Anatomy part 2 Flashcards
1
Q
Superior part of the trunk between the neck and the abdomen.
A
Thorax
Thoracic cage:
- 12 pairs of Ribs
- sternum
- costal cartilages
- 12 thoracic vertebra
- skin, fascia and muscles
2
Q
Bones that made up the Thorax
A
Sternum: common site of marrow biopsy
Ribs
Thoracic vertebra
3
Q
Bones that made up the Sternum.
A
MANUBRIUM
*superior part
*clinical landmark when counting ribs
*corresponds to T4 vertebra level
*suprasternal notch-palpable superiorly
*clavicular notch-articulate with clavicle
*manubriosternal joint-inferior
BODY
*longer, thinner, narrower
*costal notches-articulates with costal cartilages
*manubriosternal joint above; xiphisternal joint below
XIPHOID PROCESS
*thin, sword shaped, smallest
*cartilaginous at birth; becomes bony at 40
*lies opposite the body of the 9th thoracic vertebra
4
Q
All of the following features occur at the level of sternal angle, except: a, Trachea bifurcates into R/L bronchi b. 3rd rib articulates with sternum c. Aortic arch begins d. Aortic arch ends
A
d. Aortic arch ends
STERNAL Triangle
- horizontal plane intersecting sternal angle and disk between T4 and T5
- trachea bifurcates into primary bronchi
- arch or the aorta arises from ascending aorta and continues as the descending aorta
- azygous vein drain into SVC
5
Q
1st to 7th ribs.
A
True ribs/Vertebrosternal
True ribs: 1st-7th
False ribs proper: 8th, 8th, 10th
Floating ribs: 11th, 12th
Typical ribs: 3-8
Atypical ribs: 1, 2, 10, 11, 12
6
Q
False ribs/Vertebrochondral ribs.
A
8th to 12th rib
False ribs proper: 8th, 8th, 10th
Floating ribs: 11th, 12th
Typical ribs: 3-8
Atypical ribs: 1, 2, 10, 11, 12
7
Q
Wedge shaped part of rib with 2 articular facets for articulation; Facets separated by crest.
A
Head of Rib
8
Q
Stout and Flat part of rib between head and tubercle.
A
Neck of rib
9
Q
Have facets which articulates with transverse process of the numerically corresponding vertebra.
A
Tubercle
10
Q
Thin, Flat, curved; angle- where rib curves and twists
costal groove- at inferior border to protect IV nerves and BV
A
Shaft
11
Q
The body of the T4 vertebra articulates with which of the following part of the ribs?
a. Head of the 3rd rib
b. Neck of the 4th rib
c. Tubercle of the 4th rib
d. Head of the 5th rib
e. Tubercle of the 5th rib
A
d. Head of the 5th rib
Articulations
- HEAD of Rib=BODY of THORACIC vertebra
- TUBERCLE of Rib=TRANSVERSE PROCESS of vertebra
e. g.
5th Rib HEAD=superior articular facet=BODY of T4
=inferior articular facet=BODY of T5
5th Rib TUBERCLE=TRANSVERSE PROCESS of T5
12
Q
Rarely fractured; Broadest and most curved with prominent scalene tubercle for attachment of scalenus anterior muscle.
A
1st Rib
*close relationship to the lower nerves of brachial plexus and subclavian artery/vein
Anterior: subclavian vein crosses
Posterior: subclavian artery and the lower trunk of the brachial plexus crosses
13
Q
Atypical rib that is thinner, less curved, longer and has tuberosity for serratus anterior muscle.
A
2nd Rib
rib 10: articulates with T10 vertebra ONLY
14
Q
Atypical ribs, short, have single facet on their heads; No neck or tubercle.
A
Rib 11-12
rib 10: articulates with T10 vertebra ONLY
15
Q
Common area of fracture on ribs.
A
Anterior to the ANGLE of the Rib.
- weakest point of the rib
- commonly 7-10 ribs
- may cause Pneumothorax; Diaphragmatic hernia (lower part)
16
Q
This is where the thoracic cavity communicates with the root of the neck; where important vessels and nerves emerge from the thorax to enter the neck and upper limbs.
