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Basic Sciences: Questions
19
D. Transection of the afferent fibres of the vagus and glossopharyngeal nerves results in
prolonged inspiration and shortened expiration
E. The apneustic and pneumotaxic cente of the pons are essential for maintenance of the
basic rhythm of respiration
1.68 A poly-trauma victim with multiple rib fractures and flail chest was ventilated
in the ICU. In this patient if alveolar ventilation is halved (and if CO
2
production
remains unchanged), then
A. alveolar CO
2
pressure (PACO
2
) will be halved
B. alveolar O
2
pressure (PAO
2
) will double
C. arterial O
2
pressure (PaO
2
) will double
D. arterial CO
2
pressure (PaCO
2
) will double
E. arterial O
2
pressure (PaO
2
) will not change
1.69 A 42-year-old patient on arrival in ICU following mitral valve repair is given
100% O
2
to breathe. Following this his arterial blood gases are determined and a PaO
2
of 125 mm Hg is measured. This result is associated with:
A. anatomic right-to-left shunting
B. diffusion abnormality
C. profound hypoventilation
D. the normal response
E. ventilation/perfusion inequality
1.70 A 38-year-old man with low arterial oxygen saturation is evaluated for
anatomic and physiologic lung dead space. The anatomic dead space in this patient with
a tidal volume of 500 mL is 125 mL when determined by plotting nitrogen concentration
versus expired volume after a single inspiration of 100% O
2
(Fowler’s method). If the
patient’s lungs are healthy and the PaCO
2
is 40 mm Hg, the mixed expired CO
2
tension
(PECO
2
) should be about
A. 0 mmHg
B. 10 mmHg
C. 20 mmHg
D. 30 mmHg
E. 40 mmHg
1.71 A 65-year-old man with progressively increasing shortness of breath and past
history of work-related exposure to asbestosis comes for evaluation of his lung function.
Which of the following variables must be known in order to calculate inspiratory
reserve volume in this patient?
A. tidal volume and expiratory reserve volume
B. tidal volume and residual volume
C. tidal volume, vital capacity, and expiratory reserve volume
D. tidal volume, vital capacity, and residual volume
E. tidal volume and vital capacity
Shahzad G. Raja
20
1.72 A 56-year-old man complains of increasing dyspnoea. He is 2-pack a day
cigarette smoker for past 30 years. X-ray chest shows widening of intercostal spaces
with more blackening bilaterally. Which one of the following abnormalities is most
likely to be seen on pulmonary function testing in this emphysematous patient?
A. decreased functional residual capacity
B. decreased residual volume
C. increased FEV
1
/FVC
D. increased total lung capacity
E. increased vital capacity
1.73 A 45-year-old man underwent trans-hiatal oesophagectomy for oesophageal
carcinoma. On fourth postoperative day he developed chylothorax. The chylothorax was
attributed to iatrogenic injury to the thoracic duct. The thoracic duct
A. is the common trunk of all the lymphatic vessels on the right side of the head, neck,
and thorax
B. varies in length from 38 to 45 cm
C. extends from the first sacral vertebra to the root of the neck
D. enters the thorax through the vena caval hiatus of the thoracoabdominal diaphragm
E. has no valves to ensure free flow of chyle
1.74 While taking an SHO through his first median sternotomy, the consultant
asked the SHO to identify the second costal cartilage on the chest of the patient. Which
of the following structures will be palpated by the SHO to identify the second costal
cartilage?
A. costal margin
B. sternal notch
C. sternal angle
D. sternoclavicular joint
E. xiphoid process
1.75 A 35-year-old man was received in emergency department following stab
wound to the left chest. Clinical examination suggested a left-sided haemothorax. Chest
x-ray confirmed the presence of blood in the left pleural space. In the erect posture the
fluid would tend to accumulate in which part of the pleural space?
