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Question 1
Correct
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All of the following typically occurs as part of normal passive expiration except:
Your Answer: Contraction of the internal intercostal muscles
Explanation:Passive expiration is produced primarily by relaxation of the inspiratory muscles (diaphragm and external intercostal muscles) in addition to the elastic recoil of the lungs.
In expiration, several movements occur. There are:
1. depression of the sternal ends of the ribs (‘pump handle’ movement),
2. depression of the lateral shafts of the ribs (‘bucket handle’ movement) and
3. elevation of the diaphragm.
These result in a reduction of the thorax in an anteroposterior, transverse and vertical direction respectively. There is then a decreased intrathoracic volume and increased intrathoracic pressure and air is forced out of the lungs. -
This question is part of the following fields:
- Anatomy
- Thorax
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Question 2
Correct
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A 36-year-old man presented to the emergency room with a two-week history of shortness of breath, fevers, and malaise. A chest X-ray was ordered and the results confirmed the diagnosis of a right middle lobe pneumonia.
Which of the following structures of the heart lies closest to the consolidation?Your Answer: Right atrium
Explanation:In its typical anatomical orientation, the heart has 5 surfaces formed by different internal divisions of the heart:
Anterior (or sternocostal) – Right ventricle
Posterior (or base) – Left atrium
Inferior (or diaphragmatic) – Left and right ventricles
Right pulmonary – Right atrium
Left pulmonary – Left ventricleThe silhouette sign of Felson is with respect to the right middle lobe. The right heart border should have a distinct appearance due to the right atrium abutting aerated right middle lobe. The consolidation in the right middle lobe has resulted in loss of this silhouette.
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This question is part of the following fields:
- Anatomy
- Thorax
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Question 3
Correct
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Needle thoracentesis in a patient with a tension pneumothorax is performed at which anatomical landmark?
Your Answer: 4th or 5th intercostal space mid-axillary line
Explanation:Tension pneumothorax is a fatal disease causing acute and severe compromise of patients’ ventilation and circulation, in which case immediate decompression is necessary for better prognosis [6]. A previous study has shown that the incidence of tension pneumothorax varies from 0.2% to 1.7% in patients with prehospital trauma. Several trauma guidelines recommend needle thoracostomy as a life-saving intervention, with placement in the second intercostal space at the midclavicular line (second ICS-MCL), the fourth intercostal space at the anterior axillary line (fourth ICS-AAL), or the fifth intercostal space at the midaxillary line (fifth ICS-MAL) for tension pneumothorax in a prehospital environment.
In 2018, according to newly issued the Advanced Trauma Life Support (ATLS) guidelines, the fifth ICS-MAL was suggested as the preferred place, and an 8 cm needle rather than the common 5 cm needle was proved to increase success rate of adults’ decompression.
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This question is part of the following fields:
- Anatomy
- Thorax
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Question 4
Correct
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A 45-year old man presented to the emergency room with complains of chest pain and breathlessness. Upon history taking and examination, it was discovered that he had a right-sided spontaneous pneumothorax and had a failed attempt at pleural aspiration. The pneumothorax is still considerable in size, but he remains breathless. A Seldinger chest drain was inserted but it started to drain frank blood shortly after.
Which of the following complications is most likely to have occurred?Your Answer: Intercostal artery laceration
Explanation:Injury to the intercostal artery (ICA) is an infrequent but potentially life-threatening complication of all pleural interventions.
Traditional anatomy teaching describes the ICA as lying in the intercostal groove, protected by the flange of the rib. This is the rationale behind the recommendation to insert needles just above the superior border of the rib. Current recommendations for chest drain insertion suggest that drains should be inserted in the ‘safe triangle’ in order to avoid the heart and the mediastinum and be above the level of the diaphragm.
The safe triangle is formed anteriorly by the lateral border of the pectoralis major, laterally by the lateral border of the latissimus dorsi, inferiorly by the line of the fifth intercostal space and superiorly by the base of the axilla. Imaging guidance also aids in the safety of the procedure.
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This question is part of the following fields:
- Anatomy
- Thorax
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Question 5
Correct
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Which anatomical structure is divided following an emergency department anterolateral thoracotomy?