A
THORACIC INLET
Boundaries:
🔘Post: T1
🔘 Lat: Medial border or first rib
🔘Ant: Manubrium sterni
17
Q
Symptoms caused by pressure on the lower trunk of plexus producing pain down and medial forearm and hand; wasting hand muscles.
A
Thoracic OUTLET Syndrome
✔pressure of the blood vessels may compromise the circulation of the upper limb
✔brachial plexus and subclavian artery/vein related to upper surface of the 1st rib and clavicle
18
Q
Relationship of VERTICAL Diameter of thoracic wall on Respiration.
A
INSpiration: INCreases; diaphragm moves down
Expiration: DECreases; diaphragm moves up
19
Q
TRANSVERSE diameter of thoracic wall as described by “Bucket-handle inspiratory movement”.
A
TRANSVERSE diameter
“Bucket-handle inspiratory movement”
🔘IC muscle contract
🔘ribs moves laterally (covex)
🔘INCrease in diameter
20
Q
TRANSVERSE diameter of thoracic wall as described by “Pump-handle inspiratory movement”.
A
ANTEROPOSTERIOR diameter
“Pump-handle inspiratory movement”
INSpiration: Sternum moves UP; INCreases
Expiration: Sternum moves DOWN; DECreases
21
Q
Muscles use in inspiration.
A
Muscles that ELEVATE the ribs: ✔Serratus posterior SUPerior muscle ✔Levators ✔External and Innermost IC ✔Subcostal
22
Q
Muscles use in expiration.
A
Muscles that DEPRESS the ribs:
✔Serratus posterior INFerior muscle
✔Internal IC
✔Transverse thoracis
23
Q
The mediastinum is divisible into superior and inferior divisions by an imaginary plane passing from the angle of Louie anteriorly and ____ posteriorly.
a. Lower border of T4
b. Upper border of T4
c. Lower border of T6
d. Upper border of T4
A
a. Lower border of T4
anterior: angle of Louie
posterior: lower border of T4 (T4-T5)
24
Q
A patient has a small but solid tumor in the mediastinum which is confined at the level of sternal angle. which of the following structures are most likely to be found at this level?
a, Bifurcation of Trachea
b. Beginning of Ascending aorta
c. Articulation of the 3rd rib with the sternum
d. Superior border of the superior mediastinum
A
c. Articulation of the 3rd rib with the sternum (?)
25
Imaging of the thorax in an 18 month old female reveals a diffuse structure in the superior mediastinum representing the Thymus as gland. All of the following would be found in the superior mediastinum, except:
a. Ascending aorta
b. Brachiocephalic artery
c. Left Brachiocephalic vein
d. Phrenic nerve
e. Vagus nerve
a. Ascending aorta
Superior mediastinum
* thymus gland
* SVC
* brachiocephalic artery/vein
* L common carotid artery
* L subclavian artery
* arch of aorta
* phrenic and vagus nerve
* trachea
* esophagus
* thoracic duct
* L recurrent laryngeal nerve
* lymph nodes
* sympathetic trunk
26
A cross sectional image of the thorax reveals an absence of an anterior mediastinum shadow in a patient diagnosed with Di George syndrome. What else will be missing in this patient?
a. thyroid gland
b. palatine tonsil
c. malleus and incus
d. parathyroid gland
e. adrenal medulla
d. parathyroid gland
Di George Syndrome
* improper development of 3rd and 4th pharyngeal pouches
* THYMUS and Prathyroid gland are absent.
27
A patient was admitted to the hospital because of stab wound on he chest just left to the sternum. He is slightly cyanotic, with distention of veins of neck during inspiration. You suspect that the patient has a cardiac tamponade and order a pericardiocentesis. What is the last tissue layer that the needle must traverse in order to reach the accumulating blood?
a. Epicardium
b. Fibrous pericardium
c. Mediastinal pleura
d. Visceral pericardium
e. Serous layer of Parietal pericardium
e. Serous layer of Parietal pericardium
Pericardiocentesis
* site: Left Xiphocostal angle
* enters the skin - fascia - rectus sheath - rectus abdominis - fibrous layer - serous layer of the parietal pericardium
28
Patient presents with Kussmaul sign due to pericardial effusion and cyanosis.
