
To compensate for low blood volume to
lower parts of body, enormous collateral
circulation develops, with dilatation of
the internal thoracic, subclavian, and
posterior intercostal arteries.
o Dilated intercostal arteries erode
lower border of the ribs,
produces notching seen on X-ray.
13. Patent Ductus Arteriosus
-> Ductus arteriosus- represents distal portion of 6th
aortic arch, connects the Left Pulmonary Artery to the
descending aorta.
->During fetal life, blood passes through it from
pulmonary artery to aorta, bypassing the lungs. It
closes after birth, becoming the ligamentum
arteriosum
->Failure of ductus arteriosus results in high-pressure
aortic blood passing into the pulmonary artery, which
raises pressure in the pulmonary circulation.
14. Paralysis of the Diaphragm
-> Due to paralysis of phrenic nerve as resuls of
pressure from malignant tumors in the mediastinum.
-> Can result from surgical sectioning of phrenic nerve
of neck, which was once used to treat tuberculosis
15. Sympathetic Trunk in Treatment of Raynaud
Disease
-> Preganglionic sympathectomy of T2 and T3 ganglia
can be performed to increase blood flow of fingers
such as in Raynaud disease
-> Causes vasodilation of arterioles in the upper limb
16. Spinal Anesthesia and Sympathetic Nervous
System
-> Blocks the preganglionic sympathetic fibers from
lower thoracic segments of spinal cord
-> Produces temporary vasodilation below this level,
with a consequent fall in blood pressure
17. Esophageal Constrictions
-> Three Anatomic Constrictions: Pharyngeal,
Bronchial, Esophageal
->Sites where swallowed foreign bodies can lodge
-> May produce difficulty to pass an esophagoscope
-> Causes slight delay of passage of fluid, thus
strictures develop after drinking of caustic fluids
->Also common sited of carcinoma of esophagus
18. Portal-Systemic Venous Anastomosis- occurs at
lower third of esophagus
-> Esophageal tributaries of azygous veins anastomose
with esophageal tributaries of left gastric vein.

-> In liver cirrhosis, portal hypertension develops,

portal bein becomes obstructed and the portal-
systemic anastomoses dilate and varicose.
Hematemesis- vomiting of blood dues to
varicosed esophageal veins that rupture
during passage of food, can be fatal
19. Carcinoma of Lower Third of Esophagus
-> Lymph drainage of lower third of esophagus occurs
in celiac nodes around celiac artery.
-> Malignant tumor in this area spreads below the
diaphragm
-> Surgical removal of lesion includes the celica lumpg
nodes, stomach, duodenum, spleen, omenta
-> Restoration of continuity of gut is accomplished by
performing an esophagojejunostomy
20. Esophagus and Left Atrium
-> Barium swallow may help a physician assess the
size of the LA in cases of left-sided heart failure, where
LA becomes distended because of back pressure of
venous blood
21. Chest Pain
->Presenting symptom of chestpain is common
problem in clinical practice, common to many
conditions and may be caused by varying diseases.
-> Severity of pain is unrelated to seriousness of cause
-> Myocardial pain- may mimic esophagitis,
musculoskeletal chest wall pain, or other non life-
threatening causes.
-> Types of chest pain:
Somatic Chest Pain: Pain from chest wall
is intense and localized. Arises in sensory
nerve endings in the area and is
conducted to CNS by segmental spinal
nerves
Visceral Chest Pain: Pain is diffuse and
poorly localized. Conducted to CNS along
afferent autonomic nerves. Visceral pain -
> sympathetic nerves -> posterior nerve
roots of segmental spinal nerves-> spinal
cord
o Some pain fibers from pharynx,
esophagus and trachea enter CNS
through parasympathetic nerves
via glossopharyngeal and vagus
nerves
Referred Chest Pain: Feeling of pain at
location other than site of origin of
stimulus which is supplied by same
segments of spinal cord.
Thoracic Dermatomes
Pain and Lung Disease
Cardiac Pain