Q1

X-ray Chest TextX-ray Chest

Demonstrate the lobes of the lungs.

  • Right superior mediastinum to apex; right upper lobe
    • RUL: apex -horizontal fissure /upper right mediastinum medially
  • Right heart border; right middle lobe
    • RML: right heart border & horizontal fissure (superior border 4th rib) to 6th costal cartilage
  • Left upper mediastinum to apex; left upper lobe
    • LUL: 4th left intercostal space, 6th intercostal space mid-clavicular line, 5th left intercostal space & 5th left intercostal space anterior axillary line
  • Left heart border; Lingula lobe: left heart border
  • Lower lobes posteriorly, sit over domes of diaphragms rise as high as 3rd intercostal space posteriorly R & L lower lobes: from Obliques fissures (T2 spinous process-6th costal cartilage anteriorly) to level T10 spinous process posteriorly, 10th ribs at scapular line & 8th ribs in mid-axillary line

Pass Criteria

  • Demonstrate all 5 lobes

What are their immediate relationships?

PROMPT – What are the boundaries of the lobes?

  • Right superior mediastinum to apex; right upper lobe
    • RUL: apex -horizontal fissure /upper right mediastinum medially
  • Right heart border; right middle lobe
    • RML: right heart border & horizontal fissure (superior border 4th rib) to 6th costal cartilage
  • Left upper mediastinum to apex; left upper lobe
    • LUL: 4th left intercostal space, 6th intercostal space mid-clavicular line, 5th left intercostal space & 5th left intercostal space anterior axillary line
  • Left heart border; Lingula lobe: left heart border
  • Lower lobes posteriorly, sit over domes of diaphragms, rise as high as 3rd intercostal space posteriorly
    • R & L lower lobes: from Oblique fissures (T2 spinous process-6th costal cartilage anteriorly) to level T10 spinous process posteriorly, 10th ribs at scapular line & 8th ribs in mid-axillary line

Pass Criteria

  • Demonstrate all 5 lobes

Describe the surface anatomy of the parietal pleura

  • Supraclavicular fossa, medially follow the middle of the sternum to the level of the 6th intercostal cartilage, deviates laterally reaching mid-clavicular line at 8th rib, mid-axillary line at the 10th rib, paravertebral line 12th rib
  • Notch on Left

Pass Criteria

  • Reasonable description

Q2

X-ray Chest TextX-ray Chest

Outline the structures that make up the cardiomediastinal borders on this normal X-ray.

  • Right:
    • Right brachiocephalic vein
    • Superior vena cava
    • Right pulmonary artery
    • Right atrium
    • Inferior vena cava
  • Left:
    • Aorta
    • Left pulmonary trunk/artery
    • Left atrium
    • Left ventricle

Pass Criteria:

  • bold to pass

Which parts of the lung lie adjacent to the cardiomediastinum?

  • Right upper mediastinum: Right superior lobe
  • Right heart border: Right middle lobe
  • Left upper mediastinum: Left superior lobe
  • Left heart border: Lingula segment of Left superior lobe

Pass Criteria:

  • RML plus one other

An 80 year old woman is transferred to your ED following a motor vehicle accident 12 hours ago, where she sustained serious chest injuries. In this patient, what injuries may be seen on a CXR?

PROMPT – The patient has sustained blunt trauma.

  • Chest wall: # ribs, clavicle, sternum
  • Lung: pneumothorax, haemothorax, contusion
  • Cardiovascular: aorta, other vessels (widen mediastinum)

Pass Criteria:

  • 1 example from each bold category to pass

Q3

Heart Text Heart

Identify the arterial supply of the heart.

  • Left and right coronary arise from corresponding aortic sinuses above aortic valve
  • Right coronary artery
    • Courses inferiorly in AV groove
    • Gives off branches to SA node, Marginal, Posterior interventricular and AV nodal
  • Left coronary artery
    • Bifurcates into circumflex and Left anterior descending (anterior interventricular artery)
    • Then Circumflex gives off Marginal branch, and LAD gives off diagonals

Pass Criteria:

  • Bold to pass

What does the right coronary artery supply?