Cardiac tamponade
* Kussmaul sign --- distention of veins of neck during inspiration
* accumulation of fluid in the pericardial cavity that compresses the chambers of the heart --- decreased venous return and reduced cardiac output
29
Normal amount of pericardial fluid.
30 ml
| *serous / visceral layer
30
Double walled fibro-serous sac located anteriorly to T5-T8, and posteriorly to body of sternum and 2nd-6th costal cartilages.
Pericardium
Fibrous Layer
Serous: Parietal and Visceral
31
Th sternocostal surface of the heart is formed primarily by the:
a. Right Atrium
b. Right Ventricle
c. Left Atrium
d. Left Ventricle
b. Right Ventricle
3 SURFACES of the Heart
* STERNOCOSTAL: Anterior --- RV
* DIAPHRAGMATIC: Inferior --- both ventricles, mainly LV
* PULMONARY: Left --- LV
BASE: LA
APEX: LV; 5th ICS LMCL
```
Borders
Right: RA
Left: LV
Superior: R/L auricles
Inferior: RV
```
32
Normal weight of the heart in males?
280 - 340 grams
33
Normal weight of the heart in females?
230 - 280 grams
34
Where is the Auscultatory site for pulmonary valve?
a. 5th iCS LMCL
b. Lower end of sternum
c. 2nd ICS Left
d. 2nd ICS Right
c. 2nd ICS Left
AUCULTATORY Areas
* Tricuspid: Lower end of sternum
* Pulmonary: 2nd ICS Left
* Aortic: 2nd ICS Right
* Mitral: 5th iCS LMCL
35
Located behind the medial end of 3rd Left costal cartilage:
a. Tricuspid
b. Pulmonary
c. Aortic
d. Mitral
b. Pulmonary
Surface Anatomy
* Tricuspid: behind the R half of sternum (4th ICS)
* Pulmonary: behind the medial end of 3rd L costal cartilage
* Aortic: behind L half of sternum (3rd ICS)
* Mitral: behind L half or sternum (4th costal cartilage)
36
A 147/F with history of RF is examined by her physician. PE is significant of low pitch, rumbling diastolic murmur preceeded by an opening snap. The affected valve can be best evaluated by auscultation at which of the following location?
a. Left second intercostal space
b. Left fifth intercostal space
c. Let lower sternal body border
d. Right second intercostal space
b. Left fifth intercostal space
* This is a case of Rheumatic Heart disease affecting mitral valves.
* Mitral regurgitation: low pitch, rumbling diastolic murmur preceeded by an opening snap
* Mitral valve best heard at 5th ICS LMCL
37
The second heart sound is due to closure of what valves?
a. Aortic and Pulmonary
b. Aortic and Tricuspid
c. Tricuspid and Mitral
d. Pulmonary and Mitral
a. Aortic and Pulmonary
S1: Tricuspid and Mitral
S2: due to closure of Aortic and Pulmonary valves
S3: Early diastole in Rapid ventricular filling
S4: Late diastole; High atrial pressure
38
The following veins drain into the Right Atrium, except:
a. Coronary sinus
b. Superior vena cava
c. Anterior cardiac
d. Great cardiac
b. Superior vena cava
VENOUS DRAINAGE of the Heart
- --drains into RA
* Coronary sinus and tributaries
(1) Great cardiac
(2) Small cardiac
(3) Middle cardiac: Anterior cardiac; Venae cordis minimae---opens directly to RA
39
A 19y/o came to the ER and his angiogram exhibited that he was bleeding from the vein that is accompanied by the posterior interventricular artery. Which of the following veins is most likely ruptured?
a. Great Cardiac vein
b. Middle Cardiac vein
c. Anterior Cardiac vein
d. Small Cardiac vein
b. Middle Cardiac vein
Posterior descending artery not visible, but it runs near the middle cardiac vein at the Base and diaphragmatic surface of heart.
