Deck 3: The Chest Wall, Chest Cavity, Lungs, and Pleural Cavities

Question 1

A 31-year-old soldier received a shrapnel wound in the neck during the Persian Gulf War. Recently, during a physical examination, it was noticed that when he blew his nose or sneezed, the skin above the right clavicle bulged upward.

-The upward bulging of the skin could be explained by

A) injury to the cervical pleura.
B) damage to the suprapleural membrane.
C) damage to the deep fascia in the root of the neck.
D) ununited fracture of the first rib.

Answer 1

damage to the suprapleural membrane.

Question 2

A 52-year-old woman was admitted to the hospital with a diagnosis of right-sided pleurisy with pneumonia. It was decided to remove a sample of pleural fluid from her pleural cavity. The resident inserted the needle close to the lower border of the eighth rib in the anterior axillary line. The next morning he was surprised to hear that the patient had complained of altered skin sensation extending from the point where the needle was inserted downward and forward to the midline of the abdominal wall above the umbilicus.

-The altered skin sensation in this patient after the needle thoracostomy could be explained by which of the following?

A) The needle was inserted too low down in the intercostal space.
B) The needle was inserted too close to the lower border of the eighth rib and damaged the eighth intercostal nerve.
C) The needle had impaled the eighth rib.
D) The needle had penetrated too deeply and pierced the lung.

Answer 2

The needle was inserted too close to the lower border of the eighth rib and damaged the eighth intercostal nerve.

Question 3

A 68-year-old man complained of a swelling in the skin on the back of the chest. He had noticed it for the last 3 years and was concerned because it was rapidly enlarging. On examination, a hard lump was found in the skin in the right scapula line opposite the seventh thoracic vertebra. A biopsy revealed that the lump was malignant.

-Because of the rapid increase in the size of the tumor, the following lymph nodes were examined for metastases:

A) Superficial inguinal nodes
B) Anterior axillary nodes
C) Posterior axillary nodes
D) External iliac nodes
E) Deep cervical nodes

Answer 3

Posterior axillary nodes

Question 4

A 65-year-old man and a 10-year-old boy were involved in a severe automobile accident. In both patients the thorax had been badly crushed. Radiographic examination revealed that the man had five fractured ribs but the boy had no fractures.

-What is the most likely explanation for this difference in medical findings?

A) The patients were in different seats in the vehicle.
B) The boy was wearing his seat belt and the man was not.
C) The chest wall of a child is very elastic, and fractures of ribs in children are rare.
D) The man anticipated the impact and tensed his muscles, including those of the shoulder girdle and abdomen.

Question 5

On examination of a posteroanterior chest radiograph of an 18-year-old woman, it was seen that the left dome of the diaphragm was higher than the right dome and reached to the upper border of the fourth rib.

-The position of the left dome of the diaphragm could be explained by the following conditions except which?

A) The left lung could be collapsed.
B) There is a collection of blood under the diaphragm on the left side.
C) There is an amoebic abscess in the left lobe of the liver.
D) The left dome of the diaphragm is normally higher than the right dome.
E) There is a peritoneal abscess beneath the diaphragm on the left side.

Question 6

A 43-year-old man was involved in a violent quarrel with his wife over another woman. In a fit of rage, the wife picked up a carving knife and lunged forward at her husband, striking his anterior neck over the left clavicle. The husband collapsed on the kitchen floor, bleeding profusely from the wound. The distraught wife called for an ambulance.

-On examination in the emergency department of the hospital the following conditions were found except which?

A) A wound was seen about 1 in. $(2.5 \mathrm{~cm})$ wide over the left clavicle.
B) Auscultation revealed diminished breath sounds over the left hemithorax.
C) The trachea was deflected to the left.
D) The left upper limb was lying stationary on the table, and active movement of the small muscles of the left hand was absent.
E) The patient was insensitive to pin prick along the lateral side of the left arm, forearm, and hand.

Question 7

A 72-year-old man complaining of burning pain on the right side of his chest was seen by his physician. On examination the patient indicated that the pain passed forward over the right sixth intercostal space from the posterior axillary line forward as far as the midline over the sternum. The physician noted that there were several watery blebs on the skin in the painful area.

-The following statements are correct except which?

A) This patient has herpes zoster.
B) A virus descends along the cutaneous nerves, causing dermatomal pain and the eruption of vesicles.
C) The sixth right intercostal nerve was involved.
D) The condition was confined to the anterior cutaneous branch of the sixth intercostal nerve.

Question 8

An 18-year-old woman was thrown from a horse while attempting to jump a fence. She landed heavily on the ground, striking the lower part of her chest on the left side. On examination in the emergency department she was conscious but breathless. The lower left side of her chest was badly bruised, and the ninth and tenth ribs were extremely tender to touch. She had severe tachycardia, and her systolic blood pressure was low.

-The following statements are possibly correct except which?

