1. Blockage of which of the following arteries would lead to ischemia
of the apex of the heart?
Anterior interventricular (descending)
Left circumflex
Posterior interventricular (descending)
Right marginal
Right coronary
2. If the ductus arteriosus does not spontaneously close off soon
after birth (to become the ligamentum arteriosum), it may have to
be surgically ligated. When clamping or ligating it, what important
structure immediately behind it must be identified and saved?
arch of the azygos vein
internal thoracic artery
left phrenic nerve
left recurrent laryngeal nerve
left superior intercostal vein
3. 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
4. A stethoscope placed over the left second intercostal space just
lateral to the sternum would be best positioned to detect sounds
associated with which heart valve?
aortic
pulmonary
mitral
tricuspid
5. Which valves would be open during ventricular systole?
Aortic and pulmonary
Aortic and tricuspid
Mitral and aortic
Tricuspid and mitral
Tricuspid and pulmonary
6. Which chamber's anterior wall forms most of the sternocostal
surface of the heart?
Left atrium
Left ventricle
Right atrium
Right ventricle
7. 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
8. 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
9. Which statement is true of the right atrioventricular valve?
it is also called the mitral valve
it is open during ventricular diastole
it transmits oxygenated blood
it is opened by the pull of chordae tendineae
it consists of 2 leaflets
10.
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:
Coronary sinus
Coronary sulcus
Costomediastinal recess
Oblique sinus
Transverse sinus
11.
An elderly lady suffers a coronary occlusion and
subsequently it is noted that there is a complete heart block (that
is, the right and left bundles of the conduction system have been
damaged). The artery most likely involved is the:
acute marginal branch
circumflex branch
anterior interventricular (Left anterior descending)
obtuse marginal
posterior interventricular (posterior descending)
12.
During fetal life and sometimes persisting into the adult there
is an opening between the right and left atria; this opening is called
the:
atrioventricular canal
coronary sinus
foramen ovale
sinus venosus
truncus arteriosis
13.
The heart sound associated with the mitral valve is best
heard:
In the jugular notch
In the second left intercostal space
In the second right intercostal space
In the fifth left intercostal space
To the right of the xiphoid process
14.
Which heart valve has leaflets described as "anterior, left and
right"?
Aortic
Pulmonary
Left atrioventricular
Right atrioventricular
15.
In preparation for thoracic surgery, a median sternal splitting
procedure was carried out. But an improper depth setting on the
saw blade resulted in a slight nick on the underlying sternocostal
surface of the heart. Which heart chamber would most likely have
been opened had the blade completely penetrated this wall?
Left atrium
Left ventricle
Right atrium
Right ventricle
16.
The sound associated with tricuspid stenosis (narrowing) in a
40-year-old male would be best heard at which location on the
anterior chest wall?
Below the left nipple
In the right 2nd intercostal space near the sternum
Over the apex of the heart
Over the sternal angle
Xiphoid area, just off the sternum
17.
Blockage of blood flow in the proximal part of the anterior
interventricular artery could deprive a large area of heart tissue of
blood supply, unless a substantial retrograde flow into this artery
develops via an important anastomosis with which other artery?
Circumflex
Left marginal
Posterior interventricular
Right coronary
Right marginal
18.
Traumatic, acceleration/deceleration injuries to the aorta
usually occur where its mobile and fixed portions meet. This would
be at the:
at the ligamentum arteriosum
junction of aortic arch with the descending portion
junction of the ascending aorta with the heart
origin of the brachiocephalic artery on the arch
point where the descending aorta passes through the
diaphragm
19.
Which structure does NOT lie in the coronary sulcus?
circumflex artery
coronary sinus
right coronary artery
right marginal artery
20.
left coronary artery
Which structure contains postganglionic sympathetic fibers?
greater thoracic splanchnic nerve
recurrent laryngeal nerve
sympathetic trunk
ulnar nerve
vagus nerve
21.
Which posterior mediastinal structure is most closely applied
to the posterior surface of the pericardial sac?
Aorta
Azygos vein
Esophagus
Thoracic duct
Trachea
22.
