Download 1. You are called to perform thoracentesis (remove fluid from the

1. You are called to perform thoracentesis (remove fluid from the
pleural cavity). If you are to avoid injuring lung or neurovascular
elements, where would you insert the aspiration needle?
the top of interspace 8 in the midclavicular line
the bottom of interspace 8 in the midclavicular line
the top of interspace 9 in the midaxillary line
the bottom of interspace 9 in the midaxillary line
the top of interspace 11 in the scapular line
2. The pleural space into which lung tissue just above the cardiac
notch would tend to expand during deep inspiration is the:
Anterior mediastinum
Costodiaphragmatic recess
Costomediastinal recess
Cupola
Pulmonary ligament
3. Which feature is found only in the left lung?
Cardiac notch
Horizontal fissure
Oblique fissure
Superior lobar bronchus
Three lobes
4. Which of the following nerves would be most vulnerable to irritation
when the tracheobronchial lymph nodes are enlarged due to a
diseased situation?
Right phrenic
Left phrenic
Right recurrent laryngeal
Left recurrent laryngeal
Right vagus
5. Which part of the left lung might partially fill the costomediastinal
recess in full inspiration?
Apex
Cupola
Hilum
Lingula
Middle lobe
6. The oblique fissure of the right lung separates which structures?
Lower lobe from lingula
Lower lobe from upper lobe only
Lower lobe from both upper and middle lobes
Lower lobe from middle lobe only
Upper from middle lobe
7. In a post-soccer match brawl, a 35-year-old man was stabbed in
the back with a knife that just nicked his left lung halfway between
its apex and diaphragmatic surface. Which part of the lung was
most likely injured?
Hilum
Inferior lobe
Lingula
Middle lobe
Superior lobe
8. A 4-year-old girl is brought in with coughing, and you are told by
her mother that she had been playing with some beads and had
apparently aspirated one (gotten it into her airway). Where would
you expect it to most likely be?
Apicoposterior segmental bronchus of left lung
Left main bronchus
Lingular segment of left lung
Right main bronchus
Terminal bronchiole of right lung, lower lobe
9. Which statement is true about the right lung?
it is slightly smaller than the left lung
it has a lingular segmental bronchus
it occupies the rightmost portion of the mediastinum
its upper lobar bronchus lies behind and above the right
pulmonary artery
it has the right phrenic nerve passing posterior to the lung root
10.
During a surgical procedure in the vicinity of the descending
aorta, a surgeon accidentally cuts the first aortic intercostal
arteries. Which of the following structures might be deprived of its
main source of blood supply?
first posterior intercostal space
first anterior intercostal space
left bronchus
right bronchus
fibrous pericardium
11.
A sick person, lying supine in bed, aspirates (breathes in)
some fluid into her lungs while swallowing. It would most likely end
up in which of the following bronchopulmonary segments?
anterior segmental bronchus of right superior lobe
medial segmental bronchus of right middle lobe
superior segmental bronchus of right inferior lobe
medial basal segmental bronchus of left inferior lobe
inferior segmental bronchus of lingular lobe
12.
A 22-year-old male involved in a bar-room brawl suffered a
stab wound through the posterior thoracic wall that entered the
posterior surface of the right lung half way between its apex and
diaphragmatic surface. Which part of the lung did the knife first
enter?
Cupola
Inferior lobe
Lingula
Middle lobe
Superior lobe
13.
A 20-year-old man was stabbed in the back with a knife that
just nicked his right lung halfway between its apex and
diaphragmatic surface. Which part of the lung was most likely
injured?
Middle lobe
Inferior lobe
Cardiac notch
Lingula
Superior lobe
14.
A 10-year-old boy underwent a tonsillectomy under general
anesthesia. At home he lay supine in bed for two weeks and
developed a fever and chest pain with cough. He returned to the
hospital and was diagnosed as having right lung pneumonia due to
aspiration of infectious material during the tonsillectomy. In which
bronchopulmonary segment of the lung would fluid (pus) most
likely have accumulated by the simple force of gravity?
Anterior basal segment--inferior lobe
Anterior segment--superior lobe
Lateral segment--middle lobe
Superior segment--inferior lobe
Superior lingual segment--lingula
15.
You are observing a doctor perform a bronchoscopy. As he
passes the bronchoscope down the trachea, a cartilagenous
structure is observed separating the right and left main stem
bronchi. He asks what it is called. You reply that it really does look
like a ship's keel and that it is called the:
Carina
Cricoid cartilage
Costal cartilage
Pulmonary ligament
16.
