Anatomy- Thorax

Structure Clinical Importance Plate # in Netter

INTEGUMENTARY
Mammary Gland Breast cancer is most common malignancy in women; movement of breast with pectoral muscles indicates invasion of retromammary space 188
SKELETAL
Ribs Rib fractures may breach pleural space and cause pneumothorax; flail chest occurs when multiple rib fractures lead to thoracic cage instability 192
Sternal Angle (of Louis) Surface landmark for counting ribs (2nd pair of ribs articulate here) and intercostal spaces; divides superior from inferior mediastinum 192
Chest wall (ribs and Knowledge of relationships between chest wall and underlying organs is necessary for thoracotomy
intercostal spaces) 194, 202, 204

Left ribs (ribs 9, 10, 11) If fractured, may cause injury to underlying spleen 202
Superior thoracic aperture Compression of neurovascular structures traversing superior thoracic aperture may produce thoracic outlet syndrome 198
MUSCULAR
Intercostal spaces Important relationship of intercostal neurovascular bundle to ribs when placing chest drainage tube to relieve pneumothorax or hemothorax 195, 221
Respiratory Diaphragm Widening of esophageal hiatus or congenital defect allows for protrusion of stomach into thorax (hiatal hernia) 201, 239
RESPIRATORY
Lines of pleural reflection Knowledge of location of lung and pleura with respect to chest wall is necessary for chest tube thoracostomy 202, 203
Pleural of lungs Air or gas (spontaneous or traumatic) can leak into pleural space between visceral and parietal pleura and compress lung 202, 204
Cervical Pleura Extends into neck superior to 1st rib; it may therefore be punctured during neck procedures, producing pneumothorax 202
Tracheal bifurcation Right main bronchus is shorter, more vertical, and wider; aspirated objects are therefore often in right lung 208
Apex of lung Pancoast syndrome (bronchiogenic carcinoma) of apex invades sympathetic trunk, resulting in Horner’s syndrome (ipsilateral miosis, ptosis,
202, 234
anhidrosis, facial flushing)
NERVOUS
Long thoracic nerve May be damaged during chest tube placement or mastectomy, resulting in winged scapula (denervation of serratus anterior muscle) 189, 194
Intercostal Nerve Site of local anesthetic nerve block for procedures such as thoracostomy or to alleviate pain caused by shingles 196, 197
Posterior root (spinal) Can house dormant varicella zoster virus, which, when activated, can result in herpes zoster (shingles)
197
ganglion
Phrenic nerve and respiratory Ipsilateral injury to phrenic nerve may cause ipsilateral paralysis of hemidiaphragm Diaphragmatic irritation may manifest as shoulder pain 199, 201, 199,
diaphragm because of referral to C3-5 spinal levels 216
Recurrent laryngeal branch of Pathologic findings in aorticopulmonary window may compress this nerve and produce hoarseness of voice
235, 236
vagus nerve (CNX)
Visceral pain afferents from Pain of myocardial ischemia referred to upper thoracic dermatomes; may be perceived as somatic pain in chest and medial upper limb
231
heart
CARDIOVASCULAR
Internal thoracic artery Commonly used for coronary artery bypass grafts 196, 197
Pulmonary arteries Thromboemboli may obstruct pulmonary vasculature, leading to infarction 205, 210
pericardium Pericardial effusion (accumulation of fluid or blood) may compromise heart function (cardiac tamponade) 215, 219
Coronary arteries Atherosclerotic blockage may cause myocardial ischemia and/or infarct; anterior interventricular (left anterior descending) artery most
222
commonly diseased
Interventricular septum of Ventricular septal defect is most common congenital cardiac defect; most often involves membranous part of septum
225, 228
heart
Heart Valve Congenital variations of valve anatomy or valvular disease (e.g., rheumatic heart disease) can cause valvular stenosis 226
Sinoatrial node Aging, previous heart surgery, and some medications can cause cardiac arrhythmias 229
Ligamentum arteriosum Abnormal closure of ductus arteriosus can produce aortic coarctation; lack of closure produces patent ductus arteriosus; if not closed, may cause
233
exertional dyspnea, pulmonary vascular disease, or heart failure
Thoracic Aorta Congenital coarctation of aorta can compromise systemic blood flow; collateral vascular connections can alleviate this condition 240
Azygos venous system Drains posterior thorax and provides important collateral channel between inferior vena cava and superior vena cava 241
LYMPHATIC
Mammary gland lymphatics Metastatic spread of cancer cells to axilla and chest via lymphatics draining breast 191
Axillary lymph nodes Primary nodes that receive lymphatic drainage from upper limb, thoracic wall, and breast; commonly enlarged in patients with breast cancer 190, 191
