TX-SBA-30

1.A hypertensive, heavy smoking, 73-year-old man suffers a massive cardiac infarct following occlusion of his anterior
interventricular artery, (anterior descending artery). Angiography is performed to demonstrate the coronary vessels. Which
anatomical relationship of these vessels should be borne in mind?

The anterior interventricular artery arises above the left posterior aortic cusp

Correct answer
The anterior interventricular artery supplies almost all of the left ventricle

There is a rich collateral circulation between the right and left coronary arteries

The circumflex artery is the major branch of the right coronary artery

The posterior interventricular artery is a branch of the circumflex artery

The left coronary artery arises above the left posterior aortic cusp. After a short course it divides into an anterior interventricular
and a circumflex branch. The former is the main arterial supply to the left ventricle. Unfortunately, there is only a poor collateral
supply between the branches of the two coronary arteries. The posterior interventricular artery arises from the right coronary
artery.
2.
In the clinical examination of the chest, accurate knowledge of the surface markings of the lungs is essential.
Which of the following corresponds to the clinical situation?

The apex of the lung corresponds precisely to the upper border of the medial third of the clavicle

The oblique fissure of the lung corresponds to the medial border of the scapula when the arm is fully Correct answer
abducted

The transverse (horizontal) fissure of the right lung corresponds to the right fifth intercostal space

The lower border of the lung on each side corresponds to the tenth rib in the mid-axillary line

The lower border of the lung reaches the twelfth rib posteriorly
The apex of the lung extends about 4 cm above the medial one-third of the clavicle. The oblique fissure does indeed
correspond closely to the medial border of the scapula when the arm is fully abducted. The transverse fissure of the right lung
corresponds to the level of the fourth rib. The lower border of the lung on each side corresponds to the eighth rib in the mid-
axillary line and the tenth rib posteriorly.
3.
Which of the following structures is located in the anterior mediastinum on computed tomography (CT)?

Correct answer
Thymus

Oesophagus

Aorta

Heart

Trachea
The anterior mediastinum is bordered anteriorly by the sternum and posteriorly by the great vessels. It contains the thymus,
lymph nodes, fat, and vessels. Disorders of the anterior mediastinum are generally thymic, thyroid (substernal goitre), teratoma
(and other germ cell tumors), and lymphomas (Hodgkin's disease, non-Hodgkin's lymphoma).
4.
You have performed a liver biopsy, and shortly after the procedure the patient develops pain on the tip of his right shoulder.
Which nerve is most likely to be responsible for his pain? Single best answer - choose ONE true option only
Correct answer
Right phrenic nerve

Axillary nerve

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 Right vagus

Right sympatheticus

Intercostobrachial nerve
The phrenic nerve on both sides originates from the ventral rami of the third to fifth cervical nerves. It passes inferiorly down the
neck to the lateral border of the scalenus anterior, then it passes medially across the border of scalenus anterior parallel to the
internal jugular vein that lies inferomedially.
The right phrenic nerve pierces the diaphragm in its tendinous portion just slightly lateral to the inferior vena caval foramen. It
then forms three branches on the inferior surface of the diaphragm: anterior, lateral and posterior. These ramify out in a radial
manner from the point of perforation to supply all but the periphery of the muscle.
5.
You are reviewing a 52-year-old man who has suffered a myocardial infarction. You suspect occlusion of the posterior
descending coronary artery.
In this case, which region of myocardium would you expect to be most affected?
Single best answer - choose ONE true option only

The right atrium

The right ventricle

The anterior septum

The anterior left ventricular wall

Correct answer
The posterior portion interventricular septum and the posterior left ventricular wall
The coronary system consists of left and right coronary arteries, which arise immediately above the aortic valve. They are
unique in that they fill during diastole, when not occluded by valve cusps and when not squeezed by myocardial contraction.
The right coronary artery arises from the right coronary sinus, giving off branches supplying the right atrium and right ventricle.
It then continues as the posterior descending coronary artery, which supplies the posterior portion of the interventricular
septum and the posterior left ventricular wall.
The left coronary artery divides into the left anterior descending (LAD) and circumflex arteries. The LAD runs in the anterior
interventricular groove and supplies the anterior septum and the anterior left ventricular wall. The left circumflex artery gives off
branches that supply the left atrium and left ventricle.
The sinus node is supplied by the right coronary artery in around 60% of people, the AV node in around 90%.

