- A 32-year-old patient who weighs 275 lb comes to the doctor’s office. On the surface of the chest, the physician is able to locate the apex of the heart:
(A) At the level of the sternal angle
(B) In the left fourth intercostal space
(C) In the left fifth intercostal space
(D) In the right fifth intercostal space
(E) At the level of the xiphoid process of the sternum
C. On the surface of the chest, the apex of the heart can be located in the left fifth intercostal space slightly medial to the midclavicular (or nipple) line. The sternal angle is located at the level where the second ribs articulate with the sternum. The xiphoid process lies at the level of T10 vertebra.
- A 43-year-old female patient has been lying down on the hospital bed for more than 4 months. Her normal, quiet expiration is achieved by contraction of which of the follow- ing structures?
(A) Elastic tissue in the lungs and thoracic wall
(B) Serratus posterior superior muscles
(C) Pectoralis minor muscles
(D) Serratus anterior muscles
(E) Diaphragm
A. Normal, quiet expiration is achieved by contraction of extensible tissue in the lungs and the thoracic wall. The serratus posterior superior muscles, diaphragm, pectoralis major, and serratus anterior are muscles of inspiration.
- A 23-year-old man received a gunshot wound, and his greater splanchnic nerve was destroyed. Which of the following nerve fibers would be injured?
(A) General somatic afferent (GSA) and pre- ganglionic sympathetic fibers
(B) General visceral afferent (GVA) and post- ganglionic sympathetic fibers
(C) GVA and preganglionic sympathetic fibers
(D) General somatic efferent (GSE) and post-ganglionic sympathetic fibers
(E) GVA and GSE fibers
C. The greater splanchnic nerves contain general visceral afferent (GVA) and pre- ganglionic sympathetic general visceral efferent (GVE) fibers.
- A 17-year-old boy was involved in a gang fight, and a stab wound severed the white rami communicantes at the level of his sixth thoracic vertebra. This injury would result in degeneration of nerve cell bodies in which of the following structures?
(A) Dorsal root ganglion and anterior horn of the spinal cord
(B) Sympathetic chain ganglion and dorsal root ganglion
(C) Sympathetic chain ganglion and posterior horn of the spinal cord
(D) Dorsal root ganglion and lateral horn of the spinal cord
(E) Anterior and lateral horns of the spinal cord
D. The white rami communicantes contain preganglionic sympathetic GVE fibers and GVA fibers, whose cell bodies are located in the lateral horn of the spinal cord and the dor- sal root ganglia. The sympathetic chain ganglion contains cell bodies of the postganglionic sym- pathetic nerve fibers. The anterior horn of the spinal cord contains cell bodies of the GSE fibers. The dorsal root ganglion contains cell bodies of GSA and GVA fibers.
- A 27-year-old cardiac patient with an irregular heartbeat visits her doctor’s office for examination. Where should the physician place the stethoscope to listen to the sound of the mitral valve?
(A) Over the medial end of the second left intercostal space
(B) Over the medial end of the second right intercostal space
(C) In the left fourth intercostal space at the midclavicular line
(D) In the left fifth intercostal space at the mid-clavicular line
(E) Over the right half of the lower end of the body of the sternum
D. The mitral valve (left atrioventricular [AV] valve) produces the apical beat (thrust) of the heart, which is most audible over the left fifth intercostal space at the midclavicular line. The pulmonary valve is most audible over the medial end of the second left intercostal space, the aortic valve is most audible over the medial end of the second right intercostal space, and the right AV valve is most audible over the right half of the lower end of the body of the sternum.
6. A19-year-old man came to the emergency department, and his angiogram exhibited that he was bleeding from the vein that is accompanied by the posterior interventricular artery. Which of the following veins is most likely to be ruptured? (A) Great cardiac vein (B) Middle cardiac vein (C) Anterior cardiac vein (D) Small cardiac vein (E) Oblique veins of the left atrium
B. The middle cardiac vein ascends in the posterior interventricular groove, accompanied by the posterior interventricular branch of the right coronary artery. The great cardiac vein is accompanied by the anterior interventricular artery, the anterior cardiac vein drains directly into the right atrium, and the small cardiac vein is accompanied by the marginal artery.
