A 35-year-old man was in a head on motor vehicle accident and the airbag hit his chest wall.

He is in the ER with shortness of breath, chest pain on the right side, and fatigue. On admission he is anxious and is in severe respiratory distress. The patient has tachycardia, his blood pressure is 90/60, and he is cyanosed. The cyanosis is not improved with 100% oxygen. On examination you find that his right chest wall is hyperexpanded and has a jugular venous distension. You also find that the breath sounds are decreased on the right side. What injury will need the most emergent care? A Open pneumothorax B Closed pneumothorax C Tension pneumothorax D Fractured rib E One sided phrenicus paresis

C Tension pneumothorax Rib fractures are clinically important because they can impair respiration, can cause pain, and can damage other structures in the area like heart, lung, or liver, for example. They are quite common and represent about 70% of all injuries to the thorax. A fractured rib, if at all, will most likely cause a closed pneumothorax. A closed pneumothorax causes a slow influx of air and usually seals itself. An open pneumothorax is a little more dangerous because it causes the effected side of the lung to collapse, and a shift of the mediastinum to the opposite side might occur. In addition, there is a risk of the wound causing an infection. Damage to one phrenic nerve will cause this side of the diaphragm to relax and therefore stand higher in the thorax during inspiration, which can be seen on radiographs. Most important is that in all those cases described above, only one side of the lung is seriously affected, while the opposite side, although impaired, is still functioning. This is very different in case of a tension pneumothorax. A one-way valve causes air to enter the pleural cavity during inspiration, which can not escape during expiration. This leads to an increase in pressure on the affected side, and the lung will collapse. In addition, the other side of the thorax is compressed and can kill the victim because now both sides of the lung are impaired to an extent where life can no longer be sustained.
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A 50-year-old woman comes to the PCD (primary care doctor) for her annual examination. During the breast exam, it is noticed that when she puts her arms up, there is a retraction on the skin at the right upper external quadrant. What anatomical structure is retracting the skin? A Clavipectoral fascia B Costocoracoid ligament C Ligamenta suspensoria (Cooper) D Pectoral fascia E Suspensory ligament of the axilla

C Ligamenta suspensoria (Cooper) The ligamenta suspensoria (Cooper) is part of the superficial fascia of the anterior thoracic region. These are fibrous processes that come from the fascia that covers the mamma and passes forward to the integument and papilla. Sir A. Cooper called those the ligamenta suspensoria. This is the structure that retracts the breast skin in breast cancer patients. The clavipectoral fascia is located between the Pectoralis minor and Subclavius, also called Coracoclavicular Fascia. It protects the axillary vessels and nerves. The costocoracoid ligament is a portion of the coracoclavicular fascia. It goes from the first rib to the coracoid process. The pectoral fascia covers the surface of the Pectoralis major. The suspensory ligament of the axilla is the name that the pectoralis fascia receives in the axillary region. References:

A 24-year-old man presents with a chief complaint of 1-week history of shortness of breath and a nonproductive cough. On physical exam, he is tachycardic, tachypneic, and febrile. He also indicated that for some reason, he has lost weight without a change in dietary habits. Auscultation of this chest reveals bibasilar crackles. A chest x-ray is ordered and demonstrates diffuse interstitial infiltrates. You collect an arterial blood gas, and the results show moderate hypoxemia. A metabolic panel is ordered, and the only abnormality is an isolated elevated lactate dehydrogenase (LDH) enzyme. What is the most likely diagnosis? A Bowens disease B Streptococcal pneumoniae C Mycoplasma pneumoniae D StevensJohnson syndrome E Pneumocysti s jiroveci

Pneumocystis jiroveci The clinical picture is suggestive of Pneumocystis jiroveci pneumonia. Signs and symptoms include fever, dyspnea, and a nonproductive cough. Chest examination reveals bibasilar crackles on auscultation, and x-rays reveal diffuse interstitial infiltrates. Isolated elevated LDH is often a finding on serum chemistries. The infectious agent is Pneumocystis jiroveci. This type of pneumonia is common in AIDS patients. Bowen's disease is a form of early squamous cell carcinoma. Lesions can appear as solitary or multiple and are pink or red in color with a slightly scaling surface, small erosions, and possible crusting. Streptococcal pneumoniae and/or Mycoplasma pneumoniae pneumonia are community-acquired pneumonias that present similarly to Pneumocystis jiroveci pneumonia except bibasilar crackles are not present and isolated LDH is not a finding. Steven-Johnson syndrome is a mucocutaneous drug-induced or idiopathic reaction of the skin that is characterized by skin tenderness and erythema of skin and mucosa, followed by extensive cutaneous and mucosal epidermal necrosis and sloughing.

Which of the following statements about the thoracic cage is true? A The costal groove runs on the upper border of a rib B The intercostal artery, vein, and nerve run in the costal groove on the lower border of the rib in that order from above downward C To prevent nerve damage an injection in between ribs should be made close to the upper border of the rib D The posterior costal arteries derive from the internal thoracic artery E The interior thoracic artery anastomoses with the femoral artery

To prevent nerve damage an injection in between ribs should be made close to the upper border of the rib The costal groove runs on the lower border of a rib. It contains the intercostal vein , artery, and nerve, in this order from above downward. Therefore, injections and punctures should be made close to the upper border of a rib. The anterior costal arteries are branches of the internal thoracic artery. The posterior costal arteries derive from the aorta. Collaterals between them exist. The internal thoracic artery anastomoses via the superior and inferior epigastric arteries with the external iliac arteries.

Contraction of the heart begins on day A Ten to eleven of embryo development B Fifteen to sixteen of embryo development C Eighteen to Nineteen of embryo development D Twentyone to twenty-two of embryo development E Twentyfive to twenty-six of embryo development

Twenty-one to twenty-two of embryo development The cardiovascular system begins to develop toward the end the third week, and the heart starts to beat at 21 to 22 days. The heart develops from splanchnic mesenchyme in the cardiogenic area. Paired endothelial tubes form and fuse into a single endothelial heart tube. The primordium of the primitive heart consists of four chambers (sinus venosus, atrium, ventricle, and bulbus cordis). The truncus arteriosus is continuous caudally with the bulbus cordis and enlarges cranially to form the aortic sac.

