Q11

Media: CXR with focus on lung and pleura.

Describe the expected positions of the fissures of the lung on a normal CXR.

  • The right lung has 3 lobes, and the left lung has 2 lobes
  • The oblique fissures separate upper from lower lobes, and the horizontal fissure separates the right upper and middle lobes
  • Oblique fissures follow the 5th ribs (run from the 4th thoracic vertebrae to 3cm posterior of the junction between the diaphragm and the sternum on the left, and to the sternodiaphragmatic junction on the right)
  • Horizontal fissure on the right at the level of the 4th costal cartilage or hilum

Pass Criteria:

  • Bold to pass (within 1 space either way).

Describe the position of the neruovascular structures in the intercostal space.

Between the middle and innermost layers, protected by the costal groove of the superior rib of each intercostal space. From superior to inferior, the order of structures is vein, artery, nerve.

Pass Criteria:

  • Bold to pass.

When placing an intercostal catheter (ICC) in the 5th intercostal space laterally, what anatomical structures are traversed?

  • Skin
  • Subcutaneous tissues
  • External intercostal muscle
  • Internal intercostal muscle
  • Innermost intercostal muscle
  • Parietal pleura

Pass Criteria:

  • 2 of the Bold to pass.

What structures may be at risk from an ICC inserted laterally?

  • Neurovascular bundle
  • Long thoracic nerve (lies in serratus anterior behind the mid axillary line)
  • Lung
  • Diaphragm
  • Pericardium/heart
  • Spleen if on the left
  • Liver if on the right

Pass Criteria:

  • 2 of the Bold to pass.

Q12

Media: Thoracic inlet photo.

Identify the venous structures in this image.

  • Left internal jugular vein (8)
  • Right and left subclavian veins (24)
  • Left brachiocephalic vein (13)
  • Superior vena cava (26)
  • Right brachiocephalic vein (18)
  • Inferior thyroid veins (7)

Pass Criteria:

  • Bold to pass.

Identify the major arterial structures in this image.

  • Brachiocephalic trunk (4)
  • Right common carotid artery (19)
  • Left common carotid artery (14)
  • Right subclavian artery (21)
  • Internal thoracic artery (9)

Pass Criteria:

  • Bold to pass.

What other structures can you identify?

  • Cricoid
  • Thyroid gland
  • Trachea
  • Lung
  • Pleura
  • Phrenic nerve
  • Scalenus anterior
  • Thyrocervical trunk

Pass Criteria:

  • Must get at least 3 to pass.

What are some complications of an internal jugular line insertion?

  • Pneumothorax
  • Misplacement/arterial puncture
  • Haemorrhage
  • Infection
  • Injury to the thoracic duct on the left

Pass Criteria:

  • Must get at least 3 to pass.

Q13

 Heart TextHeart

Using the model, identify the great vessels which enter and exit the heart.

  • Ascending aorta
  • Superior vena cava
  • Inferior vena cava
  • Pulmonary trunk/arteries
  • Pulmonary veins

Pass Criteria:

  • Bold to pass.

Identify the arteries that supply the heart.

  • Coronary arteries arise from the aortic sinuses
  • Left (main)  coronary artery
  • Left anterior descending artery
  • Diagonal branches
  • Circumflex artery
  • Marginal branches
  • Right coronary artery
  • Posterior descending (interventricular) artery

Pass Criteria:

  • Bold plus 1 to pass.

Which areas of the heart are supplied by the left coronary artery and its branches?

  • Most of the left atrium
  • Most of the left ventricle
  • Part of the right ventricle (anterior wall)
  • Interventricular septum
  • Ventricular apex
  • AV Bundle (of His)
  • SA node in 40% of cases (from the circumflex artery)

Pass Criteria:

  • Bold plus 1 to pass.

Bonus Question: Describe the position of the heart in the left hemithorax.

  • Inferior border lies on the diaphragm
  • Apex is in the 5th intercostal space
  • Base is against the thoracic vertebrae (T6 – T9)

Q14

Media: Surface anatomy of the chest/pleural reflections (photo).

Describe the surface anatomy of the lungs and the pleura.

  • Apices of both lungs begin the supraclavicular fossa
  • Lungs and visceral pleura run parasternal to 6th costal cartilage on the right, 4th costal cartilage on the left, then pass laterally to MCL 6th rib, MAL 8th rib, scapular line at 10th rib, T10, then paravertebrally to T12
  • This is in contrast to the parietal pleura, which is at MCL at 8th rib, MAL at 10th rib and SL at 12th rib (2 ribs below lungs/visceral pleura)
  • Oblique fissure – spinous provess T2 posteriorly to 6th costal cartilage anteriorly
  • Horizontal fissure – on right, from oblique fissure at level of 4th rib to costal cartilage

Pass Criteria:

  • 4 of 6 bold
  • Understanding of left and right variance
  • Understanding of parietal vs. visceral pleura (2 ribs below)

What are the anatomical structures to consider when inserting a lateral intercostal catheter?

  • Above the rib below to avoid neurovascular bundle
  • Above 5th – 6th intercostal space to avoid diaphragm (at nipple line)
  • Anterior to mid axillary line or latissimus dorsi
  • Posterior to pectoralis major

Pass Criteria:

  • Bold plus 1 to pass

Q15

 X-ray Chest TextX-ray Chest

Outline the structures that make up the right and left cardiomediastinal borders on this Xray.

  • Right
    • Right brachiocephalic vein
    • Superior vena cava
    • Right pulmonary trunk
    • Right atrium
    • Inferior vena cava
  • Left
    • Left subclavian artery/left brachiocephalic vein
    • Aortic arch
    • Left pulmonary trunk
    • Left atrial appendage
    • Left ventricle

Pass Criteria:

  • 6 out of 10 to pass

Describe the lobes of the lungs and their fissures.

  • Both lungs: oblique fissures separate upper and lower lobes (T2 posteriorly to 6th costal cartilage anteriorly)
  • Right lung: upper and middle lobes separated by the horizontal fissure (at level of right lung hilum along the line of the 4th rib)
  • Left lung: prominent cardiac notch in the lower lobe

Pass Criteria:

  • Bold to pass

Which part of the lung forms the right heart border?

  • Right middle lobe

Pass Criteria:

  • Bold to pass

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