MyPasTest: MRCS A Online - Jan Exam 2015
02. Anatomy; Thorax(120Qs)
-----------------------------------------------------------------------------------------------------------------
01. A 17-year-old male is stabbed over the left lower ribs whilst travelling home from a night out. He
is alert and haemodynamically stable on admission. A naso gastric tube is inserted and a chest x-
ray shows this to be in the thoracic cavity and a traumatic diaphragmatic injury is thought likely.
What is the best imaging technique to visualise the anatomy of the diaphragm? Select one answer
only.
Abdominal CT« YOUR ANSWER Page |
Barium swallow 70
Chest CT
Gastrograffin swallow
MRI« CORRECT ANSWER.
Diaphragmatic injuries result from either blunt or penetrating trauma. A traumatic diaphragmatic
rupture is more commonly diagnosed on the left side, perhaps because the liver obliterates the
defect or protects it on the right side. In addition, the appearance of bowel, stomach or a
nasogastric (NG) tube is more easily detected in the left side of the chest. Right diaphragmatic
ruptures are rarely diagnosed in the early post-injury period. The liver often prevents herniation of
other abdominal organs into the chest.
This, however, may not be representative of the true incidence of laterality and autopsy studies
have revealed that left- and right-sided ruptures occur almost equally. Blunt trauma produces large
radial tears measuring 5–15 cm, most often at the posterolateral aspect of the diaphragm. In
contrast, penetrating trauma usually create only small linear incisions or perforations, which are
less than 2 cm in size and may often take some time, even years, to develop into diaphragmatic
hernias.
If a laceration of the left diaphragm is suspected, a NG tube should be inserted. If the tube appears
in the thoracic cavity on the chest film, the need for special contrast studies can be eliminated.
Minimally invasive endoscopic procedures (thoracoscopy) may be helpful in evaluating the injury to
the diaphragm in indeterminate cases.
Abdominal computed tomography scan is usually not helpful because of its poor visualisation of
the diaphragm. Magnetic resonance imaging is more accurate in visualising the anatomy of the
diaphragm. It is very sensitive and specific and so is the investigation of choice. Surgical repair is
necessary, even for small tears, because the defect will not heal spontaneously.
02. A 32-year-old female complains of a long history of pain and paraesthesiae along the ulnar
border of her left arm and forearm precipitated by placing her upper limb in certain positions. She
reports episodes of dropping items in her left hand recently and also episodes of left arm swelling.
On examination wasting of the small muscles of the left hand is noted. Which of the following is the
most likely diagnosis? Select one answer only.
Carpal tunnel syndrome« YOUR ANSWER
Cubital tunnel syndrome
Erbs palsy
Klumpke’s paralysis
-------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Dr Mohammed Shamsul Islam Khan, Medical Officer, Clinical Neuro-Surgery, National Institute of Neuro-Sciences and Hospital Sher-E-Bangla
Nagar, Dhaka-1207, Bangladesh. Mobile: +880 1713 455 662, E-mail:
, MyPasTest: MRCS A Online - Jan Exam 2015
02. Anatomy; Thorax(120Qs)
-----------------------------------------------------------------------------------------------------------------
Thoracic outlet syndrome« CORRECT ANSWER.
Cervical rib is present in about 0.5% of the population, of which 60% are symptomatic. Symptoms
due to the presence of a cervical rib depend on the structure it is compressing. Neurological
symptoms are the most common presentation, usually compression of the C8 and T1 nerve roots,
which causes pain and paraesthesiae on the ulnar aspect of the arm and forearm and wasting of the Page |
small muscles of the hand. Vascular changes are seen less often. The arm can become swollen as a
result of venous compression. Compression of the subclavian artery can lead to thrombus 71
formation, emboli, ischaemic changes, and even gangrene.
03. A 65-year-old diabetic with hypertension and a long smoking history is due to undergo a CABG
for triple vessel disease. Which of the following grafts would be likely to have the highest patency
rates at 10 years? Select one answer only.
Left internal mammary« YOUR ANSWER
Long saphenous vein
Radial artery
PTFE graft
Cryopreserved allograft vein.
During the first year following a CABG up to 15% of vein grafts occlude. Between 1–6 years the
graft attrition is 1% to 2% per year and between 6–10 years it is 4% per year. By 10 years after
bypass surgery, only 60% are patent and only 50% are free of significant stenosis. The internal
thoracic (mammary) artery has a reported patency of up to 90% at 10 years.
The left internal thoracic artery is usually anastomosed to the left anterior descending artery (or
anterior interventricular artery). A number of studies have been carried out to assess the use of
alternative grafts for coronary bypass surgery, including PTFE and cryopreserved allograft veins
(CAVs). The results so far have been disappointing.
04. A 32-year-old man is brought in after a RTA in which he was doing 40 mph and collided with an
on-coming vehicle after he lost concentration momentarily. He was not wearing a seatbelt and a
sternal fracture is seen on imaging. There is concern about a myocardial contusion. What is the
best way to establish this diagnosis? Select one answer only.
ECG« YOUR ANSWER
Direct inspection of myocardium
Serial troponin levels and ECG« CORRECT ANSWER
Transoesophageal echo
Transthoracic echo.
