Intercostal Neurovascular
- Runs on the inferior portion of the rib, NAV from low to high
- Thoracocentesis should occur on the superior portion of the rib
Internal Thoracic
- Supply intercostals and also terminate as superior epigastrics
- In post ductal coarctation these will enlarge, rib notching and anastamoses to increased flow to lower limbs
CT of Thorax
- Trachea is central
- Esophagus is smaller and to the patients left followed more laterally by the descending aorta
- Azygous vein and arch of the azygous are midline behind the trachea and partially to R of midline
Nodal Supply
SA and AV nodes are supplied by the RCA and infarction will lead to conduction abnormalities
Cardiac Auscultation
- Aortic area is in the right second intercostal space
- Pulmonary is the left second intercostal space
- Tricuspid is the Rightlower sternal border
- Mitral is the 5th intercostal space on the left side
Truncus Arteriosus
-Becomes the outflow tract
Bulbus Cordis
Smooth part of right ventricle
Sinus Venosus
Smooth part of right atrium and coronary sinuses
Arches
3: Common carotide
4: arch of aorta and proximal brachiocephalic
6: pulmonary artery etc
Cardinal Veins
Anterior forms the internal jugular and superior vena cava
-Posterior forms the inferior vena cava and the illiac veins
Vittleine
Returns blood from the yolk sac
Fat soluble vitamin deficency
Mineral Oil
Function of Vitamins
- B1: Decarboxylation reactions (PDH, Transketolase (HMP shnt), alpha ketoglutarate, BCAA)
- B2: FAD: oxidation and reduction
- B3: NAD: Oxidation and reduction
- B5: Pantothenic Acid: CoA (FA synthesis)
- B6: Pyidoxal phosphate, Transamination and decarboxylation. (Heme, ALT/AST, Niacin, Caetacholamines, cystathione
- B7, Biotin: Carboxylation reactions (Pyruvate carboxylase in GNG and Acetyl CoA carboxylase in FA synthesis)
- B9 Folic Acid: THF, leads to 1 carbon transfers
- B12: cobalamin, 1 carbon transfer
B1, Thiamine
- Functions in decarboxylation reactions. PDH, Transketolase, AA metabolism via BCAA and ketoglutarate
- Highly metabolic tissues are at most risk (Heart and nerves) because of decreased flux capacity of oxidative phosphorylation
- Dry Beri Beri: Neuropathy and muscle Weakness
- Wet Beri Beri: DCM and high output cardiac failure
- Wernicke Korsakoff: Often precipirated by glucose infusion leads to necrosis of mamillary bodies
Vitamin A
- Necessary as transcription factor receptor ligand
- Requried to maintain specialized tissues (Keratomalacia, squamous metaplasia) (also secretory and glandular epithelium is at most risk)
- Also Makes retinal for rods function, Night Blindness commonly seen
- Can be used to treat Measles and APL (ATRA)
- Teratogenic in high doses: Cleft lip and palate and cardiac defects
B2 Riboflavin
- FAD, used in oxidation and reductaion reactions (2 ATP generated per molecule)
- Deficency leads to cheliosis which is dry mouth and lips, glossitis, corneal neovascularization
- Can be seen in patietns given phototherapy due to aromatic flavin strucutre
B3 Niacin
- NAD, used in oxidation and reduction reactions, 3 ATP per molecule
- Synthesized de novo from tryptphan using B6 as a coenzyme
- Deficency can occur in B6 loss (INH), Hartnup’s disease (Impaired neutral AA resprbtion), carcinoid syndrome
- Pellegra: Dermatitis, Dementia, Diahrrea
- Is used pharmacologically to raise HDL levels, flushin is a side effect, can be reduced with admintration of COX inhibitors
B5 Panthothenat
-Compenent of Acetyl CoA deficency is rare
B6 Pyridoxine
- Coenzyme in transamination reactions
- Requried for Heme synthesis, Niacin Synthesis, ALT and AST function, Caetacholamine Synthesis and cystiene synthesis
- Symptoms of defecit are peripheral neruopathy and sideroplastic anemia (Decrease ALA-D function)
B7 Biotin
- Necessary for carboxylation reactions (anabolic combination reactions)
- Required for GNG and FA synthesis (Pyruvate Carboxylase, etc)
- Deficecny is rare but can occur with antibiotics or conssumption of raw eggs
- Symptoms are diahrrea and dermatitis and also hypoglycemia from impired GNG
B9: Folate
- Part of 1 methyl tansfers (actually bind methyl) necessary for pyrimidine synthesis (Thymidine)
- Requries B12 also
- Homocysteine to methionine is methyl donor source
- Labs will show macrocytic anemia without neurologic signs and also elevated methylmalonyl coa and homocystine
- Associated with neural tube defects
- Imparied function and metabolism leading to functional deficency occurs with MTX, Slufonamides, Phenytoin
B12 Cyanocobalamine
Necessary Co factor for 1 methyl transfers.
-Homocysteine to methionine and Methylmalonyly CoA to succinyl CoA
-B6 subseqeuntly metabolizes homocystine to cystine and succiinyl coA to Heme
-Trasnfers 1 methyl to SAM from methionine which is necessary for caetacholamine synthesis
-Deficency leads to elevated methylmalonyl CoA, and homocystine, also megaloblastic anemia with subacute combined degeneration (Corticospinal, spinocerebellar, dorsal columns)
-Deficency Caused by:
Destruction of parietal Cells (pernicous anemia or gastric bypass)
-Impaired absorption from crons or sprue
-Diphylatthum Latum tapeworm from fish
