Dib-dibin mo na toh!

(Chest and <3)

Questions in Red Answers in Blue
1.
The second costal cartilage can be
located by palpating the:
a) costal margin
b) sternal angle
c) sternal notch
d) sternoclavicular joint
e) xiphoid process
The sternal angle is the point where the costal
cartilage attaches the second rib to the
sternum. This is an important anatomical
landmark to remember--it is used to find the
valves when auscultating the heart! The costal
margins are formed by the medial borders of
the 7th through 10th costal cartilages. They
are easily palpable and extend inferolaterally
from the xiphisternal joint. The sternal
notch/jugular notch is the notch located at the
superior border of the manubrium, between
the sternal ends of the clavicles. The
sternoclavicular joints are simply the joints
connecting the sternum with the clavicles.
Finally, the xiphoid process is the bone that
makes the inferior part of the sternum.
2.

The thoracic wall is innervated by:

a) Dorsal primary rami
b) Intercostal nerves
c) Lateral pectoral nerves
d) Medial pectoral nerves
e) Thoracodorsal nerves

Intercostal nerves are the ventral primary rami

of spinal nerves T1-T11. They provide motor
innervation to intercostal muscles, abdominal

wall muscles (via T7-T11) and muscles of the

forearm and hand (via T1). They provide
sensory innervation to the skin of the chest
and abdomen on the anterior and lateral sides.
The other nerves listed do not innervate the
chest wall. Dorsal primary rami provide motor
innervation to true back muscles and sensory
innervation to the skin on the back. The lateral
pectoral nerve provides motor innervation to
pectoralis major only, while the medial
pectoral nerve provides motor innervation to
pectoralis major and minor. The thoracodorsal
nerve provides motor innervation to latissimus
dorsi
3.
The sternocostal surface of the heart
is formed primarily by the anterior wall of
which heart chamber?
a) Left atrium
b) Left ventricle
c) Right atrium
d) Right ventricle
The heart has three important surfaces: an
anterior surface, a diaphragmatic surface, and
a pulmonary surface. The anterior surface, or
sternocostal surface, is mostly made up of the
right ventricle. The diaphragmatic surface is
mostly the left ventricle, but a little bit of the
right ventricle sits on the diaphragm as well.
Finally, the pulmonary surface, which is on the
left, is mostly made up of the left ventricle.
4.
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

Medicine 1-C
Batch 2017
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
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. Definitely not the wrong ventricle :D
5.
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
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. At the mid-clavicular line,

Jose Isiah R. Planes

Medicine 1-C
Batch 2017

Dib-dibin mo na toh! (Chest and <3)

the costodiaphragmatic recess is between ribs
6 and 8; at the midaxillary line it is between 8
and 10; and at the paravertebral line it is
between 10 and 12.
The costomediastinal recess is found where
the costal pleura becomes the mediastinal
pleura. The cupola is the part of the pleural
cavity which extends above the level of the 1st
rib into the root of the neck. The hilar
reflection is the point at the root of the lung
where the mediastinal pleura is reflected and
becomes continuous with the visceral pleura.
Finally, the middle mediastinum is the space in
the mediastinum which contains the heart,
pericardium, great vessels, and bronchi (at the
roots of the lung).

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.
The coronary sinus is a large vein on the heart
which drains into the right atrium. The
coronary sulcus is a groove on the heart which
separates the atria from the ventricles. The
costomediastinal recess is an area in the
pleural sac where the costal pleura changes to
the mediastinal pleura.

6.
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

7.
When inserting a chest tube,
intercostal vessels and nerves are avoided by
placing the tube immediately:
a) above the margin of a rib
b) below the margin of a rib
c) tinamad magtype 2 choices na lang

The oblique sinus is an area of the pericardial

cavity located behind the left atrium of the
heart where the serous pericardium reflects

The VAN triad of an intercostal vein, artery,

and nerve run along the bottom of a rib, in the
costal groove. To avoid hitting any of these
important structures, it is important to
remember to always place a tube or needle
above the margin of a rib (or,if you prefer to
think about it this way, at the bottom of an
intercostal space).
8.
A hand slipped behind the heart at its
apex can be extended upwards until stopped
by a line of pericardial reflection that forms
the:

a)
b)
c)
d)
e)

Cardiac notch
Costomediastinal recess
Hilar reflection
Oblique pericardial sinus
Transverse pericardial sinus

The oblique pericardial sinus is an area of the

pericardial cavity located behind the left
atrium of 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 this space. 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.
The cardiac notch is an indentation in the
superior lobe of the left lung which creates the
lingula. The costomediastinal recess is an area
in the pleural sac where the costal pleura
changes to the mediastinal pleura. Finally, the
hilar reflection is the reflection of pleura on
the root of the lung, where visceral pleura on
the lung becomes continuous with the
mediastinal pleura.
9.
The first rib articulates with the
sternum in close proximity to the:
a) Nipple
b) Root of the lung
c) Sternal angle
d) Sternoclavicular joint
e) Xiphoid process

Jose Isiah R. Planes

Medicine 1-C
Batch 2017

Dib-dibin mo na toh! (Chest and <3)

The first rib articulates with the sternum
directly below the sternoclavicular joint. The
nipple is found in the fourth intercostal space,
between the 4th and 5th ribs. The sternal
angle is connected to the costal cartilage of rib
2. Finally, the xiphoid process is located just
below the point where the costal cartilage of
rib 7 articulates with the sternum. The root of
the lung consists of the main bronchus,
pulmonary and bronchial vessels, lymphatic
vessels, and nerves entering and leaving the
lung.
10.
The portion of the parietal pleura that
extends above the first rib is called the :
a) costodiaphragmatic recess
b) costomediastinal recess
c) costocervical recess
d) cupola
e) endothoracic fascia
The cupola is the cervical parietal pleura which
extends slightly above the level of the 1st rib
into the root of the neck. The
costodiaphragmatic recess is the part of the
pleural sac where the costal pleura changes
into the diaphragmatic pleura. It is the lowest
extent of the pleural sac. The costomediastinal
recess is found where the costal pleura
becomes the mediastinal pleura. Endothoracic
fascia is connective tissue between the inner
chest wall and costal parietal pleura. The
costocervical recess is a made up term
11.
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, "Please repeat the question
a)
b)
c)
d)
e)

left phrenic
left sympathetic trunk
left vagus
right phrenic
right sympathetic trunk