40
A 55/M is brought to the ER due to sharp, squeezing chest pain behind the sternum after meal. History reveals repeated episodes of chest pain after exertion over the past several years. A diagnosis of an acute MI of the interventricular bundle is made. What was most likely site of the occlusion?
a. Posterior Interventricular artery
b. Circumflex artery
c. Marginal artery
d. Right coronary artery
e. Anterior interventricular artery
e. Anterior interventricular artery (?)
* LA and LV: circumflex branch of the LCA
* Interventricular septum and Apex: Anterior interventricular branch of LCA
* RV: Anterior interventricular artery and Marginal branch of RCA
* RA: RCA
41
Dermatome of substernal pain felt in Angina pectoris.
T1 - T5
* T1: medial aspect of L arm and forearm
* Angina pectoris: narrowing of coronary arteries (transient ischemia)
42
Common site of occlusion in Myocardial infarction.
Anterior interventricular artery
43
As a pathologist, you are examining the heart of a victim of fatal trauma and note a tear at the junction of SVC and RA. This tear would likely damage the?
a. Atrioventricular bundle
b. AV node
c. Sinoatrial node
d. Right bundle branch
e. Left bundle branch
c. Sinoatrial node
* SA node: pace maker; within atrial wall of the R side of its junction with SVC
* AV node: interatrial septum superior to the opening of coronary sinus
* AV bundle/Bundle of His: membranous
* R/L bundle branches: muscular portion of the interventricular septum
* Purkinje fibers
44
In doing ECG, where is V1 lead placed?
a. 4th ICS just to the right of the sternum
b. 4th ICS just to the left of the sternum
c. Midclavicular line, 5th ICS
d. anterior axillary line, 5th ICS
e. anteroapical
a. 4th ICS just to the right of the sternum
V1 - 4th ICS just to the R of the sternum
V2 - 4th ICS just to the L of the sternum
V3 - midway between V2 and V4
V4 - Midclavicular line, 5th ICS
V5 - anterior axillary line, 5th ICS
V6 - Midaxillary line, 5th ICS
45
Results of ECG showing ST elevation in lead II, II, avF. Where is the most likely site of infarction?
a. inferior wall
b. posterolateral
c. anterior wall
d. anteroseptal
e. midaxillary line, 5th ICS
a. inferior wall
I,avL, V1-V6: Large Anterior wall --- Proximal LAD
V2 - V4: Anteroapical --- Distal LAD
II, III, avF: Inferior wall --- Distal LAD
V1 - V3: Anteroseptal --- Distal LAD
V4 - V6: Posterolateral --- Circumflex
46
Results of ECG showing ST elevation in lead V1 to V3. Where is the most likely site of infarction?
a. inferior wall
b. posterolateral
c. anterior wall
d. anteroseptal
e. anteroapical
d. anteroseptal
I,avL, V1-V6: Large Anterior wall --- Proximal LAD
V2 - V4: Anteroapical --- Distal LAD
II, III, avF: Inferior wall --- Distal LAD
V1 - V3: Anteroseptal --- Distal LAD
V4 - V6: Posterolateral --- Circumflex
47
The fossa ovalis is seen in what chamber of the heart?
a. Left atrium
b. Right atrium
c. Left ventricle
d. Right ventricle
b. Right atrium
RIGHT ATRIUM:
* Fossa ovalis --- remnant of Foramen Ovale (ASD)
* Receives blood from: SVC, IVC, coronary sinus, ant cardiac vein, and vena cordis minimae
* internal wall: sinus venarum - ant; musculi pectinati - post
* interatrial septum: with an oval depression
48
The moderator band, a modified trabeculae carnae that crosses the interventricular septum is seen in what chamber of the heart?
a. Left atrium
b. Right atrium
c. Left ventricle
d. Right ventricle
d. Right ventricle
RIGHT VENTRICLE:
* thicker wall than RA
* internal surface with irregular muscular ridges called TRABECULAE CARNAE where Papillary muscles originates
* apices are connected by Fibrous strands called CHORDA TENDINAE
49
If the esophageal mass expands anteriorly into the middle mediastinum, what structure is initially become compressed?
a. Left ventricle
b. Right ventricle
c. Left atrium
d. Right atrium
c. Left atrium (?)
