1.

The second costal cartilage can be located by palpating the:

costal margin
sternal angle
sternal notch
sternoclavicular joint
xiphoid process
2. The thoracic wall is innervated by:
Dorsal primary rami
Intercostal nerves
Lateral pectoral nerves
Medial pectoral nerves
Thoracodorsal nerves
3. The sternocostal surface of the heart is formed primarily by the
anterior wall of which heart chamber?
Left atrium
Left ventricle
Right atrium
Right ventricle
4. 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

5. You are caring for a 68-year-old male who has copious amounts of
fluid in the left pleural cavity due to acute pleurisy. When you
examine him as he sits up in bed (trunk upright), where would the
fluid tend to accumulate?
costodiaphragmatic recess
costomediastinal recess
cupola
hilar reflection
middle mediastinum
6. 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
7. When inserting a chest tube, intercostal vessels and nerves are
avoided by placing the tube immediately:
above the margin of a rib
below the margin of a rib
8. 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
9. The first rib articulates with the sternum in close proximity to the:
Nipple
Root of the lung
Sternal angle
Sternoclavicular joint
Xiphoid process
10. The portion of the parietal pleura that extends above the first
rib is called the :
costodiaphragmatic recess
costomediastinal recess
costocervical recess
cupola
endothoracic fascia
11. You are attending an operation to remove a thymic tumor
from the superior mediastinum. The surgeon asks, "What
important nerve lying on and partly curving posteriorly around the
arch of the aorta should we be careful of as we remove this
mass?" You quickly answer, "The--
left phrenic
left sympathetic trunk
left vagus
right phrenic
right sympathetic trunk

12. In cardiac surgery it is sometimes necessary to clamp off all
arterial flow out of the heart. This could be done within the
pericardial sac by inserting the index finger immediately behind the
two great arteries and compressing them with the thumb of the
same hand. The index finger would have to be inserted into which
space?
Cardiac notch
Coronary sinus
Oblique pericardial sinus
Coronary sulcus
Transverse pericardial sinus
13. A needle inserted into the 9th intercostal space along the
midaxillary line would enter which space?
Cardiac notch
Costodiaphragmatic recess
Costomediastinal recess
Cupola
Oblique pericardial sinus
14. During a heart transplant procedure, the surgeon inserted his
left index finger through the transverse pericardial sinus, and then
pulled forward on the two large vessels lying ventral to his finger.
Which vessels were these?
Pulmonary trunk and brachiocephalic trunk
Pulmonary trunk and aorta
Pulmonary trunk and superior vena cava
Superior vena cava and aorta
Superior vena cava and right pulmonary artery
15. While observing in the OR, you see the resident insert a
needle through the body wall just above the ninth rib in the mid-

axillary line. She was obviously trying to enter the:
Costodiaphragmatic recess
Costomediastinal recess
Cupola
Hilar reflection
Pulmonary ligament
16. The pleural cavity near the cardiac notch is known as the:
Costodiaphragmatic recess
Costomediastinal recess
Cupola
Hilum
Pulmonary ligament
17. The tubercle of the 7th rib articulates with which structure?
Body of vertebra T6
Body of vertebra T7
Body of vertebra T8
Transverse process of vertebra T6
Transverse process of vertebra T7
18. The ductus arteriosus sometimes remains open after birth
requiring surgical closure. When placing a clamp on the ductus,
care must be taken to avoid injury to what important structure
immediately dorsal to it?
Accessory hemiazygos vein
Left internal thoracic artery
Left phrenic nerve

Left recurrent laryngeal nerve
Thoracic duct
19. A 16-year-old male suffered a stab wound in which a knife
blade entered immediately superior to the upper edge of the right
clavicle near its head. He was in extreme pain, which was
interpreted by the ER physician as a likely indicator of a collapsed
lung following disruption of the pleura. If that was true, what portion
of the pleura was most likely cut or torn?
costal pleura
cupola
hilar reflection
mediastinal pleura
pulmonary ligament
20. During a lung transplant procedure, an observing 4th year
attempted to pass his index finger posteriorly inferior to the root of
the left lung, but he found passage of the finger blocked. Which
structure would most likely be responsible for this?
Costodiaphragmatic recess
Cupola
Inferior vena cava
Left pulmonary vein
Pulmonary ligament
21. Which of the following layers provides a natural cleavage
plane for surgical separation of the costal pleura from the thoracic
wall?
Deep fascia
Endothoracic fascia
Parietal pleura