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.
The left and right phrenic nerves, which
innervate the diaphragm, are lateral to the
vagus nerves and are not looping near the
aortic arch. The left and right sympathetic
trunks lie on the posterior chest wall and are
not involved with the aortic arch.
12.
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
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. You should understand what these two
sinuses are and how they can be entered!
The cardiac notch is a structure on the left lung
which separates the lingula below from the
upper portion of the superior lobe of left lung.
The coronary sinus is a venous sinus on the
posterior surface of the heart which receives
blood from the smaller veins which drain the
heart. The coronary sulcus is a groove on the
heart, between the atria and ventricles. The
coronary sinus, circumflex artery, and right
coronary artery lie in the coronary sulcus
13.
A needle inserted into the 9th
intercostal space along the midaxillary line
would enter which space?
a) Cardiac notch
b) Costodiaphragmatic recess
c) Costomediastinal recess

Jose Isiah R. Planes

Dib-dibin mo na toh! (Chest and <3)

d) Cupola
e) Oblique pericardial sinus
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. It 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. At the
mid clavicular line, the costodiaphragmatic
recess is between ribs 6 and 8; at the
midaxillary line it is between 8 and 10; and at
the paravertebral line it is between 10 and 12.
So, inserting the needle just above the 9th rib
at the midaxillary line should put you in the
costodiaphragmatic recess.
The cardiac notch is a structure on the left lung
which separates the lingula below from the
upper portion of the superior lobe of left lung.
The costomediastinal recess is found where
the costal pleura becomes the mediastinal
pleura. The cupola is the part of the pleural
cavity which extends above the level of the 1st
rib into the root of the neck. The oblique
pericardial sinus is an area of the pericardial
cavity located behind the left atrium of the
heart.
14.
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?
a) Pulmonary trunk and brachiocephalic
trunk

b) Pulmonary trunk and aorta

c) Pulmonary trunk and superior vena
cava
d) Superior vena cava and aorta
e) Superior vena cava and right
pulmonary artery
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. So, the two large vessels
lying ventral to his finger are the pulmonary
trunk and aorta; the large vessel lying dorsal to
his finger is the superior vena cava.
15.
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:
a) Costodiaphragmatic recess
b) Costomediastinal recess
c) Cupola
d) Hilar reflection
e) Pulmonary ligament
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. It 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. At the
mid clavicular line, the costodiaphragmatic
recess is between ribs 6 and 8; at the
midaxillary line it is between 8 and 10; and at
the paravertebral line it is between 10 and 12.
So, inserting the needle just above the 9th rib

Medicine 1-C
Batch 2017
at the midaxillary line should put the resident's
needle in the costodiaphragmatic recess. Make
sure you know where to enter the
costodiaphragmatic recess at the midclavicular
line, the mid axillary line, and the
paravertebral line!
The costomediastinal recess is found where
the costal pleura becomes the mediastinal
pleura. The cupola is the part of the pleural
cavity which extends above the level of the 1st
rib into the root of the neck. The hilar
reflection is the point at the root of the lung
where the mediastinal pleura is reflected and
becomes continuous with the visceral pleura.
The pulmonary ligament is a fold of pleura
located below the root of the lung, where the
visceral pleura and the mediastinal parietal
pleura are continuous with each other.
16.
The pleural cavity near the cardiac
notch is known as the:
a) Costodiaphragmatic recess
b) Costomediastinal recess
c) Cupola
d) Hilum
e) Pulmonary ligament
The costomediastinal recess is an area right
next to the cardiac notch, which is an
indentation in the superior lobe of the left
lung. If you take a very deep breath, the lingula
of the left lung, which is formed by the cardiac
notch, will tend to expand into the
costomediastinal 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

Jose Isiah R. Planes

Dib-dibin mo na toh! (Chest and <3)

changes into the diaphragmatic pleura. The
cupola is the part of the pleural cavity which
extends above the level of the 1st rib into the
root of the neck. The hilum is found on the
medial surface of the lung--it is the point at
which the structures forming the root enter
and leave the lung. The pulmonary ligament is
a fold of pleura located below the root of the
lung, where the visceral pleura and the
mediastinal parietal pleura are continuous
with each other.
17.
The tubercle of the 7th rib articulates
with which structure?
a) Body of vertebra T6
b) Body of vertebra T7
c) Body of vertebra T8
d) Transverse process of vertebra T6
e) Transverse process of vertebra T7
The tubercle of a rib is a projection located
posteroinferior and lateral to the neck of the
rib. It articulates with the transverse process of
the vertebra of the same number. So, the
tubercle of rib 7 should articulate with the
transverse process of the T7 vertebra. The
head of the rib is the part of the rib that
articulates with the demifacets of two adjacent
vertebral bodies. So, the head of rib 7 should
articulate with the 6th vertebra superiorly and
the 7th vertebra inferiorly
18.
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?

a)
b)
c)
d)
e)

Accessory hemiazygos vein

Left internal thoracic artery
Left phrenic nerve
Left recurrent laryngeal nerve
Thoracic duct