6.
You are asked to see a 45-year-old man who is haemodynamically compromised and plan to insert a right subclavian line. He
has a body mass index (BMI) of 38, where is the correct position for central venous cannulation?
Single best answer - choose ONE true option only

1 cm under the mid-point of the clavicle and 0.5 cm laterally

Correct answer
2 cm under the mid-point of the clavicle and 1 cm laterally

2.5 cm under the mid-point of the clavicle and 2 cm laterally

0.5 cm under the mid-point of the clavicle and 1 cm laterally

1 cm under the mid-point of the clavicle and 1 cm laterally

In obese patients, the standard position for right subclavian central venous cannulation is 2 cm under the mid-point of the
clavicle and 1 cm laterally. In thin patients the standard position for insertion is 1 cm under the mid-point of the clavicle and 0.5
cm laterally. Jugular vein cannulation is now the prepared choice for central venous catheterisation, as insertion under
ultrasound guidance is associated with a much lower rate of complications than subclavian insertion. The major hazard of the
subclavian approach is arterial puncture, as the artery lies close to the vein.
7.
Where would you visualise the azygous lobe on an antero-posterior (A-P) chest X-ray? Single best answer - choose ONE true
option only

Left lower zone

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 Left middle zone

Left upper zone

Correct answer
Right upper zone

Right lower zone

An azygous lobe is seen in about 0.5% of routine chest X-rays and is a normal variant. It is seen as a ‘reverse comma sign’
behind the medial end of the right clavicle.
8.
A 60-year-old previously fit and well man dies suddenly after two separate syncopal episodes. At post mortem examination,
which one of the following congenital cardiac defects that could be associated with his sudden death would you expect to find?

Dextrocardia with situs inversus

Patent foramen ovale

Correct answer
Bicuspid aortic valve

Ventricular septal defect

Single coronary artery

Whilst isolated dextrocardia can be associated with severe cardiac anomalies, dextrocardia with situs inversus has a low
incidence of accompanying defects and the heart functions normally. Isolated patent foramen ovale is of no haemodynamic
significance. The relatively common (1-2% of people) bicuspid aortic valve leads to accelerated calcific stenosis, which is
associated with syncope and sudden death. Small ventricular septal defects are insignificant, whereas large defects lead to
massive left to right shunts. A single coronary artery is not common, but does occur. When present, there is no clinical
consequence unless disease (such as atheroma) affects the vessel.
9.
In a 27-year-old restrained passenger from a high speed collision with a tree, you suspect a deceleration injury to the aorta.
Which feature on chest X-ray would most reliably support your suspicion?

Obliteration of the aortic knuckle

Obscuration of the aorto-pulmonary window

Presence of a pleural cap

Depression of the left main stem bronchus

Correct answer
Widened mediastinum
All of the above can be associated with a traumatic aortic injury. However, they are non-specific signs with high false positive
and false negative rates. Occasionally, no chest X-ray changes are visible following traumatic aortic injury. In a trauma supine
CXR, a widened mediastinum is the most consistent feature of aortic disruption. About 3% of these patients would prove to
have aortic injury on contrast CT or aortic angiogram.
10.
You suspect a lower respiratory tract infection in an elderly post operative patient and request a chest X-ray. Which of the
following chest X-ray appearances is most likely?

Blunting of the costophrenic angles

Correct answer
Indistinct hemidiaphragms

Kerley B lines

Indistinct right heart border

Indistinct left heart border

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Blunting of the costophrenic angles occurs when a (relatively) small volume of fluid has collected in the pleural spaces. This
can occur in a number of scenarios, but it is not the most likely appearance in the above patient. Immobilisation puts such a
patient at risk of basal atelectasis, subsequent consolidation and therefore a less distinct air-tissue interface at the diaphragm
on chest X-ray. Kerley B lines occur when there is interstitial oedema. An indistinct right heart border occurs with right middle
lobe consolidation, and an indistinct left heart border occurs when there is left upper lobe consolidation. Both of these are less
likely sites for consolidation given the above history.
11.
You are concerned about myocardial ischaemia in a post-operative patient who is complaining of chest pain. The ECG shows
tachycardia and isolated ST-segment depression in leads V1 and V2. Which coronary artery is most likely to be responsible?