Arteries of the pericardium are derived from A The left coronary artery, and its branches B The left subclavian artery C The right coronary artery D The internal mammary and its musculo-phrenic branch, and from the descending thoracic aorta

The internal mammary and its musculo-phrenic branch, and from the descending thoracic aorta Both left (arising from left posterior sinus of aorta) and right coronary arteries (arising from anterior sinus of aorta), ascending from thoracic aorta, supply the musculature of the heart, while the left subclavian artery, arising from the end of the arch of The arteries supplying the pericardium are derived from the internal mammary and its musculo-phrenic branch, and from the descending thoracic aorta. The aorta, opposite to the fourth thoracic vertebra, ascends nearly vertically and supplies the inner margin of the Scalenus anticus (= anterior) muscle

The myocardium is the thinnest in the A Right atrium B Right ventricle C Left ventricle D Left atrium E The thickness of the myocardium does not vary; it remains the same throughout

Choose the correct statement pertaining to the mature female breast A The breast receives its dominant blood supply from the anterior branch of the fourth intercostal artery B The breast occupies an area extending from the second to the sixth anterior ribs C The breast has six to eight mammary ducts that dilate to form ampullae just before opening to the surface of the nipple D It receives its principal nerve supply from the thoracodorsal nerve E The lymphatic vessels of the skin surrounding the areola drain only into the axillary lymph nodes

The breast occupies an area extending from the second to the sixth anterior ribs

The developed female breast is a glandular structure that varies in size and shape. It occupies an area extending from the second to the sixth ribs and from the sternum to the anterior axillary line. The arterial blood supply to the breast arises from the posterior intercostal arteries that branch off the descending aorta, the large lateral thoracic artery, and the internal mammary artery arising from the subclavian artery. Branches of the thoracoacromial vessels are the principal blood supply to the pectoralis muscles and also contribute to the blood supply of the breast. Fifteen to twenty-five mammary ducts extend radially from the nipple and divide into a variable number of secondary tubules that terminate by forming the lobular or acinous structures of the breast. The ducts dilate to form ampullae just before opening to the surface at the nipple eminence. The parenchyma of the breast is enveloped by a capsule or fascial layer that is continuous with the pectoral fascia. This same fascia subdivides the breast into lobules, and a few strands extend to the overlying skin. The slips of fascia are more numerous in the upper hemisphere of the breast, where they are known as the suspensory ligaments of Cooper. The cutaneous sensory nerves to the breast are derived from the supraclavicular branch of the cervical plexus and from the anterior and lateral perforating branches of the second, third, fourth, and fifth intercostal branches. The deep nerve supply to the breast is derived almost entirely from the fourth, fifth, and sixth intercostal branches. The innervation of the nipple and areolar complex is from the fourth intercostal nerve. The thoracodorsal nerve is the motor nerve to the latissimus dorsi muscle. The lymphatic vessels of the skin surrounding the areola and nipple drain into the axillary, deep cervical, and deltopectoral nodes, and also into the parasternal (internal thoracic) nodes of both sides.

Oxygen and nutrients are supplied to the lungs by which vessel?

A B C D E

The pulmonary artery The pulmonary vein The bronchial arteries The bronchial veins The left subclavian artery

C The bronchial arteries Although oxygen is present at the level of the alveoli, it is not present in the supporting tissues such as the septa, and large and small bronchi. The bronchial arteries supply these structures with about 1 to 2% of cardiac output.

Identify the anatomy indicated by the solid arrows in the attached image

A Costophren ic angle B Cardiac notch C Oblique fissure D Lingula E Bronchus F Horizontal fissure G Pulmonary ligament

Which attribute contributes to inverted nipples?

A B C D E

An abnormal volume of the nipple Increased connective tissue beneath the nipple Increased diameter of the areola Hypoplasia of the underlying parenchyma Decreased length of the lactiferous ducts

Decreased length of the lactiferous ducts Inverted nipples have shortened and fewer functional lactiferous ducts than everted nipples. In addition, there is less fibrous connective tissue beneath the nipple. Scarring after surgery may increase tension on these ducts and lead to inversion. Surgical correction is based on the cause of inversion. It usually involves cutting the shortened lactiferous ducts, everting the nipple, and gently placing mattress sutures throughout the base of the nipple to maintain eversion. Sectioning the ducts may preclude later breastfeeding. Although inverted, the nipple has normal volume, and will appear normal when everted. The areolar diameter is not affected, and the breast parenchyma is usually normal.

he internal thoracic (internal mammary) artery A Arises directly from the aorta B Arises from the brachiocephalic artery C Arises from the first part of the subclavian artery D Arises from the costocervical trunk E Arises from the axillary artery

Arises from the first part of the subclavian artery The internal thoracic artery (internal mammary artery) arises from the first part of the subclavian artery and passes downward behind the sternocleidomastoid muscle, the clavicle, and subclavian veins, passing downward through the thorax behind the costal cartilages lateral to the sternum. It has several, including the pericardiacophrenic artery, mediastinal and bronchial branches, anterior intercostal branches, perforating and lateral costal branches, terminating in the superior epigastric artery and musculophrenic artery.

hich of the following is true of the intercostal spaces A The intercostal nerves and vessels lie between the external and internal intercostal muscles B The subcostal muscles connect directly to the adjacent rib spanning a single intercostal space C The intercostal nerves are dorsal branches of the thoracic nerves D The posterior intercostal veins drain into the azygos and hemiazygos venous systems E The anterior intercostal arteries arise from the internal azygos artery