7. A 37-year-old patient with palpitation was examined by her physician, and one of the diagnostic records included a posterior–anterior chest radiograph. Which of the following comprises the largest portion of the sternocostal surface of the heart seen on the radiograph? (A) Left atrium (B) Right atrium (C) Left ventricle (D) Right ventricle (E) Base of the heart
D. The right ventricle forms a large part of the sternocostal surface of the heart. The left atrium occupies almost the entire posterior surface of the right atrium. The right atrium occupies the right aspect of the heart. The left ventricle lies at the back of the heart and bulges roundly to the left. The base of the heart is formed by the atria, which lie mainly behind the ventricles.
8. A 5-year-old girl is brought to the emergency department because of difficulty breath- ing (dyspnea), palpitations, and shortness of breath. Doppler study of the heart reveals an atrial septal defect (ASD). This malformation usually results from incomplete closure of which of the following embryonic structures? (A) Ductus arteriosus (B) Ductus venosus (C) Sinus venarum (D) Foramen ovale (E) Truncus arteriosus
D. An atrial septal defect (ASD) is a congenital defect in the interatrial septum. During partitioning of the two atria, the opening in the foramen secundum (the foramen ovale) usually closes at birth. If this foramen ovale is not closed completely, this would result in an ASD, shunting blood from the left atrium to the right atrium.
9. A 54-year-old patient is implanted with an artificial cardiac pacemaker. Which of the following conductive tissues of the heart had a defective function that required the pacemaker? (A) Atrioventricular (AV) bundle (B) AV node (C) Sinoatrial (SA) node (D) Purkinje fiber (E) Moderator band
C. The sinoatrial (SA) node initiates the impulse of contraction and is known as the pacemaker of the heart. Impulses from the SA node travel through the atrial myocardium to the AV node and then race through the AV bundle (bundle of His), which divides into the right and left bundle branches. The bundle breaks up into terminal conducting fibers (Purkinje fibers) to spread out into the ventricular walls. The moderate band carries the right limb of the AV bundle from the septum to the sternocostal wall of the ventricle.
10. A thoracic surgeon removed the right middle lobar (secondary) bronchus along with lung tissue from a 57-year-old heavy smoker with lung cancer. Which of the following broncho- pulmonary segments must contain cancerous tissues? (A) Medial and lateral (B) Anterior and posterior (C) Anterior basal and medial basal (D) Anterior basal and posterior basal (E) Lateral basal and posterior basal
A. The right middle lobar (secondary) bronchus leads to the medial and lateral bronchopulmonary segments. The right superior lobar bronchus divides into the superior, posterior, and anterior segmental (tertiary) bronchi. The right inferior lobar bronchus has the anterior, lateral, posterior, and anterior segmental bronchi.
11. The bronchogram of a 45-year-old female smoker shows the presence of a tumor in the eparterial bronchus. Which airway is most likely blocked? (A) Left superior bronchus (B) Left inferior bronchus (C) Right superior bronchus (D) Right middle bronchus (E) Right inferior bronchus
C. The eparterial bronchus is the right superior lobar (secondary) bronchus; all
of the other bronchi are hyparterial bronchi.
- An 83-year-old man with a typical coro- nary circulation has been suffering from an embolism of the circumflex branch of the left coronary artery. This condition would result in ischemia of which of the following areas of the heart?
(A) Anterior part of the left ventricle
(B) Anterior interventricular region (C) Posterior interventricular region (D) Posterior part of the left ventricle
(E) Anterior part of the right ventricle
D. The circumflex branch of the left coronary artery supplies the posterior portion of the left ventricle. The anterior interventricular artery supplies the anterior aspects of the right and left ventricles and the anterior interventricular septum.