A. costodiaphragmatic recess
B. costomediastinal recess
C. cupola
D. hilar reflection
E. middle mediastinum
1.76 An SHO is about to perform his first ever aspiration of fluid from the pleural
space of a 62-year-old patient with left-sided pleural effusion. The registrar supervising
him asks him to identify the correct order of structures, from superficial to deep the
needle must pass before it enters the pleural cavity. The correct response is
A. External intercostals — Innermost intercostals — Internal intercostals — Parietal
pleura
Basic Sciences: Questions
21
B. External intercostals — Internal intercostals — Parietal pleura — Innermost
intercostals
C. Parietal pleura — Innermost intercostals — Internal intercostals — External
intercostals
D. External intercostals — Internal intercostals — Innermost intercostals — Parietal
pleura
E. External intercostals — Internal intercostals — Innermost intercostals — Visceral
pleura
1.77 A 38-year-old male presented with a lump on his back. While removing this
lump, the thoracodorsal nerve (C6-C8) is accidentally injured. What muscle is most
likely affected?
A. Serratus posterior inferior muscle
B. Serratus anterior muscle
C. Levator scapulae muscle
D. Longissimus muscle
E. Latissimus dorsi muscle
1.78 A 68-year-old man complained of sudden onset of shortness of breath on
postoperative day 7 following coronary artery bypass grafting. He underwent
pulmonary angiography with a suspected episode of pulmonary embolism. The
pulmonary angiogram showed that the blood clot occluded the apical segmental
pulmonary artery that supplies the superior lobe of left lung. The blood clot travelled to
this segmental pulmonary artery from a leg vein. Track the appropriate course of the
blood clot to the obstructed artery.
A. Inferior vena cava — right atrium — mitral valve — right ventricle — pulmonary
trunk — left pulmonary artery — left superior lobar artery — left apical segmental artery
B. Inferior vena cava — left atrium — mitral valve — left ventricle — pulmonary trunk
— left pulmonary artery — left superior lobar artery — left apical segmental artery
C. Inferior vena cava — right atrium — tricuspid valve — right ventricle — pulmonary
trunk — left pulmonary artery — left bronchial artery — left apical segmental artery.
D. Inferior vena cava — right atrium — tricuspid valve — right ventricle — pulmonary
trunk — left pulmonary artery — left superior lobar artery — left apical segmental artery
E. Coronary sinus — right atrium — tricuspid valve — right ventricle — pulmonary
trunk — left pulmonary artery — left superior lobar artery — left apical segmental
artery
1.79 Which of the following statements regarding the venous drainage of the heart is
CORRECT?
A. The coronary sinus drains into the left atrium
B. The anterior cardiac veins begin over the anterior surface of the left ventricle, cross
over the atrioventricular groove (coronary groove), and directly drain into the left atrium
C. The great cardiac vein is the largest tributary of the coronary sinus and this vein
starts at the apex of the heart and ascends with the anterior ventricular branch of the left
coronary artery
Shahzad G. Raja
22
D. The middle and small cardiac veins drain most of the areas supplied by the left
coronary artery
E. The coronary sinus drains into the great cardiac vein
1.80 A patient presents with a clinically significant atrial septal defect (ASD). The
ASD is most likely due to incomplete closure of the following structure:
A. Foramen ovale
B. Ligamentum arteriosum
C. Ductus arteriosus
D. Sinus venarum
E. Coronary Sinus
1.81 A patient presents with a right bundle branch block due to blockage in the
atrioventricular (AV) nodal artery. Part of the right bundle branch of the AV bundle is
carried by which structure?
A. Pectinate muscles
B. Anterior papillary muscle of the left ventricle
C. Moderator band (septomarginal trabecula)
D. Crista terminalis
E. Chordae tendineae
1.82 A surgeon following every posterolateral thoracotomy likes to infiltrate local
anaesthetic both above and below the incision in order to block the nerves supplying the
thoracic wall. The thoracic wall is innervated by the:
A. Dorsal primary rami
B. Intercostal nerves
C. Lateral pectoral nerves
D. Medial pectoral nerves
E. Thoracodorsal nerves
1.83 An SHO has been asked to aspirate some pleural fluid for culture sensitivity
from the left pleural space of a 65-year-old male who has post-pneumonic effusion. If
the SHO wants to aspirate the fluid with the patient sitting up in bed, where would the
fluid tend to accumulate?