Circumflex coronary artery

Left anterior descending coronary artery

Correct answer
Posterior descending coronary artery

Left main stem coronary artery

Right coronary artery

The coronary artery anatomy is variable, as are the relative territories of myocardium supplied by each of the arteries. ST-
segment depression across all leads implies ischaemia (angina), whereas isolated ST-segment depression in leads V1 and V2
may indicate a posterior myocardial infarction. The most likely involved artery in this case is therefore the posterior descending
artery. Either the right coronary or circumflex arteries can supply the posterior descending artery, but it is not possible to
identify which from the ECG alone. Left main stem and left anterior descending artery lesions would cause changes over a
much larger area.
12.
After a difficult right-sided subclavian central line insertion, which is the least likely structure to be damaged?

Correct answer
Thoracic duct

Brachial plexus

Subclavian vein

Subclavian artery

Lung apex
The thoracic duct has usually crossed over to the left side by the level of the 5th or 6th vertebral body, and is therefore the
furthest structure from the advancing needle. The brachial plexus, subclavian artery and lung can all be reached and damaged
by a needle during subclavian cannulation. The subclavian vein, although the target vessel in this case (and therefore
intentionally punctured) can be damaged (torn) during line insertion.
13.
In a post-operative immunosuppressed transplant patient, some small vesicles have formed on the chest wall, in a linear patch,
approximately level with his xiphoid process. Which dermatome is most likely to be affected?

C4

T4

Correct answer
T7

T10

L1
C4 corresponds to the lower neck just above the clavicle. T4 corresponds to the level of the nipples. T7 is the level of the
xiphoid process. T10 corresponds to the level of the umbilicus, and L1 corresponds to the lower abdomen / inguinal region.
14.
A pre-operative patient is on β-blockers. Where in the thoracic cage are the beta-1 adrenoceptors concentrated?

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 Correct answer
Ventricles

Atria

Aortic arch

Lungs

Carotid body
The beta-1 adrenoceptors are located within the ventricles of the heart. The atria contain cholinergic receptors. The aortic arch
contains baroreceptors. The Lungs contain beta-2 adrenoceptors. The carotid body contains baroreceptors.
15.
A 62-year-old ex-smoker has been diagnosed with non-small cell lung carcinoma by endobronchial biopsy. At standard
mediastinoscopy, what is the least likely lymph node station to be sampled?

Paratracheal nodes

Subcarinal nodes

Tracheobronchial nodes

Correct answer
Aortopulmonary nodes

Pretracheal nodes
During mediastinoscopy, the pretracheal fascia is incised and blunt dissection creates a tunnel inferiorly. The linear passage of
the mediastinoscope along this tunnel allows visualisation of the nodes lying to the front (pretracheal) and sides (paratracheal)
of the trachea. The subcarinal and tracheobronchial nodes can also be reached at the distal end of this tunnel. The
aortopulmonary nodes, however, cannot easily be reached as the aorta is “in the way” of the advancing finger or
mediastinoscope.
16.
You are required to insert a chest drain in a patient with penetrating trauma. Which anatomical landmark is least useful to you?

Anterior border of latissimus dorsi

Correct answer
The mid-clavicular line

The nipple

The mid-axillary line

Inferolateral border of pectoralis major

The “safe triangle” for the insertion of an intercostal drain is bounded anteriorly by the inferolateral border of pectoralis major,
posteriorly by the anterior border of latissimus dorsi and inferiorly by the axial plane at the level of the nipple. The mid-axillary
line may be used within this triangle to help guide placement of the incision. The mid-clavicular line should not be used for
placement of an intercostal tube drain.
17.
A young man is about to undergo bronchoscopy for suspected inhaled peanut. Where is the most likely site for the inhaled
peanut?