The left recurrent laryngeal nerve is a branch

of the vagus that wraps around the aorta,
posterior to the ductus arteriosus or
ligamentum arteriosum. It then travels
superiorly to innervate muscles of the larynx.
It's important to protect this nerve during
surgery! If the left recurrent laryngeal nerve
becomes paralyzed, a patient might
experience a hoarse voice or even have
difficulty breathing due to a laryngeal spasm.
You should make sure that you understand
what this nerve does, what types of
procedures might injure this nerve, and the
effects of a damaged left recurrent laryngeal
The accessory hemiazygos vein is a vein on the
left side of the body. It drains the
posterolateral chest wall and empties blood
into the azygos vein. The left internal thoracic
artery is a branch of the left subclavian artery
that supplies blood to the anterior thoracic
wall. The left phrenic nerve runs lateral to the
vagus nerve and its branches in the thorax; it is
not close enough to be damaged by the
surgery. The thoracic duct is deep in the chest it travels between the azygos vein and the
aorta, posterior to the esophagus.
19.
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

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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?
a) costal pleura
b) cupola
c) hilar reflection
d) mediastinal pleura
e) pulmonary ligament
The cupola is the part of the plural cavity
which extends above the level of the 1st rib
into the root of the neck. So, if a patient was
stabbed above the clavicle, it would be very
likely that the cupola was damaged. The costal
pleura is the layer of parietal pleura that
covers the costal surface. The hilar reflection is
the point where the visceral pleura of the lung
reflects to become continuous with the
parietal pleura. The mediastinal pleura is the
parietal pleura on the mediastinal surface,
found medial to the lung. Finally, the
pulmonary ligament is a double layer of pleura
extending from the inferior end of the hilar
reflection downward to the diaphragm below
20.
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?
a) Costodiaphragmatic recess
b) Cupola
c) Inferior vena cava
d) Left pulmonary vein

Jose Isiah R. Planes

Medicine 1-C
Batch 2017

Dib-dibin mo na toh! (Chest and <3)

e)

Pulmonary ligament

The pulmonary ligament is a double layer of

pleura extending from the inferior end of the
hilar reflection downward to the diaphragm.
So, it is a structure that would block you from
moving your finger posteriorly at the root of a
lung. The costodiaphragmatic recess is the
space at the inferior border of the lung where
the costal pleura touches the diaphragmatic
pleura. The cupola is the part of the pleura
that extends superiorly above the first rib--it's
not associated with the root of the lung in any
way. The inferior vena cava is found in the
mediastinum and would not be near the root
of the lung. The left pulmonary veins are part
of the root of the lung and would not block
someone from reaching behind the lung.

21.
Which of the following layers provides
a natural cleavage plane for surgical separation
of the costal pleura from the thoracic wall?
a) Deep fascia
b) Endothoracic fascia
c) Parietal pleura
d) Visceral pleura
e) Transversus thoracis muscle fascia
The endothoracic fascia is the connective
tissue between the inner aspect of chest wall
and the costal parietal pleura. By clearing the
endothoracic fascia, it is easy to separate the
costal pleura from the thoracic wall. Deep
fascia is a fascial layer that invests a muscle or
muscle group - it is not present around the
lungs. The parietal pleura is made up of the

cupula or cervical pleura, costal pleura,

diaphragmatic pleura, and mediastinal pleura.
It lines the inner surfaces of the walls of the
pleural cavity. The visceral pleura is the serous
membrane that covers the lungs. Finally, the
transversus thoracis muscle fascia is only
associated with the transversus thoracis - it
would not provide a natural cleavage plane for
separating the costal pleura from the thoracic
wall
22.
The lowest extent of the pleural
cavity, into which lung tissue does not extend,
is known as the:
a) costodiaphragmatic recess
b) costomediastinal recess
c) cupola
d) inferior mediastinum
e) pulmonary ligament

The costodiaphragmatic recess is the area

inferior to the lung where the costal and
diaphragmatic pleura are continuous. This is
the lowest extent of the pleural cavity. The
costomediastinal recess is a small anterior
recess where the costal and mediastinal pleura
are continuous. The cupola is the pleural space
that extends above the first rib. The inferior
mediastinum is a term sometimes used to
refer to the anterior, middle, and posterior
subdivisons of the mediastinum all together.
The pulmonary ligament is a fold of pleura
located beneath the root of the lung.
23.
The sternal angle is a landmark for
locating the level of the:

a)
b)
c)
d)
e)

Costal margin
Jugular notch
Second costal cartilage
Sternoclavicular joint
Xiphoid process

The sternal angle is a very important

anatomical landmark which is used when
placing the stethoscope and listening for heart
sounds. The sternal angle is the location of the
attachment of the costal cartilage of the
second rib to the sternum. So, once you locate
the sternal angle on a patient, you know the
location of the second rib, and you can use
that landmark to find the right spots to
auscultate each valve of the heart. Also
remember that a horizontal plane through the
sternal angle passes through the T4/T5
intervertebral disc and marks the inferior
boundary of the superior mediastinum.
24.
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?
a) 1
b) 2
c) 3
d) 4
2, Remember, the sternal angle is where the
costal cartilage of the second rib attaches to
the sternum. This is a significant landmark

Jose Isiah R. Planes

Medicine 1-C
Batch 2017

Dib-dibin mo na toh! (Chest and <3)