A. costodiaphragmatic recess
B. costomediastinal recess
C. cupola
D. hilar reflection
E. middle mediastinum
1.84 A 36-year-old bomb blast victim was found to have multiple small metal
fragments in his thoracic cavity. He also had pericardial effusion suggestive of a tear in
the pericardium. He underwent emergency thoracotomy which revealed that the
pericardium was torn inferiorly. The surgeon began to explore for fragments in the
pericardial sac. Slipping his hand under the heart apex, he slid his fingers upward and
Basic Sciences: Questions
23
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. His fingertips were then in the
A. coronary sinus
B. coronary sulcus
C. costomediastinal recess
D. oblique sinus
E. transverse sinus
1.85 A 22-year-old victim of anterior chest stabbing received a stab in a structure
which is in close proximity to where the first rib articulates with the sternum. The
structure most likely to be injured is the
A. Nipple
B. Root of the lung
C. Sternal angle
D. Sternoclavicular joint
E. Xiphoid process
1.86 A victim of anterior chest stabbing was brought to A& E with impending
cardiac tamponade. There was a single puncture wound in anterior chest 2 cm lateral to
the left sternal border. An emergency thoracotomy revealed clots in pericardium with a
puncture wound in the right ventricle. In order to evacuate clots from the pericardial
cavity the surgeon slipped his hand behind the heart at its apex. A hand slipped behind
the heart can be extended upwards until stopped by a line of pericardial reflection that
forms the
A. Cardiac notch
B. Costomediastinal recess
C. Hilar reflection
D. Oblique pericardial sinus
E. Transverse pericardial sinus
1.87 A 21-year-old man was stabbed in the right supraclavicular fossa. The knife
punctured the portion of the parietal pleura that extends above the first rib. This
portion of the parietal pleura is called the
A. costodiaphragmatic recess
B. costomediastinal recess
C. costocervical recess
D. cupola
E. endothoracic fascia
1.88 While performing thymectomy to remove a malignant thymoma the surgeon is
careful to avoid damaging an important nerve lying on and partly curving posteriorly
around the arch of the aorta. Which of the following nerves is the surgeon trying to
preserve?
A. left phrenic
B. left sympathetic trunk
C. left vagus
Shahzad G. Raja
24
D. right phrenic
E. right sympathetic trunk
1.89 In a 12-week-old boy with a large subaortic VSD, the congenital cardiac
surgeon decides to perform pulmonary artery banding through a left thoracotomy as
the child is not fit for surgical closure. In order to pass the tape around the pulmonary
artery, the surgeon initially passes his index finger immediately behind the two great
arteries in the pericardial sac to mobilise both the great arteries. The surgeon’s index
finger is inserted into which space?
A. Cardiac notch
B. Coronary sinus
C. Oblique pericardial sinus
D. Coronary sulcus
E. Transverse pericardial sinus
1.90 During pericardiectomy sudden bleeding was noticed due to accidental injury
to a major vascular structure in the pericardium. The surgeon inserted his left index
finger through the transverse pericardial sinus, pulled forward on the two large vessels
lying ventral to his finger and compressed these vessels with his thumb to control
bleeding. Which vessels were these?
A. Pulmonary trunk and brachiocephalic trunk
B. Pulmonary trunk and aorta
C. Pulmonary trunk and superior vena cava
D. Superior vena cava and aorta
E. Superior vena cava and right pulmonary artery
1.91. A 22-year-old patient with a cystic swelling in his left chest underwent a CT-
guided biopsy. The radiologist inserted the biopsy needle into the 9th intercostal space
along the midaxillary line to aspirate the swelling and obtain tissue for histological
diagnosis. The swelling is most likely to be in which space?