Anatomy- Thorax
 Anatomy- Thorax
MUSCLE
MUSCLE ORIGIN INSERTION INNERVATION BLOOD SUPPLY MAIN ACTIONS
GROUP
Posterior Xiphoid process, lower
Respiratory Converge into central Pericardiacophrenic, musculophrenic, superior Draws central tendon down and
abdominal six costal cartilages, Phrenic nerve
diaphragm tendon and inferior phrenic arteries forward during inspiration
wall L1–L3 vertebrae
Posterior intercostal arteries, collateral branches
Supports intercostal spaces in
External Upper border of rib of posterior intercostal arteries, costocervical
Thoracic wall Lower border of ribs Intercostal nerves inspiration and expiration,
intercostal below rib of origin trunk, anterior intercostal branches of internal
elevates ribs in inspiration
thoracic artery, musculophrenic artery
Muscular branches of anterior intercostal arteries,
muscular branches of posterior intercostal arteries,
Innermost Upper border of rib
Thoracic wall Lower border of ribs Intercostal nerves intercostal branches of internal thoracic and Elevates ribs
intercostal below rib of origin
musculophrenic arteries, costocervical trunk
branches
Muscular branches of anterior intercostal arteries,
Prevents pushing out or drawing
Costal cartilage and muscular branches of posterior intercostal arteries,
Internal in of intercostal spaces in
Thoracic wall Lower border of ribs edge of costal groove of Intercostal nerves intercostal branches of internal thoracic and
intercostal inspiration and expiration, lowers
rib above rib of origin musculophrenic arteries, costocervical trunk
ribs in forced expiration
branches
Posterior ramus of
Levator Transverse processes of Subjacent ribs between
Thoracic wall lower thoracic Posterior intercostal arteries Elevates ribs
costarum C7 and T1–T11 tubercle and angle
nerves
Sternal half of clavicle,
sternum to 7th rib,
Pectoral/ Lateral lip
Pectoralis cartilages of true ribs, Medial and lateral Pectoral branch of thoracoacromial artery, Flexes, adducts, and medially
axillary of intertubercular sulcus
major aponeurosis of external pectoral nerves perforating branches of internal thoracic artery rotates arm
regions of humerus
abdominal oblique
muscle
Pectoral/
Pectoralis Outer surface of upper Coracoid process of Medial pectoral Pectoral branch of thoracoacromial artery, and Lowers lateral angle of scapula
axillary
minor margin of ribs 3–5 scapula nerve superior and lateral thoracic arteries and protracts scapula
regions
Serratus Lateral surfaces of Costal surface of medial Protracts and rotates scapula and
Shoulder Long thoracic nerve Lateral thoracic artery
anterior upper 8–9 ribs border of scapula holds it against thoracic wall
Serratus Anterior rami of
Intermediate Spinous processes of Inferior aspect of ribs
posterior lower thoracic Posterior intercostal arteries Depresses ribs
back T11–L2 9–12
inferior nerves
Serratus Nuchal ligament, Anterior rami of
Intermediate Superior aspect of ribs
posterior spinous processes of upper thoracic Posterior intercostal arteries Elevates ribs
back 2–5
superior C7–T3 nerves
Internal surface of
Superior borders of 2nd Intercostal nerves
Subcostal Thoracic wall lower ribs near their Posterior intercostal artery, musculophrenic artery Depresses ribs
or 3rd rib below 2nd–5th
angles
Transversu Internal surfaces of Posterior surface of Anterior intercostal arteries, internal thoracic Depresses ribs and costal
Thoracic wall Intercostal nerves
s thoracis costal cartilages 2–6 lower sternum artery cartilages
1. A 32-year-old patient who weighs 275 lb comes to the On the surface of the chest, the apex of the heart can be
doctor’s office. On the surface of the chest, the physician located in the left fifth intercostal space slightly medial
is able to locate the apex of the heart: to the midclavicular (or nipple) line. The sternal angle is
In the left fifth intercostal space located at the level where the second ribs articulate with
 Anatomy- Thorax
the sternum. The xiphoid process lies at the level of T10 most audible over the left fifth intercostal space at the atria, the opening in the foramen secundum (the
vertebra. midclavicu- lar line. The pulmonary valve is most foramen ovale) usually closes at birth. If this foramen
audible over the medial end of the second left intercostal ovale is not closed completely, this would result in an
2. A 43-year-old female patient has been lying down on space, the aortic valve is most audible over the medial ASD, shunting blood from the left atrium to the right
the hospital bed for more than 4 months. Her normal, end of the second right intercostal space, and the right atrium.