Visceral pleura
Transversus thoracis muscle fascia
22. The lowest extent of the pleural cavity, into which lung tissue
does not extend, is known as the:
costodiaphragmatic recess
costomediastinal recess
cupola
inferior mediastinum
pulmonary ligament
23. The sternal angle is a landmark for locating the level of the:
Costal margin
Jugular notch
Second costal cartilage
Sternoclavicular joint
Xiphoid process
24. 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
Can't be determined



1.
The correct answer is: sternal angle
The sternal angle is the point where the costal cartilage attaches the
second rib to the sternum. This is an important anatomical landmark to
remember--it is used to find the valves when auscultating the heart! The
costal margins are formed by the medial borders of the 7th through 10th
costal cartilages. They are easily palpable and extend inferolaterally
from the xiphisternal joint. The sternal notch/jugular notch is the notch
located at the superior border of the manubrium, between the sternal
ends of the clavicles. The sternoclavicular joints are simply the joints
connecting the sternum with the clavicles. Finally, the xiphoid process is
the bone that makes the inferior part of the sternum.

2. The correct answer is: intercostal nerves
Intercostal nerves are the ventral primary rami of spinal nerves T1-T11.
They provide motor innervation to intercostal muscles, abdominal wall
muscles (via T7-T11) and muscles of the forearm and hand (via T1).
They provide sensory innervation to the skin of the chest and abdomen
on the anterior and lateral sides. The other nerves listed do not innervate
the chest wall. Dorsal primary rami provide motor innervation to true
back muscles and sensory innervation to the skin on the back. The
lateral pectoral nerve provides motor innervation to pectoralis major
only, while the medial pectoral nerve provides motor innervation to
pectoralis major and minor. The thoracodorsal nerve provides motor
innervation to latissimus dorsi.

3. 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.

4. 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.

5. The correct answer is: costodiaphragmatic recess
The costodiaphragmatic recess is the lowest extent of the pleural cavity
or sac. It is the part of the pleural sac where the costal pleura changes
into the diaphragmatic pleura. Because this is the most inferior part of
the pleural sac, fluid in the pleural sac will fall to this region when a
patient sits up. The costodiaphragmatic recess is also the area into
which a needle is inserted for thoracocentesis, and it is found at different
levels at different areas of the thorax. At the mid-clavicular line, the
costodiaphragmatic recess is between ribs 6 and 8; at the midaxillary
line it is between 8 and 10; and at the paravertebral line it is between 10
and 12.
The costomediastinal recess is found where the costal pleura becomes
the mediastinal pleura. The cupola is the part of the pleural cavity which
extends above the level of the 1st rib into the root of the neck. The hilar
reflection is the point at the root of the lung where the mediastinal pleura
is reflected and becomes continuous with the visceral pleura. Finally, the
middle mediastinum is the space in the mediastinum which contains the
heart, pericardium, great vessels, and bronchi (at the roots of the lung).


6. 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 a large vein on the heart which drains into the right
atrium. The coronary sulcus is a groove on the heart which separates
the atria from the ventricles. The costomediastinal recess is an area in
the pleural sac where the costal pleura changes to the mediastinal
pleura.

7. The correct answer is: above the margin of a rib
The VAN triad of an intercostal vein, artery, and nerve run along the
bottom of a rib, in the costal groove. To avoid hitting any of these
important structures, it is important to remember to always place a tube
or needle above the margin of a rib (or,if you prefer to think about it this
way, at the bottom of an intercostal space).
.

8. 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 costomediastinal 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 on the root of the
lung, where visceral pleura on the lung becomes continuous with the
mediastinal pleura.

9. The correct answer is: sternoclavicular joint
The first rib articulates with the sternum directly below the
sternoclavicular joint. The nipple is found in the fourth intercostal space,
between the 4th and 5th ribs. The sternal angle is connected to the
costal cartilage of rib 2. Finally, the xiphoid process is located just below
the point where the costal cartilage of rib 7 articulates with the sternum.
The root of the lung consists of the main bronchus, pulmonary and
bronchial vessels, lymphatic vessels, and nerves entering and leaving
the lung.

10. The correct answer is: cupola
The cupola is the cervical parietal pleura which extends slightly above
the level of the 1st rib into the root of the neck. The costodiaphragmatic
recess is the part of the pleural sac where the costal pleura changes into
the diaphragmatic pleura. It is the lowest extent of the pleural sac. The
costomediastinal recess is found where the costal pleura becomes the
mediastinal pleura. Endothoracic fascia is connective tissue between the
inner chest wall and costal parietal pleura. The costocervical recess is a
made up term.