A. Cardiac notch
B. Costodiaphragmatic recess
C. Costomediastinal recess
D. Cupola
E. Oblique pericardial sinus
1.92 A 34-year-old woman with history of cough and weight loss for over a month is
noticed to have a rounded opacity in the pleural cavity near the cardiac notch on her
chest x-ray. The opacity is most likely to be present in the:
A. Costodiaphragmatic recess
B. Costomediastinal recess
C. Cupola
D. Hilum
E. Pulmonary ligament
Basic Sciences: Questions
25
1.93 A 25-year-old motorcyclist involved in a road traffic accident fractured a
structure which articulates with the tubercle of the 7th rib. Which of the following
structures is fractured?
A. Body of vertebra T6
B. Body of vertebra T7
C. Body of vertebra T8
D. Transverse process of vertebra T6
E. Transverse process of vertebra T7
1.94 A 28-year-old male suffered a gunshot wound which entered immediately
superior to the upper edge of the left clavicle near its head. He was in extreme pain,
which was interpreted by the trauma 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 to be punctured?
A. costal pleura
B. cupola
C. hilar reflection
D. mediastinal pleura
E. pulmonary ligament
1.95 A specialist registrar is performing his first ductus arteriosus ligation. The
consultant supervising him instructs him to be careful when placing a clamp on the
ductus so as to avoid injury to an important structure immediately dorsal to it. Which of
the following structures is the consultant referring to?
A. Accessory hemiazygos vein
B. Left internal thoracic artery
C. Left phrenic nerve
D. Left recurrent laryngeal nerve
E. Thoracic duct
1.96 During a demonstration on anatomy of the lung the tutor asked one of the
medical students to pass his index finger posteriorly inferior to the root of the left lung
and identify the structure which is blocking the passage of the finger. Which structure
would most likely be responsible for this?
A. Costodiaphragmatic recess
B. Cupola
C. Inferior vena cava
D. Left pulmonary vein
E. Pulmonary ligament
1.97 A patient with a malignant mesothelioma is to undergo pleuropneumonectomy
which involves removal of the entire pleura and lung on the affected side. Which of the
following layers provides a natural cleavage plane for surgical separation of the costal
pleura from the thoracic wall?
A. Deep fascia
B. Endothoracic fascia
Shahzad G. Raja
26
C. Parietal pleura
D. Visceral pleura
E. Transversus thoracis muscle fascia
1.98 A patient following cardiac surgery is noticed to have a small effusion in the
lowest extent of the pleural cavity, into which lung tissue does not extend. This part of
the pleural cavity is known as the:
A. costodiaphragmatic recess
B. costomediastinal recess
C. cupola
D. inferior mediastinum
E. pulmonary ligament
1.99 A medical student was asked by the supervising consultant to identify the
sternal angle. The sternal angle is a landmark for locating the level of the:
A. Costal margin
B. Jugular notch
C. Second costal cartilage
D. Sternoclavicular joint
E. Xiphoid process
1.100 A 28-year-old man was stabbed in the left chest. The tip of the knife entered
the pleural space just above the cardiac notch however the lung was spared as it would
only occupy this space during deep inspiration. Which of the following structures was
pierced by the knife?
A. Anterior mediastinum
B. Costodiaphragmatic recess
C. Costomediastinal recess
D. Cupola
E. Pulmonary ligament
Chapter II
Cardiac Surgery
2.1 A 66-year-old female was diagnosed with heparin-induced thrombocytopenia
(HIT). HIT is
an immune-mediated, potentially life-threatening thrombotic
complication
of heparin therapy that
A. does not occur with the use of low-molecular-weight heparin.
B. occurs approximately 3 to 5 weeks after heparin exposure.
C. occurs in 3 to 5% of individuals
after heparin exposure.
D. resolves within 3 days of heparin discontinuation.
E. should be suspected in any patient who experiences a 20% decrease in platelet count
from baseline.