quiet expiration is achieved by contraction of which of AV valve is most audible over the right half of the lower
the following structures? end of the body of the sternum. 9. A 54-year-old patient is implanted with an artificial
Elastic tissue in the lungs and thoracic wall cardiac pacemaker. Which of the following conductive
Normal, quiet expiration is achieved by contraction of 6. A 19-year-old man came to the emergency tissues of the heart had a defective function that required
extensible tissue in the lungs and the thoracic wall. The department, and his angiogram exhibited that he was the pacemaker?
serratus posterior superior muscles, diaphragm, bleeding from the vein that is accompanied by the (C) Sinoatrial (SA) node
pectoralis major, and serratus anterior are muscles of posterior interventricular artery. Which of the following The sinoatrial (SA) node initiates the impulse of
inspiration. veins is most likely to be ruptured? contraction and is known as the pacemaker of the heart.
(B) Middle cardiac vein Impulses from the SA node travel through the atrial
3. A 23-year-old man received a gunshot wound, and his The middle cardiac vein ascends in the posterior myocardium to the AV node and then race through the
greater splanchnic nerve was destroyed. Which of the interventricular groove, accompanied by the posterior AV bundle (bundle of His), which divides into the right
following nerve fibers would be injured? interventricular branch of the right coronary artery. The and left bundle branches. The bundle breaks up into
GVA and preganglionic sympathetic fibers great cardiac vein is accompanied by the anterior terminal conducting fibers (Purkinje fibers) to spread
The greater splanchnic nerves contain general visceral interventricular artery, the anterior cardiac vein drains out into the ventricular walls. The moderate band
afferent (GVA) and pre- ganglionic sympathetic general directly into the right atrium, and the small cardiac vein carries the right limb of the AV bundle from the septum
visceral efferent (GVE) fibers. is accompanied by the marginal artery. to the sternocostal wall of the ventricle.

4. A 17-year-old boy was involved in a gang fight, and a 7. A 37-year-old patient with palpitation was examined 10. A thoracic surgeon removed the right middle
stab wound severed the white rami communicates at the by her physician, and one of the diagnostic records lobar (secondary) bronchus along with lung tissue from a
level of his sixth thoracic vertebra. This injury would included a posterior–anterior chest radiograph. Which of 57-year-old heavy smoker with lung cancer. Which of
result in degeneration of nerve cell bodies in which of the following comprises the largest portion of the the following bronchopulmonary segments must contain
the following structures? sternocostal surface of the heart seen on the radiograph? cancerous tissues?
Dorsal root ganglion and lateral horn of (D) Right ventricle (A) Medial and lateral
the spinal cord The right ventricle forms a large part of the sternocostal The right middle lobar (secondary) bronchus leads to
The white rami communicates contain preganglionic surface of the heart. The left atrium occupies almost the the medial and lateral bronchopulmonary segments. The
sympathetic GVE fibers and GVA fibers, whose cell entire posterior surface of the right atrium. The right right superior lobar bronchus divides into the superior,
bodies are located in the lateral horn of the spinal cord atrium occupies the right aspect of the heart. The left pos- terior, and anterior segmental (tertiary) bronchi.
and the dorsal root ganglia. The sympathetic chain ventricle lies at the back of the heart and bulges roundly The right inferior lobar bronchus has the ante- rior,
ganglion contains cell bodies of the postganglionic sym- to the left. The base of the heart is formed by the atria, lateral, posterior, and anterior segmental bronchi.
pathetic nerve fibers. The anterior horn of the spinal which lie mainly behind the ventricles.
cord contains cell bodies of the GSE fibers. The dorsal
root ganglion contains cell bodies of GSA and GVA 11. The bronchogram of a 45-year-old female smoker
fibers. shows the presence of a tumor in the eparterial bronchus.