A) There was evidence of tenderness and muscle spasm in the left upper quadrant of the anterior abdominal wall.
B) A posteroanterior radiograph of the chest revealed fractures of the left ninth and tenth ribs near their angles.
C) The blunt trauma to the ribs had resulted in a tear of the underlying spleen.
D) The presence of blood in the peritoneal cavity had irritated the parietal peritoneum, producing reflex spasm of the upper abdominal muscles.
E) The muscles of the anterior abdominal wall are not supplied by thoracic spinal nerves.

Question 9

A 55-year-old man states that he has noticed an alteration in his voice. He has lost $40 \mathrm{lb}(18 \mathrm{~kg})$ and has a persistent cough with blood-stained sputum. He smokes 50 cigarettes a day. On examination, the left vocal fold is immobile and lies in the adducted position. A posteroanterior chest radiograph reveals a large mass in the upper lobe of the left lung with an increase in width of the mediastinal shadow on the left side.

-The symptoms and signs displayed by this patient can be explained by the following statements except which?

A) This patient has advanced carcinoma of the bronchus in the upper lobe of the left lung, which was seen as a mass on the chest radiograph.
B) The carcinoma had metastasized to the bronchomediastinal lymph nodes, causing their enlargement and producing a widening of the mediastinal shadow seen on the chest radiograph.
C) The enlarged lymph nodes had pressed on the left recurrent laryngeal nerve.
D) Partial injury to the recurrent laryngeal nerve resulted in paralysis of the abductor muscles of the vocal cords, leaving the adductor muscles unopposed.
E) The enlarged lymph nodes pressed on the left recurrent nerve as it ascended to the neck anterior to the arch of the aorta.

Question 10

A 35-year-old woman had difficulty breathing and sleeping at night. She says she falls asleep only to wake up with a choking sensation. She finds that she has to sleep propped up in bed on pillows with her neck flexed to the right.

-The following statements concerning this case are correct except which?

A) Veins in the skin at the root of the neck are congested.
B) The U-shaped cartilaginous rings in the wall of the trachea prevent it from being kinked or compressed.
C) The left lobe of the thyroid gland is larger than the right lobe.
D) On falling asleep, the patient tends to flex her neck laterally over the enlarged left thyroid lobe.
E) The enlarged thyroid gland extends down the neck into the superior mediastinum.
F) The brachiocephalic veins in the superior mediastinum were partially obstructed by the enlarged thyroid gland.

Question 11

A 15-year-old boy was rescued from a lake after falling through thin ice. The next day, he developed a severe cold, and 3 days later his general condition deteriorated. He became febrile and started to cough up bloodstained sputum. At first, he had no chest pain, but later, when he coughed, he experienced severe pain over the right fifth intercostal space in the midclavicular line.

-The following statements would explain the patient's signs and symptoms except which?

A) The patient had developed lobar pneumonia and pleurisy in the right lung.
B) Disease of the lung does not cause pain until the parietal pleura is involved.
C) The pneumonia was located in the right middle lobe.
D) The visceral pleura is innervated by autonomic nerves that contain pain fibers.
E) Pain associated with the pleurisy was accentuated when movement of the visceral and parietal pleurae occurred, for example, on deep inspiration or coughing.

Question 12

A 2-year-old boy was playing with his toy car when his baby-sitter noticed that a small metal nut was missing from the car. Two days later the child developed a cough and became febrile.

-This child's illness could be explained by the following statements except which?

A) The child had inhaled the nut.
B) The metal nut could easily be seen on posteroanterior and right oblique radiographs.
C) The left principal bronchus is the more vertical and wider of the two principal bronchi, and inhaled foreign bodies tend to become lodged in it.
D) The nut was successfully removed through a bronchoscope.
E) Children who are teething tend to suck on hard toys.

Question 13

A 23-year-old woman was examined in the emergency department because of the sudden onset of respiratory distress. The physician was listening to breath sounds over the right hemithorax and was concerned when no sounds were heard on the front of the chest at the level of the tenth rib in the midclavicular line.

-The following comments concerning this patient are correct except which?

A) In a healthy individual, the lower border of the right lung in the midclavicular line in the midrespiratory position is at the level of the sixth rib.
B) The parietal pleura in the midclavicular line crosses the tenth rib.
C) The costodiaphragmatic recess is situated between the lower border of the lung and the parietal pleura.
D) The lung on extreme inspiration could descend in the costodiaphragmatic recess only as far as the eighth rib.
E) No breath sounds were heard because the stethoscope was located over the liver

Question 14

A 36-year-old woman with a known history of emphysema (dilatation of alveoli and destruction of alveolar walls with a tendency to form cystic spaces) suddenly experiences a severe pain in the left side of her chest, is breathless, and is obviously in a state of shock.

-Examination of this patient reveals the following findings except which?

A) The trachea is displaced to the right in the suprasternal notch.
B) The apex beat of the heart can be felt in the fifth left intercostal space just lateral to the sternum.
C) The right lung is collapsed.
D) The air pressure in the left pleural cavity is at atmospheric pressure.
E) The air has entered the left pleural cavity as the result of rupture of one of the emphysematous cysts of the left lung (left-sided pneumothorax).
F) The elastic recoil of the lung tissue caused the lung to collapse.