<3 <3 <3
25.
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
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.
The right coronary artery has two major
branches: the right marginal and the posterior
interventricular artery. (The right coronary also
gives off two smaller branches to the SA node
and the AV node.) The right marginal artery
supplies the right ventricle, while the posterior
IV artery supplies the interventricular septum
and the two ventricles. Neither of these
arteries provides a major source of blood to
the apex of the heart.
26.
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?
a) arch of the azygos vein
b) internal thoracic artery
c) left phrenic nerve
d) left recurrent laryngeal nerve
e) left superior intercostal vein
The left recurrent laryngeal nerve leaves the
vagus nerve and loops under the arch of the
aorta near the ligamentum arteriosum/ductus
arteriosis. When performing surgery in this
area, like the repair of a patent ductus
arteriosis, a surgeon must be very careful to
identify and preserve the left recurrent
laryngeal nerve. If this nerve is damaged, it
may lead to paralysis of the left vocal fold and
cause hoarseness in the patient.
The arch of the azygos vein is located on the
right side of the body and would not be
damaged by surgery near the aortic arch. The
internal thoracic artery is a branch of the
subclavian artery and is not near the ductus
arteriosis. The left phrenic nerve, which
innervates the diaphragm, is lateral to the
vagus nerve and would not be damaged in this
procedure. The left superior intercostal vein
lies lateral to the vagus and aortic arch, so it
would not be disturbed by surgery.
27.
A hand slipped behind the heart at its
apex can be extended upwards until stopped
by a line of pericardial reflection that forms
the:
a) Cardiac notch
b) Costomediastinal recess
c) Hilar reflection

d) Oblique pericardial sinus

e) Transverse pericardial sinus
The oblique pericardial sinus is an area of the
pericardial cavity located behind the left
atrium of 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 this space. 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.
The cardiac notch is an indentation in the
superior lobe of the left lung which creates the
lingula. The costamediastinal recess is an area
in the pleural sac where the costal pleura
changes to the mediastinal pleura. Finally, the
hilar reflection is the reflection of pleura at the
root of the lung, where visceral pleura on the
lung becomes continuous with the parietal
mediastinal pleura.
28.
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?
a) aortic
b) pulmonary
c) mitral
d) tricuspid
e) fossa ovalis

Jose Isiah R. Planes

Dib-dibin mo na toh! (Chest and <3)

The best place to listen to heart valves is not at
their actual sternocostal projections. If you
place your stethoscope exactly where a valve
is located, you may not hear anything because
the valve might be deep in the chest or the
sound might be muffled by bone or cartilage.
Instead, you want to listen to the valves by
putting your stethescope at a point
downstream from the valve where you can
hear the blood flowing and colliding with the
muscular chest wall. There are points of
auscultation for all four heart valves:
Pulmonic: left second intercostal space, lateral
to the sternal angle; Aortic: right second
intercostal space, lateral to the sternal angle;
Mitral: left fifth intercostal space, 8cm away
from the midline; Tricuspid: left fourth
intercostal space, just lateral to the sternum.
29.
Which valves would be open during
ventricular systole?
a) Aortic and pulmonary
b) Aortic and tricuspid
c) Mitral and aortic
d) Tricuspid and mitral
e) Tricuspid and pulmonary
Remember that ventricular systole is the
period when the ventricles are contracting.
This contraction forces blood out of the heart,
which pushes the aortic and pulmonary valves
open.
During systole, the tricuspid and mitral valves
are closed. They are prevented from
prolapsing (being pushed back into the atrium)
by the chordae tendinae and papillary muscles.

30.
Which chamber's anterior wall forms
most of the sternocostal surface of the heart?
a) Left atrium
b) Left ventricle
c) Right atrium
d) Right ventricle
The heart has three important surfaces: an
anterior surface, a diaphragmatic surface, and
a pulmonary surface. The anterior surface, or
sternocostal surface, is mostly made up of the
right ventricle. The diaphragmatic surface is
mostly the left ventricle, but a little bit of the
right ventricle sits on the diaphragm as well.
Finally, the pulmonary surface, which is on the
left, is mostly made up of the left ventricle.
31.
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?
a) 1
b) 2
c) 3
d) 4
Remember, the sternal angle is where the
costal cartilage of the second rib attaches to
the sternum. This is a significant landmark
32.
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

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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
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
33.
Which statement is true of the right
atrioventricular valve?
a) it is also called the mitral valve
b) it is open during ventricular diastole
c) it transmits oxygenated blood
d) it is opened by the pull of chordae
tendineae
e) it consists of 2 leaflets
Ventricular diastole is the period when the
ventricles relax and fill with blood. So, the AV
valves need to be open at this time so that
blood can flow from the atria to the ventricles.
The right AV valve is called the tricuspid valve-it has three leaflets. The left AV valve is called
the mitral valve and has two leaflets.
Remember, the right side of the heart is
pumping blood to the lungs so that it can be
oxygenated. So, the blood flowing through the
right AV valve will be deoxygenated, while the
blood flowing through the left AV valve will be
oxygenated. Finally, remember that the
chordae tendineae and the papillary muscles

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Dib-dibin mo na toh! (Chest and <3)

do not pull the AV valves open! These
structures serve to prevent the valves from
prolapsing during systole.
34.
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
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.
The coronary sinus is the large vein on the
posterior surface of the heart which drains into
the right atria. It receives blood from the great,
middle, and small cardiac veins, the oblique

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vein of the left atrium, and the left posterior

ventricular vein. The coronary sulcus is the
groove on the heart which separates the atria
from the ventricles. Many arteries and veins
run in this sulcus. The costomediastinal recess
is an area in the pleural sac where the costal
pleura changes to the mediastinal pleura.

between the right and left atria; this opening is

called the:
a) atrioventricular canal
b) coronary sinus
c) foramen ovale
d) sinus venosus
e) truncus arteriosis

35.
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:
a) acute marginal branch
b) circumflex branch
c) anterior interventricular (Left anterior
descending)
d) obtuse marginal
e) posterior interventricular (posterior
descending)

The foramen ovale is an opening in the

interatrial septum which exists in the fetus.
This opening and the ductus arteriosus serve
as two shunts which divert blood away from
the developing lungs. Both should close soon
after birth.
The coronary sinus is the large vein on the
posterior surface of the heart which drains into
the right atrium. It receives blood from the
great, middle, and small cardiac veins, the
oblique vein of the left atrium, and the left
posterior ventricular vein. The sinus venosus
and truncus arteriosus are structures in the
developing heart that will be covered in
embryology.