Which airway is most likely blocked?
8. A 5-year-old girl is brought to the emergency Right superior bronchus
5. A 27-year-old cardiac patient with an irregular department because of difficulty breathing (dyspnea), The eparterial bronchus is the right superior lobar
heartbeat visits her doctor’s office for examination. palpitations, and shortness of breath. Doppler study of (secondary) bronchus; all of the other bronchi are
Where should the physician place the stethoscope to the heart reveals an atrial septal defect (ASD). This hyparterial bronchi.
listen to the sound of the mitral valve? malformation usually results from incomplete closure of
In the left fifth intercostal space at the midclavicular which of the following embryonic structures? 12. An 83-year-old man with a typical coronary
line (D) Foramen ovale circulation has been suffering from an embolism of the
The mitral valve (left atrioventricular [AV] valve) An atrial septal defect (ASD) is a congenital defect in circumflex branch of the left coronary artery. This
produces the apical beat (thrust) of the heart, which is the interatrial septum. During partitioning of the two
 Anatomy- Thorax
condition would result in ischemia of which of the tricuspid valve, AV node, pectinate muscles, and septo- subclavian artery, causing upper limb hypertension and
following areas of the heart? marginal trabecula are present in the right atrium and diminished blood flow to the lower limbs and abdominal
(D) Posterior part of the left ventricle ventricle. viscera.
The circumflex branch of the left coronary artery
supplies the posterior por- tion of the left ventricle. The 16. A 75-year-old patient has been suffering from lung 19. A 33-year-old patient is suffering from a
anterior interventricular artery supplies the anterior cancer located near the cardiac notch, a deep indentation sudden occlusion at the origin of the descending
aspects of the right and left ventricles and the anterior on the lung. Which of the following lobes is most likely (thoracic) aorta. This condition would most
interventricular septum. to be excised? likely decrease blood flow in which of the following
(D) Superior lobe of the left lung intercostal arteries?
13. A 44-year-old man with a stab wound was brought The cardiac notch is a deep indentation of the anterior (E) Lower six posterior
to the emergency department, and a physician found that border of the superior lobe of the left lung. Therefore, The first two posterior intercostal arteries are branches
the patient was suffering from a laceration of his right the right lung is not involved. of the highest (supe- rior) intercostal artery of the
phrenic nerve. Which of the following conditions has costocervical trunk; the remaining nine branches are
likely occurred? 17. A thoracentesis is performed to aspirate an abnormal from the thoracic aorta. The internal thoracic artery
(C) Loss of sensation in the fibrous pericardium accumulation of fluid in a 37-yearold patient with gives off the upper six anterior intercostal arteries and
and mediastinal pleura pleural effusion. A needle should be inserted at the is divided into the superior epigastric and
The phrenic nerve supplies the pericardium and midaxillary line between which of the following two ribs musculophrenic arteries, which gives off anterior
mediastinal and diaphrag- matic (central part) pleura so as to avoid puncturing the lung? intercostal arteries in the 7th, 8th, and 9th intercostal
and the diaphragm, an important muscle of inspiration. (D) Ribs 7 and 9 spaces and ends in the 10th intercostal space where it
It contains general somatic efferent (GSE), general A thoracentesis is performed for aspiration of fluid in anastomoses with the deep circumflex iliac artery.
