GARQ Questions 15-18

Question 15: (b) The plane of the oblique fissure slopes anteriorly and downward to intersect the diaphragmatic surface of the lung, just behind the anteroinferior border of the lung; this fissure roughly parallels which rib?

6th rib

Question 18: Indicate which of these images was acquired with intravenous contrast and which was acquired without contrast.

B was acquired without contrast A, C, and D use contrast

Question 18: Briefly describe the adrenal (suprarenal) glands - location, blood supply, and innervation? Location

superomedial to each kidney Surrounded by renal fascia and attached to the crura of the diaphragm. The renal fascia forms a septum between the glands and the kidney

Question 18: Describe the gross structure of a kidney (cortex, medulla, major and minor calyces, renal pelvis), including its blood supply and venous drainage.

*Renal cortex - outer layer *Renal medulla - inner layer *Renal columns - Extensions of the renal cortex that project inward and divide the renal medulla into renal pyramids *Renal papilla - the apex of each renal pyramid *Each renal papilla opens into a minor calyx *Each minor calyx opens into a major calyx *Each kidney has 2-3 major calyces which unite to form the renal pelvis

Question 16: What is the main action performed by the internal intercostal muscles?

- The internal intercostal muscles assist active expiration by pulling the ribs downward and inward (opposite to the action of the external intercostal muscles), thus decreasing the thoracic volume. - In addition, they stiffen the intercostal spaces to prevent them from bulging outward during straining.

Question 18: A patient presents to you with colicky pain and tells you he has had kidney stones in the past. You are worried that the patient has an obstruction of the urinary system from a new kidney stone. What exam would you order 1) to determine if the patient has an obstruction of the collecting system? 2) to determine if the patient has kidney stones in the kidney and 3) determine if the patient has kidney stones in the ureters or bladder? Explain briefly what you look for in each imaging test that indicates these conditions.

1) Ultrasound Upstream dilatation of the collecting system - the calyces and renal pelvis will be wide; the urine is anechoic and shows acoustic enhancement Second line: CT w/o contrast 2) Ultrasound small echogenic reflections that produce an acoustic shadow (posterior acoustic shadowing) The "twinkle artifact"= a sign to confirm that the echogenic focus is a stone and not another tissue reflecting Twinkle artifact = it occurs as a focus of alternating colors on Doppler signal behind a reflective object (such as a calculus), which gives the appearance of turbulent blood flow 3) CT urogram without contrast identify radiopaque kidney stones or stones in the ureters or bladder that are calcified

Question 15: (c) In the right lung, the horizontal fissure intersects the oblique fissure as it crosses the midaxillary line and then intersects the anterior border of the lung at the level of which costal cartilage?

4th costal cartilage

Question 18: What is the renal sinus?

A hollow space within the kidney containing perinephric fat, major and minor calyces and neurovascular structures

Question 16: Why is it critical that the integrity (tone) of the intercostal muscles be maintained?

All of the intercostal muscles keep the intercostal spaces rigid, preventing them from bulging out during expiration and being drawn in during inspiration. It resists pressure changes in the thorax, especially during inspiration.

Question 15: Lower lobes of the lungs are best heard anteriorly or posteriorly, and in which intercostal space (spaces)?

Ant: midaxillary line at 6th intercostal space Post: between T3-T10

Question 15: Describe the location of placement of a stethoscope to best "hear" the middle lobe of the right lung.

Anterior only: 4th intercostal space mid-clavicular line

Question 18: Describe the relationship of each kidney to the structures immediately anterior to it.

Anterior to the right kidney Liver Duodenum Ascending colon Anterior to the left kidney Stomach Spleen Pancreas jejunum

Question 15: Upper lobes of the lungs are best heard anteriorly or posteriorly, and in which intercostal space (spaces)?

Anterior: 2nd intercostal space (on left could go to 4th intercostal space) Posterior: between C7-T3

Question 15: (d) Where should a stethoscope be placed to best "hear" the apical segment of the lung?

Anterior: root of the neck, above medial clavicle Posterior: above scapula

Question 18: What generally happens to the suprarenal gland during renal transplantation?

Because the renal fascia forms a septum between the kidney and adrenal gland, the suprarenal glands are left unharmed and remain attached to the posterior abdominal wall after a renal transplantation

Question 18: What is the location of the majority of renal corpuscles? Of convoluted tubules? Of loops of Henle and collecting tubules?