  • Right atrium
  • Most of right ventricle
  • Diaphragmatic surface left ventricle
  • Posterior 1/3 septum
  • 60% SA
  • 80% AV

Pass Criteria:

  • 3 out of 6 to pass

Describe the venous drainage of the heart.

  • Major drainage is via the coronary sinus
  • 3 main tributaries are:
    • Great cardiac vein (accompanies LAD, then circumflex)
    • Middle (accompanies PIV)
    • Small cardiac veins (accompanies right marginal). Oblique vein left atrium marks start of sinus.
  • Anterior cardiac veins start anterior surface RV, drain straight into right atrium. Smallest cardiac veins (venae cordis minimae) drain direct into chambers.

Pass Criteria:

  • Bold + 2

Q4

Heart Text Heart

Using this model please describe the arterial supply of the heart.

  • Left and right coronary arise from coronary sinuses.
  • Left coronary artery divides into Left anterior descending and Circumflex
    • LAD – diagonal branches
    • Circumflex – marginal brnaches
  • Right coronary artery inferior in AV groove – SA nodal, AV nodal, marginal, posterior IV (2/3)

Pass Criteria:

  • Bold + 1 other

What does the right coronary artery supply?

  • Right atrium
  • Most of right ventricle
  • Diaphragmatic (inferior) part of left ventricle
  • Posterior 1/3 interventricular septum
  • SA node in 60%
  • AV node in 80%

Pass Criteria:

  • 3 out of 6 to pass

Describe the cardiac conduction system.

  • SA node – Junction of SVC and RA.
  • AV node – postero-inferior AV septum near coronary sinus.
  • AV bundle of His.
  • Left and Right Bundles.

Pass Criteria:

  • Bold + 1 other

Q5

Heart Text Heart

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

  • Superior vena cava
    • R brachiocephalic v
    • L brachiocephalic v
  • Inferior vena cava
  • Ascending aorta
    • Brachiocephalic trunk
    • L common carotid artery
    • L subclavian artery
  • Pulmonary trunk & pulmonary arteries
  • Pulmonary veins

Pass Criteria:

  • Bold to pass

Identify the main coronary arteries and their branches.

  • RCA
  • LCA
  • Circumflex
  • LAD/anterior interventricular
  • Marginal

Pass Criteria:

  • 4/5 to pass

Which areas of the heart is supplied by the LCA?

  • Most of the left atrium
  • Most of the left ventricle
  • Part of right ventricle
  • Intraventricular septum
  • AV bundle
  • SA node in 40%

Pass Criteria:

  • Bold + 2 to pass

(If required) Describe the position of the heart in the left hemithorax

  • Inferior border lies on the diaphragm
  • Apex is in the 5th ICS
  • Base is against the thoracic vertebrae vertebrae T6 to T9

Q6

Model: First Rib

Please identify this bone and demonstrate its features.
Prompt: What is this? (Arrow)

  • First rib
    • Head
    • Neck
    • Shaft
    • Tubercle (articulates with TP of T1)
    • Articulation with costal cartilage to manubrium
    • Groove for subclavian vein (anterior) and artery (posterior to scalene tubercle)
    • Arrow = scalene tubercle

Pass Criteria:

  • Bold to pass

What are the important relations?

  • Apex of lung
  • Subclavian vessels & intercostal vessels
  • Sympathetic trunk
  • Lower trunk of brachial plexus (superior)
  • Scalenus anterior/medius
  • Intercostals
  • Serratus anterior
  • Subclavius

Pass Criteria:

  • Bold to pass

Q7

 

Thoracic Inlet

Identify the vascular structures in this photo.

  • Left common carotid artery
  • Right common carotid
  • Brachiocephalic trunk
  • Right subclavian artery
  • Right brachiocephalic vein
  • Left brachiocephalic vein
  • Subclavian vein
  • Left internal jugular
  • Thyrocervical trunk

Pass Criteria:

  • 5 of 9 to pass

What important structures may be damaged during insertion of an IJ line?

  • Carotid artery
  • Phrenic nerve
  • Brachial plexus
  • Pulmonary dome
  • Thoracic duct
  • Trachea
  • Subclavian vessels

Pass Criteria:

  • Bold + 1

What clinical complications may occur from damage to these structures?

