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*What could cause coronary sinus dilation?
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 *Pulmonary hypertension, Tricuspid valve stenosis anything that would cause Right Atrium dilation, as coronary sinus drains deoxygenated VENOUS blood from coronary circulation into right atirum.(Check pic and visualize location)Pulmonary hypertension increases afterload for Right heart to work against it>Higher pressure in right heart)*Note that Coronary sinus is derived from Left horn of sinus venosus.(I remember this by: C LEFT=cleft :)*Now another Major HY point is that Left ventricular leads in Biventricular pacemakers course trough the coronary sinus and that coronary sinus itself resides in AtrioVentricular groove on POSTERIOR surface of the heart.*Remember Coronary sinus comes from LEFT horn of Sinus venosus. |
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*CXR>>Blunting of costophrenic angles(Pleural effusion), increased vascular shadowing(alveolar edema) in a "batwing" perihilar pattern, Cardiomegaly(heart >1 hemithorax in size), what could cause crackles and wheezing in this patient?
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*Patient likely has Left-sided HF(can follow MI,Arrhythmia,Cocaine use,Hypertension) thus blood can't be pumped out of Left heart properly thus it backs up in lungs trough pulmonary veins that enter left atrium>Dyspnea(SOB),Orthopena(Cough when lying down) Cardiogenic asthma with crackles,wheezing due to edema of bronchial airways. CXR might also show Kerley B lines( horizontal lines located Perpendicularly to the pleural surface and represent edema of interlobular septa.)*Patient would present with complains of suffocating every time he lies down/can wake them up+Dyspnea,tachypnea.*Remember that acute LHF often results in NON-Productive cough that is not relieved by drug but over time patients develop Pink frothy sputum.(Remember Heart failure cells-Hemosiderin laden macrophages which have phagocytosed RBCs)
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Why guy who has MI would have radiation of pain from the chest to the left shoulder/down the arm?
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*Because Generel VISCERAL SENSORY pain fibers synapse in thoracic DORSAL ROOT ganglia and CNS perceives pain coming from SOMATIC regions innervated by those levels of spinal cord(Levels at which the visceral sensory fibers carrying pain synapse)*As afferent visceral cardiac fibers carrying pain enter dorsal horn at the levesl of brachial plexus pain can be perceived in region of Neck,shoulder,arm.
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*Female in third trimester of pregnancy complains of light-headedness, when she lies down in the bed.*When she lies down you note that she becomes hypotensive.*Most likely MAP?*Why?*What she can do?
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*Hypotension when supine in pregnant patient should make u think of Large uterus in 3rd trimester of pregnancy compressing the IVC.*MAP(Cardiac Output xTPR) will likely be low as compression of IVC will decrease the preload(thus SV will also be decreased and subsequently CO will also be compromised-which btw equals HRxSV)*Now they love to ask management of this one:She should either start lying on the LEFT or she could place the pillow under the RIGHT hip.(To remove the weight of gravid uterus from IVC)*Also don't confuse this condition(manifest with Hypotension that gets Worse when lying down) with ORTHOSTATIC hypotension(Hypotension gets WORSE on standing and gets better when supine-here management could be rehydration if it is due to hypovolemia or salt tablets and other drugs if it is due to autonomic dysregulation), also don't confuse this condition with CHF(which would also get worse with standing-orthostatic nature, and u would also have other signs like peripheral edema)*They really want you to know that IVC is made by union of Left and Right Common iliac veins at L4 and that Renal veins join IVC at L1/2.(as we speak of IVC remember that it enter diaphragm at the level of T8)<But don't worry i'll MIND FUCK u on IVC many times lol, for now remember that pregnant lady,IVC,hypotension,pillow :)
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 *Defect in Coronary sinus can be due to abnormal development of? |
*Abnormal development of Left horn of the sinus venosus can result in defective coronary sinus.*Coronary sinus-LEFT horn of sinus venosus(remember - CLEFT)
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*Defective development of Primitive Atria would most likely result in defective?
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*Trabeculated part of Left and Right atria.*If primitive Ventricle couldn't develop properly there will be defect in Trabeculated part of Left and Right Ventricle(Simple as that) all you've got to remember now is 1 word-Trabeculated :)
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*In experiment you note that valves located at the bases of aorta and pulmonary artery are abnormal due to failure of proper development of embryonic structure.What other structures are likely to be defective?
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*Endocardial cushion develops into semilunar valves(Valves with 3 cusps located at the bases of aorta and pulmonary artery).*AV valves, Atrial septum and MEMBRANOUS part of InterVENTRICULAR septum can be defective too as Endocardial cushion gives rise to these structures as well.
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*Older female who loves to smoke cigarettes give a birth to a baby who becomes cyanotic and has difficulty breathing.*Single Loud S2 sound is audible on baby, you also hear ejection click at the left sternal boder.*You ordered Echocardiogram and diagnosed Persisent truncus arteriosus.*Normally this embryonic structure gives rise to?