In obstruction of the superior or inferior vena cava, venous
blood is returned to the heart by an alternate route via the azygos
vein, which becomes dilated in the process. Which of the following
structures might it compress as a result?
trachea
root of the left lung
phrenic nerve
thoracic duct
descending aorta
23.
Elevated systolic blood pressure in the right ventricle
suggests stenosis of which valve?
Aortic
Mitral
Pulmonary
Tricuspid
24.
During examination of a 62-year-old man, the senior resident
tells you to put your stethoscope on the left 5th intercostal space,
slightly below the nipple, and listen for a clearly audible murmur.
You hear it distinctly and know it must be associated with severe
stenosis of which heart valve?
Aortic
Mitral
Pulmonary
Tricuspid
25.
A 26-year-old male is brought into the emergency room after
having been kicked in the chest by a horse. After examination, it is
concluded that the most likely immediate danger is cardiac
tamponade (bleeding into the pericardial sac). You prepare to draw
off some of the blood from the sac to relieve the pressure on the
heart. The safest site at which to insert the needle of the syringe in
order to miss the pleura would be:
Just below the nipple on the left
Just to the left of the xiphisternal junction
Near the sternal angle
Through the jugular notch
4th left intercostal space in the midaxillary line
26.
A 22-year-old male involved in an automobile accident
presents with symptoms suggestive of myocardial contusion due to
blunt trauma, specifically compression of the sternocostal surface
of the heart by the sternum when his chest hit the steering wheel.
Which heart chamber was most likely damaged?
Left atrium
Left ventricle
Right atrium
Right ventricle
27.
While attempting to suture the distal end of a coronary
bypass onto the anterior interventricular artery, the surgeon
accidentally passed the needle through the adjacent vein. Which
vein was damaged?
Anterior cardiac vein
Coronary sinus
Great cardiac vein
Middle cardiac vein
Small cardiac vein
28.
While listening to a patient's heart sounds with a
stethoscope, you identify a high-pitched sound in the second right
intercostal space, just lateral to the edge of the sternum. Your
correct conclusion is that you have detected stenosis of which
heart valve?
Aortic
Mitral
Pulmonary
Tricuspid
1. The correct answer is:
Anterior interventricular (descending)
The anterior interventricular artery is a branch of the left coronary artery.
It supplies both ventricles as well as the interventricular septum. It also
reaches the apex, supplying that area as well. The left circumflex artery
is the other major branch of the left coronary artery. It supplies the
posterior surface of the left ventricle, but does not reach the apex of the
heart.
The right coronary artery has two major branches: the right marginal and
the posterior interventricular artery. (The right coronary also gives off two
smaller branches to the SA node and the AV node.) The right marginal
artery supplies the right ventricle, while the posterior IV artery supplies
the interventricular septum and the two ventricles. Neither of these
arteries provides a major source of blood to the apex of the heart.
2. The correct answer is:
Left recurrent laryngeal nerve
The left recurrent laryngeal nerve leaves the vagus nerve and loops
under the arch of the aorta near the ligamentum arteriosum/ductus
arteriosis. When performing surgery in this area, like the repair of a
patent ductus arteriosis, a surgeon must be very careful to identify and
preserve the left recurrent laryngeal nerve. If this nerve is damaged, it
may lead to paralysis of the left vocal fold and cause hoarseness in the
patient. This is a very significant complication that you want to
remember!
The arch of the azygos vein is located on the right side of the body and
would not be damaged by surgery near the aortic arch. The internal
thoracic artery is a branch of the subclavian artery and is not near the
ductus arteriosis. The left phrenic nerve, which innervates the
diaphragm, is lateral to the vagus nerve and would not be damaged in
this procedure. The left superior intercostal vein lies lateral to the vagus
and aortic arch, so it would not be disturbed by surgery.
3. 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 costamediastinal 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 at the root of the
lung, where visceral pleura on the lung becomes continuous with the
parietal mediastinal pleura.
4. The correct answer is:
pulmonary
The best place to listen to heart valves is not at their actual sternocostal
projections. If you place your stethoscope exactly where a valve is
located, you may not hear anything because the valve might be deep in
the chest or the sound might be muffled by bone or cartilage. Instead,
you want to listen to the valves by putting your stethescope at a point
downstream from the valve where you can hear the blood flowing and
colliding with the muscular chest wall.