The posterior intercostal veins drain into the azygos and hemiazygos venous systems The intercostal spaces contain intercostal muscles, nerves, and arteries. The intercostal nerves and vessels lie between the internal and innermost intercostal muscles. The subcostal muscles attach posteriorly, running in the same direction as the internal intercostals, and pass over two or three intercostal spaces before attaching to the rib below. The intercostal nerves are ventral branches of the thoracic nerves. There are two sets of intercostal vessels, the posterior and anterior. The posterior arteries arise from the aorta, and the posterior intercostal veins drain into the azygos and hemiazygos system. The anterior intercostal arteries arise from the internal thoracic artery and the veins drain into the internal thoracic vein.
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A typical value for intrapleural pressure at the base of the lung at the beginning of inspiration is -2.5 mm Hg relative to atmospheric pressure. Which of the following values is typical of the intrapleural pressure created when the diaphragm contracts during eupnea? A B C D E -1.0 mm Hg -6.0 mm Hg 0.0 mm Hg -2.0 mm Hg -760 mm Hg

-6.0 mm Hg The potential "space" between the visceral and parietal pleurae is filled by a few milliliters of a mucoid secretion called pleural fluid. This thin layer of fluid between the lungs and chest wall provides both lubrication and cohesion. Lubrication allows the layers to slide past one another, while cohesion provides resistance to the layers being pulled apart. The pressure in the intrapleural space is approximately -2.5 to -4 mm Hg relative to atmospheric pressure. The collapse tendency, or pressure, of the lung is approximately -4 mm Hg, therefore pleural fluid pressure must be at least -4 mm Hg to keep the lung inflated and pressed tightly against the parietal pleura of the chest wall. (The lung is normally separated from the wall by a very small amount of pleural fluid.) The subatmospheric pressure of the intrapleural space is produced by the pumping action of lymphatic vessels that move fluid out of the pleural space to maintain the negative pressure. Lymphatics open into the lateral surface of the parietal pleura, the superior surface of the diaphragm, and the medial surface of the mediastinum. Scavenging of excess fluid from the pleural cavity maintains the slight suction that is characteristic of the intrapleural pressure. As the diaphragm contracts and descends, the intrapleural volume increases, thus reducing the intrapleural pressure to approximately -6.0 to -7.0 mm Hg during eupnea. These pleural pressure changes cause a change in intra-alveolar pressure of -1 cm H2O during inspiration and +1 cm H2O during expiration. This pressure gradient, relative to atmospheric pressure, is sufficient to move approximately 0.5 L of air into and out of the lungs. Forced inspiratory efforts can reduce the intrapleural pressure to approximately -30.0 mm Hg, relative to atmospheric pressure. Intrapleural pressures of zero or greater are not sufficient to maintain the lungs in an expanded state. Instead, the lungs must be contained in a "space" that has negative pressure. For example, if the chest wall on one side of the thorax is opened, the negative pressure of the pleural cavity is lost and the lung on that side collapses inward due to its intrinsic elasticity.
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During forced expiration A B C D The diaphragm contracts maximally The diaphragm is pushed upward by the increase in intra-abdominal pressure The muscles of the anterior abdominal wall contract to increase the intra-abdominal volume Intrapleural pressures may decrease to values as low as -40 cm H2O

The diaphragm is pushed upward by the increase in intra-abdominal pressure

The principal muscle of pulmonary ventilation is the diaphragm. However, it is assisted by various accessory muscles of breathing during forced ventilatory maneuvers. During quiet breathing (eupnea) the diaphragm contracts, flattens, and descends a few centimeters (1 - 1.5 cm) to bring about inspiration. When it relaxes, the natural elasticity of the lungs and chest wall return the various structures to their pre-inspiratory equilibrium positions to reverse the volume and pressure changes and produce expiration. Since the diaphragm is completely passive during the expiratory phase of the ventilatory cycle, it is considered an inspiratory muscle of breathing. During forced inspiration the downward excursion of the diaphragm increases to as much as 10 cm to result in a substantial increase in intrapleural volume. The powerful piston-like action of the muscle generates intrapleural pressures that may range from approximately -3 cm H2O to -5 cm H2O at the start of inspiration, decreasing during normal inspiration to an average of -6 cm H2O to -7.5 cm H2O, relative to atmospheric pressure. Strong inspiratory effort may reduce intrapleural pressure to approximately -40 cm H2O. (Overall, this inspiratory pressure range is approximately equal to -2.5 mm Hg to -30 mm Hg, relative to atmospheric pressure.) As in conditions of eupnea, the diaphragm remains passive during forced expiration. Unlike the conditions of eupnea, its upward movement is assisted by the ventral abdominal group of muscles acting as accessory expiratory muscles. These muscles include the rectus abdominis, transversus abdominis, internal oblique, and external oblique muscles. They aid expiration by pulling the thorax downward and inward to pressurize the abdominal cavity and force the diaphragm upward, essentially reversing the volume and pressure changes produced during inspiration. The muscles of the abdominal wall also contract with considerable force during nonrespiratory maneuvers, such as defecation, vomiting, and coughing. For example, in coughing intrapleural pressure can rise to +100 mm Hg against a closed glottis. When the glottis and vocal cords suddenly open, air leaves the lung with explosive force, effectively clearing the upper airways.
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Which of the following muscles or muscle groups are used during expiration by a patient experiencing severe dyspnea associated with emphysema? A B C D E Internal intercostals Trapezius Sternocleidomastoid Pectoralis major Scalenus group

A Internal intercostals

In conditions of emphysema, destruction of the elastin protein network of the lung parenchyma causes loss of radial traction of small airways. The structural proteins, elastin and collagen, impart resiliency to lung tissue. Elastin allows the lung parenchyma to expand, whereas collagen prevents overexpansion. As the walls of alveoli become thin and disorganized, the alveoli enlarge and coalesce. As a result of these histologic changes, the compliance of the lung increases and the lung becomes more distensible. In other words, the loss of elasticity within the lung parenchyma results in decreased elastic recoil of the lung. The pathogenesis thus leads to chronic air trapping which increases the size of the airway during inspiration but prolongs the time of various forced expiratory maneuvers. As a result of loss of elastic recoil of the emphysematous lung, forced expiratory volume in 1 second (FEV1), forced vital capacity (FVC), and forced expiratory volume as a percentage of vital capacity (FEV/FVC %) are all significantly reduced. Expiratory time is greatly increased over the forced expiration. The FVC is reduced because the airways close at a high lung volume. This in turn increases the residual volume (RV) of the lung. Because of hyperinflation of the lungs and loss of elastic recoil, the anteroposterior thorax diameter may increase. Chest radiographs reveal low, flat diaphragms. Accessory inspiratory muscles such as the external intercostals, pectoralis major, trapezius, scalenus group, and sternocleidomastoid either elevate the ribs, increase the anteroposterior diameter of the thorax, or increase the lateral diameter of the thorax to increase the chest volume during inspiration and assist the diaphragm. Accessory expiratory muscles such as the internal intercostals depress the ribs during expiration while the abdominal group pressurizes the abdominopelvic cavity to assist the upward excursion of the diaphragm during expiration.

