Exam 1

Question 1

Horner Syndrome

Answer 1

Thoracic anterior roots are damaged:The nerves of the sympathetic trunk arise from the spinal cord in the chest, and from there ascend to the neck and face. The nerves are part of the sympathetic nervous system, a part of the autonomic (or involuntary) nervous system

Question 2

Cardiac Tamponade:

Answer 2

the pericardial sac fills with fluid and the heart compresses, he heart cannot fill completely and patients present with engorged veins of the face and neck due to the backup of blood

Question 3

LAD:

Answer 3

common site of myocardial infarction

Question 4

blue baby

Answer 4

infidibular stenosis

Question 5

lungs at midaxillary line reside at:

Answer 5

8th rib

Question 6

thoracocentesis is:

Answer 6

draining of fluid filled pleural cavity

Question 7

at mid axillary line, thoracocentesis should be carried out at;

Answer 7

9th intercostal space

Question 8

_____coronary artery supplies:

Answer 8

blood supply to sa node and av node

Question 9

chorion becomes:

Answer 9

placenta

Question 10

yolk sac is site of:

Answer 10

blood vessels

Question 11

amnion serves to:

Answer 11

cushion the embryo in a fluid filled sac

Question 12

allantois becomes

Answer 12

umbilical cord

Question 13

neural tube forms, somite differentiation and upper limbs are present during week:

Answer 13

4

Question 14

yolk sac and extraembryonic endoderm is derived from:

Answer 14

hypoblast

Question 15

A woman with breast cancer subsequently develops metastases in her vertebral column. The most direct route for spread of the tumor to the vertebral column was via:

Answer 15

The correct answer is: branches of the intercostal veins
The most likely route for the cancer to reach the vertebral column is through the intercostal veins, i.e. hematogenous spread. The cephalic vein and thoracoacromial vein would not be draining the breast, and the lateral thoracic vein would not be directing blood toward the vertebral column. Lymphatic vessels may carry some tumor cells to the axillary lymph nodes and may participate in the spread of the cancer, but this isn’t the best answer for this question. The most direct way for the cancer to spread to the vertebral column is through the venous system.

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Question 16

Sympathetic fibers in the greater thoracic splanchnic nerve arise from neuron cell bodies found in the:

Answer 16

The correct answer is: spinal cord
The sympathetic fibers in the greater thoracic splanchnic nerve are preganglionic sympathetic fibers that have left the sympathetic chain and are going to synapse in an abdominal ganglia. These preganglionic sympathetic fibers originate in the lateral horn of the spinal cord grey matter. The celiac ganglia and the superior mesenteric ganglia are the two ganglia where the fibers from the greater thoracic splanchnic nerve can go to synapse. Finally, remember that these fibers did not originate in the chain ganglia–the fibers from there are the postganglionic sympathetic fibers.

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Question 17

Which nerve fiber would have its cell body in the lateral horn of the spinal cord at segmental level T1?

Answer 17

The correct answer is: efferent fibers to the skin of the forehead
Efferent fibers to the skin of the forehead might have their cell bodies located in the lateral horn of the T1 level. Because these fibers are at the superior edge of the thoracolumbar outflow (located from T1 to L2), they might go up the chain, synapse at a higher ganglion, and provide sympathetic innervation to the head and face. Afferent fibers would not have their cell bodies located in the lateral horn–afferent sensory fibers have cell bodies in dorsal root ganglia. Efferent fibers to the sweat glands of the lumbar region would be sympathetic fibers, but these cell bodies would be located at the T12, L1, or L2 levels–not at T1. T1 is too high for the lumbar region! Finally, parasympathetic fibers to the heart come from the vagus nerve.

Question 18

Gray rami communicantes contain postganglionic sympathetic fibers that innervate which of the following structures in the thoracic region?

Answer 18

The correct answer is: sweat glands
Sympathetic fibers innervate sweat glands by synapsing in the sympathetic chain, jumping on the grey rami to rejoin the spinal nerve, and heading for the periphery. The sympathetic nerves to the heart, aorta, lungs, and bronchi are carried in the cardiac and pulmonary plexuses. These fibers are not found in spinal nerves.

