Thoracic I Flashcards
You are auscultating the heart of a 68-year-old patient who has presented with chest pain. Your stethoscope is placed in the second intercostal space on the right sternal edge.
Aortic valve
The best sites for heart valve auscultation are:
Aortic valve: the second intercostal space on the right sternal edge.
Pulmonary valve: the third costal cartilage on the left sternal edge.
Mitral valve: at the apex of the left ventricle or the site of the apex beat in the fifth intercostal space in the mid-clavicular line.
Tricuspid valve: the fifth intercostal space on the right sternal edge.
You are auscultating the heart of a 50-year-old patient who has presented with shortness of breath. Your stethoscope is placed over the apex of the heart.
Mitral valve
The best sites for heart valve auscultation are:
Aortic valve: the second intercostal space on the right sternal edge.
Pulmonary valve: the third costal cartilage on the left sternal edge.
Mitral valve: at the apex of the left ventricle or the site of the apex beat in the fifth intercostal space in the mid-clavicular line.
Tricuspid valve: the fifth intercostal space on the right sternal edge.
You are auscultating the chest of a 63-year-old lady in a pre-operative clinic. Your stethoscope is placed in the fifth intercostal space on the right sternal edge.
Tricuspid valve
The best sites for heart valve auscultation are:
Aortic valve: the second intercostal space on the right sternal edge.
Pulmonary valve: the third costal cartilage on the left sternal edge.
Mitral valve: at the apex of the left ventricle or the site of the apex beat in the fifth intercostal space in the mid-clavicular line.
Tricuspid valve: the fifth intercostal space on the right sternal edge.
In the case of a patient sitting upright with his arms by his side, a line drawn between the tips of the scapulae will correspond to the vertebral body of which of the following? (Please select 1 option) T6 T7 T8 T9 T10
T7
A line drawn between the tips of the scapulae corresponds to the vertebral body of T7.
A line drawn between the superior margin of the iliac crests is level with the vertebral body of L4.
In the right lung, the number of bronchopulmonary segments is which of the following? (Please select 1 option) 7 8 9 10 11
10
There are 10 bronchopulmonary segments in the right lung.
These are:
Upper lobe:
Apical
Posterior
Anterior
Middle Lobe:
Medial
Lateral
Lower Lobe:
Superior ('apical')
Anterior basal
Posterior basal
Medial basal
Lateral basal.
A 72-year-old male attends the emergency department with severe upper abdominal pain.
He also complains of shoulder tip pain and you think he has a perforated duodenal ulcer.
The shoulder pain is explained by irritation of the diaphragmatic peritoneum referred to which dermatome?
(Please select 1 option)
C2 dermatome
C3 dermatome
C4 dermatome
C5 dermatome
C6 dermatome
C4
Irritation of the diaphragm is usually referred to the C4 dermatome which supplies the shoulder regions.
Regarding the diaphragm, which of the following is correct?
(Please select 1 option)
Has accessory motor innervation from the intercostal nerves
Has an origin from the body of the sternum
Has the aorta passing behind it at T10
Has the left phrenic nerve passing through its central tendon
Is partly derived from the pleuroperitoneal membranes
Is partly derived from the pleuroperitoneal membranes This is the correct answerThis is the correct answer
The diaphragm is partly derived from the pleuroperitoneal membranes and mesoderm, innervation is from C345 via the phrenic nerve. It consists of a central tendon and a muscular margin.
The fleshy fibres rise in front from the back of the xiphoid cartilage of the sternum, laterally by six serrations from the inner surfaces of the lower six ribs interdigitating with the transversalis, posteriorly from the arcuate ligaments, of which there are five, a pair of external, a pair of internal, and a single median one.
The external arcuate ligament stretches from the tip of the twelfth rib to the costal process of the first lumbar vertebra in front of the quadratus lumborum muscle, the internal and middle are continuations of the crura which rise from the ventro-lateral aspects of the bodies of the lumbar vertebrae, the right coming from three, the left from two.
On reaching the level of the twelfth thoracic vertebra each crus spreads out into a fan-shaped mass of fibres, of which the innermost join their fellows from the opposite crus in front of the aortic opening to form the middle arcuale ligament; the outer ones arch in front of the psoas muscle to the tip of the costal process of the first lumbar vertebra to form the internal arcuate ligament, while the intermediate ones pass to the central tendon.
The aorta crosses the diaphragm at T12.
Which of the following is correct of the left main bronchus?
(Please select 1 option)
Contains complete cartilagenous rings
Divides into 3 secondary bronchi
Divides into 10 tertiary bronchi
Is shorter than the right bronchus
Runs more vertically than the right bronchus
Divides into 10 tertiary bronchi
The left bronchus is narrower and less vertical than the right, is nearly 5 cm long and once entered the hilum divides into a superior and inferior lobar bronchus.
The right bronchus is 2.5 cm long and gives off three branches to the three lobes of the right lung.
Both lungs have 10 tertiary (segmental) bronchi.