50
Most posterior of all chambers that receives 4 pulmonary veins on its posterior wall.
a. Left atrium
b. Right atrium
c. Left ventricle
d. Right ventricle
a. Left atrium
LEFT ATRIUM:
* thicker wall >RA
* with musculi pectinati
51
Formed the diaphragmatic and pulmonary surface of the heart.
a. Left atrium
b. Right atrium
c. Left ventricle
d. Right ventricle
c. Left ventricle
LEFT VENTRICLE:
* walls that are twice as thick as that of RV
* conical cavity that is longer than RV
* trabecuale carnae is finer & more numerous than RV
* papillary muscles larger than RV
52
In the OR, a surgeon perform median sternotomy to gain access to the heart for a CABG. While cutting through the sternum, a large quantity of blood suddenly erupts from the chest. What structure is most likely to be injured?
a. Azygous vein
b. Arch or Aorta
c. Left Atrium
d. Right Atrium
e. Right ventricle
b. Arch or Aorta (?)
53
```
Which forms the venous coronary sinus?
A. L horn of the sinus venosus
b. R horn of the sinus venosus
c. Primitive atrium
d. Bulbus cordis
e. Truncus arteriosus
```
A. L horn of the sinus venosus
Primitive atrium ---> LA
L horn of the sinus venosus ---> Coronary sinus
R horn of the sinus venosus ---> RA
Primitive ventricle ---> all the LV
Bulbus cordis ---> all the RV
Truncus arteriosus ---> root of Aorta and Pulmonary trunk
54
A 12 y/o boy was admitted to a hospital with a known history of heart problems. Hist left ventricular hypertrophy could result from which of the following conditions?
a. constriction of pulmonary trunk
b. abnormally small left AV valve
c. improper closing of the pulmonary valves
d. an abnormally large right AV opening
e. stenosis of the aorta
e. stenosis of the aorta
* Stenosis of the aorta can cause left ventricular hypertrophy. Right ventricular hypertrophy may occur as a result of pulmonary stenosis, pulmonary and tricuspid valve defects, or mitral valve stenosis.
55
Defect that shunts blood from the LA to the RA. Most common form is Patent Foramen ovale.
Atrial Septal Defect (ASD)
*RA, RV and pulmonary trunk hypertrophy
56
Most common type of CHD that is more common in males; where there is left to right shunting of blood, increase blood flow to the lungs, thus, causing Pulmonary hypertension.
Ventricular Septal Defect (VSD)
*MEMBRANOUS VSD --- incomplete closure of the IV foramen results from failure of the membranous part of the IV septum to develop.
57
Results from failure of the truncal ridges and aorticopulmonary septum to develop normally.
TRUNCUS ARTERIOSUS
*VSD iis always present and the TA overrides the VSD.
58
Most common cause of cyanotic heart disease.
Transposition of Great Arteries (TGA)
* associated with ASD and VSD
* aorta lies anterior to the R of the pulmonary trunk and arises anteriorly from the morphological RV;
* pulmonary trunk arises from the morphological LV
59
Components of Tetralogy of Fallot.
*R to L shunting
1. Pulmonary stenosis
2. VSD
3. Overriding of the Aorta / Dextro position of Aorta
4. RVH
60
Most common congenital anomaly associated with maternal Rubella infection during early pregnancy.
Patent Ductus Arteriosus (PDA)
* aortic blood is shunted to pulmonary artery
* failure of ductus arteriosus to involute after birth and form ligamentum arteriosum
61
3 shunts that cease to function after birth.
Foramen Ovale: closes
Ductus arteriosus: constricts
Umbilical arteries: constricts
62
Anatomical closure of Foramen ovale and fossa ovalis.