- A 44-year-old man with a stab wound was brought to the emergency department, and a physician found that the patient was suffering from a laceration of his right phrenic nerve. Which of the following conditions has likely occurred?
(A) Injury to only GSE fibers
(B) Difficulty in expiration
(C) Loss of sensation in the fibrous pericardium and mediastinal pleura
(D) Normal function of the diaphragm
(E) Loss of sensation in the costal part of the diaphragm
C. The phrenic nerve supplies the pericardium and mediastinal and diaphragmatic (central part) pleura and the diaphragm, an important muscle of inspiration. It contains general somatic efferent (GSE), general somatic afferent (GSA), and GVE (postganglionic sympathetic) fibers. The costal part of the diaphragm receives GSA fibers from the intercostal nerves.
- An 8-year-old boy with ASD presents to
a pediatrician. This congenital heart defect shunts blood from the left atrium to the right atrium and causes hypertrophy of the right atrium, right ventricle, and pulmonary trunk. Which of the following veins opens into the hypertrophied atrium?
(A) Middle cardiac vein
(B) Small cardiac vein
(C) Oblique cardiac vein
(D) Anterior cardiac vein
(E) Right pulmonary vein
D. The anterior cardiac vein drains into the right atrium. The middle, small, and oblique cardiac veins drain into the coronary sinus. The right and left pulmonary veins drain into the left atrium.
15. A 37-year-old patient with severe chest pain, shortness of breath, and congestive heart failure was admitted to a local hospital. His coronary angiograms reveal a thrombosis in the circumflex branch of the left coronary artery. Which of the following conditions could result from the blockage of blood flow in the circum- flex branch? (A) Tricuspid valve insufficiency (B) Mitral valve insufficiency (C) Ischemia of AV node (D) Paralysis of pectinate muscle (E) Necrosis of septomarginal trabecula
B. The circumflex branch of the left coronary artery supplies the left ventricle, and thus its blockage of blood flow results in necrosis of myocardium in the left ventricle, producing mitral valve insufficiency. The tricuspid valve, AV node, pectinate muscles, and septomarginal trabecula are present in the right atrium and ventricle.
16. A 75-year-old patient has been suffering from lung cancer located near the cardiac notch, a deep indentation on the lung. Which of the following lobes is most likely to be excised? (A) Superior lobe of the right lung (B) Middle lobe of the right lung (C) Inferior lobe of the right lung (D) Superior lobe of the left lung (E) Inferior lobe of the left lung
D. The cardiac notch is a deep indentation of the anterior border of the superior lobe of the left lung. Therefore, the right lung is not involved.
17. A thoracentesis is performed to aspirate an abnormal accumulation of fluid in a 37-year- old patient with pleural effusion. A needle should be inserted at the midaxillary line between which of the following two ribs so as to avoid puncturing the lung? (A) Ribs 1 and 3 (B) Ribs 3 and 5 (C) Ribs 5 and 7 (D) Ribs 7 and 9 (E) Ribs 9 and 11
D. A thoracentesis is performed for aspiration of fluid in the pleural cavity at
or posterior to the midaxillary line, one or two intercostal spaces below the fluid level but not below the ninth intercostal space and, therefore, between ribs 7 and 9. Other intercostals spaces are not preferred.
18. A newborn baby is readmitted to the hospital with hypoxia and upon testing is found to have pulmonary stenosis, dextraposition of the aorta, interventricular septal defect, and hyper- trophy of the right ventricle. Which of the following is best described by these symptoms? (A) ASD (B) Patent ductus arteriosus (C) Tetralogy of Fallot (D) Aortic stenosis (E) Coarctation of the aorta
C. Tetralogy of Fallot is a combination of congenital cardiac defects consisting
of (a) pulmonary stenosis, (b) dextraposition of the aorta (so that it overrides the ventricular septum and receives blood from the right ventricle), (c) ventricular septal defect (VSD), and
(d) right ventricular hypertrophy. ASD is a congenital defect in the atrial septum, resulting from a patent foramen ovale. Patent ductus arteriosus shunts blood from the pulmonary trunk to
the aorta, bypassing the lungs. Aortic stenosis is an abnormal narrowing of the aortic valve ori- fice, impeding the blood flow. Coarctation of the aorta is a congenital constriction of the aorta, commonly occurs just distal to the left subclavian artery, causing upper limb hypertension and diminished blood flow to the lower limbs and abdominal viscera.