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Question 19

In the midregion of the thorax the thoracic duct lies immediately posterior to the:

Answer 19

The correct answer is: esophagus
In the mid thorax, the aorta, thoracic duct, and azygos vein are all posterior to the esophagus. (They are in that order, from left to right.) The superior vena cava and the trachea are not located in the mid thorax–the superior vena cava terminates as it feeds into the right atrium and the trachea ends as it splits into the two mainstem bronchi which enter the lungs.

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Question 20

Lymph nodes can be found in which mediastinal compartment(s)?

Answer 20

The correct answer is: all of the above
Lymph nodes are found in all of the mediastinal compartments. They are the one structure that can be found in the anterior, middle, and posterior compartments. What else is in each compartment? The anterior compartment contains areolar tissue and sternopericardial ligaments. The middle compartment contains the pericardium,heart, great vessels, and bronchi. The posterior compartment contains the descending thoracic aorta, azygos system, esophagus, and thoracic duct.

Question 21

Which structure contains postganglionic sympathetic fibers?

Answer 21

The correct answer is: ulnar nerve
White rami communicantes carry presynaptic sympathetic fibers to the sympathetic trunk. When a presynaptic nerve fiber reaches the sympathetic chain, there are three things that can happen. First, the nerve fibers can enter a ganglia, synapse at that level, and rejoin the spinal nerve via the grey rami communicantes. Second, the preganglionic nerve fibers can travel up and down the trunk, synapse in a ganglia at another level, and then rejoin a spinal nerve. This is how sympathetic fibers join spinal nerves at the cervical and lumbar levels, which are above and below the lateral horn. Third, some preganglionic fibers do not synapse in the trunk and, instead, form splanchnic nerves. These nerves descend into the abdomen and synapse in other ganglia.

Question 22

Which posterior mediastinal structure is most closely applied to the posterior surface of the pericardial sac?

Answer 22

The correct answer is: esophagus
The esophagus is closely related to the posterior surface of the pericardial sac. After coming from the heart, the aorta arches over the left pulmonary artery and left bronchus. Eventually, this vessel is posterior to the esophagus. The azygos vein, on the right side of the thorax, arches over the right pulmonary artery and bronchus. It is also posterior to the esophagus. The thoracic duct is posterior to the esophagus as well and does not contact the pericardial sac. Finally, the trachea is superior to the heart.

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Question 23

A tumor of the posterior mediastinum is most likely to compress which of the following structures?

Answer 23

The correct answer is: esophagus
The posterior mediastinum is bounded superiorly by the plane through the sternal angle and T4/5, inferiorly by the diaphragm, anteriorly by the middle mediastinum, and posteriorly by the spinal cord. This area contains the descending thoracic aorta, the azygos system, the esophagus, the thoracic duct, and lymph nodes. Of the answer choices, the esophagus is the only one in the posterior mediastinum. The great vessels and bronchi at the roots of the lung are in the middle mediastinum.

Question 24

The aorta is located in which mediastinal compartment(s)?

Answer 24

The correct answer is: middle and posterior
The ascending aorta is located in the middle mediastinum, along with the other great vessels. The aortic arch is located in the lowest part of the superior mediastinum (its lower border lies at the level of the sternal angle). The descending aorta is in the posterior mediastinum. Remember what’s in what part of the mediastinum–it’s important!

Question 25

The aorta is located in which mediastinal compartment(s)?

Answer 25

The correct answer is: middle and posterior The ascending aorta is located in the middle mediastinum, along with the other great vessels. The aortic arch is located in the lowest part of the superior mediastinum (its lower border lies at the level of the sternal angle). The descending aorta is in the posterior mediastinum. Remember what's in what part of the mediastinum--it's important! Close Window

Question 26

While performing transesophageal echocardiography on a patient, the posterior wall of the esophagus, immediately behind the left atrium, was punctured from within. The patient subsequently developed an infection in the space around the esophagus at this point, namely the:

Answer 26

The correct answer is: posterior mediastinum The esophagus is in the posterior mediastinum, along with the descending aorta, thoracic duct, and azygos system. Close Window

Question 27

Since the puncture in the previous question was through the posterior wall of the esophagus, the doctors were also very concerned about possible damage to a thin-walled vessel just behind the esophagus and between the azygos vein and aorta, i.e., the:

Answer 27

The correct answer is: 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. Close Window

Question 28

During a surgical procedure, a patient's right sympathetic trunk was accidentally severed just cranial to the level of spinal nerve T1. Which function would be left intact in the affected region?