What structure is indicated with the open arrows in the attached image? A

Aortic arch B IVC C SVC D Aneurys m of the atrium E Aneurys m of the ventricle F Aortic aneurys m

What venous route from the breast provides a route for carcinomatous metastases to the bones and to the nervous system? A Perforating tributaries of the internal thoracic vein B Axillary vein C Intercostal veins D Subclavian vein E Basilic vein

Intercostal veins The intercostal veins, which drain the breast, connect with the vertebral venous plexus, and provide a route for carcinomatous metastases to the bones and to the nervous system. The basilic vein drains the arm, continues into the axillary vein, and then the subclavian vein. The tributaries of the internal thoracic veins drain into the brachiocephalic veins.
What is the nipple to sternal notch distance in the mature human breast (B or C cup)? A B C D E 15 cm 21 cm 30 cm 35 cm 40 cm

21 cm The sternal notch to nipple distance in the mature woman having a B or C cup breast measures 21 cm despite variations in height and weight. The inter-nipple distance is also 21 cm as is the midclavicular to nipple distance. Women with macromastia often have a sternal notch to nipple distance of more than 30 cm.

One mechanism of metastasizing for neoplastic tumors is via the blood stream, when neoplastic cells leave the original tumor and spread throughout the body. Assuming the spreading tumor is in the kidneys, where would you expect to find metastases? A Pancreas B Lungs C Brain D Liver E Spleen

Lungs The venous blood from the kidneys flows through the kidney vein directly into the cava and from there into the lungs, which represent the first capillary bed. This is not to suggest that all neoplastic growth with access to the cava vein metastasizes into the lung. Other capillary beds performing filter functions are the lungs and the brain. There are other mechanisms for tumors to metastasize.
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A patient comes into the emergency room with a screwdriver stuck in his left chest. You determine from the position of the tool that the heart is injured. What do you believe would be the most likely cause, if that patient dies very quickly? A The heart is penetrated and the patient died because of the blood loss B The left crus of the ventricular bundle was damaged and prevented coordinated systoles C A pericardial inflammation killed the patient immediately after the injury occurred D The vacuum within the pericardial cavity was lost and the heart collapsed E Systoles after the injury pressed blood into the pericardial cavity and prevented the heart from expanding during the diastole

Systoles after the injury pressed blood into the pericardial cavity and prevented the heart from expanding during the diastole A pressure within the pericardial cavity is only of concern if positive (P>0), thus preventing an expansion of the heart during the diastole. Without adequate filling of the ventricles, a systolic contraction will not pump any blood into the circulatory systems. This can kill a patient within a few minutes. This serious condition is referred to as cardiac tamponade. Every systole pumps blood into the pericardial cavity under pressure, thus decreasing the space for the heart to expand, respectable to fill during the diastole, until failure.It is unlikely that a screwdriver would precisely damage a crus of the ventricular bundle, and even if it did, the electrical pulse would find a way around the injury and lead to a contraction of the ventricle. An inflammation can kill a patient, but more or less in the long run and not on a short term basis.

What percentage of congenital heart diseases result from ventricular septal defect (VSD) A One percent B Five percent C Ten percent D Twenty percent E Twenty -five percent

Twenty -five percent VSD is the most common cardiac defect. It occurs in about 25 percent of children with congenital heart disease. Most patients with a large VSD have massive left-to-right shunt of blood.
Which of the following represents the most distal portion of the conducting zone of the respiratory system? A B C D E Bronchioles Respiratory bronchioles Alveolar ducts Terminal bronchioles Subsegmental bronchi

D Terminal bronchioles Gaseous exchange in the respiratory system occurs only in the respiratory zone , that is, within the alveoli that make up the acini, or primary lobules of the lung. This tissue is also known as the lung parenchyma. The alveoli serve as the sites of external respiration. They are found in various structural configurations, including several branches, or generations, of respiratory bronchioles, alveolar ducts, and alveolar sacs. Such respiratory units represent a continuation of the terminal bronchioles of the tracheobronchial tree of conducting passages. The terminal bronchioles are very small diameter branches of the bronchioles, and mark the end of the conducting zone of the respiratory system. The volume of gas contained in the various classes of the conducting airway is not available for exchange with pulmonary capillary blood. The gas contained in this anatomic dead space volume, is nonfunctional. As a general rule, the anatomic dead space volume in milliliters, is approximately equal to the body weight, in pounds, of a man. In a 150lb man, with a tidal volume of 500mL, the anatomic dead space volume will be approximately 150mL. Consequently, only the first 350mL of inspired air reaches the alveoli for gaseous exchange. During expiration, the first 150mL of gas expired occupied the conducting zone, and only the last 350mL of gas exhaled was in contact with the alveoli. For these reasons, alveolar ventilation (or the alveolar minute volume), is always less than the respiratory minute volume. In the example of the 150lb male, rapid shallow breathing pattern: Respiratory rate: 30 breaths / min. Tidal volume: 200mL. Respiratory minute volume = 200 mL 30 / min = 6000 mL / min. Alveolar minute volume = (200 mL - 150 mL) 30 / min = 1500 mL / min. Since the anatomic dead space volume (150 mL, in this case) is fixed for an individual of a particular size, alveolar ventilation is dramatically affected by the depth of ventilation. For a given respiratory minute volume, slow deep respirations produce greater alveolar ventilation than rapid shallow breathing. For example, a 150lb male, slow deep breathing pattern: Respiratory rate: 10 breaths / min. Tidal volume: 500mL. Respiratory minute volume = 500 mL 10 / min = 5000 mL / min. Alveolar minute volume = (500 mL - 150 mL) 10 / min = 3500 mL / min.