Tracheal ring
The minor (horizontal) fissure separates:
the lower lobe from the lingula
the upper lobe from the lingula
the lower lobe from both the middle and upper lobes
the lower lobe from the middle lobe
the middle lobe from the upper lobe
17.
Your patient, an 86-year-old female who has been bedridden and lying supine for many weeks, has developed a right
lung abscess that is draining by gravity into one particular region of
the lung. Where is the most likely site of fluid accumulation?
Apical segment of upper lobe
Lingula
Lower lobe
Middle lobe
Superior segment of lower lobe
18.
Because of its angle with the trachea and size of the main
bronchus, a bronchoscope would pass more readily into which
lung?
Left
Right
19.
Which vessel courses across the mediastinum in an almost
horizontal fashion?
Left subclavian artery
Left subclavian vein
Left brachiocephalic vein
Left internal jugular vein
Left common carotid artery
20.
A 78-year-old female presented with edema of the left upper
limb due to poor venous return. Examination revealed an
aneurysm of the ascending aorta that was impinging on a large
vein lying immediately anterosuperior to it, most likely the:
Azygos v.
Internal thoracic v.
Left brachiocephalic v.
Left superior intercostal v.
Right brachiocephalic v.
21.
An 8-year-old boy is found to have a mid-line tumor of the
thymus gland that is impinging posteriorly on a blood vessel. The
affected vessel is most likely the:
left brachiocephalic vein
left pulmonary vein
left bronchial vein
right pulmonary artery
right superior intercostal vein
1. The correct answer is:
line
the bottom of interspace 9 in the midaxillary
For a thoracocentesis, the needle needs to be inserted below the level of
the lungs, in the costodiaphragmatic recess. At the midclavicular line,
the recess is between rib spaces 6 and 8, at the midaxillary line it is
between 8 and 10, and at the paravertebral line between 10 and 12.
Additionally, the needle needs to be inserted at the top of the rib (or the
bottom of the intercostal space). This is essential for avoiding damage to
the neurovascular bundles that are found below the ribs, running in the
costal groove. Taken together, these two pieces of information point to
the conditions listed in D as the only appropriate ones for a
thoracocentesis.
2. 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. This is where
the medial area of the superior lobe of the left lung would tend to expand
if it became very inflated. The lung would not enter the anterior
mediastinum, which is an area between the two pleural sacs, bounded
anteriorly by the sternum and posteriorly by the pericardium. The
anterior mediastinum contains areolar tissue, sternopericardial
ligaments, lymph vessels and nodes, but no lung tissue. The
costodiaphragmatic recess is the recess at the inferior border of a lung.
This is the space into which the inferior lobe of the lung would expand
following deep inhalation. The cupola is the serous membrane lining the
pleural cavity which extends above the level of the 1st rib into the root of
the neck. The most superior portion of the superior lobe might expand
into this space. The pulmonary ligament is the fold of pleura located
below the root of the lung where the visceral pleura and the mediastinal
parietal pleura are continuous with each other.
3. The correct answer is:
cardiac notch
The cardiac notch is only found on the left lung, which makes sense
since the heart is located on the left side of the mediastinum. The
horizontal fissure is a deep groove that separates the middle lobe from
the upper lobe of the right lung. The left lung does not have a horizontal
fissure. The oblique fissure is found in both lungs. It separates the upper
lobe from the lower lobe in both lungs and the middle lobe from the
lower lobe in the right lung. Both lungs also have a superior lobar
bronchus leading to their superior lobes. Finally, the right lung has three
lobes while the left lung has two lobes.
4. The correct answer is:
left recurrent laryngeal
The tracheobronchial nodes are at the tracheal bifurcation. There are
three groups of these nodes: right superior, left superior, and inferior.
The aorta loops over the left bronchus, near the tracheal bifurcation. So,
it is reasonable to assume that any nerve that is closely associated with
the aorta might be irritated if the tracheobronchial lymph nodes became
inflamed. This means that the correct answer is the left recurrent
laryngeal nerve, which loops under the aorta to ascend to the larynx.
The right and left phrenic nerves are lateral and would not be irritated by
the inflammation. The right recurrent laryngeal nerve loops around the
right subclavian artery and is not close enough to this area. Finally, the
right vagus is not closely associated with the aorta.