Your Answer: Latissimus dorsi
Explanation:Thoracotomy describes an incision made in the chest wall to access the contents of the thoracic cavity. Thoracotomies typically can be divided into two categories; anterolateral thoracotomies and posterolateral thoracotomies. These can be further subdivided into supra-mammary and infra-mammary and, of course, further divided into the right or left chest. Each type of incision has its utility given certain circumstances.
A scalpel is used to sharply divide the skin along the inframammary crease overlying the fifth rib. Electrocautery is then used to divide the pectoralis major muscle and serratus anterior muscle. Visualization of the proper operative field can be achieved with the division and retraction of the latissimus dorsi. Either the fourth or fifth intercostal space is then entered after the division of intercostal muscles above the rib to ensure the preservation of the neurovascular bundle. Once the patient is properly secured to the operating table, the ipsilateral arm is raised and positioned anteriorly and cephalad to rest above the head. The incision is started along the inframammary crease and extended posterolaterally below the tip of the scapula. It is then extended superiorly between the spine and the edge of the scapula, a short distance. The trapezius muscle and the subcutaneous tissues are divided with electrocautery. The serratus anterior and latissimus dorsi muscles are identified and can be retracted. The intercostal muscles are then divided along the superior border of the ribs, and the thoracic cavity is accessed.
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This question is part of the following fields:
- Anatomy
- Thorax
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Question 6
Incorrect
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Which coronary artery is mostly likely affected if an ECG shows ST segment elevation in leads II, III and aVF, and ST segment depression in V1-V3?
Your Answer: Left anterior descending artery
Correct Answer: Right coronary artery
Explanation:A posterior wall MI occurs when posterior myocardial tissue (now termed inferobasilar), usually supplied by the posterior descending artery — a branch of the right coronary artery in 80% of individuals — acutely loses blood supply due to intracoronary thrombosis in that vessel. This frequently coincides with an inferior wall MI due to the shared blood supply.
The ECG findings of an acute posterior wall MI include the following:
1. ST segment depression (not elevation) in the septal and anterior precordial leads (V1-V4). This occurs because these ECG leads will see the MI backwards; the leads are placed anteriorly, but the myocardial injury is posterior.
2. A R/S wave ratio greater than 1 in leads V1 or V2.
3. ST elevation in the posterior leads of a posterior ECG (leads V7-V9). Suspicion for a posterior MI must remain high, especially if inferior ST segment elevation is also present.
4. ST segment elevation in the inferior leads (II, III and aVF) if an inferior MI is also present.The following ECG leads determine the location and vessels involved in myocardial infarction:
ECG Leads Location Vessel involved
V1-V2 Septal wall Left anterior descending
V3-V4 Anterior wall Left anterior descending
V5-V6 Lateral wall Left circumflex artery
II, III, aVF Inferior wall Right coronary artery (80%) or Left circumflex artery (20%)
I, aVL High lateral wall Left circumflex artery
V1, V4R Right ventricle Right coronary artery
V7-V9 Posterior wall Right coronary artery -
This question is part of the following fields:
- Anatomy
- Thorax
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Question 7
Correct
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Contraction of the diaphragm results in which of the following effects:
Your Answer: Increased vertical dimension of the thorax
Explanation:Contraction of the diaphragm (as in inspiration) results in flattening (depression) of the diaphragm with an increase in vertical dimension of the thorax. This results in decreased intrathoracic pressure and increased intra-abdominal pressure.
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This question is part of the following fields:
- Anatomy
- Thorax
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Question 8
Incorrect
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A 28-year-old woman with history of blunt thoracic trauma develops hypotension chest pain, and breathlessness. A bedside echocardiogram was performed and revealed a large pericardial effusion. Due to this finding, a pericardiocentesis was to be performed.
Which of the following statements is considered true regarding pericardiocentesis?Your Answer: The patient should be lying flat during the procedure
Correct Answer: The needle should be aimed at the midpoint of the left clavicle
Explanation:Pericardiocentesis is a procedure done to remove fluid build-up in the sac around the heart known as the pericardium. The pericardium can be tapped from almost any reasonable location on the chest wall. However, for the usual blind pericardiocentesis, the subxiphoid approach is preferred. Ideally, 2-D echocardiography is used to guide needle insertion and the subsequent path of the needle/catheter.