3rd month after birth
63
A 9 month old girl was admitted to pediatric ward. PE exhibits tachycardia, a bounding peripheral pulse and angiographs reveal a PDA. Which of the following embryonic structures is most likely responsible for the origin of PDA?
a. R 4th arch
b. L 5th arch
c. R 5th arch
d. L 6th arch
e. R 6th arch
d. L 6th arch
1st pair: Maxillary arteries
2nd pair: Stapedial arteries
3rd pair: P -- Common carotid arteries; D -- Internal carotid arteries
4th pair: L -- arch of aorta; R -- R subclavian artery
5th pair: NONE
6th pair:
(L) P -- L pulmonary artery; D -- Ductus arteriosus
(R) P -- R pulmonary artery; D -- degenerates
64
Traumatic, acceleration/deceleration injuries to the aorta usually occur where its mobile and fixed portions meet. This would be at the:
a) at the ligamentum arteriosum
b) junction of aortic arch with the descending portion
c) junction of the ascending aorta with the heart
d) origin of the brachiocephalic artery on the arch
e) point where the descending aorta passes through the diaphragm
a) at the ligamentum arteriosum
65
A patient involved in an automobile accident presents with a sharp object puncture of the middle of the sternum at about the level of the 4th or 5th costal cartilage. If the object also penetrated pericardium and heart wall, which heart chamber would most likely be damaged?
a) Left atrium
b) Left ventricle
c) Right atrium
d) Right ventricle
d) Right ventricle
Remember, the anterior surface, or sternocostal surface, of the heart is mostly made up of the right ventricle. So, if an object punctured the sternum, it would be likely to pierce the right ventricle.
66
A 23-year-old male injured in an industrial explosion was found to have multiple small metal fragments in his thoracic cavity. Since the pericardium was torn inferiorly, the surgeon began to explore for fragments in the pericardial sac. Slipping her hand under the heart apex, she slid her fingers upward and to the right within the sac until they were stopped by the cul-de-sac formed by the pericardial reflection near the base of the heart. Her fingertips were then in the:
a) coronary sinus
b) coronary sulcus
c) costomediastinal recess
d) oblique sinus
e) transverse sinus
d) oblique sinus
The oblique sinus is an area of the pericardial cavity located behind the left atrium of the heart where the serous pericardium reflects onto the inferior vena cava and pulmonary veins. If you slide your fingers under the heart, they will be in the oblique sinus. The other pericardial sinus that you should be familiar with is the transverse sinus. The transverse sinus is an area of the pericardial cavity located behind the aorta and pulmonary trunk and anterior to the superior vena cava. It separates the outflow vessels from inflow vessels.
67
Blockage of which of the following arteries would lead to ischemia of the apex of the heart?
a) Anterior interventricular (descending)
b) Left circumflex
c) Posterior interventricular (descending)
d) Right marginal
e) Right coronary
a) Anterior interventricular (descending)
The anterior interventricular artery is a branch of the left coronary artery. It supplies both ventricles as well as the interventricular septum. It also reaches the apex, supplying that area as well. The left circumflex artery is the other major branch of the left coronary artery. It supplies the posterior surface of the left ventricle, but does not reach the apex of the heart.
68
You are attending an operation to remove a thymic tumor from the superior mediastinum. The surgeon asks, "What important nerve lying on and partly curving posteriorly around the arch of the aorta should we be careful of as we remove this mass?" You quickly answer, "The--
a) left phrenic
b) left sympathetic trunk
c) left vagus
d) right phrenic
e) right sympathetic trunk
c) left vagus
The left vagus nerve lies against the lateral surface of the arch of the aorta. The left recurrent laryngeal nerve is an especially important nerve from the vagus which loops around the aortic arch. This nerve innervates the muscles of the left larynx. If it is damaged, a patient may experience hoarseness after surgery. Care must be taken to preserve this nerve, especially during thyroid surgery.
69
In cardiac surgery it is sometimes necessary to clamp off all arterial flow out of the heart. This could be done within the pericardial sac by inserting the index finger immediately behind the two great arteries and compressing them with the thumb of the same hand. The index finger would have to be inserted into which space?
a) Cardiac notch
b) Coronary sinus
c) Oblique pericardial sinus
d) Coronary sulcus
e) Transverse pericardial sinus
e) Transverse pericardial sinus
The transverse pericardial sinus is an area of the pericardial cavity located behind the aorta and pulmonary trunk and anterior to the superior vena cava. When entering the transverse pericardial sinus, a surgeon will insert an index finger between the aorta and pulmonary trunk on the ventral side and the superior vena cava on the dorsal side. The oblique pericardial sinus is an area of the pericardial cavity located behind the left atrium of the heart. If a surgeon places fingers under the apex of the heart, then moves the fingers until they are stopped by a pericardial reflection, then the fingers are in the oblique sinus.