11. The correct answer is: left vagus
The left vagus nerve lies against the lateral surface of the arch of the
aorta. The left recurrent laryngeal nerve is an especially important nerve
from the vagus which loops around the aortic arch. This nerve
innervates the muscles of the left larynx. If it is damaged, a patient may
experience hoarseness after surgery. Care must be taken to preserve
this nerve, especially during thyroid surgery.
The left and right phrenic nerves, which innervate the diaphragm, are
lateral to the vagus nerves and are not looping near the aortic arch. The
left and right sympathetic trunks lie on the posterior chest wall and are
not involved with the aortic arch.

12. The correct answer is: Transverse pericardial sinus
The transverse pericardial sinus is an area of the pericardial cavity
located behind the aorta and pulmonary trunk and anterior to the
superior vena cava. When entering the transverse pericardial sinus, a
surgeon will insert an index finger between the aorta and pulmonary
trunk on the ventral side and the superior vena cava on the dorsal side.
The oblique pericardial sinus is an area of the pericardial cavity located
behind the left atrium of the heart. If a surgeon places fingers under the
apex of the heart, then moves the fingers until they are stopped by a
pericardial reflection, then the fingers are in the oblique sinus. You
should understand what these two sinuses are and how they can be
entered!
The cardiac notch is a structure on the left lung which separates the
lingula below from the upper portion of the superior lobe of left lung. The
coronary sinus is a venous sinus on the posterior surface of the heart
which receives blood from the smaller veins which drain the heart. The
coronary sulcus is a groove on the heart, between the atria and

ventricles. The coronary sinus, circumflex artery, and right coronary
artery lie in the coronary sulcus.

13. The correct answer is: Costodiaphragmatic recess
The costodiaphragmatic recess is the lowest extent of the pleural cavity
or sac. It is the part of the pleural sac where the costal pleura changes
into the diaphragmatic pleura. It is also the area into which a needle is
inserted for thoracocentesis, and it is found at different levels at different
areas of the thorax. At the mid clavicular line, the costodiaphragmatic
recess is between ribs 6 and 8; at the midaxillary line it is between 8 and
10; and at the paravertebral line it is between 10 and 12. So, inserting
the needle just above the 9th rib at the midaxillary line should put you in
the costodiaphragmatic recess.
The cardiac notch is a structure on the left lung which separates the
lingula below from the upper portion of the superior lobe of left lung. The
costomediastinal recess is found where the costal pleura becomes the
mediastinal pleura. The cupola is the part of the pleural cavity which
extends above the level of the 1st rib into the root of the neck. The
oblique pericardial sinus is an area of the pericardial cavity located
behind the left atrium of the heart.

14. The correct answer is: Pulmonary trunk and aorta
The transverse pericardial sinus is an area of the pericardial cavity
located behind the aorta and pulmonary trunk and anterior to the
superior vena cava. So, the two large vessels lying ventral to his finger
are the pulmonary trunk and aorta; the large vessel lying dorsal to his
finger is the superior vena cava.


15. The correct answer is: Costodiaphragmatic recess
The costodiaphragmatic recess is the lowest extent of the pleural cavity
or sac. It is the part of the pleural sac where the costal pleura changes
into the diaphragmatic pleura. It is also the area into which a needle is
inserted for thoracocentesis, and it is found at different levels at different
areas of the thorax. At the mid clavicular line, the costodiaphragmatic
recess is between ribs 6 and 8; at the midaxillary line it is between 8 and
10; and at the paravertebral line it is between 10 and 12. So, inserting
the needle just above the 9th rib at the midaxillary line should put the
resident's needle in the costodiaphragmatic recess. Make sure you know
where to enter the costodiaphragmatic recess at the midclavicular line,
the mid axillary line, and the paravertebral line!
The costomediastinal recess is found where the costal pleura becomes
the mediastinal pleura. The cupola is the part of the pleural cavity which
extends above the level of the 1st rib into the root of the neck. The hilar
reflection is the point at the root of the lung where the mediastinal pleura
is reflected and becomes continuous with the visceral pleura. The
pulmonary ligament is a fold of pleura located below the root of the lung,
where the visceral pleura and the mediastinal parietal pleura are
continuous with each other.

16. The correct answer is: Costomediastinal recess
The costomediastinal recess is an area right next to the cardiac notch,
which is an indentation in the superior lobe of the left lung. If you take a
very deep breath, the lingula of the left lung, which is formed by the
cardiac notch, will tend to expand into the costomediastinal recess.
The costodiaphragmatic recess is the lowest extent of the pleural cavity
or sac. It is the part of the pleural sac where the costal pleura changes
into the diaphragmatic pleura. The cupola is the part of the pleural cavity
which extends above the level of the 1st rib into the root of the neck. The
hilum is found on the medial surface of the lung--it is the point at which

the structures forming the root enter and leave the lung. The pulmonary
ligament is a fold of pleura located below the root of the lung, where the
visceral pleura and the mediastinal parietal pleura are continuous with
each other.