In the subxiphoid approach, the needle is inserted 1 cm inferior to the left xiphocostal angle with an angle of 30 degrees from the patient’s chest with a direction towards the left mid-clavicle.
The fingers may sense a distinct give when the needle penetrates the parietal pericardium. Successful removal of fluid confirms the needle’s position.
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This question is part of the following fields:
- Anatomy
- Thorax
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Question 9
Correct
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When inserting a Seldinger chest drain for management of pneumothorax, the 'safe triangle' should be identified. Which of the following forms the inferior border of the 'safe triangle'?
Your Answer: 5 th intercostal space
Explanation:Care and management of the thoracostomy tubes (chest tubes) are subject to the direction and practice pattern of the responsible physician. Therefore, it is difficult to make a “one size fits all” set of instructions about the specific management recommendations for all chest tubes. It is recommended to discuss specific expectations for management with the patient’s attending physician. Facility specific Clinical Practice Guidelines (CPGs) may provide further guidance for one’s practice.
Placement of the appropriately sized chest tube is performed on the affected side. The typical landmark for placement is the 4th or 5th intercostal space (nipple line for males, inframammary fold for females) at the anterior axillary line. The space above the 5th intercostal space and below the base of the axilla that is bordered posteriorly by the trapezius and anteriorly by the pectoralis muscle has recently been described as the safe triangle. Tubes are positioned anteriorly for pneumothoraces and posteriorly for fluid processes.
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This question is part of the following fields:
- Anatomy
- Thorax
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Question 10
Correct
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A 38-year-old taxi driver sustained blunt force trauma to his anterior chest from the steering wheel of his car after falling asleep while driving headlong into an oncoming HGV lorry. Bruising around his sternum was observed, which appears to be the central point of impact.
Which of the following structures is most likely injured by the blunt force trauma?Your Answer: Right ventricle
Explanation:In its typical anatomical orientation, the heart has 5 surfaces formed by different internal divisions of the heart:
Anterior (or sternocostal) – Right ventricle
Posterior (or base) – Left atrium
Inferior (or diaphragmatic) – Left and right ventricles
Right pulmonary – Right atrium
Left pulmonary – Left ventricle -
This question is part of the following fields:
- Anatomy
- Thorax
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Question 11
Correct
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In inserting a nasogastric tube, which area is least likely to be a site of resistance when the tube goes from the nose to the stomach?
Your Answer: In the posterior mediastinum where the oesophagus is crossed by the pulmonary trunk
Explanation:In the posterior mediastinum where the oesophagus is crossed by the pulmonary trunk offers the least resistance when nasogastric tube is inserted from the nose to the stomach.
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This question is part of the following fields:
- Anatomy
- Thorax
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Question 12
Incorrect
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Which of the following muscles is least likely to be involved in forceful expiration:
Your Answer: Innermost intercostal muscles
Correct Answer: External intercostal muscles
Explanation:Forceful expiration is primarily produced by the deeper thoracic muscles (internal and innermost intercostal muscles, subcostals and transversus thoracis) aided by contraction of the abdominal wall muscles which increase intra-abdominal pressure thus further reducing the volume of the thorax.
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This question is part of the following fields:
- Anatomy
- Thorax
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Question 13
Incorrect
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During quiet respiration, position of the right oblique fissure can be marked by a line drawn on the thoracic wall that:
Your Answer: Begins at the spinous process of T3, crosses the fifth intercostal space laterally and follows the contour of rib 5 anteriorly.
Correct Answer: Begins at the spinous process of T4, crosses the fifth intercostal space laterally and follows the contour of rib 6 anteriorly.
Explanation:During quiet respiration, the approximate position of the right oblique fissure can be marked by a line on the thoracic wall that begins at the spinous process of vertebra T4, crosses the fifth intercostal space laterally and then follows the contour of rib 6 anteriorly.
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This question is part of the following fields:
- Anatomy
- Thorax
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Question 14
Correct
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Which of the following occurs at the transverse thoracic plane:
Your Answer: Bifurcation of the trachea
Explanation:A way to help remember the structures transected by the transverse thoracic plane is CLAPTRAP:
C: cardiac plexus
L: ligamentum arteriosum
A: aortic arch (inner concavity)
P: pulmonary trunk
T: tracheal bifurcation (carina)
R: right-to-left movement of the thoracic duct (posterior to the oesophagus)
A: azygos vein drains into superior vena cava
P: pre-vertebral fascia and pre-tracheal fascia end -
This question is part of the following fields:
- Anatomy
- Thorax
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Question 15
Correct
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Which of the following is true regarding respiration?