somatic afferent (GSA), and GVE (postganglionic the pleural cavity at or posterior to the midaxillary line,
sympa- thetic) fibers. The costal part of the diaphragm one or two intercostal spaces below the fluid level but 20. A 56-year-old patient recently suffered a
receives GSA fibers from the intercostal nerves. not below the ninth intercostal space and, therefore, myocardial infarction in the area of the apex of
between ribs 7 and 9. Other intercostals spaces are not the heart. The occlusion by atherosclerosis is in
14. An 8-year-old boy with ASD presents to a preferred. which of the following arteries?
pediatrician. This congenital heart defect shunts blood Anterior interventricular artery
from the left atrium to the right atrium and causes 18. A newborn baby is readmitted to the hospital The apex of the heart typically receives blood from the
hypertrophy of the right atrium, right ventricle, and with hypoxia and upon testing is found to anterior interventricu- lar branch of the left coronary
pulmonary trunk. Which of the following veins opens have pulmonary stenosis, dextraposition of the artery. The marginal artery supplies the right inferior
into the hypertrophied atrium? aorta, interventricular septal defect, and hypertrophy margin of the right ventricle, the right coronary artery
(D) Anterior cardiac vein of the right ventricle. Which of the following at its origin supplies the right atrium and ventricle, and
The anterior cardiac vein drains into the right atrium. is best described by these symptoms? the posterior interventricular artery and a circumflex
The middle, small, and oblique cardiac veins drain into (C) Tetralogy of Fallot branch of the left coronary artery supply the left
the coronary sinus. The right and left pulmonary veins ventricle.
drain into the left atrium. 21. A 75-year-old woman was admitted to a local
Tetralogy of Fallot is a combination of congenital hospital, and bronchograms and radiographs revealed a
15. A 37-year-old patient with severe chest pain, cardiac defects consisting of (a) pulmonary stenosis, (b) lung carcinoma in her left lung. Which of the following
shortness of breath, and congestive heart failure was dextraposition of the aorta (so that it overrides the structures or characteristics does the cancerous lung
admitted to a local hospital. His coronary angiograms ventricular septum and receives blood from the right contain?
reveal a thrombosis in the circumflex branch of the left ventricle), (c) ventricular septal defect (VSD), and (d) (D) Lingula
coronary artery. Which of the following conditions could right ventricular hypertrophy. ASD is a congenital The lingula is the tongue-shaped portion of the upper
result from the blockage of blood flow in the circumflex defect in the atrial septum, resulting from a patent lobe of the left lung. The right lung has a groove for the
branch? foramen ovale. Patent ductus arteriosus shunts blood horizontal fissure, superior vena cava (SVC), and
Mitral valve insufficiency from the pulmonary trunk to the aorta, bypassing the middle lobe and has a larger capacity than the left lung.
The circumflex branch of the left coronary artery lungs. Aortic stenosis is an abnormal narrowing of the
supplies the left ventricle, and thus its blockage of blood aortic valve ori- fice, impeding the blood flow. 22. An 18-year-old girl is thrust into the steering wheel
flow results in necrosis of myocardium in the left Coarctation of the aorta is a congenital constriction of while driving and experiences difficulty in expiration.
ventricle, pro- ducing mitral valve insufficiency. The the aorta, commonly occurs just distal to the left Which of the following muscles is most likely damaged?
 Anatomy- Thorax
(E) Muscles of the abdominal wall aorta is to the right of the pulmonary trunk. Cyanosis is A cardiovascular silhouette or cardiac shadow is the
The abdominal muscles are the major muscles of common in transposition of the great vessels. Excessive contour of the heart and great vessels seen on posterior–
expiration, whereas the other distractors are muscles of resorption of septum primum results in a secundum type anterior chest radiographs. Its right border is formed by
inspiration. of ASD. Pulmonary valve atresia may result in cyanosis, the SVC, right atrium, and inferior vena cava; its left
but it will not cause the aorta to be to the right of the border is formed by the aortic arch (aortic knob),
23. A 78-year-old patient presents with an advanced pulmonary trunk. A persistent truncus arteriosus is pulmonary trunk, left auricle, and left ventricle. The
cancer in the posterior mediastinum. The surgeons are in caused by lack of devel- opment of the aorticopulmonary ascending aorta becomes the arch of the aorta and is
a dilemma as to how to manage the condition. Which of septum resulting in a single outflow track. Coarctation found in the middle of the heart.
the following structures is most likely damaged? of the aorta is a severe narrowing of the aorta.