The physiologic dead space volume, is the volume of gas in the respiratory system, that does not equilibrate with blood. In pulmonary pathophysiologic states, this nonequilibrating gas volume includes the volume of gas in non-perfused alveoli, as well as any volume of gas in the alveoli that is in excess of that needed to properly exchange with the blood in pulmonary capillaries. Such ventilation-perfusion inequalities in the lung may lead to hypoxemia. In healthy lungs, however, ventilation-perfusion matching is optimal, and the physiologic dead space volume equals the anatomic dead space volume. In other words, virtually all of the gas that reaches the alveoli is available for equilibration with blood in the pulmonary capillaries. Only the volume of gas in the conducting passages, the anatomic dead space, is non-equilibrating and non-functional. Such a volume, in a healthy individual, is identical to the physiologic dead space.
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he mitral valve A Consists of three segments of a triangular or trapezoidal shape, connected by their bases to the fibrous ring surrounding the right atrioventricular orifice, and by their sides with one another, so as to form a continuous annular membrane, which is attached round the margin of the atrioventricular opening. The free margins and ventricular surfaces afford attachment to chordae tendineae B Guard the orifice of the pulmonary

trunk. The free margin is somewhat thicker than the rest of the valve, is strengthened by a bundle of tendinous fibers, and presents, at its middle, a small projecting thickened nodule called corpus Arantii C Is attached to the circumference of the left atrioventricular orifice. It consists of two segments: the larger placed in front and to the right between the left atrioventricular and aortic orifices, the smaller to the left and behind the opening, close to the wall of the left ventricle D Is the small and usually incompetent endocardial fold at the entry of the coronary sinus into the right atrium E Is the rudimentary valve at the entry of inferior vena cava

Is attached to the circumference of the left atrioventricular orifice. It consists of two segments: the larger placed in front and to the right between the left atrioventricular and aortic orifices, the smaller to the left and behind the opening, close to the wall of the left ventricle The mitral valve, consisting of two cusps, guards the opening of left atrioventricular orifice. Of the two cusps, the anterior cusp lies between the atrioventricular and aortic orifices, and is frequently referred to as the aortic cusp of the mitral valve. From two large papillary muscles, chordae tendineae proceed to both cusps of the mitral valve, but those which pass to the anterior cusp are attached to its free edge, and the ventricular surface of this cusp is therefore smooth. The trabeculae carneae are more numerous than in the right ventricle. Answers (A), (B), (D) and (E) describe the tricuspid valve of the heart, the semilunar valve of the pulmonary trunk, the coronary valve (= valve of Thebesius) and the valve of the inferior vena cava, respectively.
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The valve of Thebesius A Is situated between the anterior margin of the inferior vena cava and the atrioventricular orifice. It is semicircular in form, and is formed by a duplicature of the lining membrane of the right atrium containing a few muscular fibers. In the adult, it may or may not be present. If it is present, it may assist in preventing the reflux of blood into the inferior vena cava B Is a semicircular fold of the

lining membrane of the right atrium, protecting the orifice of the coronary sinus. It prevents the regurgitation of blood into the sinus during the contraction of the auricle. This valve is occasionally double C Is the large oval aperture of communication between the right atrium and right ventricle D Is an oval depression corresponding to the situation of the foramen ovale in the fetus. It is situated at the lower part of the interatrial septum, above and to the left of the orifice of the inferior vena cava E Is a small slit-like valvular opening, occasionally found at the upper margin of fossa ovalis. It leads upward beneath the annulus into the left atrium, and is the remains of the aperture

between the two atria in the fetus

Is a semicircular fold of the lining membrane of the right atrium, protecting the orifice of the coronary sinus. It prevents the regurgitation of blood into the sinus during the contraction of the auricle. This valve is occasionally double The valve of Thebesius, also called the coronary valve, is a semicircular fold of the lining membrane of the right atrium, protecting the orifice of the coronary sinus. It prevents the regurgitation of blood into the sinus during the contraction of the auricle. This valve is occasionally double. Answer (A) describes the coronary sinus, (C) the right atrioventricular opening, (D) the fossa ovalis and (E) the annulus ovalis, forming the prominent oval margin of the foramen ovale.
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Which of the following statements about the lungs is true? A The apex of the lung is situated in the neck, behind the interval between the 2 heads of origin of the sternomastoid. The height to which it rises above the clavicle varies very considerably, but is generally about 1 inch. B The posterior border of lung is indicated by a line drawn from the level of the spinous process of the first or second thoracic vertebra, down either side of the spine, corresponding to the costovertebral joints as low as the spinous process of the ninth thoracic vertebra C The lower border of the lung is marked out by slightly curved line with its convexity downward from the articulation of the fourth costal

cartilage to its rib to the spinous process of the ninth thoracic vertebra D The medial surface of the lung conforms with the anterior, lateral, and posterior portions of the thoracic wall, from which it is separated only by the parietal and visceral pleurae

A The apex of the lung is situated in the neck, behind the interval between the 2 heads of origin of the sterno-mastoid. The height to which it rises above the clavicle varies very considerably, but is generally about 1 inch. Each lung possesses an apex, 3 surfaces, a base, a costal and a medial, and 3 borders: an anterior, a posterior, and an inferior. The rounded apex of each lung is situated in the neck, under the cervical pleura, and behind the interval between the 2 heads of the origin of the sterno-mastoid muscle. The height to which it rises above the clavicle varies considerably, but is generally about 1 inch. However, posterior border begins from the level of seventh cervical vertebra and ends at the level of tenth thoracic vertebra. The costal surface conforms with the anterior, lateral, and posterior portions of the thoracic wall, from which it is separated only by the parietal and visceral pleurae. The medial surface is in contact with the side of the mediastinum, except at the root where lung and mediastinum are continuous. The lower border of the lung begins from the articulation of sixth costal cartilage and ends at tenth thoracic vertebra.