  • Pneumothorax
  • Haemothorax
  • Hydro/chylothorax
  • Stroke
  • Air embolism
  • Bleeding
  • Haematoma –> airway obstruction
  • AV fistula, etc

Pass Criteria:

  • Appropriate example for each

Bonus: What other complications can occur from central line insertion?

  • Line misplacement/misdirection
  • Arrhythmias
  • Infection
  • Thrombosis/PE
  • Catheter loss/embolus
  • Wire knotting

Q8

Describe the intercostal muscles.

  • External intercostal
    • From tubercles of ribs posteriorly to costochondral junction (thence external intercostal membrane) run infero-anteriorly and are most active during inspiration (to increase tonus of intercostal space) and during forced inspiration
  • Internal intercostal
    • Deep to and at right angles to externals from sternum to angle of ribs posteriorly (continued posteriorly as internal intercostal membrane) run infero-posteriorly and are most active during expiration (to increase tonus of intercostal space)
    • Interosseous portions act during forced expiration whilst interchondral portion act during active inspiration
  • Innermost intercostals
    • Essentially the deeper parts of the internals separated from them by the intercostal nerves and vessels
    • Occur laterally
  • Subcostals
    • Run in the same direction as the internals, but cross 2 or 3 spaces, lower spaces
  • Transverse thoracic
    • Run from sternum and xiphisternum transversely to lower ribs
  • Levator costarum
    • From transverse processes to ribs

Pass Criteria:

  • External + internal + one other to pass

Describe the pattern of distribution of neurovascular structures in the thoracic wall.

  • Enter medial most part of posterior intercostal space
  • Run between parietal pleura and internal intercostal membrane in the middle of the space
  • Near angle of ribs pass between internal and innermost intercostal muscles
  • Here in costal grooves, with nerve inferior to artery inferior to vein
  • Collateral branches arise here and run along superior border of rib
  • Vessels also have anterior supply and drainage

Pass Criteria:

  • Order of neurovascular and relation to rib and groove

If needed: Describe the arterial supply of the intercostal spaces.

  • Posterior intercostal arteries (branches of the supreme intercostal from the subclavian and of the thoracic aorta)
  • Anterior intercostal arteries (branches of the internal thoracic (previously internal mammary – space 1 to 6 and musculo-phrenic spaces 7 to 9)

Q9

Model: Heart

Demonstrate the chambers of the heart and their borders.

  • Left ventricle
  • Right ventricle
    • Anterior & posterior interventricular grooves
  • Right atrium & auricle
  • Left atrium & auricle
    • Coronary groove
  • Crux of heart

Pass Criteria:

  • Need to identify chambers to pass

Demonstrate the arterial supply of the heart.
Prompt: Main branches of right & left coronary artery?

  • Right coronary artery – sinoatrial nodal – R marginal – AV nodal – posterior interventricular (2/3) – interventricular septum
  • Left coronary artery – circumflex – sinoatrial nodal (40%) – L marginal – posterior interventricular (15%)
  • Left coronary artery – left anterior descending – anterior 2/3 septum – lateral diagonal

Pass Criteria:

  • Bold to pass

Demonstrate the venous drainage of the heart.

  • Coronary sinus
  • Great cardiac veins
  • Middle cardiac veins
  • Small cardiac veins
  • Left posterior ventricular
  • Left marginal
  • Anterior cardiac
  • Oblique veins on the left atrium

Pass Criteria:

  • Coronary sinus to pass

Q10

Media: Chest Xray

What structures make up the mediastinal contours?

  • Right:
    • Right brachiocephalic vein
    • Superior vena cava
    • Right pulmonary trunk
    • Right atrium
  • Left:
    • Aorta
    • Pulmonary trunk
    • Left atrium
    • Left ventricle

Pass Criteria:

  • Bold required plus one other to pass.

Which lobes of the lung lie adjacent to the right and left cardio-mediastinum?
Prompt: Which part of the lung forms the right heart border? etc.

  • Right upper mediastinum
    • Right superior lobe
  • Right heart border
    • Right middle lobe
  • Left upper mediastinum
    • Left superior lobe
  • Left heart border
    • Left superior lobe (lingular segment)

Pass Criteria:

  • Bold required to pass.

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Abdomen  Pelvis & Perineum Head & Neck