(E) Hemiazygos vein 31. A 37-year-old man is brought to the emergency
The hemiazygos vein is located in the posterior 27. A 12-year-old boy was admitted to a local hospital department complaining of severe chest pain. His
mediastinum. The brachioce- phalic veins, trachea, and with a known history of heart problems. His left angiogram reveals thromboses of both brachiocephalic
arch of the aorta are located in the superior ventricular hypertrophy could result from which of the veins just before entering the superior vena cava. This
mediastinum, whereas the arch of the azygos vein is following conditions? condition would most likely cause a dilation of which of
found in the middle mediastinum. Stenosis of the aorta the following veins?
Stenosis of the aorta can cause left ventricular (E) Left superior intercostal
24. A 46-year-old patient comes to his doctor’s office hypertrophy. Right ventricu- lar hypertrophy may occur The left superior intercostal vein is formed by the
and complains of chest pain and headache. His computed as a result of pulmonary stenosis, pulmonary and second, third, and fourth posterior intercostal veins and
tomography (CT) scan reveals a tumor located just tricuspid valve defects, or mitral valve stenosis. drains into the left brachiocephalic vein. The right
superior to the root of the right lung. Blood flow in superior inter- costal vein drains into the azygos vein,
which of the following veins is most likely blocked by 28. A 31-year-old man was involved in a severe which in turn drains into the SVC. The hemiazygos vein
this tumor? automobile accident and suffered laceration of the left drains into the azygos vein, whereas the internal
(B) Arch of the azygos vein primary bronchus. The damaged primary bronchus: thoracic vein empties into the brachiocephalic vein.
The azygos vein arches over the root of the right lung (D) Is longer than the right primary bronchus
and empties into the SVC. Other veins do not pass over The right primary bronchus is shorter than the left one 32. A cardiologist is on clinical rounds with her medical
the root of the right lung. and has a larger diam- eter. More foreign bodies enter it students. She asks them, “During the cardiac cycle,
via the trachea because it is more vertical than the left which of the following events occurs?”
25. A 21-year-old patient with a stab wound reveals a primary bronchus. The right primary bronchus runs (D) Blood flow in coronary arteries is maximal
laceration of the right vagus nerve proximal to the origin under the arch of the azygos vein and gives rise to the during diastole
of the recurrent laryngeal nerve. Which of the following eparterial bronchus. During diastole, the AV valves open, and the aortic and
conditions would most likely result from this lesion? 29. A 62-year-old woman who is a heavy smoker has an pulmonary valves close; whereas during systole, the AV
(C) Dilation of the bronchial lumen advanced lung cancer that spread into her right third valves close, and the aortic and pulmonary valves open.
The parasympathetic nerve fibers in the vagus nerve posterior intercostal space posterior to the midaxillary
constrict the bronchial lumen, contract bronchial line. If cancer cells are carried in the venous drainage, 33. Coronary angiographs of a 44-year-old male patient
smooth muscle, stimulate bronchial gland secretion, they would travel first to which of the following veins? reveal an occlusion of the circumflex branch of the left
decrease heart rate, and constrict the coronary artery. (B) Right superior intercostal vein coronary artery. This patient has been suffering from
The vagus nerve also carries afferent fibers of pain, The superior intercostal vein is formed by the union of myocardial infarction in which of the following areas?
cough reflex, and stretch of the lung (during the second, third, and fourth posterior intercostal veins Left atrium and ventricle
inspiration). and drains into the azygos vein on the right and the The left atrium and ventricle receive blood from the
brachioce- phalic vein on the left. The azygos vein circumflex branch of the left coronary artery. The
26. A neonate appears severely cyanotic and breathing drains into the SVC. The hemiazygos vein usually drains interventricular septum and the apex of the heart are
rapidly. Cardiac echocardiogram reveals that the aorta into the azygos vein. supplied by the anterior interventricular branch of the
lies to the right of the pulmonary trunk. Which of the left coronary artery. The right ventricle receives blood
following is most likely occurred during development? 30. A radiologist examines posterior–anterior chest from the anterior interventricular artery and the
(A) AP septum failed to develop in a spiral radiographs of a 27-year-old victim of a car accident. marginal branch of the right coronary artery. The right
Fashion Which of the following structures forms the right border atrium receives blood from the right coronary artery.