Blunt cardiac injury, commonly seen in patients with decelerating trauma, can cause valvular
disruption, pericardial effusion, myocardial muscle contusion and cardiac chamber rupture.
Patients with myocardial contusion may complain of chest discomfort/pain and may be
hypotensive. However, cardiogenic shock is rarely seen with myocardial contusion alone.
-------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Dr Mohammed Shamsul Islam Khan, Medical Officer, Clinical Neuro-Surgery, National Institute of Neuro-Sciences and Hospital Sher-E-Bangla
Nagar, Dhaka-1207, Bangladesh. Mobile: +880 1713 455 662, E-mail:
, MyPasTest: MRCS A Online - Jan Exam 2015
02. Anatomy; Thorax(120Qs)
-----------------------------------------------------------------------------------------------------------------
A two-dimensional echocardiography may reveal an abnormal ventricular wall motion. The
electrocardiographic changes are variable: They include multiple premature ventricular
contractions, unexplained sinus tachycardia, atrial fibrillation, bundle branch block (usually right),
non-specific ST and T wave changes and features suggestive of frank myocardial infarction.
In current practice, the widespread availability of cardiospecific troponin I and troponin T assays Page |
has made it easier to detect myocardial injury, especially in patients with no major signs of cardiac 72
injury. Troponin I and troponin T have also facilitated the stratification of patients at risk for life
threatening complications.
Serial measurements of troponin I or T in combination with ECG have shown to be sufficient for
identifying the vast majority of patients at risk, thus avoiding extensive diagnostic screening.
Moreover, patients with normal troponin I or T concentrations and ECG may be safely discharged
after a period of observation.
Ref: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1767619/
05. A 64-year-old man is admitted with a tearing chest pain radiating through to his back. He is
haemodynamically stable and a CT angiogram shows a type A thoracic aneurysm with dissection.
Which of the following vessels normally arise from the aortic arch? Select one answer only.
Left subclavian artery« YOUR ANSWER (Correct)
Left vertebral artery
Right internal mammary artery
Right common carotid artery
Right subclavian artery.
The arch of the aorta commences from the manubriosternal joint and passes backwards over the
left bronchus to reach the body of T4 vertebra just to the left of the midline. The arch is crossed on
its left side by the phrenic and vagus nerves as they pass downwards in front of and behind the
lung root, respectively. The left vertebral artery and the right internal mammary artery come off the
left and right subclavian arteries, respectively.
06. Following excision of a left cervical rib a 28-year-old female is found to have a milky, white fluid
in her drain. What structure is most likely to have been damaged? Select one answer only.
Cisterna chyli« YOUR ANSWER
Hemiazygos vein
Left subclavican artery
Left subclavican vein
Thoracic duct« CORRECT ANSWER.
-------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Dr Mohammed Shamsul Islam Khan, Medical Officer, Clinical Neuro-Surgery, National Institute of Neuro-Sciences and Hospital Sher-E-Bangla
Nagar, Dhaka-1207, Bangladesh. Mobile: +880 1713 455 662, E-mail:
, MyPasTest: MRCS A Online - Jan Exam 2015
02. Anatomy; Thorax(120Qs)
-----------------------------------------------------------------------------------------------------------------
The thoracic duct leaves the cysterna chyli at the level of L1–L2, ascends into the thorax to the right
of the descending thoracic aorta, crosses the midline gradually to reach the left border of the
oesophagus (plane of Louis, T4), where it continues to run upwards, reaching the root of the neck.
It then curves behind the carotid sheath and arches over the left subclavian artery to drain into the
left brachiocephalic vein, although it can also drain into the other adjacent major veins. It carries
lymph from the lower limbs, abdominal and pelvic regions, left thorax, left head and neck plus the Page |
left arm. 73
07. A 27-year-old male is rushed into A&E after being involved in a RTA. From the history he was a
front seat passenger in a stolen car that crashed into a wall at approximately 70mph. He is
complaining of generalised pain and on examination prominent marks are seen corresponding to
his seatbelt. His trauma series chest x-ray shows an obliterated aortic knuckle and there is concern
about blunt aortic rupture. Which of the following imaging modalities is the gold standard in
diagnosing this? Select one answer only.
Aortography« YOUR ANSWER (Correct)
Contrast- enhanced CT of the chest
MRI
Transoesophageal echocardiography
Transthoracic echocardiography.
Traumatic aortic disruption, a time-sensitive injury, is a common cause of sudden death after an
automobile collision or a fall from great height. A complete tear through the tunica intima, media
and adventitia usually leads to rapid exsanguination and death. In aortic rupture survivors,
immediate death is prevented due to the vascular continuity maintained by a pseudoaneurysm
within an intact adventitial layer or a mediastinal haematoma.
A large mediastinal haematoma may shift the trachea to the right. This condition has a variable
course ranging from a relatively clinically silent period due to the contained rupture
(pseudoaneurysm), to rupture of the pseudoaneurysm, exsanguination and death. Radiographic
findings may include a widened mediastinum, obliteration of the aortic knuckle, deviation of the
trachea to the right, obliteration of the space between the pulmonary artery and the aorta
(obscuration of AP (aorto-pulmonary) window), depression of the left main stem bronchus,
deviation of the oesophagus (nasogastric tube) and fractures of the first or second rib or scapula.