Bowman's capsules and proximal and distal convoluted tubules lie in the renal cortex Loops of Henle and collecting tubule lie in the medulla

Question 18: Please indicate, for each image, the imaging modality that was used to acquire it.

CT imaging

Question 15 RAD: The following coronal image of a CT of the chest (A) is presented in a lung window. In this reformat you can identify the trachea and central bronchial structures. On this image, please number the following: trachea (1), left and right main bronchus (2; 3 respectively), right upper lobe bronchus (4), intermediate bronchus (5) right lower lobe bronchus (6) as well as the left upper (7) and lower lobe (8) bronchi.

Diagram!!!

Question 18: During which of the time points at which these images were obtained (A, B, C or D) do you expect the urinary bladder (not shown) to be filled with contrast?

During the excretory/ urographic phase

Question 15 RAD: In which "window" would you try to look for the pulmonary fissures?

In CT we look at the lung parenchyma in the LUNG WINDOW.

Question 16: Describe the movement of the diaphragm during inspiration and expiration. (For the sake of clarity, consider forced inspiration and expiration.)

Inspiration: - diaphragm contracts - abdominal contents are forced downward and forward - the vertical dimensions of the chest cavity is increased (negative pressure allows air to flow in) - a total movement of up to 10 cm may occur with forced inspiration Expiration: - the diaphragm is pushed upward (vertical diameter returns to a neutral position) - decreased thoracic dimensions vertically = higher pressure that promotes air exiting body

Question 16: How does diaphragmatic motion influence thoracic dimensions?

It increases the vertical dimensions during inspiration, increasing the intrathoracic volume and diameters of the thorax. The resulting pressure change (negative intrathoracic pressure) results in air being drawn in.

Question 18: Describe the spatial relationship between the superior mesenteric artery, the aorta, and the left renal vein.

Its course to the IVC includes passing anteriorly to the aorta and inferiorly to the superior mesenteric artery close to each respective vessel It courses between the superior mesenteric artery and the aorta to the IVC The superior mesenteric artery and the aorta typically form a 90 degree angle

Question 18: Describe the location of the kidneys relative to the vertebral column and indicate the differences in position of the right and left kidneys.

Kidneys are on the posterior abdominal wall between T12 - L3 The right kidney is about 2.5 cm lower than the left due to the position of the liver

Question 18: Describe the unique arrangement of fat and fasciae associated with the kidney (and adrenal gland).

Paranephric (pararenal) fat → an extension of the extraperitoneal fat and is substantial in the lumbar region Renal fascia → deep to the paranephric fat; a fibrous connective tissue that helps suspend the kidneys and suprarenal glands on the posterior abdominal wall Perinephric (perirenal) fat → deep to the renal fascia; surrounds the kidneys and suprarenal glands and is continuous with the fat in the renal sinus (p. 176) Renal capsule → deep to the perinephric fat; it surrounds the kidney as a tough, fibrous layer

Question 18: Describe the relationship of the kidneys to the structures immediately posterior to them.

Posterior structures Psoas major m. Quadratus lumborum m Subcostal nerve, artery and vein Iliohypogastric and ilioinguinal nerves

Question 18: Place the images in the chronological order (from the beginning of the examination through the later stages of the examination) that correctly reflects the order in which they were acquired during a CT of the kidney/CT urography.

Renal mass protocol: B (non contrast - before injection), A (arterial phase - corticomedullary phase), D (nephrographic phase), C (excretory phase - urographic phase)

Question 16: Next, describe the motions of the ribs and sternum during forced inspiration and expiration. Consider movements in the vertical, anterior-posterior, and transverse planes. In the description, include the names of the moving structures and a description of their motion(s).

Rib margins are lifted and moved out, causing an increase in the transverse and anteroposterior diameter of the thorax. The lateral parts of the ribs are raised creating a "bucket handle movement". The sternocleidomastoid muscles raise the sternum in inspiration ------------------------------------------------------------------------ When the external intercostal muscles contract, the ribs are pulled upward and forward, causing an increase in both the lateral and anteroposterior diameters of the thorax Transverse dimension of the thorax increases slightly when the intercostal muscles contract, raising the most lateral parts of the ribs, especially the most inferior ones = "the bucket handle movement" The accessory muscles of inspiration include the scalene muscles which elevate the first two ribs and the sternocleidomastoids which raise the sternum

Question 18: Briefly describe the adrenal (suprarenal) glands - location, blood supply, and innervation? Innervation