Right middle lobe bronchus

Left inferior lobe bronchus

Right superior lobe bronchus

Left superior lobe bronchus

Correct answer
Right lower lobe bronchus

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The right main bronchus is wider, shorter and runs more vertically than the left main bronchus. Consequently, foreign bodies
small enough to be inhaled more commonly enter the right lung. As a result of gravity, the right lower lobe is more likely to
receive such foreign bodies.
18.
A patient presents with a right bundle branch block due to blockage in the atrioventricular nodal artery.
Part of the right bundle branch of the arteriovenous bundle is carried by which structure?

Pectinate muscles

Anterior papillary muscle of the left ventricle

Correct answer
Moderator band (septomarginal trabecula)

Crista terminalis

Chordae tendineae
A muscular band, well marked in sheep and some other animals, frequently extends from the base of the anterior papillary
muscle to the ventricular septum. From its attachments it was thought to prevent overdistension of the ventricle and was
named the ‘moderator band’. However, more recent research has indicated that it is more properly considered part of the
electrical conduction system of the heart and in that capacity it is now called the septomarginal trabecula.
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19.
An SHO has been asked to aspirate some pleural fluid for culture and sensitivity from the left pleural space of a 65-year-old
man who has postpneumonic effusion.
If the SHO wants to aspirate the fluid with the patient sitting up in bed, where would the fluid tend to accumulate?

Correct answer
Costodiaphragmatic recess

Costomediastinal recess

Cupola

Hilar reflection

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 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, the
costodiaphragmatic recess is between ribs 6 and 8; at the mid-axillary line it is between ribs 8 and 10; and at the paravertebral
line it is between ribs 10 and 12. The costomediastinal recess is found where the costal pleura become the mediastinal pleura.
The cupola is the part of the pleural cavity that extends above the level of the first 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 that contains the heart, pericardium, great vessels and
bronchi (at the roots of the lung).
20.
A victim of anterior chest stabbing received a stab in a structure that is in close proximity to where the first rib articulates with
the sternum.
The structure most likely to be injured is the:

Nipple

Root of the lung

Sternal angle

Correct answer
Sternoclavicular joint

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 Xiphoid process
The first rib articulates with the sternum directly below the sternoclavicular joint. The nipple is found in the fourth intercostals
space, between the fourth and fifth 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.
21.
A 25-year-old man was stabbed in the right supraclavicular fossa. The knife punctured the portion of the parietal pleura that
extends above the first rib.
This portion of the parietal pleura is called the:

Costodiaphragmatic recess

Costomediastinal recess

Costocervical recess

Correct answer
Cupola

Endothoracic fascia
The cupola is the cervical parietal pleuron, which extends slightly above the level of the first 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 become the mediastinal pleura.
The endothoracic fascia is connective tissue between the inner chest wall and the costal parietal pleura. The costocervical
recess is a made-up term.
22.
During pericardiectomy, sudden bleeding was noticed due to accidental injury to a major vascular structure in the pericardium.
The surgeon inserted his left index finger through the transverse pericardial sinus, pulled forward on the two large vessels lying
ventral to his finger and compressed these vessels with his thumb to control bleeding.
Which vessels were these?

Pulmonary trunk and brachiocephalic trunk

Correct answer
Pulmonary trunk and aorta

Pulmonary trunk and superior vena cava

Superior vena cava and aorta

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. Therefore, 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.
23.
A patient with a cystic swelling in his left chest underwent a computer tomography-guided biopsy. The radiologist inserted the
biopsy needle into the ninth intercostal space along the mid-axillary line to aspirate the swelling and obtain tissue for
histological diagnosis.
The swelling is most likely to be in which space?

Cardiac notch

Correct answer
Costodiaphragmatic recess

Costomediastinal recess

Cupola

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 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 in different areas of the thorax. At the mid-clavicular line, the costodiaphragmatic recess is between
ribs 6 and 8; at the mid-axillary line it is between ribs 8 and 10; and at the paravertebral line it is between ribs 10 and 12.
Therefore, inserting the needle just above the ninth rib at the mid-axillary 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 the left lung. The costomediastinal recess is found where the costal pleura become the mediastinal pleura. The cupola is the
part of the pleural cavity, which extends above the level of the first 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.
24.
A patient with a malignant mesothelioma is to undergo pleuropneumonectomy, which involves removal of the entire pleura and
lung on the affected side.
Which of the following layers provides a natural cleavage plane for surgical separation of the costal pleura from the thoracic
wall?