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he right superior intercostal vein A Runs across the transverse aorta and opens into the left innominate vein. It usually receives the left bronchial and left superior phrenic vein, and communicates below with the vena azygos minor superior. B Passes downwards and inward and opens into the vena azygos major. C Commences opposite the 1st or 2nd lumbar vertebra by a branch from the right lumbar vein and terminates in the superior vena cava just before that vessel enters the pericardium. D Forms a plexus in front of the trachea behind the Sterno-thyroid muscles. From this plexus a left vein descends and joins the left innominate

trunk and a right vein passes obliquely downward and outward across the innominate arteryto open into the right innominate vein just at its junction with the superior vena cava. These veins receive esophageal, tracheal and inferior laryngeal veins and are provided with valves at their termination in the innominate veins. E Is a short vessel 1 inch long commencing at the inner end of the clavicle passing almost vertically downward joins with the left innominate vein just below the cartilage of the 1st rib close to the right border of the sternum to form the superior vena cava. It lies superficial and external to innominate artery; on its

right side is the phrenic nerve and the pleura is interposed between it and the apex of the lung. This vein at the angle of junction of the internal jugular with the subclavian receives the right vertebral vein and lower down the right internal mammary, right inferior thyroid and sometimes the right superior intercostal veins.

Passes downwards and inward and opens into the vena azygos major. The right superior intercostal vein drains blood from two or three intercostal spaces below the first intercostal space. It passes downward and inward and drains into the vena azygos major . Answers (A), (C), (D) and (E) are the descriptions of the left superior intercostal, the larger or right azygos vein (= vena azygos major), the inferior thyroid veins and the right innominate vein, respectively.
Which of the following ribs are regarded as "floating ribs"? A The upper seven ribs B The upper six ribs C The last two ribs D The lower three ribs E The last rib

only Which one of the following parts of the mammary gland is usually called the axillary tail? A The deep slightly concave surface extending vertically from the second to the sixth rib and horizontally from the sternal border to the midaxillary line B The conical elevation transversed by lactiferous ducts opening on its surface C The upper outer quadrant that is prolonged over the lateral border of the pectoralis major muscle and pierces the deep fascia D The strands of connective

tissue (continuous with the deep fascia), which tie down the parenchyma and the fatty tissue

The upper outer quadrant that is prolonged over the lateral border of the pectoralis major muscle and pierces the deep fascia The prolonged upper outer quadrant of the breast lying over the lateral border of the pectoralis major muscle and piercing the deep fascia at the axilla is known as the axillary tail. The deep slightly concave surface extending vertically from the second to the sixth rib and horizontally from the sternal border to the mid-axillary line is the superficial surface. The conical elevation transversed by lactiferous ducts opening on its surface is the nipple, and the strands of connective tissue (continuous with the deep fascia), which tie down the parenchyma, and the fatty tissue are the ligaments of Cooper.

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Which of the following structures are in close apposition to the esophagus as it passes through the thoracic cavity? A Trachea, vertebrae, thoracic duct B Trachea, thymus gland, phrenic nerves C Trachea, vertebrae, thoracic duct, thymus D Larynx, thoracic duct, azygous

vein, phrenic nerves E Trachea, vertebrae, phrenic nerves

Trachea, vertebrae, thoracic duct Within the thorax, the esophagus is in close apposition to trachea, vertebrae, and the thoracic duct. The phrenic nerves are located laterally and anteriorly in relationship to the esophagus. The thymus is located anterior to the trachea; whereas, the esophagus is located posterior. The azygous vein is closely associated with the esophagus, especially ventrally. The larynx is not located in the thorax.
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Which of the following statements is correct for the superior mediastinum? A At the level of the 4th thoracic vertebrae (Th4), the esophagus is located ventral of the trachea B If you are looking at a horizontal section of the thorax at the level of the 4th thoracic vertebrae from below, the esophagus is to the right of the

descending aorta C The right recurrent laryngeal nerve leaves the vagus nerve just after passing over the subclavian artery in the root of the neck D The left vagus nerve descends down into the thorax and gives off the left recurrent nerve after crossing the pulmonary artery E If you cut through the right vagus nerve at the level of the aortic arch the patient's right vocal cord will be affected

The right recurrent laryngeal nerve leaves the vagus nerve just after passing over the subclavian artery in the root of the neck The esophagus is always located dorsal of the trachea. You can feel the trachea, but not the esophagus when examining somebody's or your own neck. Looking at a cross section from below reveals that the esophagus lies behind the trachea (when looking at the picture it is actually below the trachea), but to the left of the aorta. The two vagi nerves do not follow identical tracks descending into the thorax. The right vagus enters the thorax in close proximity to the trachea and when passing over the subclavian artery gives off the right recurrent laryngeal nerve, therefore cutting it at the level of the thoracic arch does not effect the vocal cords. The left vagus nerve is separated from the trachea by the arch of the aorta. It gives off the left recurrent laryngeal nerve after passing over the aorta, not the pulmonary artery. The left recurrent laryngeal nerve runs beneath the arch of the aorta and the ligamentum arteriosum towards a groove between the trachea and the esophagus and back up towards the pharynx.
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The posterior mediastinum A Contains the heart enclosed in the pericardium, the ascending aorta, and the lower half of the superior vena cava, with the vena azygos major B Encloses the bifurcation of the trachea and the two bronchi, the pulmonary artery dividing into its two branches and the right and left pulmonary veins, the phrenic nerves, and some bronchial lymphatic glands C Contains a quantity of loose areolar tissue, some lymphatic vessels which ascend from the convex surface of liver, two or three lymphatic glands (anterior mediastinal glands), and the small mediastinal branches of the internal mammary artery D Contains the descending thoracic aorta, the greater and lesser azygos veins, and the pneumogastric and splanchnic nerves, the esophagus, thoracic duct and some lymphatic glands E Is bounded in front by the sternum, on each side by the pleura, and behind by the pericardium. It is narrow above, but widens out a little below, and, owing to the oblique course taken by the left pleura, which is directed from above obliquely downward and to the left

D Contains the descending thoracic aorta, the greater and lesser azygos veins, and the pneumogastric and splanchnic nerves, the esophagus, thoracic duct and some lymphatic glands The posterior mediastinum is an irregular triangular space running parallel with the vertebral column. It is bounded in front by the pericardium and roots of the lungs, behind by the vertebral column from the lower border of the fourth thoracic vertebra, and on either side by the pleura. It contains the descending thoracic aorta, the greater and lesser azygos veins, and the pneumogastric and splanchnic nerves, the esophagus, thoracic duct and some lymphatic glands. Descriptions given under answers (A) and (B) apply to the middle mediastinum, and those under (C) and (E) apply to anterior mediastinum.