Failure of the aorticopulmonary septum results in of the cardiovascular silhouette?
transposition of the great vessels, exhibiting that the (C) SVC
 Anatomy- Thorax
34. A patient has a small but solid tumor in the 38. The attending faculty in the coronary intensive care Which of the following structures is required to remain
mediastinum, which is confined at the level of the sternal unit demonstrates to his students a normal heart patent until surgical correction of the deformity?
angle. Which of the following structures would most examination. The first heart sound is produced by near- (C) Ductus arteriosus
likely be found at this level? simultaneous closure of which of the following valves? A patent ductus arteriosus shunts blood from the
(A) Bifurcation of the trachea (D) Tricuspid and mitral pulmonary trunk to the aorta, partially bypassing the
The sternal angle is the junction of the manubrium and The first heart sound (“lub”) is produced by the closure lungs, and thus allowing mixed blood to reach the body
the body of the ster- num. It is located at the level where of the tricuspid and mitral valves, whereas the second tissues and causing cyanosis. Dextroposition or
the second rib articulates with the sternum, the trachea heart sound (“dub”) is produced by the closure of the transposition of the great arteries must be accompa-
bifurcates into the right and left bronchi, and the aortic aortic and pulmonary valves. nied by a VSD or a patent ductus arteriosus for the
arch begins and ends. It marks the end of the ascending infant to survive. The transposition causes oxygenated
aorta and the beginning of the descending aorta, and it 39. A 27-year-old patient with Marfan syndrome blood to pass from the left ventricle into the pulmonary
forms the inferior bor- der of the superior mediastinum. has an aneurysm of the aortic arch. trunk and then into the lungs, but deoxygenated blood
This may compress which of the following travels from the right ventricle into the aorta and then
35. A 37-year-old house painter fell from a ladder and structures? into the systemic circulation.
fractured his left third rib and the structures with which Left recurrent laryngeal nerve
it articulated. Which of the following structures would The left recurrent laryngeal nerve loops around the arch 43. During early development of the respiratory system,
most likely be damaged? of the aorta near the ligamentum arteriosum, whereas the laryngotracheal tube maintains communication with
(B) Body of the second thoracic vertebra the right recurrent laryngeal nerve hooks around the the primitive foregut. Which of the following embryonic
The third rib articulates with the body of the sternum, right subclavian artery. All other nerves are not closely structures is most likely responsible for partitioning
bodies of the second and third thoracic vertebrae, and associated with the aortic arch. these two embryonic structures?
transverse process of the third thoracic vertebra. (C) Tracheoesophageal septum
40. A 47-year-old man with a known atrial Fibrillation The tracheoesophageal septum is formed by the fusion of
36. A 45-year-old woman presents with a tumor returns to see his cardiologist for follow-up of his the tracheoesopha- geal folds in the midline. This
confined to the posterior mediastinum. This could result cardiac health. The right atrium is important in this case septum divides the foregut into a ventral portion, the
in compression of which of the following structures? because it: laryngo- tracheal tube (primordium of the larynx,
(B) Descending aorta (C) Contains the SA node trachea, bronchi, and lungs), and a dorsal portion
The SA and AV nodes are in the wall of the right atrium (primordium of the oropharynx and esophagus).
The descending aorta is found in the posterior and are not associated with the apex of the heart. The
mediastinum. The superior mediastinum contains the oblique cardiac vein drains into the coronary sinus, and 44. A 32-year-old patient has a tension pneumothorax
trachea and arch of the aorta, and the middle the pul- monary veins empty into the left atrium. The that can be treated with needle aspiration. To avoid an
mediastinum contains the ascending aorta, arch of the right ventricle is hypertrophied by the pulmonary injury of the intercostal neurovascular bundle, the needle
azygos vein, and main bronchi. The phrenic nerve runs stenosis. may be inserted in which of the following locations?
in the middle mediastinum. Above the upper border of the ribs
41. A 57-year-old patient has a heart murmur resulting The intercostal veins, arteries, and nerves run in the
from the inability to maintain constant tension on the costal groove beneath the inferior border of the ribs
37. A 62-year-old patient with pericardial effusion cusps of the AV valve. Which of the following structures between the internal and innermost layers of muscles.
comes to a local hospital for aspiration of pericardial is most likely damaged? The transversus thoracis muscles are situated in the
fluid by pericardiocentesis. The needle is inserted into internal surface of the lower anterior thoracic wall.