Deep fascia

Correct answer
Endothoracic fascia

Parietal pleura

Visceral pleura

Transversus thoracis muscle fascia

The endothoracic fascia is the connective tissue between the inner aspect of the 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 comprise the cupola 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 are 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.
25.
A 78-year-old man with pseudobulbar palsy, lying supine in bed, aspirates one of his tablets into his lungs while swallowing.
It would be most likely to end up in which of the following bronchopulmonary segments?

Anterior segmental bronchus of the right superior lobe

Medial segmental bronchus of the right middle lobe

Correct answer
Superior segmental bronchus of the right inferior lobe

Medial basal segmental bronchus of the left inferior lobe

Inferior segmental bronchus of the lingular

Remember: 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 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.
26.
A 32-year-old man was shot in the chest. The bullet punctured a vessel that courses across the mediastinum in an almost
horizontal fashion.
Which one of the following vessels was injured?

Left subclavian artery

Left subclavian vein

8
 Correct answer
Left brachiocephalic vein

Left internal jugular vein

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. Therefore, 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.

27.
While performing a surgical procedure in the mid-region of the thorax the surgeon accidentally injured an important structure
that lies immediately anterior to the thoracic duct.
Which one of the following structures was most likely to be injured?

Aorta

Azygos vein

Correct answer
Oesophagus

Superior vena cava

Trachea
In the mid-thorax, the aorta, thoracic duct and azygos vein are all posterior to the oesophagus. (They are in that order, from left
to right.) The superior vena cava and the trachea are not located in the mid-thorax - the superior vena cava terminates as it
feeds into the right atrium and the trachea ends as it splits into the two main stem bronchi, which enter the lungs.
28.
The sinus venosus is the large quadrangular cavity located between the two vena cava vessels in the embryonic human heart.
In the adult heart the sinus venosus gives rise to the:

Aortic vestibule of the left ventricle

Correct answer
Coronary sinus

Fossa ovalis

Trabeculated part of the right ventricle

Trabeculated portion of the right atrium

The derivatives of the embryonic sinus venosus include: the smooth part of the right atrium (sinus venarum), the ‘valve’ of the
superior vena cava and the sinoatrial node from the right horn; the coronary sinus and the valve of coronary sinus from the left
horn; the border of smooth part of right atrium (crista terminalis) from the right half of the valve of the sinus venosus and part of
the atrial septum from the left half of the valve of the sinus venosus.
29.
The human embryonic heart rate is nearly twice that of the adult.
Which of the following statements regarding the development of the human heart is CORRECT?

In the second week, the endocardial tubes begin to fuse to form a single tube

The septum primum appears in the eighth week

Correct answer
The heart begins to beat in the fourth week

The primordium of the heart forms in the cardiogenic plate located at the caudal end of the embryo

The bulboventricular loop is formed in the sixth week

9
The primordium of the heart forms in the cardiogenic plate located at the cranial end of the embryo. Angiogenic cell clusters,
which lie in a horseshoe-shaped configuration in the plate, coalesce to form two endocardial tubes. These tubes are then
forced into the thoracic region due to cephalic and lateral foldings, where they fuse together forming a single endocardial tube
during the third week. The heart begins to beat in the fourth week at about the same time that the septum primum appears and
the bulboventricular loop is formed. From the fourth week onwards, septa begin to grow in the atria, ventricle and bulbus cordis
to form right and left atria, right and left ventricles and the two great vessels - the pulmonary artery and the aorta. By the end of
the eighth week, partitioning is completed and the fetal heart has formed.
30.
Endoderm is one of the germ layers formed during embryogenesis.
Which of the following organs is a derivative of the endoderm?

Adrenal medulla

Dermis of the skin

Correct answer
Epithelial part of the tympanic cavity

Gonads

Lens
Derivatives of endoderm include the epithelium of the gastrointestinal tract and its associated glands as well as glandular cells
of the liver and pancreas, epithelium of the urachus and urinary bladder, epithelium of respiratory passages (the pharynx,
trachea, bronchi and alveoli), epithelial parts of the tonsils, thyroid, parathyroids, tympanic cavity and thymus and epithelial
parts of the anterior pituitary.

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