The pleural cavity usually contains only a very small amount of fluid, which assists in reducing friction between the pleural surfaces. Which of the following statements is NOT true? A The pressure in the pleural cavity is negative B If an opening exists between the pleural cavity and the outside air, air will be drawn into the pleural cavity and will cause the intrapleural pressure to rise and the lung to collapse C An opening between the thoracic wall and the pleural cavity is called open pneumothorax D In case of an open pneumothorax on one side, the mediastinum will shift to that side E A closed pneumothorax is defined as an opening between the lung and the pleural cavity

In case of an open pneumothorax on one side, the mediastinum will shift to that side The pressure in the pleural cavity is negative. This causes the lung to follow the excursions of the thorax and the diaphragm, in other words respiration. If an opening exists between the pleural cavity and the outside air, air will be drawn into the pleural cavity and will cause the intrapleural pressure to rise and the lung to collapse. Remember the tissue of the lung is elastic, like a balloon, which is inflated not by pumping air into it, but by lowering the pressure around it. If that pressure surrounding the balloon rises, it will collapse. An opening between the thoracic wall and the pleural cavity is called open pneumothorax. In case of an open pneumothorax on one side, the mediastinum will shift to the opposite side. A closed pneumothorax is defined as an opening between the lung and the pleural cavity.

he intercostal arteries: A Usually 4 or 5 in number, arise from the front of aorta, and pass obliquely downwards, forming a chain of anastomoses along that tube and with ascending branches from the phrenic and gastric arteries below. B Vary in number, size, and origin. Each vessel is directed to the back part of the corresponding bronchus along which it runs, dividing and subdividing to supply the cellular tissue of the lungs and the bronchial glands. C Usually 9 in number, arise from the back of the aorta. Each artery passes at first outwards and then ascends obliquely to the lower border of the rib above it, and continues further in the groove on the

lower border of the rib. It then anastomoses with the branches of internal thoracic. D Are numerous in number and arise by a common trunk with the left bronchial from the front of the thoracic aorta. Each vessel is directed to the back part of the corresponding bronchus along which it runs, dividing and subdividing along the bronchial tube, supplying them, the cellular tissue of the lungs, the bronchial glands, and the esophagus.

C Usually 9 in number, arise from the back of the aorta. Each artery passes at first outwards and then ascends obliquely to the lower border of the rib above it, and continues further in the groove on the lower border of the rib. It then anastomoses with the branches of internal thoracic. The intercostal arteries arise from the back of aorta. They are usually 9 in number. In each intercostal space, each artery passes outwards, at first lying upon the external intercostal muscle and covered in front by the pleura and a thin fascia. It then passes between the 2 layers of intercostal muscles, and, having ascended obliquely to the lower border of the rib above it, is continued forward in the groove on its lower border and anastomoses with the anterior intercostal branches of internal thoracic.

Description given in answer (A) applies to esophageal arteries, and those in (B) and (D) apply to the bronchial arteries. The esophageal arteries, usually 4 or 5 in number, arise from the front of aorta and pass obliquely downwards, forming a chain of anastomoses along that tube and with ascending branches from the phrenic and gastric arteries below. The bronchial arteries, on the other hand, are the nutrient vessels of the lungs and vary in number, size, and origin. Those of the right side arise from the first aortic intercostal or by a common trunk with the left bronchial from the front of the thoracic aorta. Those of the left side, usually 2 in number, arise from the thoracic aorta, one a little lower than the other. Each vessel is directed to the back part of the corresponding bronchus along which it runs, dividing and subdividing along the bronchial tube, supplying them, the cellular tissue of the lungs, the bronchial glands, and the esophagus.

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our 37-year-old male patient on your pulmonary therapy service has a history of asthma and is a chain smoker. By now, he has developed emphysema. When measuring peak flow, you note how he labors to exhale. Which of the following muscles are responsible for active expiration? A External intercostal muscles B Internal intercostal muscles C Sternocleidomastoid muscle D Anterior serrati muscles E Scaleni muscles

B Internal intercostal muscles The external intercostal muscles assist in active inspiration. Diaphragmatic contraction is responsible for quiet inspiration.The internal intercostal muscles pull the ribs downward, decrease the volume of the thoracic cavity, causing air to be forced from the lungs. Under resting conditions, these muscles are not used and expiration relies on the elasticity of the lungs. The sternocleidomastoid muscle is used in active inspiration. It elevates the sternum, increasing thoracic volume. The anterior serrati muscles help to stabilize the scapula and is responsible for protraction of the scapula. The scaleni muscles are used in active inspiration. They elevate the sternum, increasing thoracic volume.

