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23 Cards in this Set
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1.The second costal cartilage can be located by palpating the:
costal margin sternal angle sternal notch sternoclavicular joint xiphoid process |
The correct answer is: sternal angle
The sternal angle is the point where the costal cartilage attaches the second rib to the sternum. This is an important anatomical landmark to remember--it is used to find the valves when auscultating the heart! The costal margins are formed by the medial borders of the 7th through 10th costal cartilages. They are easily palpable and extend inferolaterally from the xiphisternal joint. The sternal notch/jugular notch is the notch located at the superior border of the manubrium, between the sternal ends of the clavicles. The sternoclavicular joints are simply the joints connecting the sternum with the clavicles. Finally, the xiphoid process is the bone that makes the inferior part of the sternum. |
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2.The thoracic wall is innervated by:
Dorsal primary rami Intercostal nerves Lateral pectoral nerves Medial pectoral nerves Thoracodorsal nerves |
The correct answer is:
intercostal nerves Intercostal nerves are the ventral primary rami of spinal nerves T1-T11. They provide motor innervation to intercostal muscles, abdominal wall muscles (via T7-T11) and muscles of the forearm and hand (via T1). They provide sensory innervation to the skin of the chest and abdomen on the anterior and lateral sides. The other nerves listed do not innervate the chest wall. Dorsal primary rami provide motor innervation to true back muscles and sensory innervation to the skin on the back. The lateral pectoral nerve provides motor innervation to pectoralis major only, while the medial pectoral nerve provides motor innervation to pectoralis major and minor. The thoracodorsal nerve provides motor innervation to latissimus dorsi. |
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3.The sternocostal surface of the heart is formed primarily by the anterior wall of which heart chamber?
Left atrium Left ventricle Right atrium Right ventricle |
The correct answer is: right ventricle
The heart has three important surfaces: an anterior surface, a diaphragmatic surface, and a pulmonary surface. The anterior surface, or sternocostal surface, is mostly made up of the right ventricle. The diaphragmatic surface is mostly the left ventricle, but a little bit of the right ventricle sits on the diaphragm as well. Finally, the pulmonary surface, which is on the left, is mostly made up of the left ventricle. |
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4.A patient involved in an automobile accident presents with a sharp object puncture of the middle of the sternum at about the level of the 4th or 5th costal cartilage. If the object also penetrated pericardium and heart wall, which heart chamber would most likely be damaged?
Left atrium Left ventricle Right atrium Right ventricle |
The correct answer is: right ventricle
Remember, the anterior surface, or sternocostal surface, of the heart is mostly made up of the right ventricle. So, if an object punctured the sternum, it would be likely to pierce the right ventricle. |
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6.A 23-year-old male injured in an industrial explosion was found to have multiple small metal fragments in his thoracic cavity. Since the pericardium was torn inferiorly, the surgeon began to explore for fragments in the pericardial sac. Slipping her hand under the heart apex, she slid her fingers upward and to the right within the sac until they were stopped by the cul-de-sac formed by the pericardial reflection near the base of the heart. Her fingertips were then in the:
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The correct answer is: oblique sinus
The oblique sinus is an area of the pericardial cavity located behind the left atrium of the heart where the serous pericardium reflects onto the inferior vena cava and pulmonary veins. If you slide your fingers under the heart, they will be in the oblique sinus. The other pericardial sinus that you should be familiar with is the transverse sinus. The transverse sinus is an area of the pericardial cavity located behind the aorta and pulmonary trunk and anterior to the superior vena cava. It separates the outflow vessels from inflow vessels. The coronary sinus is a large vein on the heart which drains into the right atrium. The coronary sulcus is a groove on the heart which separates the atria from the ventricles. The costomediastinal recess is an area in the pleural sac where the costal pleura changes to the mediastinal pleura. |
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5.You are caring for a 68-year-old male who has copious amounts of fluid in the left pleural cavity due to acute pleurisy. When you examine him as he sits up in bed (trunk upright), where would the fluid tend to accumulate?