(C) Chordae tendineae
the pericardial cavity through which of the following
The chordae tendineae are tendinous strands that extend
intercostal spaces adjacent to the sternum? 45. A 9-month-old girl was admitted to the children’s
from the papillary muscles to the cusps of the valve. The
(C) Left fifth intercostal space hospital with tachypnea (fast breathing) and shortness of
papillary muscles and chordae tendineae prevent the
To aspirate pericardial fluid, the needle should be breath. Physical examination further exhibits tachycardia
cusps from being everted into the atrium during
inserted into the pericardial cavity through the fifth (fast heart rate), a bounding peripheral pulse, and her
ventricular contraction.
intercostals space just left to the sternum. Because of the angiographs reveal a patent ductus arteriosus. Which
cardiac notch, the needle misses the pleura and lungs, of the following embryonic arterial structures is most
42. A mother with diabetes gives birth to a baby who is
but it penetrates the pericardium. Lung tissues lie likely responsible for the origin of the patent ductus
diagnosed as having dextroposition of the aorta and the
beneath the fourth and sixth intercostal spaces. arteriosus?
pulmonary trunk with cyanosis and shortness of breath.
(E) Left sixth arch
 Anatomy- Thorax
The left sixth aortic arch is responsible for the 50. Into which structure does the azygos vein drain 58. Takes its origin from the left ventricle andends at the
development of both the ductus arteriosus and the venous blood? A. The azygos vein drains venous sternal angle? D. The ascending aorta takes its origin
pulmonary arteries. The ductus arteriosus closes blood into the SVC. from the left ventricle and ends at the level of the
functionally in an infant soon after birth, with anatomic sternal angle by becoming the arch of the aorta.
closure requiring several weeks. 51. The left coronary artery arises from which structure?
C. The right and left coronary arteries arise from the
46. A 7-day-old baby is diagnosed as having ascending aorta.
congenital neonatal emphysema, which is
caused by collapsed bronchi because of failure 52. Which structure is crossed superiorly by the aortic
of bronchial cartilage development. Bronchial arch and left pulmonary artery? D. The left primary
cartilages are derived from which of the following bronchus is crossed superiorly by the arch of the
derivations? aorta and the pulmonary artery.
(B) Mesoderm
Bronchial cartilages, smooth muscles, and connective
tissue are derived from the mesoderm. The bronchial
epithelium and glands are derived from the endoderm.

53. Can be removed in a surgical resection of

a lobe to remove lung cancer on the diaphragmatic
surface? B. The right inferior lobar bronchus may be
removed in a surgical resection of the inferior lobe of
47. Stenosis of which structure may produce left the right lung that is in contact with the diaphragm.
ventricular hypertrophy? C. Stenosis of the ascending
aorta results in left ventricular hypertrophy. 54. Becomes hypertrophied as result of the pulmonary
stenosis? C. Pulmonary stenosis results in right
48. Which structure is most likely to be ventricular hypertrophy.
removed by a pulmonary surgeon in a surgical
resection of a lobe (lobectomy) to remove lung cancer in 55. Receives oxygenated blood via pulmonary veins? E.
the apex of the right lung? B. During surgical The left atrium receives oxygenated blood from the
treatment for cancer in the apex of the right lung by lung by way of the pulmonary veins.
a lobectomy, the right superior secondary (eparterial)
bronchus should be removed. 56. Lies on the right side of the aortic arch and
ascending aorta? A. The SVC lies on the right side of
49. Which structure branches into the bronchial arteries? the ascending aorta and the arch of the aorta.
E. The right and left bronchial arteries arise from
the descending (thoracic) aorta. 57. Contains the septomarginal trabecula? C. The right
ventricle contains the septomarginal trabecula.