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1.

Blockage of which of the following arteries would lead to ischemia of the apex
of the heart?

Anterior interventricular (descending)

Left circumflex

Posterior interventricular (descending)

Right marginal

Right coronary
2. If the ductus arteriosus does not spontaneously close off soon after birth (to
become the ligamentum arteriosum), it may have to be surgically ligated.
When clamping or ligating it, what important structure immediately behind it
must be identified and saved?

arch of the azygos vein

internal thoracic artery

left phrenic nerve

left recurrent laryngeal nerve

left superior intercostal vein


3. A hand slipped behind the heart at its apex can be extended upwards until
stopped by a line of pericardial reflection that forms the:

Cardiac notch

Costomediastinal recess

Hilar reflection

Oblique pericardial sinus

Transverse pericardial sinus


4. A stethoscope placed over the left second intercostal space just lateral to the
sternum would be best positioned to detect sounds associated with which
heart valve?

aortic

pulmonary

mitral

tricuspid
5. Which valves would be open during ventricular systole?

Aortic and pulmonary

Aortic and tricuspid


Mitral and aortic

Tricuspid and mitral

Tricuspid and pulmonary


6. Which chamber's anterior wall forms most of the sternocostal surface of the
heart?

Left atrium

Left ventricle

Right atrium

Right ventricle
7. A 3rd-year medical student was doing her first physical exam. In order to
properly place her stethoscope to listen to heart sounds, she palpated bony
landmarks. She began at the jugular notch, then slid her fingers down to the
sternal angle. At which rib (costal cartilage) level were her fingers?

4
8. 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?

Left atrium

Left ventricle

Right atrium

Right ventricle
9. Which statement is true of the right atrioventricular valve?

it is also called the mitral valve

it is open during ventricular diastole

it transmits oxygenated blood

it is opened by the pull of chordae tendineae

it consists of 2 leaflets
10. 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:

Coronary sinus

Coronary sulcus

Costomediastinal recess

Oblique sinus

Transverse sinus
11. An elderly lady suffers a coronary occlusion and subsequently it is noted that
there is a complete heart block (that is, the right and left bundles of the
conduction system have been damaged). The artery most likely involved is
the:

acute marginal branch

circumflex branch

anterior interventricular (Left anterior descending)

obtuse marginal

posterior interventricular (posterior descending)


12. During fetal life and sometimes persisting into the adult there is an opening
between the right and left atria; this opening is called the:

atrioventricular canal

coronary sinus

foramen ovale

sinus venosus

truncus arteriosis
13. The heart sound associated with the mitral valve is best heard:

In the jugular notch

In the second left intercostal space

In the second right intercostal space

In the fifth left intercostal space

To the right of the xiphoid process


14. Which heart valve has leaflets described as "anterior, left and right"?

Aortic
Pulmonary

Left atrioventricular

Right atrioventricular
15. In preparation for thoracic surgery, a median sternal splitting procedure was
carried out. But an improper depth setting on the saw blade resulted in a slight
nick on the underlying sternocostal surface of the heart. Which heart chamber
would most likely have been opened had the blade completely penetrated this
wall?

Left atrium

Left ventricle

Right atrium

Right ventricle
16. The sound associated with tricuspid stenosis (narrowing) in a 40-year-old male
would be best heard at which location on the anterior chest wall?

Below the left nipple

In the right 2nd intercostal space near the sternum

Over the apex of the heart

Over the sternal angle

Xiphoid area, just off the sternum


17. Blockage of blood flow in the proximal part of the anterior interventricular
artery could deprive a large area of heart tissue of blood supply, unless a
substantial retrograde flow into this artery develops via an important
anastomosis with which other artery?

Circumflex

Left marginal

Posterior interventricular

Right coronary

Right marginal
18. Traumatic, acceleration/deceleration injuries to the aorta usually occur where
its mobile and fixed portions meet. This would be at the:

at the ligamentum arteriosum

junction of aortic arch with the descending portion

junction of the ascending aorta with the heart


origin of the brachiocephalic artery on the arch

point where the descending aorta passes through the diaphragm


19. Which structure does NOT lie in the coronary sulcus?

circumflex artery

coronary sinus

right coronary artery

right marginal artery

left coronary artery


20. Which structure contains postganglionic sympathetic fibers?

greater thoracic splanchnic nerve

recurrent laryngeal nerve

sympathetic trunk

ulnar nerve

vagus nerve
21. Which posterior mediastinal structure is most closely applied to the posterior
surface of the pericardial sac?