5. The correct answer is:
lingula
When inspiring fully, the lingula of the left lung might partially fill the
costomediastinal recess. The lingula, a tongue-like projection of the left
lung below the cardiac notch, is right next to the costomediastinal
recess. If the apex of the lung was highly inflated, it might expand to fill
the cupola. The hilum is the part of the lung where the structures forming
the root of the lung--the main bronchus, pulmonary vessels, bronchial
vessels, lymphatics, and nerve--enter and leave the lung. It does not
expand on inspiration. The middle lobe of the lung may expand to fill the
costomediastinal recess, but remember that the question is specifically
asking about a left lung structure, and the middle lobe is only in the right
lung!
6. The correct answer is:
lower lobe from both middle and upper lobe
The oblique fissure cuts across the right lung in such a way as to
separate the lower lobe from both the middle and upper lobes. So what
does the horizontal fissure do? It separates the middle lobe from the
upper lobe. Remember that the lingula is only on the left lung, and it is
part of the superior lobe.
7. The correct answer is:
inferior lobe
Because of the sharp angle of the oblique fissure, the posterior surface
of the left lung is almost entirely comprised of the inferior lobe. So, a
stab wound halfway between the apex and diaphragmatic surface of the
lung would result in injury to the inferior lobe. The hilum is the point at
which the structures forming the root of the lung enter the lung. The
lingula is part of the superior lobe, which forms the anterior and superior
sides of the lung. And remember, the middle lobe isn't relevant here
because it is on the right lung. (Besides, it doesn't even contribute to the
posterior surface of the right lung.)
8. The correct answer is:
right main bronchus
There are several reasons why inhaled objects will be more likely to
enter the right lung instead of the left lung. First, the carina, a ridge-like
structure at the bifurcation of the trachea, is set a little towards the left.
So, there is a more direct path for objects to fall to the right. Also, the
right bronchus is shorter, wider, and more vertical than the left bronchus.
All of these factors mean that an inhaled object will enter the right main
bronchus. It would be almost impossible for a bead to get lodged in the
terminal bronchiole of the right lung--that is a very small space!
9. The correct answer is: its upper lobar bronchus lies behind and
above the right pulmonary artery
The structures at the root of the lung have different relationships in the
right and left lungs. On both sides, the pulmonary veins are anterior and
inferior while the bronchus is posterior. The difference between the two
sides involves the pulmonary arteries. On the right side, the arteries are
anterior to the bronchus, while on the left side the arteries are superior to
the bronchus. The right lung is slightly larger than the left lung, and the
lingula is found in the left lung only. Neither lung is in the mediastinum-the mediastinum is the space between the two pleural sacs. Finally, the
phrenic nerve passes anterior to the root of the lung--on both the left and
right sides.
10. The correct answer is:
Right bronchus
The right bronchus receives blood from a single right bronchial artery.
This artery may branch from one of the left bronchial arteries or it may
branch from the right 3rd posterior intercostal artery, the first intercostal
artery that arises from the descending aorta. Damaging this artery might
stop the blood supply to the main bronchus. The intercostal arteries to
the first and second intercostal spaces are derived from the highest
intercostal artery, so the blood supply to either of these spaces would
not be disrupted. The left bronchus is supplied by two left bronchial
arteries which branch directly from the descending aorta. The fibrous
pericardium is a fibrous sac that contains the pericardial cavity and the
heart. Its blood supply is not a major concern.
11. The correct answer is:
inferior lobe
superior segmental bronchus of right
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 of the intermediate
bronchus or the inferior lobe bronchus, so it is the segmental bronchus
most likely to receive the foreign bodies that enter the right main
bronchus.
12. The correct answer is:
Inferior lobe
Because of the sharp angle of the oblique fissures, the posterior
surfaces of both the right and left lungs are almost entirely comprised of
the inferior lobe--the middle lobe of the right lung is not part of the
posterior surface of the lung. So, a stab wound halfway between the
apex and diaphragmatic surface of the lung would result in injury to the
inferior lobe. The lingula is part of the superior lobe of the left lung, which
forms the anterior and superior sides of that lung. The superior lobe
(along with the middle lobe) forms the anterior surface of the right lung.
The superior lobe also forms the superior aspect of both lungs. The
cupola is the serous membrane lining the pleural cavity which extends
above the level of the 1st rib into the root of the neck--it is not part of the
lung!