costodiaphragmatic recess costomediastinal recess cupola hilar reflection middle mediastinum |
The correct answer is: costodiaphragmatic recess
The costodiaphragmatic recess is the lowest extent of the pleural cavity or sac. It is the part of the pleural sac where the costal pleura changes into the diaphragmatic pleura. Because this is the most inferior part of the pleural sac, fluid in the pleural sac will fall to this region when a patient sits up. The costodiaphragmatic recess is also the area into which a needle is inserted for thoracocentesis, and it is found at different levels at different areas of the thorax. At the mid-clavicular line, the costodiaphragmatic recess is between ribs 6 and 8; at the midaxillary line it is between 8 and 10; and at the paravertebral line it is between 10 and 12. The costomediastinal recess is found where the costal pleura becomes the mediastinal pleura. The cupola is the part of the pleural cavity which extends above the level of the 1st rib into the root of the neck. The hilar reflection is the point at the root of the lung where the mediastinal pleura is reflected and becomes continuous with the visceral pleura. Finally, the middle mediastinum is the space in the mediastinum which contains the heart, pericardium, great vessels, and bronchi (at the roots of the lung). |
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7.When inserting a chest tube, intercostal vessels and nerves are avoided by placing the tube immediately:
above the margin of a rib below the margin of a rib |
The correct answer is: above the margin of a rib
The VAN triad of an intercostal vein, artery, and nerve run along the bottom of a rib, in the costal groove. To avoid hitting any of these important structures, it is important to remember to always place a tube or needle above the margin of a rib (or,if you prefer to think about it this way, at the bottom of an intercostal space). |
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8.A hand slipped behind the heart at its apex can be extended upwards until stopped by a line of pericardial reflection that forms the:
Cardiac notch Costomediastinal recess Hilar reflection Oblique pericardial sinus Transverse pericardial sinus |
The correct answer is: oblique pericardial sinus
The oblique pericardial sinus is an area of the pericardial cavity located behind the left atrium of heart where the serous pericardium reflects onto the inferior vena cava and pulmonary veins. If you slide your fingers under the heart, they will be in this space. The other pericardial sinus that you should be familiar with is the transverse sinus. The transverse sinus is an area of the pericardial cavity located behind the aorta and pulmonary trunk and anterior to the superior vena cava. It separates the outflow vessels from inflow vessels. The cardiac notch is an indentation in the superior lobe of the left lung which creates the lingula. The costomediastinal recess is an area in the pleural sac where the costal pleura changes to the mediastinal pleura. Finally, the hilar reflection is the reflection of pleura on the root of the lung, where visceral pleura on the lung becomes continuous with the mediastinal pleura. |
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9.The first rib articulates with the sternum in close proximity to the:
Nipple Root of the lung Sternal angle Sternoclavicular joint Xiphoid process |
The correct answer is: sternoclavicular joint
The first rib articulates with the sternum directly below the sternoclavicular joint. The nipple is found in the fourth intercostal space, between the 4th and 5th ribs. The sternal angle is connected to the costal cartilage of rib 2. Finally, the xiphoid process is located just below the point where the costal cartilage of rib 7 articulates with the sternum. The root of the lung consists of the main bronchus, pulmonary and bronchial vessels, lymphatic vessels, and nerves entering and leaving the lung. |
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10.The portion of the parietal pleura that extends above the first rib is called the :
costodiaphragmatic recess costomediastinal recess costocervical recess cupola endothoracic fascia |
The correct answer is: cupola
The cupola is the cervical parietal pleura which extends slightly above the level of the 1st rib into the root of the neck. The costodiaphragmatic recess is the part of the pleural sac where the costal pleura changes into the diaphragmatic pleura. It is the lowest extent of the pleural sac. The costomediastinal recess is found where the costal pleura becomes the mediastinal pleura. Endothoracic fascia is connective tissue between the inner chest wall and costal parietal pleura. The costocervical recess is a made up term. |
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11.You are attending an operation to remove a thymic tumor from the superior mediastinum. The surgeon asks, "What important nerve lying on and partly curving posteriorly around the arch of the aorta should we be careful of as we remove this mass?" You quickly answer, "The--
left phrenic left sympathetic trunk left vagus right phrenic right sympathetic trunk |
The correct answer is: left vagus
The left vagus nerve lies against the lateral surface of the arch of the aorta. The left recurrent laryngeal nerve is an especially important nerve from the vagus which loops around the aortic arch. This nerve innervates the muscles of the left larynx. If it is damaged, a patient may experience hoarseness after surgery. Care must be taken to preserve this nerve, especially during thyroid surgery. The left and right phrenic nerves, which innervate the diaphragm, are lateral to the vagus nerves and are not looping near the aortic arch. The left and right sympathetic trunks lie on the posterior chest wall and are not involved with the aortic arch. |
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13.A needle inserted into the 9th intercostal space along the midaxillary line would enter which space?