70
While performing transesophageal echocardiography on a patient, the posterior wall of the esophagus, immediately behind the left atrium, was punctured from within. Doctors were very concerned about possible damage to a thin-walled vessel just behind the esophagus and between the azygos vein and aorta, i.e., the:
a) Hemiazygos vein
b) Left bronchial vein
c) Left pulmonary vein
d) Superior vena cava
e) Thoracic duct
e) Thoracic duct
The thoracic duct is found directly behind the esophagus in the posterior mediastinum, with the aorta to its left and the azygos vein to its right. This relationship between these three vessels is an important one to keep in mind! The other vessels do not share the same relationship with the azygos and aorta.
71
An enlarging lymph node gradually constricts the flow of blood in the azygos venous arch. Which vessel would enlarge as a result of collateral drainage?
a) Superior vena cava
b) Inferior vena cava
c) Internal thoracic vein
d) Right brachiocephalic vein
e) Superior epigastric vein
c) Internal thoracic vein
The internal thoracic vein would provide a collateral route for drainage if the azygos vein was obstructed. In the case of an obstruction, blood could flow from the posterior intercostal veins (which usually drain into the azygos) into the anterior intercostal veins, enter the internal thoracic vein, and drain into the right brachiocephalic vein. This would allow the blood to bypass the blockage. The right brachiocephalic vein would be receiving more blood due to this blockage, but it wouldn't be the vessel that would enlarge--the internal thoracic vein would become distended. The superior epigastric vein is an inferior extension of the internal thoracic vein--it is too inferior to assist with collateral circulation.
72
A frail, elderly man, suspected of having widespread cancer of the lungs and bronchi, is brought in for bronchoscopic examination. The instrument is inserted into the airway, where it accidentally punctures the thin, brittle posterior wall of the diseased right main bronchus. A sudden gush of blood immediately indicates that the instrument has also torn the wall of the blood vessel immediately behind the right main bronchus, i.e., the:
a) Azygos vein
b) Left brachiocephalic artery
c) Pericardiacophrenic artery
d) Right pulmonary vein
e) Superior vena cava
a) Azygos vein
The azygos vein lies immediately behind the right mainstem bronchus. This vein then arches over the right mainstem bronchus to drain blood into the superior vena cava. So, this must be the structure that was damaged during the bronchoscopy.The left brachiocephalic artery doesn't exist, but the brachiocephalic trunk is a branch off the aortic arch which travels far superior to the area of interest. The pericardiacophrenic artery is a branch of the internal thoracic artery which accompanies the phrenic nerve. It is anterior to the right bronchus. The right pulmonary veins are inferior and anterior to the right mainstem bronchus. Finally, the superior vena cava is superior and anterior to the right mainstem bronchus.
73
A 4-year-old girl is brought in with coughing, and you are told by her mother that she had been playing with some beads and had apparently aspirated one (gotten it into her airway). Where would you expect it to most likely be?
a) Apicoposterior segmental bronchus of left lung
b) Left main bronchus
c) Lingular segment of left lung
d) Right main bronchus
e) Terminal bronchiole of right lung, lower lobe
d) right main bronchus
There are several reasons why inhaled objects will be more likely to enter the right lung instead of the left lung. First, the carina, a ridge-like structure at the bifurcation of the trachea, is set a little towards the left. So, there is a more direct path for objects to fall to the right. Also, the right bronchus is shorter, wider, and more vertical than the left bronchus. All of these factors mean that an inhaled object will enter the right main bronchus.