The right and left bundles of conduction travel

in the interventricular septum. So, the artery
that has been occluded must be the one that
supplies the interventricular septum. The most
important source of blood to the
interventricular septum is the anterior
interventricular artery, a branch of the left
coronary artery. Although the posterior
interventricular artery partially supplies blood
to the interventricular septum, it might not be
enough to support the tissue
36.
During fetal life and sometimes
persisting into the adult there is an opening

37.
The heart sound associated with the
mitral valve is best heard:
a) In the jugular notch
b) In the second left intercostal space
c) In the second right intercostal space
d) In the fifth left intercostal space
e) To the right of the xiphoid process
The four valves of the heart can be auscultated
at very distinct spaces. The mitral valve can be
ausculatated in the left 5th intercostal space,
slightly below the nipple.The aortic valve can
be ausculatated in the 2nd right intercostal

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Dib-dibin mo na toh! (Chest and <3)

space, just lateral to sternal angle. The
pulmonary valve can be auscultated in the 2nd
left intercostal space, just lateral to sternal
angle. The tricuspid valve can be auscultated in
the 4th left intercostal space, just lateral to
sternum.

Since the right ventricle forms the anterior, or

sternocostal, surface of the heart, this would
be the chamber most likely to be injured by
the blade. This is also the surface of the heart
most likely to be injured by an insult to the
anterior chest wall.

38.
Which heart valve has leaflets
described as "anterior, left and right"?
a) Aortic
b) Pulmonary
c) Left atrioventricular
d) Right atrioventricular

40.
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?
a) Below the left nipple
b) In the right 2nd intercostal space near
the sternum
c) Over the apex of the heart
d) Over the sternal angle
e) Xiphoid area, just off the sternum

The leaflets of the pulmonic valve are named

anterior, left, and right, according to their
orientation. The leaflets of the aortic valve are
named posterior, left, and right, with the left
and right aortic sinuses above these leaflets
giving off their respective coronary arteries.
The mitral valve has anterior and posterior
cusps, while the tricuspid valve has septal,
anterior, and smaller posterior cusps
39.
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?
a) Left atrium
b) Left ventricle
c) Right atrium
d) Right ventricle

It's best to listen to sounds associated with the

tricuspid valve at the fourth left intercostal
space, just lateral to the sternum. The answer
that comes the closest to this is E. What would
you hear in the other spaces? Below the left
nipple, in the fifth intercostal space, you would
be auscultating the mitral valve. This is also the
valve that you can hear at the apex of the
heart. The right 2nd intercostal space near the
sternum is the site for auscultating the aortic
valve
41.
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?

a)
b)
c)
d)
e)

Circumflex
Left marginal
Posterior interventricular
Right coronary
Right marginal

The anterior interventricular artery and

posterior interventricular artery travel on the
anterior and posterior surfaces of the
interventricular groove. These two vessels
often anastamose. If there was a very
extensive anastamosis between the anterior
and posterior interventricular arteries, it is
possible that the posterior interventricular
artery might supply the tissue usually fed by
the anterior interventricular artery. The other
arteries listed would not be able to
anastamose with anterior interventricular
artery; they supply other areas of the heart.
42.
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
The ligamentum arteriosum is the point where
the left pulmonary artery connects with the
undersurface of aortic arch. It is a remnant of

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the fetal ductus arteriosus, which shunted
blood away from the developing lungs.
Because the aorta is tethered to the
pulmonary artery by the ligamentum
arteriosum, the part of the aorta near the
ligamentum is vulnerable to damage in a
traumatic acceleration/deceleration injury - it
could pull away and tear. The other answer
choices do not describe points of the aorta
where a mobile and fixed portion meet.
Therefore, these parts of the aorta would not
be vulnerable to this type of traumatic injury.
43.
Which structure does NOT lie in the
coronary sulcus?
a) circumflex artery
b) coronary sinus
c) right coronary artery
d) right marginal artery
e) left coronary artery
The coronary sulcus is the groove which
separates the atria from the ventricles. The
right and left coronary arteries, circumflex
artery, and coronary sinus all lie in this groove.
The right marginal artery is a branch of the
right coronary artery which lies on the right
ventricle and supplies that chamber of the
heart.
44.
Which
structure
contains
postganglionic sympathetic fibers?
a) greater thoracic splanchnic nerve
b) recurrent laryngeal nerve
c) sympathetic trunk
d) ulnar nerve
e) vagus nerve

When a 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 ramus communicans.
Second, the preganglionic nerve fibers can
travel up or 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.
45.
Which posterior mediastinal structure
is most closely applied to the posterior surface
of the pericardial sac?
a) Aorta
b) Azygos vein
c) Esophagus
d) Thoracic duct
e) Trachea
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, just above the diaphragm, 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

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sac. Finally, the trachea is superior to the
heart.
46.
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?
a) trachea
b) root of the left lung
c) phrenic nerve
d) thoracic duct
e) descending aorta
Below the level of the sternal angle, the
thoracic duct lies posterior to the esophagus,
between the azygos vein and the descending
aorta. So, if the azygos vein became dilated, it
could impinge on the thoracic duct. The
trachea is superior to the azygos vein, which
loops over the right bronchus before emptying
into the superior vena cava. This means that a
dilated azygos vein would have little impact on
the trachea. Because the azygos is on the right
side of the body, it could not compress
anything at the root of the left lung. The right
phrenic nerve is anterior to the azygos vein.
The descending aorta is much larger and more
muscular than the azygos vein, so it is unlikely
that it would be compressed by this much
smaller structure
47.
Elevated systolic blood pressure in the
right ventricle suggests stenosis of which
valve?
a) Aortic