There are points of auscultation for all four heart valves: Pulmonic: left
second intercostal space, lateral to the sternal angle; Aortic: right second
intercostal space, lateral to the sternal angle; Mitral: left fifth intercostal
id: left fourth intercostal
space, just lateral to the sternum.
Learn these points of auscultation very well, because you will be using
them again and again!
5. The correct answer is:
Aortic and pulmonary
Remember that ventricular systole is the period when the ventricles are
contracting. This contraction forces blood out of the heart, which pushes
the aortic and pulmonary valves open.
During systole, the tricuspid and mitral valves are closed. They are
prevented from prolapsing (being pushed back into the atrium) by the
chordae tendinae and papillary muscles.
6. 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.
7. 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!
8. 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.
9. he correct answer is:
it is open during ventricular diastole
Ventricular diastole is the period when the ventricles relax and fill with
blood. So, the AV valves need to be open at this time so that blood can
flow from the atria to the ventricles. The right AV valve is called the
tricuspid valve--it has three leaflets. The left AV valve is called the mitral
valve and has two leaflets. Remember, the right side of the heart is
pumping blood to the lungs so that it can be oxygenated. So, the blood
flowing through the right AV valve will be deoxygenated, while the blood
flowing through the left AV valve will be oxygenated. Finally, remember
that the chordae tendineae and the papillary muscles do not pull the AV
valves open! These structures serve to prevent the valves from
prolapsing during systole.
10. 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 the large vein on the posterior surface of the heart
which drains into the right atria. It receives blood from the great, middle,
and small cardiac veins, the oblique vein of the left atrium, and the left
posterior ventricular vein. The coronary sulcus is the groove on the heart
which separates the atria from the ventricles. Many arteries and veins
run in this sulcus. The costomediastinal recess is an area in the pleural
sac where the costal pleura changes to the mediastinal pleura.
11. The correct answer is:
descending)
Anterior interventricular (Left anterior
The right and left bundles of conduction travel in the interventricular
septum. So, the artery that has been occluded must be the one that
supplies the interventricular septum. The most important source of blood
to the interventricular septum is the anterior interventricular artery, a
branch of the left coronary artery. Although the posterior interventricular
artery partially supplies blood to the interventricular septum, it might not
be enough to support the tissue in this region.
The circumflex branch of the left coronary artery provides blood to the
posterior surface of the left ventricle. The acute marginal branch of the
right coronary artery provides blood to the right ventricle.
12. The correct answer is:
foramen ovale
The foramen ovale is an opening in the interatrial septum which exists in
the fetus. This opening and the ductus arteriosus serve as two shunts
which divert blood away from the developing lungs. Both should close
soon after birth.
The coronary sinus is the large vein on the posterior surface of the heart
which drains into the right atrium. It receives blood from the great,
middle, and small cardiac veins, the oblique vein of the left atrium, and
the left posterior ventricular vein. The sinus venosus and truncus
arteriosus are structures in the developing heart that will be covered in
embryology.
13. The correct answer is:
In the 5th left intercostal space
The four valves of the heart can be auscultated at very distinct spaces.
The mitral valve can be ausculatated in the left 5th intercostal space,
slightly below the nipple.The aortic valve can be ausculatated in the 2nd
right intercostal space, just lateral to sternal angle. The pulmonary valve
can be auscultated in the 2nd left intercostal space, just lateral to sternal
angle. The tricuspid valve can be auscultated in the 4th left intercostal
space, just lateral to sternum.
14. The correct answer is:
Pulmonary
The leaflets of the pulmonic valve are named anterior, left, and right,
according to their orientation. The leaflets of the aortic valve are named
posterior, left, and right, with the left and right aortic sinuses above these
leaflets giving off their respective coronary arteries. The mitral valve has
anterior and posterior cusps, while the tricuspid valve has septal,
anterior, and smaller posterior cusps.
15. The correct answer is:
Right ventricle
Since the right ventricle forms the anterior, or sternocostal, surface of
the heart, this would be the chamber most likely to be injured by the
blade. This is also the surface of the heart most likely to be injured by an
insult to the anterior chest wall.