17. The correct answer is: Transverse process of vertebra T7
The tubercle of a rib is a projection located posteroinferior and lateral to
the neck of the rib. It articulates with the transverse process of the
vertebra of the same number. So, the tubercle of rib 7 should articulate
with the transverse process of the T7 vertebra. The head of the rib is the
part of the rib that articulates with the demifacets of two adjacent
vertebral bodies. So, the head of rib 7 should articulate with the 6th
vertebra superiorly and the 7th vertebra inferiorly.

18. The correct answer is: Left recurrent laryngeal nerve
The left recurrent laryngeal nerve is a branch of the vagus that wraps
around the aorta, posterior to the ductus arteriosus or ligamentum
arteriosum. It then travels superiorly to innervate muscles of the larynx.
It's important to protect this nerve during surgery! If the left recurrent
laryngeal nerve becomes paralyzed, a patient might experience a
hoarse voice or even have difficulty breathing due to a laryngeal spasm.
You should make sure that you understand what this nerve does, what
types of procedures might injure this nerve, and the effects of a
damaged left recurrent laryngeal!
The accessory hemiazygos vein is a vein on the left side of the body. It
drains the posterolateral chest wall and empties blood into the azygos
vein. The left internal thoracic artery is a branch of the left subclavian
artery that supplies blood to the anterior thoracic wall. The left phrenic
nerve runs lateral to the vagus nerve and its branches in the thorax; it is
not close enough to be damaged by the surgery. The thoracic duct is

deep in the chest - it travels between the azygos vein and the aorta,
posterior to the esophagus.

19. The correct answer is: cupola
The cupola is the part of the plural cavity which extends above the level
of the 1st rib into the root of the neck. So, if a patient was stabbed above
the clavicle, it would be very likely that the cupola was damaged. The
costal pleura is the layer of parietal pleura that covers the costal surface.
The hilar reflection is the point where the visceral pleura of the lung
reflects to become continuous with the parietal pleura. The mediastinal
pleura is the parietal pleura on the mediastinal surface, found medial to
the lung. Finally, the pulmonary ligament is a double layer of pleura
extending from the inferior end of the hilar reflection downward to the
diaphragm below.

20. The correct answer is: pulmonary ligament
The pulmonary ligament is a double layer of pleura extending from the
inferior end of the hilar reflection downward to the diaphragm. So, it is a
structure that would block you from moving your finger posteriorly at the
root of a lung. The costodiaphragmatic recess is the space at the inferior
border of the lung where the costal pleura touches the diaphragmatic
pleura. The cupola is the part of the pleura that extends superiorly above
the first rib--it's not associated with the root of the lung in any way. The
inferior vena cava is found in the mediastinum and would not be near the
root of the lung. The left pulmonary veins are part of the root of the lung
and would not block someone from reaching behind the lung.

21. The correct answer is: endothoracic fascia

The endothoracic fascia is the connective tissue between the inner
aspect of chest wall and the costal parietal pleura. By clearing the
endothoracic fascia, it is easy to separate the costal pleura from the
thoracic wall. Deep fascia is a fascial layer that invests a muscle or
muscle group - it is not present around the lungs. The parietal pleura is
made up of the cupula or cervical pleura, costal pleura, diaphragmatic
pleura, and mediastinal pleura. It lines the inner surfaces of the walls of
the pleural cavity. The visceral pleura is the serous membrane that
covers the lungs. Finally, the transversus thoracis muscle fascia is only
associated with the transversus thoracis - it would not provide a natural
cleavage plane for separating the costal pleura from the thoracic wall

22. The correct answer is: costodiaphragmatic recess
The costodiaphragmatic recess is the area inferior to the lung where the
costal and diaphragmatic pleura are continuous. This is the lowest
extent of the pleural cavity. The costomediastinal recess is a small
anterior recess where the costal and mediastinal pleura are continuous.
The cupola is the pleural space that extends above the first rib. The
inferior mediastinum is a term sometimes used to refer to the anterior,
middle, and posterior subdivisons of the mediastinum all together. The
pulmonary ligament is a fold of pleura located beneath the root of the
lung.

23. The correct answer is: Second costal cartilage
The sternal angle is a very important anatomical landmark which is used
when placing the stethoscope and listening for heart sounds. The sternal
angle is the location of the attachment of the costal cartilage of the
second rib to the sternum. So, once you locate the sternal angle on a
patient, you know the location of the second rib, and you can use that
landmark to find the right spots to auscultate each valve of the heart.
Also remember that a horizontal plane through the sternal angle passes

through the T4/T5 intervertebral disc and marks the inferior boundary of
the superior mediastinum.

24. 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!