Cardiac notch Costodiaphragmatic recess Costomediastinal recess Cupola Oblique pericardial sinus |
The correct answer is: Costodiaphragmatic recess
The costodiaphragmatic recess is the lowest extent of the pleural cavity or sac. It is the part of the pleural sac where the costal pleura changes into the diaphragmatic pleura. It is also the area into which a needle is inserted for thoracocentesis, and it is found at different levels at different areas of the thorax. At the mid clavicular line, the costodiaphragmatic recess is between ribs 6 and 8; at the midaxillary line it is between 8 and 10; and at the paravertebral line it is between 10 and 12. So, inserting the needle just above the 9th rib at the midaxillary line should put you in the costodiaphragmatic recess. The cardiac notch is a structure on the left lung which separates the lingula below from the upper portion of the superior lobe of left lung. The costomediastinal recess is found where the costal pleura becomes the mediastinal pleura. The cupola is the part of the pleural cavity which extends above the level of the 1st rib into the root of the neck. The oblique pericardial sinus is an area of the pericardial cavity located behind the left atrium of the heart. |
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14.During a heart transplant procedure, the surgeon inserted his left index finger through the transverse pericardial sinus, and then pulled forward on the two large vessels lying ventral to his finger. Which vessels were these?
Pulmonary trunk and brachiocephalic trunk Pulmonary trunk and aorta Pulmonary trunk and superior vena cava Superior vena cava and aorta Superior vena cava and right pulmonary artery |
The correct answer is: Pulmonary trunk and aorta
The transverse pericardial sinus is an area of the pericardial cavity located behind the aorta and pulmonary trunk and anterior to the superior vena cava. So, the two large vessels lying ventral to his finger are the pulmonary trunk and aorta; the large vessel lying dorsal to his finger is the superior vena cava. |
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15.While observing in the OR, you see the resident insert a needle through the body wall just above the ninth rib in the mid-axillary line. She was obviously trying to enter the:
Costodiaphragmatic recess Costomediastinal recess Cupola Hilar reflection Pulmonary ligament |
The correct answer is: Costodiaphragmatic recess
The costodiaphragmatic recess is the lowest extent of the pleural cavity or sac. It is the part of the pleural sac where the costal pleura changes into the diaphragmatic pleura. It is also the area into which a needle is inserted for thoracocentesis, and it is found at different levels at different areas of the thorax. At the mid clavicular line, the costodiaphragmatic recess is between ribs 6 and 8; at the midaxillary line it is between 8 and 10; and at the paravertebral line it is between 10 and 12. So, inserting the needle just above the 9th rib at the midaxillary line should put the resident's needle in the costodiaphragmatic recess. Make sure you know where to enter the costodiaphragmatic recess at the midclavicular line, the mid axillary line, and the paravertebral line! The costomediastinal recess is found where the costal pleura becomes the mediastinal pleura. The cupola is the part of the pleural cavity which extends above the level of the 1st rib into the root of the neck. The hilar reflection is the point at the root of the lung where the mediastinal pleura is reflected and becomes continuous with the visceral pleura. The pulmonary ligament is a fold of pleura located below the root of the lung, where the visceral pleura and the mediastinal parietal pleura are continuous with each other. |
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16.The pleural cavity near the cardiac notch is known as the:
Costodiaphragmatic recess Costomediastinal recess Cupola Hilum Pulmonary ligament |
The correct answer is: Costomediastinal recess