The trachea and extra pulmonary bronchi have a framework of incomplete ‘rings’ of hyaline cartilage, united by fibrous tissue and smooth muscle.
Which of the following numbers of segments is contained in the left lung? (Please select 1 option) 12 11 10 8 5
10
The lungs are divided first into right and left, the left being smaller to accommodate the heart.
The lungs are further subdivided into lobes (three on the right, two on the left) by the oblique and horizontal fissures on the right and only the oblique fissure on the left.
Each lobe of the lung is further divided into pyramidal bronchopulmonary segments. Bronchopulmonary segments have the apex of the pyramid in the hilum whence they receive a tertiary bronchus, and appropriate blood vessels.
There are 10 segments of the right lung and typically 10 on the left although on the left it is not uncommon for one or more segmental bronchi to share a common stem.
A smooth flat area of bone usually covered with cartilage, where a bone, such as a rib, articulates with another.
Facet
Facets, such as the superior and inferior facets on vertebrae, are flat and because they are covered in cartilage, help other bones to slide over them easily.
The name given to a ridge on a bone.
Crest
A ridge of bone is known as a crest. There are ridges along the long bones of the arms and legs where muscles insert.
The name given to a passage or tunnel through a bone.
Foramen
A channel in a bone is known as a foramen
The name given to parts of a bone which are projecting and/or spike-like.
Process
Projections are known as processes. An example includes the styloid processes.
The name given to small raised eminences on bones.
Tubercle
Small raised eminences on bones are known as tubercles. These are different from trochanters as they are much larger.
You are examining a patient with left sided weakness and test reflex knee extension.
L3/L4
Limb reflexes:
Biceps C5/C6 Triceps C7/C8 Supinator C5/C6 Knee L3/L4 Ankle S1/S2
A knife stabbed horizontally through the fourth intercostal space to the right of the sternum is most likely to damage which of the following? (Please select 1 option) Descending aorta Hemiazygos vein Right brachiocephalic vein Right pulmonary artery Thoracic duct
Right pulmonary artery
The hemiazygos vein, descending aorta and thoracic duct are found on the left.
The right brachiocephalic vein is formed behind the sternoclavicular joints by the union of the internal jugular and subclavian veins.
The left and right brachiocephalic veins join at the middle of the right border of the manubrium to form the superior vena cava.
The superior vena cava enters the right atrium at the level of the right third costal cartilage.
Which of the following is true regarding the superior mediastinum?
(Please select 1 option)
Contains the right recurrent laryngeal nerve
Has the heart and the pericardium as its contents
Has the mediastinal pleura laterally
Is bounded by the bodies of T3-T6 vertebrae posteriorly
Is traversed by the hemiazygos vein
Has the mediastinal pleura laterally
The superior mediastinum is the space between
The manubrium of the sternum anteriorly
The anterior surface of the bodies of T1-T4 vertebrae posteriorly
The plane of the thoracic inlet superiorly
The plane of the sternal angle inferiorly
The mediastinal pleura laterally.
The contents of the superior mediastinum include
Left brachiocephalic vein Right brachiocephalic vein Superior vena cava Azygos vein Brachiocephalic artery Left common carotid artery Left subclavian artery Left and right vagus nerves Left recurrent laryngeal nerve Left and right phrenic nerves Trachea Oesophagus. The heart and pericardium are the contents of the middle mediastinum, while the descending aorta, thoracic duct, azygos vein (on the right) and the hemiazygos vein (on the left side) are contents of the posterior mediastinum.
Which of the following is correct regarding the diaphragm?
(Please select 1 option)
Has an aperture for the oesophagus at the level of the twelfth thoracic vertebra
Is not attached to the pericardium
Motor innervation is received from the lower six intercostal nerves
Sensory innervations are derived solely from the anterior primary rami of the third, fourth and fifth cervical nerves
Vena caval opening lies within the central tendon
Vena caval opening lies within the central tendon This is the correct answerThis is the correct answer
The inferior vena cava enters the pericardium through the central tendon of the diaphragm. It has an aperture for the oesophagus at the level of the tenth thoracic vertebra. It is attached to the pericardium especially over the central tendon.
The diaphragm receives both sensory and motor innervation from C3, C4 and C5 through the phrenic nerve.
Peripherally, the diaphragm also receives some sensory innervation from lower intercostal nerves.
Which of the following is true regarding the female breast?
(Please select 1 option)
Develops lactiferous ducts at puberty
Is derived embryologically from endoderm
Is drained by the internal thoracic vein
Lies between the first and fifth rib
Lies only partially in the superficial fascia
Is drained by the internal thoracic vein
At the end of the first month of embryonic development the mammary gland begins to develop as a solid bud of epidermis into the underlying mesenchyme.
This primary bud occurs from the cranial part of the mammary ridges, thickened strips of ectoderm. Each primary bud give rise to several secondary buds that develop into the lactiferous ducts and their branches that make up the mammary gland.
The arteries supplying the breast are derived from
Lateral thoracic artery
Internal thoracic artery
Intercostal arteries.