35-year-old man who has smoked 3 packs of cigarettes a day for 20 years has a persistent cough and significant hoarseness. A chest radiograph reveals the presence of a tumor in the apex of the right lung and he is diagnosed with lung cancer. Which structure, close to the apex of the lung, is MOST LIKELY to explain the patient's hoarseness? A Right recurrent laryngeal nerve B Right vagus nerve C Right phrenic nerve D Right sympathetic trunk E Greater splanchnic nerve

A Right recurrent laryngeal nerve The right recurrent laryngeal nerve curves around the right subclavian artery and then ascends into the neck between the trachea and esophagus, passing close to the cupola of the lung. An apical lung tumor can encroach upon the recurrent laryngeal nerve here and affect the structures and the laryngeal muscles (except cricothyroideus), causing hoarseness. References:
1. Agur, A.M.R., and A.F. Dalley: Grant's Atlas of Anatomy, 11th ed., Lippincott

Williams & Wilkins, 762. 2. Mo

A patient is in surgery for repair of an acute aortic dissecting aneurysm. The surgeon must clamp off the blood supply from the aorta to left intercostal spaces 3, 4, and 5 in order to complete the procedure. During this time the patient A Is in danger of ischemia in the affected intercostal spaces B Will have adequate blood supply from the

collateral intercostal arteries C Will have adequate blood supply from the anterior intercostal arteries D Will have adequate blood supply from the lateral cutaneous branches of the intercostal arteries E Will have adequate blood supply from the dorsal branches of the posterior intercostal arteries

Will have adequate blood supply from the anterior intercostal arteries The intercostal spaces have a dual blood supply - from the posterior intercostal arteries, off the aorta, and the anterior intercostal arteries, off the internal throracic artery, a branch of the subclavian artery. The posterior collateral intercostal arteries branch off in the costal groove from the posterior intercostals at the angle of the ribs and cross the intercostal space to run on the superior aspects of the ribs below. The anterior collateral intercostal arteries branch off from the anterior intercostals near the costo-chondral junction and cross to the superior aspects of the ribs below in a similar manner. The blood in the anatomosing collateral intercostal arteries is dependent on bloodflow in the anterior and posterior intercostals. References:

A 45-year-old woman who discovered a lump in her left breast presents to her gynecologist with a thickened, orange-peel-like appearance of the skin of the affected breast. After further examination and tests she is diagnosed with breast cancer. The peau d'orange sign is caused by what structural alteration? A B C D E Shortening of the suspensory ligaments of the breast Reduced blood flow to the affected breast Inflammatory response in the breast Blockage of lactiferous ductules of the breast Blockage of lymphatic channels in the affected breast

Blockage of lymphatic channels in the affected breast Peau d'orange is a coarsening of the skin of the breast and dimpling of pores caused by blockage of lymphatic drainage of the breast. Breast lymphatics are blocked by tumor growth and lymph cannot enter the venous system normally. Lymphatic edema around deepened hair follicles gives the appearance of an orange peel, hence the name peau d'orange. A tumor can also cause dimpling of the skin of the breast by causing a shortening of the suspensory ligaments of the breast. Blockage of the lactiferous ductules may occur in mastitis and would prevent milk secretion. Reduced blood flow into the breast or inflammation would not cause the peau d'orange sign. References: 1. Moore, K.L., and A.F. Dalley: Cli
A 79-year-old man who returned the previous day from a long plane trip is affected with a sudden shortness of breath and collapses. He is rushed to the hospital where it is determined that he has suffered a pulmonary embolism, resulting from a blood clot that has lodged in his lung and cut off a portion of its blood supply. Most commonly, embolism is caused by thrombi which arise from the lower extremities and travel to the lung via the heart. Which is the correct path that the thrombus travels through the heart to the lung? A Left atrium-left ventricleaortabronchial artery B Right atriumsuperior vena cavabronchial vein C Left atriumpulmonary veinbronchial

vein D Right atriumright ventriclepulmonary trunkpulmonary artery E Right atriumazygos veinpulmonary vein

Right atrium-right ventricle-pulmonary trunk-pulmonary artery Venous return from the deep leg veins is through the femoral veins to the inferior vena cava to the right atrium of the heart. The thrombus enters the right atrium, travels through the tricuspid valve to the right ventricle, and is then pushed through the pulmonary valve into the pulmonary trunk. The clot travels into one of the pulmonary arteries and lodges within the lung. References:
CASE: A 79-year-old man who returned the previous day from a long plane trip is affected with a sudden shortness of breath and collapses. He is rushed to the hospital where it is determined that he has suffered a pulmonary embolism, resulting from a blood clot that has lodged in his lung and cut off a portion of its blood supply. The physician describes the condition to the patient as deep venous thrombosis. From which of the following veins did the clot most likely originate? A B C D E Great saphenous vein Pulmonary vein Posterior tibial vein Superior rectal vein Great cardiac vein

C Posterior tibial vein Deep venous thrombosis originates most commonly in the deep veins of the leg. The only deep leg vein listed among the choices is the posterior tibial vein, an affluent to the popliteal vein which then continues on as the femoral vein. The great saphenous vein is a superficial vein of the leg and thigh.The pulmonary vein carries oxygenated blood from the lungs to the left atrium. The superior rectal vein originates in the hemorrhoidal plexus or the rectum. The great cardiac vein, also called the left coronary vein, originates at the apex of the heart and ascends along the anterior longitudinal sulcus to reach the base of the ventricles.

The clavipectoral fascia continues upward from the axillary fascia, ensheathes the subclavius, and becomes attached to the clavicle. 3 structures pierce this fascia. Choose the correct combination. A Cephalic vein, thoracoacromial artery, lateral pectoral nerve B Cephalic vein, thoracoacromial artery, medial pectoral nerve C Cephalic vein, thoracodorsal artery, lateral pectoral nerve D Cephalic vein, thoracodorsal artery, medial pectoral nerve E Basilic vein, thoracoacromial artery, lateral pectoral nerve

Cephalic vein, thoraco-acromial artery, lateral pectoral nerve

The axillary fascia forms the floor of the axilla. A layer ascends and ensheathes the pectoralis minor and continues upward as the clavipectoral fascia. It ensheathes the subclavius and becomes attached to the clavicle. The clavipectoral fascia blends medially with the fascia covering the first 2 intercostal spaces and is attached to the first rib. Laterally the fascia extends to the coracoid process and joins the fascia of the biceps and the coracobrachialis. The part between the first rib and coracoid process is often thickened to form the costocoracoid ligament. Posteriorly, the clavipectoral fascia blends with the sheath of the axillary vessels. This fascia is pierced by the cephalic vein, the thoraco-acromial artery, and the lateral pectoral nerve.
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