The costomediastinal recess is an area right next to the cardiac notch, which is an indentation in the superior lobe of the left lung. If you take a very deep breath, the lingula of the left lung, which is formed by the cardiac notch, will tend to expand into the costomediastinal recess. The costodiaphragmatic recess is the lowest extent of the pleural cavity or sac. It is the part of the pleural sac where the costal pleura changes into the diaphragmatic pleura. The cupola is the part of the pleural cavity which extends above the level of the 1st rib into the root of the neck. The hilum is found on the medial surface of the lung--it is the point at which the structures forming the root enter and leave the lung. The pulmonary ligament is a fold of pleura located below the root of the lung, where the visceral pleura and the mediastinal parietal pleura are continuous with each other. |
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17.The tubercle of the 7th rib articulates with which structure?
Body of vertebra T6 Body of vertebra T7 Body of vertebra T8 Transverse process of vertebra T6 Transverse process of vertebra T7 |
The correct answer is: Transverse process of vertebra T7
The tubercle of a rib is a projection located posteroinferior and lateral to the neck of the rib. It articulates with the transverse process of the vertebra of the same number. So, the tubercle of rib 7 should articulate with the transverse process of the T7 vertebra. The head of the rib is the part of the rib that articulates with the demifacets of two adjacent vertebral bodies. So, the head of rib 7 should articulate with the 6th vertebra superiorly and the 7th vertebra inferiorly. |
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18.The ductus arteriosus sometimes remains open after birth requiring surgical closure. When placing a clamp on the ductus, care must be taken to avoid injury to what important structure immediately dorsal to it?
Accessory hemiazygos vein Left internal thoracic artery Left phrenic nerve Left recurrent laryngeal nerve Thoracic duct |
The correct answer is: Left recurrent laryngeal nerve
The left recurrent laryngeal nerve is a branch of the vagus that wraps around the aorta, posterior to the ductus arteriosus or ligamentum arteriosum. It then travels superiorly to innervate muscles of the larynx. It's important to protect this nerve during surgery! If the left recurrent laryngeal nerve becomes paralyzed, a patient might experience a hoarse voice or even have difficulty breathing due to a laryngeal spasm. You should make sure that you understand what this nerve does, what types of procedures might injure this nerve, and the effects of a damaged left recurrent laryngeal! The accessory hemiazygos vein is a vein on the left side of the body. It drains the posterolateral chest wall and empties blood into the azygos vein. The left internal thoracic artery is a branch of the left subclavian artery that supplies blood to the anterior thoracic wall. The left phrenic nerve runs lateral to the vagus nerve and its branches in the thorax; it is not close enough to be damaged by the surgery. The thoracic duct is deep in the chest - it travels between the azygos vein and the aorta, posterior to the esophagus. |
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19.A 16-year-old male suffered a stab wound in which a knife blade entered immediately superior to the upper edge of the right clavicle near its head. He was in extreme pain, which was interpreted by the ER physician as a likely indicator of a collapsed lung following disruption of the pleura. If that was true, what portion of the pleura was most likely cut or torn?
costal pleura cupola hilar reflection mediastinal pleura pulmonary ligament |
The correct answer is: cupola
The cupola is the part of the plural cavity which extends above the level of the 1st rib into the root of the neck. So, if a patient was stabbed above the clavicle, it would be very likely that the cupola was damaged. The costal pleura is the layer of parietal pleura that covers the costal surface. The hilar reflection is the point where the visceral pleura of the lung reflects to become continuous with the parietal pleura. The mediastinal pleura is the parietal pleura on the mediastinal surface, found medial to the lung. Finally, the pulmonary ligament is a double layer of pleura extending from the inferior end of the hilar reflection downward to the diaphragm below. |
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20.During a lung transplant procedure, an observing 4th year attempted to pass his index finger posteriorly inferior to the root of the left lung, but he found passage of the finger blocked. Which structure would most likely be responsible for this?