Answer 28

The correct answer is: voluntary muscle activity The sympathetic nervous system is not responsible for voluntary muscle activity. The neurons which supply voluntary muscles originate from the ventral horn of the spinal cord. One of the main functions of sympathetic nerves is maintaining the tone of blood vessels--if these nerves were damaged, it would be difficult to regulate vascular tone. The sympathetic nervous system also regulates the arrector pili muscles, sweat production, and visceral reflexes.

Question 29

Most of the drainage of the thoracic body wall reaches the superior vena cava via the azygos vein. A notable exception is the left superior intercostal vein, which normally drains into the:

Answer 29

The correct answer is: Left brachiocephalic vein The left superior intercostal vein drains intercostal spaces 2-4, and then drains into the left brachiocephalic vein. See Netter Plate 231 for a picture of this relationship. The left bronchial vein is a small vein that removes venous blood from the lungs--it drains into the accessory hemiazygos vein. The left pulmonary veins carry oxygenated blood from the lung to the left atrium of the heart. The left subclavian vein is a continuation of the left brachiocephalic vein--this vein drains blood from the arm into the left brachiocephalic vein. The superior vena cava is formed by the junction of the left and right brachiocephalic veins; it delivers blood to the right atrium.

Question 30

You are observing a physician perform a thoracoscopic procedure. She pushes the deflated lung anteroinferiorly and points out a nervous structure lying across the heads of the ribs. You identify this structure as the

Answer 30

The correct answer is: Sympathetic trunk The sympathetic trunk can be found on the posterior wall of the thorax, lying on the heads of the ribs. It contains the cell bodies of postganglionic sympathetic fibers. When a nerve fiber reaches the sympathetic chain, there are three things that can happen. First, the nerve fibers can enter a ganglia in the trunk, synapse at that level, and rejoin the spinal nerve via the grey rami communicantes. Second, the preganglionic nerve fibers can travel up and down the trunk, synapse in a ganglia at another level, and then rejoin a spinal nerve. This is how sympathetic fibers join spinal nerves at the cervical and lumbar levels, which are above and below the lateral horn. Third, some preganglionic fibers do not synapse in the trunk and, instead, form splanchnic nerves. These nerves descend into the abdomen and synapse in other ganglia. You really need to understand all three of these possibilities! The greater thoracic splanchnic nerve is one of the splanchnic nerves that is carrying preganglionic fibers away from the trunk. It lies medial to the trunk, on the vertebral bodies, and carries fibers to the celiac plexus. The phrenic nerve travels through the anterior thorax to innervate the diaphragm--it's not found near the heads of the ribs. The pulmonary plexus is located along the pulmonary vessels and primary bronchi in the root of the lung--it carries both sympathetic and parasympathetic fibers to the lungs. The vagus nerve is the major nerve carrying parasympathetic fibers in the thorax and to the abdomen. It begins in the anterior portion of the thorax, then enters the posterior mediastinum and forms the esophageal plexus covering the esophagus. Close Window

Question 31

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?

Answer 31

The correct answer is: 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. Close Window

Question 32

During a procedure to harvest lymph nodes in the posterior mediastinum, the thoracic duct is accidentally cut. The resulting accumulation of lymph in the pleural cavity is referred to as:

Answer 32

The correct answer is: Chylothorax A chylothorax is a pleural effusion composed of lymphatic fluid due to disruption of the thoracic duct. Pleurisy refers to the inflammation of the pleura with exudation into the pleural cavity. A pyothorax is an infection that occurs in the pleural space, where pus accumulates within the pleural cavity. A hemothorax involves the accumulation of blood in the pleural space. Finally, lymphedema is a swelling in a body part cause by the obstruction of lymphatic flow or the removal of the lymphatic vessels in a region.

Question 33

A cancerous growth from the body of the 9th thoracic vertebra exerts pressure anterolaterally. Which structure lies in direct contact with this growth?