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b) Mitral
c) Pulmonary
d) Tricuspid
You need to identify the valve immediately
distal to the area of high pressure. This is the
valve that must be blocked, because you can
assume that blood is backing up into the area
where the pressure is high. In this case,
pressure is high in the right ventricle. So, there
must be stenosis of the pulmonic valve, which
allows blood to leave the right ventricle and
travel to the lung.
If there was stenosis of the aortic valve,
pressure would be high in the left ventricle. If
there was stenosis of the tricuspid valve,
pressure would be high in the right atrium. If
there was stenosis of the mitral valve, pressure
would be high in the left atrium.
48.
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?
a) Aortic
b) Mitral
c) Pulmonary
d) Tricuspid
The four valves of the heart can be auscultated
at very distinct spaces. The mitral valve, which
separates the left atrium from the left
ventricle, can be ausculatated in the left 5th
intercostal space, slightly below the nipple.

This is where this patient's murmur is heard.

The tricuspid valve, which separates the right
atrium from the right ventricle, can be
auscultated in the 4th left intercostal space,
just lateral to sternum. The aortic valve, which
separates the left ventricle from the aorta, can
be ausculatated in the 2nd right intercostal
space, just lateral to sternal angle. The
pulmonary valve, which separates the right
ventricle from the pulmonary artery, can be
auscultated in the 2nd left intercostal space,
just lateral to sternal angle.
49.
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:
a) Just below the nipple on the left
b) Just to the left of the xiphisternal
junction
c) Near the sternal angle
d) Through the jugular notch
e) 4th left intercostal space in the
midaxillary line
Just to the left of the xiphisternal junction.
When fluid accumulates in the pericardial sac,
it is necessary to remove that fluid by
performing a pericardiocentesis. A needle is
inserted just to the left of the xiphisternal
junction, and the needle passes superiorly to

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enter the pericardial sac. Then, the fluid can be
aspirated into the needle.
50.
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?
a) Left atrium
b) Left ventricle
c) Right atrium
d) Right ventricle
The right ventricle forms the anterior
(sternocostal) surface of the heart. So, this is
the surface of the heart that lies against the
sternum and would be injured following a
crushing blow to the sternum. There are 2
other surfaces of the heart of which you
should be aware. The diaphragmatic surface of
the heart is formed by the left ventricle, with a
little bit of the right ventricle. This is the
surface of the heart which is in contact with
the diaphragm. The pulmonary surface of the
heart is on the left side of the heart. It is
mostly formed by the left ventricle
51.
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?
a) Anterior cardiac vein
b) Coronary sinus

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c) Great cardiac vein
d) Middle cardiac vein
e) Small cardiac vein
The anterior interventricular artery lies in the
anterior interventricular sulcus. Then, you
need to identify the vein that also lies in the
anterior interventricular sulcus. And that vein
is the great cardiac vein. The anterior cardiac
vein lies on the surface of the right atrium--it
drains directly into the right atrium. The
coronary sinus is located in the coronary
(atrioventricular) sulcus--it is formed by the
union of the great cardiac vein and the oblique
vein of the left atrium, and it drains blood
directly into the right atrium. The middle
cardiac vein is located in the posterior
interventricular sulcus--it accompanies the
posterior interventricular artery. The small
cardiac vein courses through the coronary
sulcus with the right coronary artery.
52.
While listening to a patient's heart
sounds with a stethoscope, you identify a highpitched 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?
a) Aortic
b) Mitral
c) Pulmonary
d) Tricuspid
Aortic. The four valves of the heart can be
auscultated at very distinct spaces. The aortic
valve, which separates the left ventricle from
the aorta, can be auscultated in the 2nd right

intercostal space, just lateral to sternal angle.

Since this is the space where the murmur is
heard, the problem must be with the aortic
valve. The mitral valve, which separates the
left atrium from the left ventricle, can be
auscultated in the left 5th intercostal space,
slightly below the nipple. The pulmonary valve,
which separates the right ventricle from the
pulmonary artery, can be auscultated in the
2nd left intercostal space, just lateral to sternal
angle. The tricuspid valve, which separates the
right atrium from the right ventricle, can be
auscultated in the 4th left intercostal space,
just lateral to sternum.
53.
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?
a) top of interspace 8 in the
midclavicular line
b) bottom of interspace 8 in the
midclavicular line
c) top of interspace 9 in the midaxillary
line
d) bottom of interspace 9 in the
midaxillary line
e) the top of interspace 11 in the
scapular line
the bottom of interspace 9 in the midaxillary
line. For a thoracocentesis, the needle needs
to be inserted below the level of the lungs, in
the costodiaphragmatic recess. At the
midclavicular line, the recess is between rib
spaces 6 and 8, at the midaxillary line it is

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between 8 and 10, and at the paravertebral
line between 10 and 12. Additionally, the
needle needs to be inserted at the top of the
rib (or the bottom of the intercostal space).
This is essential for avoiding damage to the
neurovascular bundles that are found below
the ribs, running in the costal groove. Taken
together, these two pieces of information
point to the conditions listed in D as the only
appropriate ones for a thoracocentesis.
54.
The pleural space into which lung
tissue just above the cardiac notch would tend
to expand during deep inspiration is the:
a) Anterior mediastinum
b) Costodiaphragmatic recess
c) Costomediastinal recess
d) Cupola
e) Pulmonary ligament
The costomediastinal recess is an area right
next to the cardiac notch, which is an
indentation in the superior lobe of the left
lung. This is where the medial area of the
superior lobe of the left lung would tend to
expand if it became very inflated. The lung
would not enter the anterior mediastinum,
which is an area between the two pleural sacs,
bounded anteriorly by the sternum and
posteriorly by the pericardium. The anterior
mediastinum
contains
areolar
tissue,
sternopericardial ligaments, lymph vessels and
nodes,
but
no
lung
tissue.
The
costodiaphragmatic recess is the recess at the
inferior border of a lung. This is the space into
which the inferior lobe of the lung would
expand following deep inhalation. The cupola