2.2 A 56-year-old patient with known triple vessel coronary artery and bare metal
stent in the dominant right coronary artery is referred for urgent in-patient coronary
artery bypass grafting due to ongoing chest pain despite maximal medical therapy. He is
on aspirin and clopidogrel. Which of the following statements regarding clopidogrel is
correct?
A. Preoperative clopidogrel usage decreases adverse events after cardiac surgery.
B. Preoperative clopidogrel usage decreases ventilation time after cardiac surgery.
C. Preoperative clopidogrel usage increases hospital length of stay after cardiac surgery.
D. Preoperative clopidogrel usage increases mortality after cardiac surgery.
E. Preoperative clopidogrel usage increases re-exploration rates after cardiac surgery.
2.3 Several trials have been conducted to determine the safety and efficacy of
clopidogrel in patients undergoing cardiological interventions for acute coronary
syndromes. Which of the following statements regarding safety and efficacy of
clopidogrel in these trials is true?
A. Cessation of clopidogrel before coronary artery bypass surgery increases the risk of
myocardial infarction by 10%.
B. Clopidogrel pretreatment significantly reduces the combined risk of death, myocardial
infarction, or urgent target vessel revascularization at 28 days.
C. For patients continuing clopidogrel to within 5 days of coronary artery bypass surgery
there was a non-significant excess in re-exploration.
Shahzad G. Raja
28
D. For patients awaiting intervention the incidence of MI was not significantly influenced
by clopidogrel therapy.
E. There was a trend to more complications prior to surgery whilst awaiting the
intervention in patient who had received clopidogrel.
2.4 Desmopressin has been used as a hemostatic agent in patients
without pre-
existing bleeding disorders undergoing major surgery,
mainly cardiac or spinal
procedures. Which of the following statements regarding desmopressin is correct?
A. It is
a naturally-occurring analogue of vasopressin.
B. It increases de novo synthesis of factor VIII and von Willebrand
factor.
C. It decreases the incidence of perioperative myocardial infarctions.
D. It influences the rate of re-operation for hemostasis.
E. It shortens the bleeding time
in patients with chronic renal failure.
2.5 The BART trial was undertaken to determine whether aprotinin
was superior to
either tranexamic acid or aminocaproic acid
in decreasing massive postoperative
bleeding and other clinically
important consequences.
Which of the following statements
regarding the BART trial is correct?
A. Aprotinin conferred a survival benefit to patients undergoing high-risk surgery.
B. At 30 days, the rate of death from any cause
was highest in the tranexamic acid group.
C. At 30 days, the rate of death from any cause
was similar for aprotinin and
aminocaproic acid.
D. There was a strong negative mortality trend associated with aprotinin.
E. The trial was terminated early because of a clear benefit of aprotinin in reducing
massive postoperative bleeding.
2.6 A 66-year-old female, with insignificant past medical history, was investigated
following a sudden transient ischemic attack. Echocardiography revealed a mobile mass
on the aortic valve. The mass had
a stippled edge with a "shimmer" or "vibration" at
the interface
of the mass with the surrounding blood. Surgical removal of the mass was
undertaken. Histopathology confirmed the mass to be a papillary fibroelastoma. Which
of the following statements regarding papillary fibroelastoma is correct?
A. Papillary fibroelastomas are best visualized with CT scanning.
B. Papillary fibroelastomas are notorious for recurrence.
C. Papillary fibroelastoma is a collection of vascular fronds
of dense connective tissue
lined by endothelium.
D. Papillary fibroelastoma is the most common benign primary cardiac
neoplasm.
E. Papillary fibroelastomas predominantly involve left-sided heart valves.
2.7 A 50-year-old male truck driver presented to Emergency Department with
increasing shortness of breath. At physical examination,
he was found to be in
respiratory distress and had a pulsus
paradoxus, a finding suggestive of cardiac
tamponade. A total
of 900 mL of bloody pericardial fluid was aspirated under
echocardiographic guidance.
Echocardiography showed a homogeneous mass that
involved
the free wall of the right atrium. The patient then underwent
computed
tomography (CT), magnetic resonance (MR) imaging, and
angiography. Findings from