Aorta

Azygos vein

Esophagus

Thoracic duct

Trachea
22. In obstruction of the superior or inferior vena cava, venous blood is returned to
the heart by an alternate route via the azygos vein, which becomes dilated in
the process. Which of the following structures might it compress as a result?

trachea

root of the left lung

phrenic nerve

thoracic duct

descending aorta
23. Elevated systolic blood pressure in the right ventricle suggests stenosis of
which valve?
Aortic

Mitral

Pulmonary

Tricuspid
24. During examination of a 62-year-old man, the senior resident tells you to put
your stethoscope on the left 5th intercostal space, slightly below the nipple,
and listen for a clearly audible murmur. You hear it distinctly and know it must
be associated with severe stenosis of which heart valve?

Aortic

Mitral

Pulmonary

Tricuspid
25. A 26-year-old male is brought into the emergency room after having been
kicked in the chest by a horse. After examination, it is concluded that the most
likely immediate danger is cardiac tamponade (bleeding into the pericardial
sac). You prepare to draw off some of the blood from the sac to relieve the
pressure on the heart. The safest site at which to insert the needle of the
syringe in order to miss the pleura would be:

Just below the nipple on the left

Just to the left of the xiphisternal junction

Near the sternal angle

Through the jugular notch

4th left intercostal space in the midaxillary line


26. A 22-year-old male involved in an automobile accident presents with
symptoms suggestive of myocardial contusion due to blunt trauma, specifically
compression of the sternocostal surface of the heart by the sternum when his
chest hit the steering wheel. Which heart chamber was most likely damaged?

Left atrium

Left ventricle

Right atrium

Right ventricle
27. While attempting to suture the distal end of a coronary bypass onto the
anterior interventricular artery, the surgeon accidentally passed the needle
through the adjacent vein. Which vein was damaged?

Anterior cardiac vein


Coronary sinus

Great cardiac vein

Middle cardiac vein

Small cardiac vein


28. While listening to a patient's heart sounds with a stethoscope, you identify a
high-pitched sound in the second right intercostal space, just lateral to the
edge of the sternum. Your correct conclusion is that you have detected
stenosis of which heart valve?

Aortic

Mitral

Pulmonary

Tricuspid
29. You are called to perform thoracentesis (remove fluid from the pleural cavity).
If you are to avoid injuring lung or neurovascular elements, where would you
insert the aspiration needle?

the top of interspace 8 in the midclavicular line

the bottom of interspace 8 in the midclavicular line

the top of interspace 9 in the midaxillary line

the bottom of interspace 9 in the midaxillary line

the top of interspace 11 in the scapular line


30. The pleural space into which lung tissue just above the cardiac notch would
tend to expand during deep inspiration is the:

Anterior mediastinum

Costodiaphragmatic recess

Costomediastinal recess

Cupola

Pulmonary ligament
31. Which feature is found only in the left lung?

Cardiac notch

Horizontal fissure

Oblique fissure
Superior lobar bronchus

Three lobes
32. Which of the following nerves would be most vulnerable to irritation when the
tracheobronchial lymph nodes are enlarged due to a diseased situation?

Right phrenic

Left phrenic

Right recurrent laryngeal

Left recurrent laryngeal

Right vagus
33. Which part of the left lung might partially fill the costomediastinal recess in full
inspiration?

Apex

Cupola

Hilum

Lingula

Middle lobe
34. The oblique fissure of the right lung separates which structures?

Lower lobe from lingula

Lower lobe from upper lobe only

Lower lobe from both upper and middle lobes

Lower lobe from middle lobe only

Upper from middle lobe


35. 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?

Hilum

Inferior lobe

Lingula

Middle lobe

Superior lobe
36. 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?

Apicoposterior segmental bronchus of left lung

Left main bronchus

Lingular segment of left lung

Right main bronchus

Terminal bronchiole of right lung, lower lobe


37. Which statement is true about the right lung?

it is slightly smaller than the left lung

it has a lingular segmental bronchus

it occupies the rightmost portion of the mediastinum

its upper lobar bronchus lies behind and above the right pulmonary artery

it has the right phrenic nerve passing posterior to the lung root
38. 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?

first posterior intercostal space

first anterior intercostal space

left bronchus

right bronchus

fibrous pericardium
39. A sick person, lying supine in bed, aspirates (breathes in) some fluid into her
lungs while swallowing. It would most likely end up in which of the following
bronchopulmonary segments?

anterior segmental bronchus of right superior lobe

medial segmental bronchus of right middle lobe

superior segmental bronchus of right inferior lobe

medial basal segmental bronchus of left inferior lobe

inferior segmental bronchus of lingular lobe


40. A 22-year-old male involved in a bar-room brawl suffered a stab wound
through the posterior thoracic wall that entered the posterior surface of the
right lung half way between its apex and diaphragmatic surface. Which part of
the lung did the knife first enter?

Cupola
Inferior lobe

Lingula

Middle lobe

Superior lobe
41. A 20-year-old man was stabbed in the back with a knife that just nicked his
right lung halfway between its apex and diaphragmatic surface. Which part of
the lung was most likely injured?