Answer 33

The correct answer is: Right greater thoracic splanchnic nerve The thoracic splanchnic nerves lie on the anterior surfaces of the vertebral bodies. Remember, the splanchnic nerves lie medial to the sympathetic trunk, which is lying on the heads of the ribs. The vagus nerve lies in the anterior chest and eventually forms the esophageal plexus, covering the esophagus. The phrenic nerve innervates the diaphragm--it is not near the posterior wall of the thorax. Intercostal nerves run in the intercostal groove at the posterior border of the rib--they are not near the vertebral bodies. Close Window

Question 34

A 45-year-old female patient complains of excessive sweating on the right side of the face and neck and in the right armpit region, where it leaves her clothing constantly stained with moisture. It is now such a terrible social embarrassment that she has become withdrawn and self-conscious. Since no medical treatment has proven effective, she is considering surgical denervation of the sweat glands in the affected areas. Which structure(s) might be removed or cut in order to alleviate her condition?

Answer 34

The correct answer is: Cervicothoracic (Stellate) gangion The cervicothoracic ganglion is a sympathetic ganglion, formed by the fusion of the inferior cervical sympathetic ganglion and the T1 ganglion of the sympathetic trunk. The postsynaptic sympathetic fibers from this ganglia innervate the vascular smooth muscle and sweat glands of the C8 & T1 cutaneous distribution on chest & upper limb. Since the sweat glands in the right armpit are innervated by fibers coming from the stellate ganglion, this ganglion might need to be removed or cut to alleviate the patient's condition. The dorsal roots of cervical spinal nerve carry afferent, sensory fibers. These sensory fibers are not involved in innervation to glands. The greater thoracic splanchnic nerve carries preganglionic sympathetic fibers to the abdomen, where they synapse in the celiac ganglion. The lumbar sympathetic trunk is involved with sympathetic innervation in the abdomen--it is far from the area where this patient is experiencing problems. Finally, the vagus nerve carries parasympathetic fibers to the thorax and abdomen; it does not innervate sweat glands. Close Window

Question 35

While viewing an exploratory surgery on a patient injured in an automobile accident, you see the surgeon elevate the esophagus off the vertebral bodies and look in the area between the azygos vein and descending aorta. What structure was she most likely looking for?

Answer 35

The correct answer is: thoracic duct The thoracic duct lies in the posterior mediastinum between the aorta on its left and the azygos vein on its right. These three structures are all found posterior to the esophagus. The greater thoracic splanchnic nerve lies anterior to the vertebral bodies, behind the azygos, thoracic duct, and aorta. The left recurrent laryngeal nerve is found in the middle mediastinum, looping under the aortic arch before it ascends to the larynx. The right pulmonary artery is also in the middle mediastinum--it leaves the heart and enters the root of the right lung. The sympathetic trunk lies on the heads of the ribs on the posterior wall of the thorax. Close Window

Question 36

The ductus arteriosus sometimes remains open after birth, requiring surgical closure. When placing a clamp on the ductus, care must be taken to avoid injury to what important structure immediately dorsal to it?

Answer 36

The correct answer is: Left recurrent laryngeal nerve The left recurrent laryngeal nerve is closely associated with the aortic arch and the ligamentum arteriosum/ductus arteriosus. As the left vagus nerve passes near the aortic arch, it gives offf the left recurrent laryngeal nerve. This nerve then loops under the aortic arch, lateral to the ligamentum arteriosum, and ascends to the larynx in the tracheoesophageal groove. During surgery to close a patent ductus arteriosus, a surgeon must be careful to protect the left recurrent laryngeal nerve, which is lateral to the duct that is being ligated. The accessory hemiazygos vein is a vein on the left side of the body which drains blood from the left chest wall into the azygos vein. The internal thoracic artery is a branch of the subclavian artery which supplies blood to the anterior chest wall and gives rise to the anterior intercostal arteries. The left phrenic nerve passes through the thorax to innervate the diaphragm. It is a bit lateral to the area where the surgeon is clamping the ductus arteriosus, so it would not be at risk during the procedure. Finally, the thoracic duct is found deep in the posterior mediastinum, lying between the aorta and azygos veins.

Question 37

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:

Answer 37

The correct answer is: 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. Take a look at Netter Plate 230 for a better understanding of these relationships.