19. A 33-year-old patient is suffering from a sudden occlusion at the origin of the descend- ing (thoracic) aorta. This condition would most likely decrease blood flow in which of the following intercostal arteries? (A) Upper six anterior (B) All of the posterior (C) Upper two posterior (D) Lower anterior (E) Lower six posterior
E. The first two posterior intercostal arteries are branches of the highest (supe- rior) intercostal artery of the costocervical trunk; the remaining nine branches are from the thoracic aorta. The internal thoracic artery gives off the upper six anterior intercostal arteries and is divided into the superior epigastric and musculophrenic arteries, which gives off anterior intercostal arteries in the 7th, 8th, and 9th intercostal spaces and ends in the 10th intercostal space where it anastomoses with the deep circumflex iliac artery.
- A 56-year-old patient recently suffered a myocardial infarction in the area of the apex of the heart. The occlusion by atherosclerosis is in which of the following arteries?
(A) Marginal artery
(B) Right coronary artery at its origin
(C) Anterior interventricular artery
(D) Posterior interventricular artery
(E) Circumflex branch of the left coronary
artery
C. The apex of the heart typically receives blood from the anterior interventricu- lar branch of the left coronary artery. The marginal artery supplies the right inferior margin of the right ventricle, the right coronary artery at its origin supplies the right atrium and ventricle, and the posterior interventricular artery and a circumflex branch of the left coronary artery supply the left ventricle.
21. A 75-year-old woman was admitted to a local hospital, and bronchograms and radiographs revealed a lung carcinoma in her left lung. Which of the following structures or characteristics does the cancerous lung contain? (A) Horizontal fissure (B) Groove for superior vena cava (SVC) (C) Middle lobe (D) Lingula (E) Larger capacity than the right
D. The lingula is the tongue-shaped portion of the upper lobe of the left lung. The right lung has a groove for the horizontal fissure, superior vena cava (SVC), and middle lobe and has a larger capacity than the left lung.
- An 18-year-old girl is thrust into the steering wheel while driving and experiences difficulty in expiration. Which of the following muscles is most likely damaged?
(A) Levator costarum
(B) Innermost intercostal muscle (C) External intercostal muscle (D) Diaphragm
(E) Muscles of the abdominal wall
E. The abdominal muscles are the major muscles of expiration, whereas the other distractors are muscles of inspiration.
23. A 78-year-old patient presents with an advanced cancer in the posterior mediastinum. The surgeons are in a dilemma as to how to manage the condition. Which of the following structures is most likely damaged? (A) Brachiocephalic veins (B) Trachea (C) Arch of the azygos vein (D) Arch of the aorta (E) Hemiazygos vein
E. The hemiazygos vein is located in the posterior mediastinum. The brachiocephalic veins, trachea, and arch of the aorta are located in the superior mediastinum, whereas the arch of the azygos vein is found in the middle mediastinum.
- A 46-year-old patient comes to his doctor’s office and complains of chest pain and head- ache. His computed tomography (CT) scan reveals a tumor located just superior to the root of the right lung. Blood flow in which of the following veins is most likely blocked by this tumor?
(A) Hemiazygos vein
(B) Arch of the azygos vein
(C) Right subclavian vein
(D) Right brachiocephalic vein (E) Accessory hemiazygos vein
B. The azygos vein arches over the root of the right lung and empties into the
SVC. Other veins do not pass over the root of the right lung.
