Your 17 year old neighbor comes over on a Saturday morning complaining of rib pain after last night's football game. If chest x-rays indicate a right rib fracture, where is the rib most likely to be broken? What is your differential diagnosis if chest x-rays reveal nothing and he has a bump right around his sternum?
Just anterior to the angle of the rib. This is the weakest part. If there is a bump around his sternum he may have dislocated a rib from the interchondral (sternochondral) joint or separated the rib from the costal cartilage.
A 24 year old female comes to the ER after a car accident complaining of chest pain and dyspnea. After you expose the chest, you notice a segment of her chest that moves inward on inspiration and outward on expiration. What is causing this paradoxical movement of her chest while breathing?
Flail chest. At least 3 ribs have been broken so that the segment goes inward when the chest cavity has negative pressure (inspiration) and outward when the cavity has positive pressure (expiration).
A 68 year old male with severe COPD has developed cancer in his left lung. Imaging reveals cancerous spread in the lingular lobe of the left lung which must be cut out. How do you gain access to the lung through the thoracic wall?
Thoracotomy. You make an H-shaped incision in the periosteum of a rib, pull out the periosteum and go through the periosteal sheath into the thoracic cavity to get to the lung. This is done to preserve intercostal muscle and allow for regrowth of the rib.
A 77 year old male came to the ER with chest pain. Thoracic radiographs only reveal calcification of the costal cartilage on ribs 5-10. Is this a normal finding?
Yes. Costal cartilage calcifies with age.
While doing rounds you visit a bedridden patient. She has a history of metastatic breast cancer and has recently experienced new bone pain. If you can't flip her over to do a bone marrow biopsy on her iliac crest, where could you do it?
Two patients come to see you in the same day, one with an outward protruding chest and another with an inward protruding chest. Malformations in the development of what bone cause these deformities?
Pectus excavatum and pectus carinatum are both caused by malformations in fusion of the two longitudinal portions of the sternum.
One of your patients has been battling lung cancer. When doing your physical exam, you note that when he inhales the right side of his diaphragm elevates and when he exhales the right side depresses. He also complains that his voice is hoarse. What is causing these symptoms?
Lung cancer is impeding on the recurrent laryngeal nerve (hoarseness) and the phrenic nerve (diaphragm).
You are performing a lymph node biopsy on a patient with metastatic liver cancer. The lymph node in question sits right along the thoracic wall. Where can you make an incision to get the lymph node without incurring risk of a lung infection?
Just enough into the thorax so you are past the thoracic wall but before the parietal pleura of the lungs.
A 22 year old specialist receives a gunshot wound to the chest. You determine that he has a sucking chest wound and need to place a chest tube. Because you're a nice doctor, you decide to anesthetize the area prior to making an incision for the chest tube. Where do you inject the needle when doing the intercostal nerve block? Where do you place the chest tube?
On the lateral side of the rib cage, placing the needle between the external and internal intercostal muscles where the nerve resides. You place the chest tube in the 5th or 6th intercostal space in the mid-axillary line.
You see a patient who received a gunshot wound to the neck. After making sure his airway is clear, you notice that he is still having trouble breathing. Further examination reveals right tracheal deviation and decreased heart sounds. Where did this bullet likely penetrate through?
The right cervical pleura causing a pneumothorax.
A 45 year old male has been waiting a decade for his kidney replacement. He finally gets it replaced, but after the surgery complains of severe shortness of breath. Physical examination reveals decreased breath sounds. What surgical mistaken is causing his symptoms?
The parietal pleura of the lung is exposed just below the costovertebral angle of the 12th rib. This is also where you cut when trying to get to a kidney, resulting in risk of a pneumothorax.
A 30 year old captain is on the table after being shot in the chest. What things do you look for when checking to see if he has a pneumothorax?
Mediastinal shift towards the affected side, decreased breath sounds and on x-ray (elevated diaphragm, smaller spacing between ribs and black area where lung should be).
A 14 year old female presents to the ED with pneumonia and plueral effusion. You need to perform a thoracentesis on her. Where do you place the needle?
Superior to the 10th rib in the mid-axillary line during expiration so as to avoid the collateral branches of the intercostal nerve and the lower lobe of the lung.
A 27 year old female comes to your clinic complaining of sharp stabbing pain in her side when she climbs stairs. She had a history of spontaneous pneumothoraxes, but had a procedure done to make that not happen anymore (pleurodesis). What is causing the pain in her side when she climbs stairs?
Pleurodesis is a procedure that essentially binds the parietal pleura to the visceral pleura of the lung so it won't collapse anymore. Anything that causes friction or rubs on the parietal pleura will cause pain to the highly sensitive area.
While pulling out your wisdom teeth, the dentist drops one down your throat. If you aspirated this tooth, where would it most likely be found?
Right main bronchus
A 50 year old female starts choking on a peanut in the cabin of an airplane. At first she is vigorously coughing, but then the coughing stops and she still feels very short of breath. Where was the peanut at when she was coughing vigorously?