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is the serous membrane lining the pleural
cavity which extends above the level of the 1st
rib into the root of the neck. The most superior
portion of the superior lobe might expand into
this space. The pulmonary ligament is the fold
of pleura located below the root of the lung
where the visceral pleura and the mediastinal
parietal pleura are continuous with each other
55.
lung?
a)
b)
c)
d)
e)

Which feature is found only in the left

Cardiac notch
Horizontal fissure
Oblique fissure
Superior lobar bronchus
Three lobes

The cardiac notch is only found on the left

lung, which makes sense since the heart is
located on the left side of the mediastinum.
The horizontal fissure is a deep groove that
separates the middle lobe from the upper lobe
of the right lung. The left lung does not have a
horizontal fissure. The oblique fissure is found
in both lungs. It separates the upper lobe from
the lower lobe in both lungs and the middle
lobe from the lower lobe in the right lung.
Both lungs also have a superior lobar bronchus
leading to their superior lobes. Finally, the
right lung has three lobes while the left lung
has two lobes.
56.
Which of the following nerves would
be most vulnerable to irritation when the
tracheobronchial lymph nodes are enlarged
due to a diseased situation?

a)
b)
c)
d)
e)

Right phrenic
Left phrenic
Right recurrent laryngeal
Left recurrent laryngeal
Right vagus

Left recurrent laryngeal. The tracheobronchial

nodes are at the tracheal bifurcation. There
are three groups of these nodes: right
superior, left superior, and inferior. The aorta
loops over the left bronchus, near the tracheal
bifurcation. So, it is reasonable to assume that
any nerve that is closely associated with the
aorta might be irritated if the tracheobronchial
lymph nodes became inflamed. This means
that the correct answer is the left recurrent
laryngeal nerve, which loops under the aorta
to ascend to the larynx.
The right and left phrenic nerves are lateral
and would not be irritated by the
inflammation. The right recurrent laryngeal
nerve loops around the right subclavian artery
and is not close enough to this area. Finally,
the right vagus is not closely associated with
the aorta.
57.
Which part of the left lung might
partially fill the costomediastinal recess in full
inspiration?
a) Apex
b) Cupola
c) Hilum
d) Lingula
e) Middle lobe

Medicine 1-C
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When inspiring fully, the lingula of the left lung
might partially fill the costomediastinal recess.
The lingula, a tongue-like projection of the left
lung below the cardiac notch, is right next to
the costomediastinal recess. If the apex of the
lung was highly inflated, it might expand to fill
the cupola. The hilum is the part of the lung
where the structures forming the root of the
lung--the main bronchus, pulmonary vessels,
bronchial vessels, lymphatics, and nerve--enter
and leave the lung. It does not expand on
inspiration. The middle lobe of the lung may
expand to fill the costomediastinal recess, but
remember that the question is specifically
asking about a left lung structure, and the
middle lobe is only in the right lung!
58.
The oblique fissure of the right lung
separates which structures?
a) Lower lobe from lingula
b) Lower lobe from upper lobe only
c) Lower lobe from both upper and
middle lobes
d) Lower lobe from middle lobe only
e) Upper from middle lobe
Lower lobe from both middle and upper lobe
The oblique fissure cuts across the right lung in
such a way as to separate the lower lobe from
both the middle and upper lobes. So what
does the horizontal fissure do? It separates the
middle lobe from the upper lobe. Remember
that the lingula is only on the left lung, and it is
part of the superior lobe.

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59.
In a post-soccer match brawl, a 35year-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
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. sorry
mataray ;p)
60.
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
a) Left main bronchus
b) Lingular segment of left lung

c) Right main bronchus

d) Terminal bronchiole of right lung,
lower lobe
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. It would be almost
impossible for a bead to get lodged in the
terminal bronchiole of the right lung--that is a
very small space!
61.
Which statement is true about the
right lung?
a) it is slightly smaller than the left lung
b) it has a lingular segmental bronchus
c) it occupies the rightmost portion of
the mediastinum
d) its upper lobar bronchus lies behind
and above the right pulmonary artery
e) it has the right phrenic nerve passing
posterior to the lung root
Its upper lobar bronchus lies behind and
above the right pulmonary artery. The
structures at the root of the lung have
different relationships in the right and left
lungs. On both sides, the pulmonary veins are
anterior and inferior while the bronchus is
posterior. The difference between the two

Medicine 1-C
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sides involves the pulmonary arteries. On the
right side, the arteries are anterior to the
bronchus, while on the left side the arteries
are superior to the bronchus. The right lung is
slightly larger than the left lung, and the
lingula is found in the left lung only. Neither
lung is in the mediastinum--the mediastinum is
the space between the two pleural sacs.
Finally, the phrenic nerve passes anterior to
the root of the lung--on both the left and right
sides.
62.
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
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