Your Answer: The diaphragm is responsible for abdominal breathing
Explanation:The following are the mechanisms of breathing during inspiration and expiration, whether normal or forced.
Normal inspiration is an active process, with the diaphragm as the main muscle. The diaphragm descends, ribs move upward and outward, and the lungs become wider and taller.
In forced inspiration, which commonly occurs during exercise, the external intercostals and accessory muscles, such as the sternocleidomastoid, anterior serrati, scalenes, alae nasi, genioglossus and arytenoid are involved. The ribs move upward and outward, and the abdominal contents move downward.
Normal expiration is a passive process, while in forced expiration, the internal intercostals and abdominal muscles, such as the rectus abdominis, internal and external obliques and transversus abdominis are involved. The ribs move downward and inward, and the abdominal contents move upward.
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This question is part of the following fields:
- Anatomy
- Thorax
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Question 16
Correct
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The 'pump handle' movement of the thoracic wall describes which of the following movements:
Your Answer: The anterior ends of the ribs moving upwards and forwards
Explanation:Because the anterior ends of the ribs are inferior to the posterior ends, when the ribs are elevated, the anterior end moves upwards and forwards, moving the sternum upwards and forwards in turn. This ‘pump handle’ upwards and forwards movement changes the anteroposterior (AP) dimension of the thorax.
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This question is part of the following fields:
- Anatomy
- Thorax
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Question 17
Correct
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The following structures all lie anteriorly to the oesophagus EXCEPT for the:
Your Answer: Thoracic duct
Explanation:Posterior to the oesophagus, the thoracic duct is on the right side inferiorly but crosses to the left more superiorly (at T5).
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This question is part of the following fields:
- Anatomy
- Thorax
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Question 18
Correct
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Which of the following muscles are primarily involved in passive inspiration:
Your Answer: Diaphragm and external intercostal muscles
Explanation:Passive inspiration is produced by contraction of the diaphragm (depressing the diaphragm) and the external intercostal muscles (elevating the ribs). In inspiration, elevation of the sternal ends of the ribs (‘pump handle’ movement), elevation of the lateral shafts of the ribs (‘bucket handle’ movement) and depression of the diaphragm result in expansion of the thorax in an anteroposterior, transverse and vertical direction respectively. This results in an increased intrathoracic volume and decreased intrathoracic pressure and thus air is drawn into the lungs.
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This question is part of the following fields:
- Anatomy
- Thorax
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Question 19
Correct
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A 4-year old boy is taken to the emergency room after a sudden onset of coughing and wheezing. Further investigation reveals that he was drawing quietly in his room, when suddenly, he became anxious and started coughing. The parents also noted that the eraser on top of the pencil was missing.
A plain radiographic chest imaging is conducted, and confirmed foreign body aspiration.
Which of the following areas in the tracheobronchial tree is the most probable location of the aspirated eraser?Your Answer: Right main bronchus
Explanation:In foreign body aspiration, the foreign body is more likely to enter the right main bronchus because it is shorter, wider and more vertical than the left main bronchus. In a patient who is standing or sitting, the foreign body tends to become lodged in the posterobasal segment of the inferior lobe of the right lung.
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This question is part of the following fields:
- Anatomy
- Thorax
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Question 20
Correct
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Regarding the lung roots, which of the following statements is CORRECT:
Your Answer: Generally the pulmonary arteries lie superior to the pulmonary veins in the lung root.
Explanation:Each lung root contains a pulmonary artery, two pulmonary veins, a main bronchus, bronchial vessels, nerves and lymphatics. Generally the pulmonary artery is superior in the lung root, the pulmonary veins are inferior and the bronchi are somewhat posterior in position. The vagus nerves pass posterior to the lung roots while the phrenic nerves pass anterior to them.
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This question is part of the following fields:
- Anatomy
- Thorax
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SESSION STATS - PERFORMANCE PER SPECIALTY