13. The correct answer is:
Inferior lobe
Because of the sharp angle of the oblique fissures, the posterior
surfaces of both the right and left lungs are almost entirely comprised of
the inferior lobes. And remember--the middle lobe of the right lung is not
part of the posterior surface of the lung. So, a stab wound halfway
between the apex and diaphragmatic surface of the right lung would
result in injury to the inferior lobe. The cardiac notch is an indentation on
the left lung which helps to form the lingula. The lingula is part of the
superior lobe of the left lung, which forms the anterior and superior sides
of that lung. The superior lobe (along with the middle lobe) forms the
anterior surface of the right lung. The superior lobe also forms the
superior aspect of both lungs.
14. The correct answer is:
Superior segment--inferior lobe
The superior segmental bronchus of the inferior lobe branches
posteriorly off of the intermediate bronchus or the inferior lobe bronchus,
so it is the most likely segmental bronchus to receive foreign bodies or
fluids that enter the right bronchus. This is even more likely to occur if
the patient is in the supine position.
15. The correct answer is:
Carina
The carina is a keel-shaped cartilage lying at the tracheal bifurcation--it
separates the right main stem bronchus from the left main stem
bronchus. The carina is a little to the left of the tracheal bifurcation, so if
there is an inhaled body the carina will tend to divert foreign objects to
the right main bronchus. The cricoid cartilage is the inferior and posterior
cartilage of the larynx. The costal cartilages prolong the ribs anteriorly
and contribute to the elasticity of the thoracic wall. They increase in
length through the first seven and then gradually decrease. The
pulmonary ligament is a fold of pleura located below the root of the lung.
Tracheal rings are the cartilagenous structures which support the
trachea and keep it patent.
16. The correct answer is:
the upper lobe from the middle lobe
The horizontal fissure cuts across the right lung in such a way as to
separate the middle lobe from the upper lobe. The oblique fissure
separates the lower lobe from both the middle and upper lobes.
Remember that the lingula is only on the left lung, and it is part of the
superior lobe.
17.
The correct answer is:
Superior segment of lower lobe
The superior segmental bronchus to the lower lobe of the right lung
branches posteriorly off of the intermediate bronchus or the inferior lobe
bronchus. So, it is the segmental bronchus most likely to receive the
fluid or foreign bodies that enter the right main bronchus. This segment
of the lung is even more likely to accumulate fluid when the patient is
supine.
18. The correct answer is:
Right
There are several reasons why a bronchoscope or inhaled objects will
be more likely to enter the right lung instead of the left lung. First, the
carina, a ridge-like structure at the bifurcation of the trachea, is set a little
towards the left. So, there is a more direct path for objects to fall to the
right. Also, the right bronchus is shorter, wider, and more vertical than
the left bronchus. All of these factors mean that an inhaled object will
usually enter the right main bronchus.
19. The correct answer is:
left brachiocephalic vein
The left brachiocephalic vein joins with the right brachiocephalic vein to
form the superior vena cava on the right side of the body. So, the left
brachiocephalic vein must course across the mediastinum to reach its
destination. The left subclavian artery and vein are lateral to the
mediastinum, while the left jugular and common carotid travel vertically.
20.
The correct answer is:
Left brachiocephalic vein
Remember that the ascending aorta is the short part of the aorta
emerging from the heart before the aortic arch. The left brachiocephalic
vein is the only vein listed which is anterosuperior to that part of the
aorta. It crosses horizontally through the mediastinum to join with the
right brachiocephalic vein and form the superior vena cava. The right
brachiocephalic vein stays on the right side of the chest and would not
be affected by the aortic aneurysm. The azygos vein is also on the right
side of the chest, and it lays deep in the thoracic cavity. The internal
thoracic vein lies on the interior surface of the anterior wall of the chest.
Although it drains into the brachiocephalic vein, it would not be affected
by the aneurysm. The left superior intercostal vein crosses the aortic
arch laterally, but its blockage would only affect drainage of intercostal
spaces 2-4 on the left side.
21.
The correct answer is:
left brachiocephalic vein
Remember--the thymus is a very superficial structure found in the
anterior mediastinum. The left brachiocephalic vein courses through the
mediastinum to join the right brachiocephalic vein and form the superior
vena cava on the right side of the thorax. Since the left brachiocephalic
vein is fairly superficial, it travels just deep to the thymus. So, it might be
compressed by the tumor. See Netter Plate 206 for a picture of the
thymus and the left brachiocephalic vein.
The left pulmonary vein, left bronchial vein, and right pulmonary arteries
are deep structures that enter and exit the lung at its root--they are not
near the thymus. The right superior intercostal vein drains intercostal
spaces 2-4. It drains into the arch of the azygos vein and is not
associated with the thymus.