Rich nerve supply from the celiac plexus and abdominopelvic (greater, lesser and least) splanchnic nerves; the nerves are mainly myelinated presynaptic fibers that derive from the lateral horn of the spinal cord and traverse the paravertebral and prevertebral ganglia without synapse to be distributed to the chromaffin cells in the suprarenal medulla

Question 18: Describe the blood supply of a kidney. Arteries

Right and left renal arteries *Branch from the abdominal aorta between L1 and L2 *The right renal artery runs posterior to the IVC *Within the renal sinus, the renal arteries typically divide into 5 segmental arteries

Question 18: Describe the blood supply of a kidney. Veins

Right and left renal veins *Several veins drain the kidney and unite in a variable fashion to form the renal vein (p. 179) *lie anterior to the renal arteries *The left renal vein travels anterior to the abdominal aorta *The left renal vein is crossed by the superior mesenteric artery

Question 18: Why does this relationship place structures with venous drainage via the left renal vein risk?

Specific anatomical variants can reduce the angle of the superior mesenteric artery and the aorta leading to constriction of the left renal vein. This constriction can lead to compression ischemia

Question 18: Briefly describe the adrenal (suprarenal) glands - location, blood supply, and innervation? Blood Supply

Suprarenal veins -Right suprarenal vein is a tributary of the IVC -Left suprarenal vein is a tributary of the left renal vein Suprarenal arteries -Superior suprarenal artery → a branch of the inferior phrenic artery -Middle suprarenal artery → a branch of the abdominal aorta -Inferior suprarenal artery → a branch of the renal artery

Question 15: (a) Identify the bony landmark located at the midline posteriorly that marks the "beginning" of the oblique fissure.

T2 vertebra

Question 16: The intercostal muscles are also critical in respiration. What is the main action performed by the external intercostal muscles?

The external intercostal muscles contract (forced inspiration), the ribs are pulled upward and forward, causing an increase in both the lateral and the anteroposterior diameters of the thorax.

Question 15 RAD: Can all interlobar fissures be seen on a chest radiograph? If so, when? If not, why not?

The fissures can typically NOT be seen on a NORMAL radiograph of the chest. Sometimes, only when the radiation beam is parallel to it, the minor fissure may be identified. If there is pathology in one lobe that reaches the fissure, it typically shows as a straight line that reflects the visceral pleura. Because we do not SEE the lobes / fissures on the chest radiograph, we typically describe the location of a pathology with in the upper/middle / lower FIELD. Can't see fissures on normal radiograph unless there is a pathology outlining the fissure (ex. Pleural fluid in the setting of a pleural effusion)

Question 18: What viscera are impacted by constriction of the left renal vein?

The viscera in the pelvic cavity (the constriction can lead to venous congestion in the pelvic cavity) Gonads (left gonadal vein empties into the left renal vein); suprarenal vein (left suprarenal vein empties into the left renal vein)

Question 16: What imaging modality can you use during the procedure to help you guide your procedure to avoid puncturing the intercostal vasculature?

Thoracentesis is typically performed with ultrasound guidance. Occasionally, CT-guidance will be used.

Question 16: Please describe where you would introduce the needle in order to avoid injuring the vasculature using the upper or lower margin of the rib as an anatomic landmark.

To avoid damage to the intercostal nerve and vessels, the needle is inserted superior to the rib, high enough to avoid the collateral branches (Fig. B1.8). (p. 78)

Question 15 RAD: Can interlobar fissures be seen on a computed tomography of the chest?

Yes, the fissures can well be seen on CT of the chest.

Question 17: Make a diagram that illustrates the neural wiring that might explain why the pain from ischemic myocardium is felt in the thoracic body wall on the left. (Include in your diagram the path taken by the sensory neurons carrying information from the ischemic myocardium to the spinal cord AS WELL AS the path taken by sensory neurons that innervate the skin of the T 3, 4, and 5 dermatomes.)

red = visceral afferent sensory (from heart) yellow = somatic sensory (from skin) going in at the same level ⇒ can cross-excite cell bodies for both in DRG (sensory root) both synapse in dorsal horn w/second-order neurons ⇒ red usually goes to another red, yellow usually goes to another yellow but in referred pain, red has collateral synapse that connects w/yellow: so red connects to yellow ⇒ looks like somatic pain

Question 18: These images are obtained at different contrast phases. Please explain briefly what this means.

the time points at which the images are taken after intravenous injection of IV contrast