74
During a surgical procedure in the vicinity of the descending aorta, a surgeon accidentally cuts the first aortic intercostal arteries. Which of the following structures might be deprived of its main source of blood supply?
a) first posterior intercostal space
b) first anterior intercostal space
c) left bronchus
d) right bronchus
e) fibrous pericardium
d) Right bronchus
The right bronchus receives blood from a single right bronchial artery. This artery may branch from one of the left bronchial arteries or it may branch from the right 3rd posterior intercostal artery, the first intercostal artery that arises from the descending aorta. Damaging this artery might stop the blood supply to the main bronchus. The intercostal arteries to the first and second intercostal spaces are derived from the highest intercostal artery, so the blood supply to either of these spaces would not be disrupted. The left bronchus is supplied by two left bronchial arteries which branch directly from the descending aorta. The fibrous pericardium is a fibrous sac that contains the pericardial cavity and the heart. Its blood supply is not a major concern.
75
You are caring for a 68-year-old male who has copious amounts of fluid in the left pleural cavity due to acute pleurisy. When you examine him as he sits up in bed (trunk upright), where would the fluid tend to accumulate?
a) costodiaphragmatic recess
b) costomediastinal recess
c) cupola
d) hilar reflection
e) middle mediastinum
a) costodiaphragmatic recess
The costodiaphragmatic recess is the lowest extent of the pleural cavity or sac. It is the part of the pleural sac where the costal pleura changes into the diaphragmatic pleura. Because this is the most inferior part of the pleural sac, fluid in the pleural sac will fall to this region when a patient sits up. The costodiaphragmatic recess is also the area into which a needle is inserted for thoracocentesis, and it is found at different levels at different areas of the thorax.
76
Which muscle forms the inferior border of the middle mediastinum?
a) Rectus abdominis
b) Diaphragm
c) External oblique
d) Internal intercostal
b) Diaphragm
77
Which feature is found only in the left lung?
a) Cardiac notch
b) Horizontal fissure
c) Oblique fissure
d) Superior lobar bronchus
e) Three lobes
a) Cardiac notch
78
In a post-soccer match brawl, a 35-year-old man was stabbed in the back with a knife that just nicked his left lung halfway between its apex and diaphragmatic surface. Which part of the lung was most likely injured?
a) Hilum
b) Inferior lobe
c) Lingula
d) Middle lobe
e) Superior lobe
b) Inferior lobe
Because of the sharp angle of the oblique fissure, the posterior surface of the left lung is almost entirely comprised of the inferior lobe. So, a stab wound halfway between the apex and diaphragmatic surface of the lung would result in injury to the inferior lobe. The hilum is the point at which the structures forming the root of the lung enter the lung. The lingula is part of the superior lobe, which forms the anterior and superior sides of the lung. And remember, the middle lobe isn't relevant here because it is on the right lung. (Besides, it doesn't even contribute to the posterior surface of the right lung.)
79
A 10-year-old boy underwent a tonsillectomy under general anesthesia. At home he lay supine in bed for two weeks and developed a fever and chest pain with cough. He returned to the hospital and was diagnosed as having right lung pneumonia due to aspiration of infectious material during the tonsillectomy. In which bronchopulmonary segment of the lung would fluid (pus) most likely have accumulated by the simple force of gravity?
a) Anterior basal segment--inferior lobe
b) Anterior segment--superior lobe
c) Lateral segment--middle lobe
d) Superior segment--inferior lobe
e) Superior lingual segment--lingula
d) Superior segment--inferior lobe
The superior segmental bronchus of the inferior lobe branches posteriorly off of the intermediate bronchus or the inferior lobe bronchus, so it is the most likely segmental bronchus to receive foreign bodies or fluids that enter the right bronchus. This is even more likely to occur if the patient is in the supine position.
80
Inferior level of the parietal pleura in the mid axillary line.
R 8
Lower margin of Lungs:
6th rib in MCL
8th rib in MAL
81
Anatomical and Surgical unit of the Lung.
Bronchopulmonary Segments
82
Distortion of the carina can lead to what pathological change of the heart?
Enlargement of the Left Atrium
83
If you do auscultation on the anterior and superior aspect of the thoracic wall, what lobe of the lung are you listening?
Superior lobe
84
In what lobe do you try to listen if you do auscultation on the posterior and inferior aspect of the back?
Inferior lobe
85
If you do auscultation on the anterior chest wall near the sternun, inferior to the Right 4th costal cartilage, what lobe of the lung are you listening?
Middle lobe