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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.
63.
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?
a) anterior segmental bronchus of right
superior lobe
b) medial segmental bronchus of right
middle lobe
c) superior segmental bronchus of right
inferior lobe
d) medial basal segmental bronchus of
left inferior lobe
e) inferior segmental bronchus of
lingular lobe
Superior segmental bronchus of right inferior
lobe. Inhaled material tends to go into the
right bronchus because it is bigger and more
vertically orientated than the left! The superior
segmental bronchus branches posteriorly off
of the intermediate bronchus or the inferior
lobe bronchus, so it is the segmental bronchus
most likely to receive the foreign bodies that
enter the right main bronchus.
64.
A 22-year-old male involved in a barroom 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?
a) Cupola
b) Inferior lobe
c) Lingula
d) Middle lobe
e) Superior lobe
Inferior lobe. Because of the sharp angle of
the oblique fissures, the posterior surfaces of
both the right and left lungs are almost
entirely comprised of the inferior lobe--the
middle lobe of the right lung is not part of the
posterior surface of the lung. So, a stab wound
halfway between the apex and diaphragmatic
surface of the lung would result in injury to the
inferior lobe. The lingula is part of the superior
lobe of the left lung, which forms the anterior
and superior sides of that lung. The superior
lobe (along with the middle lobe) forms the
anterior surface of the right lung. The superior
lobe also forms the superior aspect of both
lungs. The cupola is the serous membrane
lining the pleural cavity which extends above
the level of the 1st rib into the root of the
neck--it is not part of the lung.
65.
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?
a) Middle lobe
b) Inferior lobe
c) Cardiac notch
d) Lingula
e) Superior lobe

(Same with 64)

66.
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 segmentlingual
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.
67.
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:
a) Carina
b) Cricoid cartilage

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c) Costal cartilage
d) Pulmonary ligament
e) Tracheal ring
The carina is a keel-shaped cartilage lying at
the tracheal bifurcation--it separates the right
main stem bronchus from the left main stem
bronchus. The carina is a little to the left of the
tracheal bifurcation, so if there is an inhaled
body the carina will tend to divert foreign
objects to the right main bronchus. The cricoid
cartilage is the inferior and posterior cartilage
of the larynx. The costal cartilages prolong the
ribs anteriorly and contribute to the elasticity
of the thoracic wall. They increase in length
through the first seven and then gradually
decrease. The pulmonary ligament is a fold of
pleura located below the root of the lung.
Tracheal rings are the cartilagenous structures
which support the trachea and keep it patent.
68.
The minor (horizontal) fissure
separates:
a) the lower lobe from the lingula
b) the upper lobe from the lingula
c) the lower lobe from both the middle
and upper lobes
d) the lower lobe from the middle lobe
e) the middle lobe from the upper lobe
the upper lobe from the middle lobe
The horizontal fissure cuts across the right lung
in such a way as to separate the middle lobe
from the upper lobe. The oblique fissure
separates the lower lobe from both the middle
and upper lobes. Remember that the lingula is

only on the left lung, and it is part of the

superior lobe.
69.
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?
a) Apical segment of upper lobe
b) Lingula
c) Lower lobe
d) Middle lobe
e) Superior segment of lower lobe
The superior segmental bronchus to the lower
lobe of the right lung branches posteriorly off
of the intermediate bronchus or the inferior
lobe bronchus. So, it is the segmental
bronchus most likely to receive the fluid or
foreign bodies that enter the right main
bronchus. This segment of the lung is even
more likely to accumulate fluid when the
patient is supine.
70.
Because of its angle with the trachea
and size of the main bronchus, a bronchoscope
would pass more readily into which lung?
a) Left
b) Right
c) Up
d) Down
Right. There are several reasons why a
bronchoscope or inhaled objects will be more
likely to enter the right lung instead of the left
lung. First, the carina, a ridge-like structure at

Medicine 1-C
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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 usually
enter the right main bronchus. Theres not
such thing as Upper and lower lungs, Alien?
71.
Which vessel courses across the
mediastinum in an almost horizontal fashion?
a) Left subclavian artery
b) Left subclavian vein
c) Left brachiocephalic vein
d) Left internal jugular vein
e) Left common carotid artery
The left brachiocephalic vein joins with the
right brachiocephalic vein to form the superior
vena cava on the right side of the body. So, the
left brachiocephalic vein must course across
the mediastinum to reach its destination. The
left subclavian artery and vein are lateral to
the mediastinum, while the left jugular and
common carotid travel vertically.
72.
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:
a) Azygos v.
b) Internal thoracic v.
c) Left brachiocephalic v.
d) Left superior intercostal v.
e) Right brachiocephalic v.

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Left brachiocephalic vein. Remember that the

ascending aorta is the short part of the aorta
emerging from the heart before the aortic
arch. The left brachiocephalic vein is the only
vein listed which is anterosuperior to that part
of the aorta. It crosses horizontally through the
mediastinum to join with the right
brachiocephalic vein and form the superior
vena cava. The right brachiocephalic vein stays
on the right side of the chest and would not be
affected by the aortic aneurysm. The azygos
vein is also on the right side of the chest, and it
lays deep in the thoracic cavity. The internal
thoracic vein lies on the interior surface of the
anterior wall of the chest. Although it drains
into the brachiocephalic vein, it would not be
affected by the aneurysm. The left superior
intercostal vein crosses the aortic arch
laterally, but its blockage would only affect
drainage of intercostal spaces 2-4 on the left
side.
73.
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:
a) left brachiocephalic vein
b) left pulmonary vein
c) left bronchial vein
d) right pulmonary artery
e) right superior intercostal vein

right brachiocephalic vein and form the

superior vena cava on the right side of the
thorax. Since the left brachiocephalic vein is
fairly superficial, it travels just deep to the
thymus. So, it might be compressed by the
tumor. See Netter Plate 206 for a picture of
the thymus and the left brachiocephalic vein.
The left pulmonary vein, left bronchial vein,
and right pulmonary arteries are deep
structures that enter and exit the lung at its
root--they are not near the thymus. The right
superior intercostal vein drains intercostal
spaces 2-4. It drains into the arch of the azygos
vein and is not associated with the thymus.

End of transmission

Arranged/Editted by :

Left brachiocephalic vein. The thymus is a very

superficial structure found in the anterior
mediastinum. The left brachiocephalic vein
courses through the mediastinum to join the

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