Carina. It is the extremely sensitive bifurcation of the bronchus.
You are working the night shift in the ED one night and see three separate patients with widened mediastinums on their radiographs. One was in a car accident, the other has smoked for decades and the last has pitting edema in his lower extremity. What are the different causes of mediastinal widening in each of these patients?
Car accident = torn great vessel and hemorrhage into mediastinum. Smoker = malignant enlarged lymph nodes from cancer. Edema = congestive heart failure yields an enlarged heart.
A 66 year old male is on the table having coronary bypass surgery. You open the mediastinum and then attempt to divert blood circulation in the pulmonary artery and aorta. Where do you do this?
Transverse pericardial sinus
A 60 year old male comes to see you in the cardiology clinic. He had a heart attack less than one week ago and is feeling chest pain again. CK-MB levels are no longer elevated. Upon auscultation of his heart you hear a friction rub. What is causing his chest pain?
He had a transmural MI which is now inflamed, causing pericarditis which makes the serous pericardium roughened and painful.
A 32 year old female presents to the ED after a car crash. She cannot lay down because she feels like she is drowning when she does. Her neck veins are engorged and heart sounds are decreased. What can you do for her to relieve these symptoms while she awaits definitive care?
Pericardiocentesis. She is suffering from cardiac tamponade and you need to drain the fluid from the pericardium to relieve pressure on the heart You do this by inserting a needle in the left 5th or 6th intercostal near the sternum where the cardiac notch would be. You can also do it by proceeding superioposteriorly from the infrasternal angle.
A mom brings her 1 year old boy to your clinic complaining of chest congestion and sporadic chest pain. When trying to locate his PMI in the left lateral decubitis position, you see a slight pulse on the right side of his chest. What may be causing this boy's heart problems?
Dextrocardia and possible transposition of the great vessels. If he had situs inversus he would be fine, if not he will need surgery to correct blood flow.
A 22 year old female comes to see you for chest pain and fatigue. When you listen to her heart you hear a mid-systolic click and systolic murmur. When you have her do the valsalva maneuver the click gets stronger. What is causing her chest pain and fatigue?
Mid-systolic clicks are characteristic of mitral valve prolapse. Her chest pain and fatigue are consequences of blood back up into the left atrium, causing swelling, and into the lungs, causing pulmonary edema.
A 45 year old male has had recurrent stable angina that is progressing toward unstable angina. You are worried about an MI and decide to perform coronary angiography. When doing this procedure, where do you initially place your catheter? You fill the catheter with dye and watch it fill the coronary arteries. At what point in the cardiac cycle will the dye fill the arteries?
Femoral artery. You must go to the trunk of the aorta to get to the aortic leaflets where coronary arteries exit. Your dye will fill the arteries during diastole. This is when the aortic valve closes and pressure builds up enough to send blood into the coronary arteries.
Where are the three most common places you see coronary artery occlusion?
1) Anterior interventricular branch (40-50%) 2) RCA (30-40%) 3) LCX (15-20%)
A 30 year old male comes to see you complaining of chest pain when he exercises. He is in good health, no family history of heart problems, exercises regularly and eats a hearty meal before starting his workout. What could be causing his symptoms?
This is angina pectoris caused by diversion of blood flow from the heart to the GI after a large meal. The diversion of blood results in increase in lactic acid in the heart which results in chest pain.
Why would someone in the middle of the spectrum between complete inactivity and peak physical fitness have a lower chance of surviving an MI that people at both ends of the spectrum?
In chronic IHD and consistent physical conditioning, people develop capillary beds from the heart chamber into the myocardium, creating an extra source of oxygen supply if a coronary artery becomes clogged.
A 43 year old patient comes to the ED complaining of chest pain. EKG shows left heart block. Blockade of what coronary arteries could cause this condition?
The anterior interventricular branch (LAD) supplies the AV node and the right coronary artery supplies the SA and AV nodes. Blockade to these arteries can produce malfunction in these nodes and heart block.
A 12 year old boy presents with difficulty swallowing. What vascular anomalies could be responsible for his symptoms?
A retro-esophageal right subclavian artery or a double aortic arch that compresses the esophagus posteriorly.
What radiographic finding do you expect to see in a patient with post ductal coarctation of the aorta?
Notching of the ribs. Blood is shunted to the left subclavian artery and down through the intercostal arteries to maintain lower extremity blood flow. This will cause dilation of the intercostal arteries and notching of the ribs.
A patient with a history of blood clots comes to your clinic claiming they felt a clot in their stomach dislodge. Though rare, you confirm there is a clot in her azygos vein. The surgeon takes out the clot and less than a day later she comes to the ED complaining of shortness of breath and has decreased lung sounds with dullness when perucussing the lungs. What is causing her symptoms?
The surgeon likely nicked the thoracic duct when working around the azygos vein and caused a chylothorax in this patient.