Costodiaphragmatic recess Cupola Inferior vena cava Left pulmonary vein Pulmonary ligament |
The correct answer is: pulmonary ligament
The pulmonary ligament is a double layer of pleura extending from the inferior end of the hilar reflection downward to the diaphragm. So, it is a structure that would block you from moving your finger posteriorly at the root of a lung. The costodiaphragmatic recess is the space at the inferior border of the lung where the costal pleura touches the diaphragmatic pleura. The cupola is the part of the pleura that extends superiorly above the first rib--it's not associated with the root of the lung in any way. The inferior vena cava is found in the mediastinum and would not be near the root of the lung. The left pulmonary veins are part of the root of the lung and would not block someone from reaching behind the lung. |
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21.Which of the following layers provides a natural cleavage plane for surgical separation of the costal pleura from the thoracic wall?
Deep fascia Endothoracic fascia Parietal pleura Visceral pleura Transversus thoracis muscle fascia |
The correct answer is: endothoracic fascia
The endothoracic fascia is the connective tissue between the inner aspect of chest wall and the costal parietal pleura. By clearing the endothoracic fascia, it is easy to separate the costal pleura from the thoracic wall. Deep fascia is a fascial layer that invests a muscle or muscle group - it is not present around the lungs. The parietal pleura is made up of the cupula or cervical pleura, costal pleura, diaphragmatic pleura, and mediastinal pleura. It lines the inner surfaces of the walls of the pleural cavity. The visceral pleura is the serous membrane that covers the lungs. Finally, the transversus thoracis muscle fascia is only associated with the transversus thoracis - it would not provide a natural cleavage plane for separating the costal pleura from the thoracic wall |
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22.The lowest extent of the pleural cavity, into which lung tissue does not extend, is known as the:
costodiaphragmatic recess costomediastinal recess cupola inferior mediastinum pulmonary ligament |
The correct answer is: costodiaphragmatic recess
The costodiaphragmatic recess is the area inferior to the lung where the costal and diaphragmatic pleura are continuous. This is the lowest extent of the pleural cavity. The costomediastinal recess is a small anterior recess where the costal and mediastinal pleura are continuous. The cupola is the pleural space that extends above the first rib. The inferior mediastinum is a term sometimes used to refer to the anterior, middle, and posterior subdivisons of the mediastinum all together. The pulmonary ligament is a fold of pleura located beneath the root of the lung. |
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23.The sternal angle is a landmark for locating the level of the:
Costal margin Jugular notch Second costal cartilage Sternoclavicular joint Xiphoid process |
The correct answer is: Second costal cartilage
The sternal angle is a very important anatomical landmark which is used when placing the stethoscope and listening for heart sounds. The sternal angle is the location of the attachment of the costal cartilage of the second rib to the sternum. So, once you locate the sternal angle on a patient, you know the location of the second rib, and you can use that landmark to find the right spots to auscultate each valve of the heart. Also remember that a horizontal plane through the sternal angle passes through the T4/T5 intervertebral disc and marks the inferior boundary of the superior mediastinum. |
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24.A 3rd-year medical student was doing her first physical exam. In order to properly place her stethoscope to listen to heart sounds, she palpated bony landmarks. She began at the jugular notch, then slid her fingers down to the sternal angle. At which rib (costal cartilage) level were her fingers?
1 2 3 4 Can't be determined |
The correct answer is: 2
Remember, the sternal angle is where the costal cartilage of the second rib attaches to the sternum. This is a significant landmark! |