16. The correct answer is:
xiphoid area, just off the sternum
It's best to listen to sounds associated with the tricuspid valve at the
fourth left intercostal space, just lateral to the sternum. The answer that
comes the closest to this is E. What would you hear in the other spaces?
Below the left nipple, in the fifth intercostal space, you would be
auscultating the mitral valve. This is also the valve that you can hear at
the apex of the heart. The right 2nd intercostal space near the sternum
is the site for auscultating the aortic valve. Finally, it would be difficult to
hear anything over the sternal angle, since the stethoscope would be
over bone, which would blunt any sounds!
17. The correct answer is:
posterior interventricular
The anterior interventricular artery and posterior interventricular artery
travel on the anterior and posterior surfaces of the interventricular
groove. These two vessels often anastamose. If there was a very
extensive anastamosis between the anterior and posterior
interventricular arteries, it is possible that the posterior interventricular
artery might supply the tissue usually fed by the anterior interventricular
artery. The other arteries listed would not be able to anastamose with
anterior interventricular artery; they supply other areas of the heart.
18. The correct answer is:
at the ligamentum arteriosum
The ligamentum arteriosum is the point where the left pulmonary artery
connects with the undersurface of aortic arch. It is a remnant of the fetal
ductus arteriosus, which shunted blood away from the developing lungs.
Because the aorta is tethered to the pulmonary artery by the ligamentum
arteriosum, the part of the aorta near the ligamentum is vulnerable to
damage in a traumatic acceleration/deceleration injury - it could pull
away and tear. The other answer choices do not describe points of the
aorta where a mobile and fixed portion meet. Therefore, these parts of
the aorta would not be vulnerable to this type of traumatic injury.
19. The correct answer is:
right marginal artery
The coronary sulcus is the groove which separates the atria from the
ventricles. The right and left coronary arteries, circumflex artery, and
coronary sinus all lie in this groove. The right marginal artery is a branch
of the right coronary artery which lies on the right ventricle and supplies
that chamber of the heart.
20. The correct answer is:
ulnar nerve
When a nerve fiber reaches the sympathetic chain, there are three
things that can happen. First, the nerve fibers can enter a ganglia,
synapse at that level, and rejoin the spinal nerve via the grey ramus
communicans. Second, the preganglionic nerve fibers can travel up or
down the trunk, synapse in a ganglia at another level, and then rejoin a
spinal nerve. This is how sympathetic fibers join spinal nerves at the
cervical and lumbar levels, which are above and below the lateral horn.
Third, some preganglionic fibers do not synapse in the trunk and,
instead, form splanchnic nerves. These nerves descend into the
abdomen and synapse in other ganglia.
The greater thoracic splanchnic nerve contains preganglionic fibers that
are destined to synapse in the celiac plexus. The recurrent laryngeal
nerve provides motor and sensory innervation to the upper esophagus
and pharynx. Finally, the vagus nerve is a mixed nerve that carries
preganglionic parasympathetic fibers. None of these nerves carry
postganglionic sympathetic fibers.
The ulnar nerve innervates muscles of the hand, arm, and provides
some sensory innervation to skin of the hand and arm. It is derived from
ventral rami of spinal nerves, all of which carry postganglionic
sympathetic fibers (for vascular smooth muscle, arrector pili muscles,
and sweat glands).
21. The correct answer is:
esophagus
The esophagus is closely related to the posterior surface of the
pericardial sac. After coming from the heart, the aorta arches over the
left pulmonary artery and left bronchus. Eventually, just above the
diaphragm, this vessel is posterior to the esophagus. The azygos vein,
on the right side of the thorax, arches over the right pulmonary artery
and bronchus. It is also posterior to the esophagus. The thoracic duct is
posterior to the esophagus as well and does not contact the pericardial
sac. Finally, the trachea is superior to the heart.
22. The correct answer is:
thoracic duct
Below the level of the sternal angle, the thoracic duct lies posterior to the
esophagus, between the azygos vein and the descending aorta. So, if
the azygos vein became dilated, it could impinge on the thoracic duct.