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*Pulmonary Trunk(which normally divides into pulmonary arteries) and the Ascending aorta.*So with persistent truncus arteriosus you basically have Single trunk arising from both ventricles(as normal division to pulmonary trunk and ascending aorta failed)so now blood from R and L ventricles (Thus Deox. and oxygenated blood) mix, and when sufficient deoxygenated blood reaches systemic circulation(when o2 saturation<80%) baby becomes apparently cyanotic.*Note that Persistent truncus arteriosus is caused by Failure of Neural crest cells to migrate(Failure to form Aorticopulmonary septum which would normally separate aorta and pulmonary trunk)
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*If you had improper development of Bulbus cordis which parts of heart would be affected?
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 *OUTFLOW TRACTS(SMOOTH parts) of RIGHT and LEFT ventricles.*I remember this by : OOutflow smOOth cOOrdis bOOth venricles..(Try to sort of sing it i promise it will help :) |
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*Embryonic structure known as primitive PULMONARY vein gives rise to which structure?
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*Primitive Pulmonary Vein gives rise to SMOOTH part of LEFT ATRIUM.*Just imagine pulmonary veins entering left atrium and it will make sense.*Also make sure that you know that it is SMOOTH part.*Remember that Most of the left atrium is located at the base(Up) of the heart and is most posterior part of the heart(enlargement can compress esophagus>Dysphagia of SOLIDS)*But also know that Auricle of the left atrium is actually visible anteriorly(Between pulmonary trunk and ventricle)<can be found in uw :)
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*Improper development of _______Common Cardinal and Right _______Cardinal veins can result in defects of SVC..
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*Improper development of RIGHT common Cardinal and right ANTERIOR Cardinal veins can result in defective development of SVC.*Congenital abnormalities of SVC is asymptomatic in most of the cases but defects often become apparent during placement of CVC(Central venous cathether)
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*Patient has difficulty with plantar walking, on physical examination you notice weakness of plantar flexion and decreased achilles reflex, he also has altered sensations on lateral foot and posterolateral thigh, you think all of his symptoms are manifestations of L5-S1 disc herniation(Compressing S1 nerve), but your fellow resident thinks he is smarter than you and asks you about EMBRYOLOGIC origin of Nucleus Pulposus(Central component of intervertebral disks which functions to help intervertebral disk wistand forces of compression and torsion)
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*EMBRYOLOGIC origin of Nucleus Pulposus is NOTOCHORD.
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*Neonate has Holosystolic/Holodiastolic murmur and wide pulse pressure(difference between systolic and diastolic BP is increased).*Echocardiogram:Shunting of blood between left pulmonary artery and aorta.*Now we all know what infection her mother likely had but they ask you about the rash(Like where it began)
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*Rubella in adults presents with Maculopapular rash that begins on the FACE and spreads to the trunk.*But Rubella can cross placenta and is one of the ToRCHES infections(Toxoplasmosis,RUBELLA,CMV,HSV/Hiv,Syphilis)and is really bad one it can cause:* cataracts*glaucoma*Blueberry-muffin rash(non-blanching rash that can presents as dome shaped papules or blue macules)*Deafness.*Pulmonary artery Hypoplasia(they love to ask this too)*PATENT DUCTUS ARTERIOSUS(which our patient most likely has)-which presents as holosystolic/holodiastolic continuous machine-like murmur and widend PP.<They can ask about complications of this one(Which would be pulmonary hypertension due to too much blood enterinc pulmonary artery from aorta via PDA and also possibility of Eisenmenger's phenomenon when due to pulmonary hypertension shunt reverses), they can also ask about prevention and mother could have prevented this if she got MMR vaccine(LIVE vaccine_but only BEFORE pregnancy, if she got it during pregnancy it could actually CAUSE Congenital rubella in baby(It is still alive vaccine).They can also ask about normal post-natal derivative of ductus arteriosus which is LIGAMENTUM arteriosum.*They love this topic as it can integrate multiple disciplines.
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*You see structure contained in falciform ligament of liver, what is it/where it is derived from?
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*Ligament teres hepatis is contained in falciform ligament and is derived from Umbilical VEIN(Carries oxygenated blood in fetal circulation-HIGHEST O2 saturation in fetus<VERY IMPORTANT TO KNOW THAT)*Ligament teres hepatis(Round ligament of liver) is thus remnant of this Vein and it is RECANALIZED in conditions that cause severe Portal hypertension(Like Cirrhosis)*Don't confuse Ligamentum teres hepatis(remnant of Umbilical vein) with Ligamentum Venosum(remnant of DUCTUS venosus which in fetal circulation shunts Oxygenated blood from Umbilical vein directly into the IVC thus bypassing the liver)I hate to say it but you should know those...
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*mediaN umbilical ligament vs mediaL umbilical ligament?
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 *mediaN umbilical ligament is derived from from allaNtois(urachus)-which itself is part of allantoic duct(connects umbilicus with bladder-so if it is not obliterated after embryonic period, baby can have leakage of urine from umbilicus)*Contrast this with mediaL umbilical ligament is derived from umbilical Artery(Carries deoxygenated blood in fetus) |