Middle lobe

Inferior lobe

Cardiac notch

Lingula

Superior lobe
42. 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?

Anterior basal segment--inferior lobe

Anterior segment--superior lobe

Lateral segment--middle lobe

Superior segment--inferior lobe

Superior lingual segment--lingula


43. You are observing a doctor perform a bronchoscopy. As he passes the
bronchoscope down the trachea, a cartilagenous structure is observed
separating the right and left main stem bronchi. He asks what it is called. You
reply that it really does look like a ship's keel and that it is called the:

Carina

Cricoid cartilage

Costal cartilage

Pulmonary ligament

Tracheal ring
44. The minor (horizontal) fissure separates:

the lower lobe from the lingula


the upper lobe from the lingula

the lower lobe from both the middle and upper lobes

the lower lobe from the middle lobe

the middle lobe from the upper lobe


45. Your patient, an 86-year-old female who has been bed-ridden and lying supine
for many weeks, has developed a right lung abscess that is draining by gravity
into one particular region of the lung. Where is the most likely site of fluid
accumulation?

Apical segment of upper lobe

Lingula

Lower lobe

Middle lobe

Superior segment of lower lobe


46. Because of its angle with the trachea and size of the main bronchus, a
bronchoscope would pass more readily into which lung?

Left

Right
47. Which vessel courses across the mediastinum in an almost horizontal
fashion?

Left subclavian artery

Left subclavian vein

Left brachiocephalic vein

Left internal jugular vein

Left common carotid artery


48. A 78-year-old female presented with edema of the left upper limb due to poor
venous return. Examination revealed an aneurysm of the ascending aorta that
was impinging on a large vein lying immediately anterosuperior to it, most
likely the:

Azygos v.

Internal thoracic v.

Left brachiocephalic v.

Left superior intercostal v.

Right brachiocephalic v.
49. An 8-year-old boy is found to have a mid-line tumor of the thymus gland that is
impinging posteriorly on a blood vessel. The affected vessel is most likely the:

left brachiocephalic vein

left pulmonary vein

left bronchial vein

right pulmonary artery

right superior intercostal vein


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

brainstem

celiac ganglion

chain ganglion

spinal cord

superior mesenteric ganglion


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

Afferent fiber from cutaneous blood vessels of the nose

Afferent fiber from skin around the nipple

Efferent fibers to sweat glands in the lumbar region

Efferent fibers to skin of the forehead

Parasympathetic fibers to the heart


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

aorta

heart

lung

sweat glands

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

aorta

azygos vein
esophagus

superior vena cava

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

Anterior

Middle

Posterior

All of the above

None of the above


55. Which structure contains postganglionic sympathetic fibers?

greater thoracic splanchnic nerve

recurrent larygneal nerve

white ramus communicans

ulnar nerve

vagus nerve
56. Which posterior mediastinal structure is most closely applied to the posterior
surface of the pericardial sac?

aorta

azygos vein

esophagus

thoracic duct

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

Arch of the aorta

Esophagus

Inferior vena cava

Pulmonary trunk

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

Anterior only

Anterior and middle

Middle only

Middle and posterior

Posterior only
59. 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:

Anterior mediastinum

Middle mediastinum

Posterior mediastinum

Superior mediastinum
60. 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:

Hemiazygos vein

Left bronchial vein

Left pulmonary vein

Superior vena cava

Thoracic duct
61. 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?

Arrector pili muscle activity

Dilation/constriction of blood vessels

Sweat production

Visceral reflex activity

Voluntary muscle activity


62. 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:
Left brachiocephalic vein

Left bronchial vein

Left pulmonary vein

Left subclavian vein

Superior vena cava


63. 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

Greater thoracic splanchnic nerve

Sympathetic trunk

Phrenic nerve

Pulmonary plexus

Vagus nerve
64. 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?

Superior vena cava

Inferior vena cava

Internal thoracic vein

Right brachiocephalic vein

Superior epigastric vein


65. 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:

Pleurisy

Chylothorax

Pyothorax

Hemothorax

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

Right vagus nerve

Right phrenic nerve


Right sympathetic trunk

Right greater thoracic splanchnic nerve

Right 9th intercostal nerve


67. 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?

Cervicothoracic (stellate) ganglion

Dorsal roots of cervical nerves

Greater thoracic splanchnic nerve

Lumbar sympathetic trunk

Vagus nerve
68. 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?

Greater thoracic splanchnic nerve

Left recurrent laryngeal nerve

Right pulmonary artery

Sympathetic trunk

Thoracic duct
69. 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?

