How many cusps have the pulmonary valve?
Vertebral level of the pulmonary valve?
Where to auscultate pulmonary valve?
Branches of ascending aorta?
3
T6
Right and left coronary arteries arising from the aortic sinus opposite the aortic valve
2 nd ICS left parasternal edge
Tributaries of Azygos vein?
“Right Handed PM Loves Eating Burgers”
• Right superior intercostal vein
• Hemiazygos and accessory hemiazygos
• Pericardial veins
• Mediastinal veins
• Lower right posterior intercostal veins
• Esophageal veins
• Bronchial veins
Pulmonary ligament?
Pleural fold that connects the mediastinal surface of the lung and the pericardium to allow expansion of pulmonary veins with increased blood flow
How many bronchopulmonary segments in each lung?
What is the nerve relation anterior and post?
Describe the course of a clot from deep veins of the calf to pulmonary artery?
Nerve supply of the intercostal muscles?
10
Anterior to the root of lung Phrenic nerve Post to the root of lung. Vagus nerve
Popliteal vein → femoral vein → EIV → CIV → IVC → right atrium → AV valve → pulmonary valve → pulmonary artery
Intercostal nerves and their collateral branches
Subclavian steal syndrome?
Thoracic outlet syndrome?
Show on the skeleton where to put a chest tube?
Why bradycardia after chest tube insertion?
Tip to identify lung hilum structures
Retrograde flow of blood flow down to the vertebral artery due to stenoocclusive disease in the subclavian artery proximal to the vertebral artery. This will lead to brainstem ischemia on arm exercise
Compression of the neurovascular bundle (brachial plexus, subclavian artery) between the scalenus medius and scalenus anterior → neurological and vascular symptoms in the arm
5 th ICS midaxillary line
Due to irritation of the vagus nerve.
Use RALS — Right: Artery Anterior; Left: Artery Superior — veins always lowest.
Boundaries and contents of posterior mediastinum
The posteriormediastinum is bordered by the following thoracic structures:
Lateral: Mediastinal pleura (part of the parietal pleural membrane).
Anterior: Pericardium.
Posterior: T5-T12 vertebrae.
Roof: Imaginary line extending betweenthe sternal angle (the angle formed by the junction of the sternal body and manubrium) and the T4 vertebrae.
Floor: Diaphragm.
Contents Posterior Mediastinum
• Esophagus
• Thoracic aorta
• Azygos vein
• Thoracic duct
• Vagus nerve
• Sympathetic nerve trunks
Splanchnic nerves
Boundaries and contents anterior mediastinum
The anterior mediastinum is bordered by the following thoracic structures:
Lateral borders: Mediastinal pleura (part of the parietal pleural membrane).
Anterior border: Body of the sternum and the transversus thoracis muscles.
Posterior border: Pericardium.
Roof: Continuous with the superior mediastinum at the level of the sternal angle.
Floor: Diaphragm
Thymic remnants Lymph nodes and fat
Middle mediastinum
• Pericardium
• Heart
• Aortic root
• Arch of azygos vein
• Main bronchi
The middlemediastinum is bordered by the following thoracic structures:
Anterior: Anterior margin of the pericardium.
Posterior: Posterior border of the pericardium.
Laterally: Mediastinal pleura of the lungs.
Superiorly: Imaginary line extending betweenthe sternal angle (the angle formed by the junction of the sternal body and manubrium) and the T4 vertebrae.
Inferiorly: Superior surface of the diaphragm
Superior mediastinum
• Superior vena cava
• Brachiocephalic veins
• Arch of aorta
• Thoracic duct
• Trachea
• Esophagus
• Thymus
• Vagus nerve
• Left recurrent laryngeal nerve
• Phrenic nerve
The superiormediastinum is bordered by the following thoracic structures:
Superior – Thoracic inlet.
Inferior – Continuous with the inferior mediastinum at the level of the sternal angle.
Anterior – Manubrium of the sternum.
Posterior – Vertebral bodies of T1-4.
Lateral – Pleurae of the lungs.
Where do preganglionic sympathetic fibers come from?
What connects it to the spinal nerves?
How sympathetic nerves leave the sympathetic chain?
Where do preganglionic sympathetic fibres come from?
• They originate in the lateral horn (intermediolateral cell column) of the spinal cord segments T1–L2.
• These neurons are preganglionic sympathetic neurons — they form the starting point of the sympathetic pathway.
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🔗 2. What connects them to the spinal nerves?
• They exit the spinal cord via:
Ventral root → Spinal nerve → White ramus communicans → Sympathetic chain (paravertebral ganglia).
• So, the white ramus communicans is the connector between the spinal nerve and the sympathetic chain — carrying preganglionic fibres into the chain.
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🧩 3. How do sympathetic fibres leave the sympathetic chain?
Once inside the sympathetic chain, fibres have three possible routes:
- They may synapse at the same level — the postganglionic fibres then leave via the gray ramus communicans to join the spinal nerve and supply blood vessels, sweat glands, and piloerector muscles.
- They may ascend or descend in the chain before synapsing — for example, fibres ascending to the cervical ganglia for head and neck structures.
- They may pass through the chain without synapsing — these form the splanchnic nerves, which synapse in prevertebral ganglia like the celiac or mesenteric ganglia to supply abdominal and pelvic viscera.
Surface marking of lungs
A. Apex
• 2.5 cm above the medial third of the clavicle (in the root of the neck).
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B. Anterior Border
• Right lung: from apex → down behind the sternoclavicular joint → along the midline to xiphisternal joint.
• Left lung: same till 4th costal cartilage, then arches laterally to make the cardiac notch, and rejoins midline at the 6th costal cartilage.
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C. Inferior Border
• Midclavicular line: 6th rib
• Midaxillary line: 8th rib
• Paravertebral line: 10th rib
🧠 Mnemonic: “6, 8, 10 — down you go!”
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D. Posterior Border
• From apex (C7 spine) → down along the vertebral column to T10 (in mid-inspiration).