The internal thoracic artery and its perforating branches supply a medial part of the breast. The lateral thoracic artery supplies a lateral part of the breast. Profound part is supplied by intercostal arteries and their branches.
The veins describe an anastomotic circle round the base of the nipple, called circulus venosus by Haller. From this, large branches transmit the blood from medial part of the breast into internal thoracic veins, and from the lateral part of the breast into lateral thoracic vein and intercostal veins.
The lymph vessels of the breast are situated into two layers (superficial and profound), making networks that are interconnected. Superficial lymph vessels transmit the lymph fluid into axillary lymph nodes.
Which of the following is true concerning the oesophagus?
(Please select 1 option)
Drains all of its blood into the azygos and hemiazygos veins
Is 40 cm in length in the adult
Is lined by stratified squamous epithelium in the upper one-third
Is lined by transitional epithelium in the lower one-third
Passes behind the left main bronchus in the thorax
Passes behind the left main bronchus in the thorax This is the correct answerThis is the correct answer
Oesophagus is a muscular tube of foregut origin.
It begins at the cricoid cartilage (C6), passes through the diaphragm at T10 level and ends in the stomach at T11 level. It is 25 centimetres long. (The incisor to gastro-oesophageal junction length is 40 cm and not the length of the oesophagus).
It is lined by stratified squamous epithelium in its upper two thirds and stratified columnar epithelium in its lower third.
The normal indentations on the oesophagus are from the aortic arch, left bronchus and the diaphragm. It is narrowest at its origin.
It is supplied by:
The inferior thyroid arteries in the neck
Branches of bronchial arteries and aorta in the thorax, and
Branches from the left gastric artery.
The venous drainage similarly is also distributed:
To the brachiocephalic veins in the neck
Azygos system in the thorax, and
The lower end drains into the portal system through the cardiac and left gastric veins.
The nerve supply is from the recurrent laryngeal nerves and the middle cervical sympathetic ganglion for the upper third of the oesophagus.
The middle and lower third receive parasympathetic supply from the vagus and sympathetic supply from the thoracic sympathetic chain.
The cervical oesophagus drains into the deep cervical nodes
Thoracic oesophagus drains into tracheo-bronchial and posterior mediastinal nodes, and
The abdominal oesophagus drains into the gastric and celiac nodes.
However, the lymphatics traverse long distances within the wall of the oesophagus before draining. This is said to be the reason for synchronous or metachronous lesions seen in oesophageal cancer.
Which of the following is true of the scalenus anterior?
(Please select 1 option)
Inserts into the scalene tubercle on the second rib
Is an accessory muscle of respiration
Is pierced by the phrenic nerve
Lies anterior to the suprascapular artery
Separates the subclavian artery and brachial plexus
Is an accessory muscle of respiration
The scalenus anterior is a flat muscle that arises from four slips from the four typical cervical vertebrae (C3-6) and is inserted on the scalene tubercle on the first rib. It is one of the accessory muscles of respiration, but is more important as an anatomical landmark.
Its anterior relations are:
Phrenic nerve Ascending cervical artery Transverse cervical artery Suprascapular artery, and Internal jugular vein. The subclavian vein lies in the groove on the first rib in front of the attachment of scalenus anterior.
The trunks of the brachial plexus lie lateral to scalenus anterior.
The subclavian artery is divided into three parts:
First part is medial to it
Second part is behind (posterior) to the muscle, and
The third part is lateral to it.
Which of the following anatomical relations of the scalenus muscles is true?
(Please select 1 option)
The ascending cervical artery lies lateral to the phrenic nerve
The phrenic nerve passes behind scalenus anterior
The subclavian artery and vein are separated by scalenus medius
The subclavian vein forms the brachiocephalic vein at the lateral border of scalenus anterior
The trunks of the brachial plexus emerge from the lateral border of scalenus anterior
The trunks of the brachial plexus emerge from the lateral border of scalenus anterior This is the correct answerThis is the correct answer
The ascending cervical artery, medial to the phrenic nerve on scalenus anterior, can easily be mistaken for the phrenic nerve at operation.
The phrenic nerve passes inferiorly across scalenus anterior and medius.
The subclavian artery and vein are separated by scalenus anterior.
The subclavian vein joins with the internal jugular to form the brachiocephalic vein at the medial border of scalenus anterior.
The trunks of the brachial plexus emerge from the lateral border of scalenus anterior.
Which of the following nerve roots, if compressed by a herniated disc, would result in a diminished knee jerk? (Please select 1 option) L4 L5 S1 S2 S3
L4
L3/L4 nerve root compression results in a diminished knee jerk.
The greater sciatic foramen does not transmit which of the following? (Please select 1 option) Internal pudendal vessels Piriformis muscle Posterior femoral cutaneous nerve Sacrospinous ligament Sciatic nerve
Sacrospinous ligament
The greater sciatic foramen transmits all of the above, apart from the sacrospinous ligament which forms part of the foramen itself and the tendon of the obturator internus muscle which passes through the lesser sciatic foramen.