The trachea is superior to the azygos vein, which loops over the right
bronchus before emptying into the superior vena cava. This means that
a dilated azygos vein would have little impact on the trachea. Because
the azygos is on the right side of the body, it could not compress
anything at the root of the left lung. The right phrenic nerve is anterior to
the azygos vein. The descending aorta is much larger and more
muscular than the azygos vein, so it is unlikely that it would be
compressed by this much smaller structure.
23. The correct answer is:
Pulmonary
In these sorts of questions, you need to identify the valve immediately
distal to the area of high pressure. This is the valve that must be
blocked, because you can assume that blood is backing up into the area
where the pressure is high. In this case, pressure is high in the right
ventricle. So, there must be stenosis of the pulmonic valve, which allows
blood to leave the right ventricle and travel to the lung.
If there was stenosis of the aortic valve, pressure would be high in the
left ventricle. If there was stenosis of the tricuspid valve, pressure would
be high in the right atrium. If there was stenosis of the mitral valve,
pressure would be high in the left atrium. If you understand the path of
blood flow in the heart, you can understand all these scenarios!
24.
The correct answer is:
Mitral
The four valves of the heart can be auscultated at very distinct spaces,
and you should make sure that you know these! The mitral valve, which
separates the left atrium from the left ventricle, can be ausculatated in
the left 5th intercostal space, slightly below the nipple. This is where this
patient's murmur is heard. The tricuspid valve, which separates the right
atrium from the right ventricle, can be auscultated in the 4th left
intercostal space, just lateral to sternum. The aortic valve, which
separates the left ventricle from the aorta, can be ausculatated in the
2nd right intercostal space, just lateral to sternal angle. The pulmonary
valve, which separates the right ventricle from the pulmonary artery, can
be auscultated in the 2nd left intercostal space, just lateral to sternal
angle.
25. The correct answer is:
Just to the left of the xiphisternal junction
When fluid accumulates in the pericardial sac, it is necessary to remove
that fluid by performing a pericardiocentesis. A needle is inserted just to
the left of the xiphisternal junction, and the needle passes superiorly to
enter the pericardial sac. Then, the fluid can be aspirated into the
needle.
26. The correct answer is:
Right ventricle
The right ventricle forms the anterior (sternocostal) surface of the heart.
So, this is the surface of the heart that lies against the sternum and
would be injured following a crushing blow to the sternum. There are 2
other surfaces of the heart of which you should be aware. The
diaphragmatic surface of the heart is formed by the left ventricle, with a
little bit of the right ventricle. This is the surface of the heart which is in
contact with the diaphragm. The pulmonary surface of the heart is on the
left side of the heart. It is mostly formed by the left ventricle.
27. The correct answer is:
Great cardiac vein
To answer this question, you need to know that the anterior
interventricular artery lies in the anterior interventricular sulcus. Then,
you need to identify the vein that also lies in the anterior interventricular
sulcus. And that vein is the great cardiac vein. The anterior cardiac vein
lies on the surface of the right atrium--it drains directly into the right
atrium. The coronary sinus is located in the coronary (atrioventricular)
sulcus--it is formed by the union of the great cardiac vein and the oblique
vein of the left atrium, and it drains blood directly into the right atrium.
The middle cardiac vein is located in the posterior interventricular
sulcus--it accompanies the posterior interventricular artery. The small
cardiac vein courses through the coronary sulcus with the right coronary
artery.
28. The correct answer is:
Aortic
The four valves of the heart can be auscultated at very distinct spaces.
The aortic valve, which separates the left ventricle from the aorta, can be
auscultated in the 2nd right intercostal space, just lateral to sternal
angle. Since this is the space where the murmur is heard, the problem
must be with the aortic valve. The mitral valve, which separates the left
atrium from the left ventricle, can be auscultated in the left 5th intercostal
space, slightly below the nipple. The pulmonary valve, which separates
the right ventricle from the pulmonary artery, can be auscultated in the
2nd left intercostal space, just lateral to sternal angle. The tricuspid
valve, which separates the right atrium from the right ventricle, can be
auscultated in the 4th left intercostal space, just lateral to sternum.