Accessory hemiazygos vein

Left internal thoracic artery

Left phrenic nerve

Left recurrent laryngeal nerve

Thoracic duct
70. 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:

Azygos vein

Left brachiocephalic artery

Pericardiacophrenic artery

Right pulmonary vein

Superior vena cava


71.
The second costal cartilage can be located by palpating the:

costal margin

sternal angle

sternal notch

sternoclavicular joint

xiphoid process
72. The thoracic wall is innervated by:

Dorsal primary rami

Intercostal nerves

Lateral pectoral nerves

Medial pectoral nerves

Thoracodorsal nerves
73. The sternocostal surface of the heart is formed primarily by the anterior wall of
which heart chamber?

Left atrium

Left ventricle

Right atrium

Right ventricle
74. 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?

Left atrium

Left ventricle
Right atrium

Right ventricle
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?

costodiaphragmatic recess

costomediastinal recess

cupola

hilar reflection

middle mediastinum
76. 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:

coronary sinus

coronary sulcus

costomediastinal recess

oblique sinus

transverse sinus
77. When inserting a chest tube, intercostal vessels and nerves are avoided by
placing the tube immediately:

above the margin of a rib

below the margin of a rib


78. A hand slipped behind the heart at its apex can be extended upwards until
stopped by a line of pericardial reflection that forms the:

Cardiac notch

Costomediastinal recess

Hilar reflection

Oblique pericardial sinus

Transverse pericardial sinus


79. The first rib articulates with the sternum in close proximity to the:

Nipple

Root of the lung

Sternal angle

Sternoclavicular joint

Xiphoid process
80. The portion of the parietal pleura that extends above the first rib is called the :

costodiaphragmatic recess

costomediastinal recess

costocervical recess

cupola

endothoracic fascia
81. 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--

left phrenic

left sympathetic trunk

left vagus

right phrenic

right sympathetic trunk


82. 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?

Cardiac notch

Coronary sinus

Oblique pericardial sinus

Coronary sulcus

Transverse pericardial sinus


83. A needle inserted into the 9th intercostal space along the midaxillary line
would enter which space?
Cardiac notch

Costodiaphragmatic recess

Costomediastinal recess

Cupola

Oblique pericardial sinus


84. During a heart transplant procedure, the surgeon inserted his left index finger
through the transverse pericardial sinus, and then pulled forward on the two
large vessels lying ventral to his finger. Which vessels were these?

Pulmonary trunk and brachiocephalic trunk

Pulmonary trunk and aorta

Pulmonary trunk and superior vena cava

Superior vena cava and aorta

Superior vena cava and right pulmonary artery


85. While observing in the OR, you see the resident insert a needle through the
body wall just above the ninth rib in the mid-axillary line. She was obviously
trying to enter the:

Costodiaphragmatic recess

Costomediastinal recess

Cupola

Hilar reflection

Pulmonary ligament
86. The pleural cavity near the cardiac notch is known as the:

Costodiaphragmatic recess

Costomediastinal recess

Cupola

Hilum

Pulmonary ligament
87. The tubercle of the 7th rib articulates with which structure?

Body of vertebra T6

Body of vertebra T7

Body of vertebra T8
Transverse process of vertebra T6

Transverse process of vertebra T7


88. 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?

Accessory hemiazygos vein

Left internal thoracic artery

Left phrenic nerve

Left recurrent laryngeal nerve

Thoracic duct
89. A 16-year-old male suffered a stab wound in which a knife blade entered
immediately superior to the upper edge of the right clavicle near its head. He
was in extreme pain, which was interpreted by the ER physician as a likely
indicator of a collapsed lung following disruption of the pleura. If that was true,
what portion of the pleura was most likely cut or torn?

costal pleura

cupola

hilar reflection

mediastinal pleura

pulmonary ligament
90. During a lung transplant procedure, an observing 4th year attempted to pass
his index finger posteriorly inferior to the root of the left lung, but he found
passage of the finger blocked. Which structure would most likely be
responsible for this?

Costodiaphragmatic recess

Cupola

Inferior vena cava

Left pulmonary vein

Pulmonary ligament
91. Which of the following layers provides a natural cleavage plane for surgical
separation of the costal pleura from the thoracic wall?

Deep fascia

Endothoracic fascia

Parietal pleura
Visceral pleura

Transversus thoracis muscle fascia


92. The lowest extent of the pleural cavity, into which lung tissue does not extend,
is known as the:

costodiaphragmatic recess

costomediastinal recess

cupola

inferior mediastinum

pulmonary ligament
93. The sternal angle is a landmark for locating the level of the:

Costal margin

Jugular notch

Second costal cartilage

Sternoclavicular joint

Xiphoid process
94. A 3rd-year medical student was doing her first physical exam. In order to
properly place her stethoscope to listen to heart sounds, she palpated bony
landmarks. She began at the jugular notch, then slid her fingers down to the
sternal angle. At which rib (costal cartilage) level were her fingers?

Can't be determined

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