False-positive and false-negative findings occur with each radiographic sign and, rarely (1–2%), no
mediastinal or initial chest X-ray abnormality is present in patients with great vessel injury.
Although transoesophageal echocardiography is a useful, the less invasive diagnostic tool,
aortography is the gold standard in the diagnosis of blunt aortic rupture. Helical contrast-enhanced
computed tomography (CT) of the chest is also an accurate screening method for patients with
suspected blunt aortic injury. However, a patient who is haemodynamically abnormal should not be
placed in a CT scanner.
In stable patients, if enhanced helical CT of the chest is negative for mediastinal haematoma and
aortic rupture, no further diagnostic imaging is necessary. If it is positive for blunt aortic rupture,
the extent of the injury can best be ascertained by aortography.
-------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Dr Mohammed Shamsul Islam Khan, Medical Officer, Clinical Neuro-Surgery, National Institute of Neuro-Sciences and Hospital Sher-E-Bangla
Nagar, Dhaka-1207, Bangladesh. Mobile: +880 1713 455 662, E-mail:
02. Anatomy; Thorax(120Qs)
-----------------------------------------------------------------------------------------------------------------
01. A 17-year-old male is stabbed over the left lower ribs whilst travelling home from a night out. He
is alert and haemodynamically stable on admission. A naso gastric tube is inserted and a chest x-
ray shows this to be in the thoracic cavity and a traumatic diaphragmatic injury is thought likely.
What is the best imaging technique to visualise the anatomy of the diaphragm? Select one answer
only.
Abdominal CT« YOUR ANSWER Page |
Barium swallow 70
Chest CT
Gastrograffin swallow
MRI« CORRECT ANSWER.
Diaphragmatic injuries result from either blunt or penetrating trauma. A traumatic diaphragmatic
rupture is more commonly diagnosed on the left side, perhaps because the liver obliterates the
defect or protects it on the right side. In addition, the appearance of bowel, stomach or a
nasogastric (NG) tube is more easily detected in the left side of the chest. Right diaphragmatic
ruptures are rarely diagnosed in the early post-injury period. The liver often prevents herniation of
other abdominal organs into the chest.
This, however, may not be representative of the true incidence of laterality and autopsy studies
have revealed that left- and right-sided ruptures occur almost equally. Blunt trauma produces large
radial tears measuring 5–15 cm, most often at the posterolateral aspect of the diaphragm. In
contrast, penetrating trauma usually create only small linear incisions or perforations, which are
less than 2 cm in size and may often take some time, even years, to develop into diaphragmatic
hernias.
If a laceration of the left diaphragm is suspected, a NG tube should be inserted. If the tube appears
in the thoracic cavity on the chest film, the need for special contrast studies can be eliminated.
Minimally invasive endoscopic procedures (thoracoscopy) may be helpful in evaluating the injury to
the diaphragm in indeterminate cases.
Abdominal computed tomography scan is usually not helpful because of its poor visualisation of
the diaphragm. Magnetic resonance imaging is more accurate in visualising the anatomy of the
diaphragm. It is very sensitive and specific and so is the investigation of choice. Surgical repair is
necessary, even for small tears, because the defect will not heal spontaneously.
02. A 32-year-old female complains of a long history of pain and paraesthesiae along the ulnar
border of her left arm and forearm precipitated by placing her upper limb in certain positions. She
reports episodes of dropping items in her left hand recently and also episodes of left arm swelling.
On examination wasting of the small muscles of the left hand is noted. Which of the following is the
most likely diagnosis? Select one answer only.
Carpal tunnel syndrome« YOUR ANSWER
Cubital tunnel syndrome
Erbs palsy
Klumpke’s paralysis
-------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Dr Mohammed Shamsul Islam Khan, Medical Officer, Clinical Neuro-Surgery, National Institute of Neuro-Sciences and Hospital Sher-E-Bangla
Nagar, Dhaka-1207, Bangladesh. Mobile: +880 1713 455 662, E-mail:
, MyPasTest: MRCS A Online - Jan Exam 2015
02. Anatomy; Thorax(120Qs)
-----------------------------------------------------------------------------------------------------------------
Thoracic outlet syndrome« CORRECT ANSWER.
Cervical rib is present in about 0.5% of the population, of which 60% are symptomatic. Symptoms
due to the presence of a cervical rib depend on the structure it is compressing. Neurological
symptoms are the most common presentation, usually compression of the C8 and T1 nerve roots,
which causes pain and paraesthesiae on the ulnar aspect of the arm and forearm and wasting of the Page |
small muscles of the hand. Vascular changes are seen less often. The arm can become swollen as a
result of venous compression. Compression of the subclavian artery can lead to thrombus 71
formation, emboli, ischaemic changes, and even gangrene.
03. A 65-year-old diabetic with hypertension and a long smoking history is due to undergo a CABG
for triple vessel disease. Which of the following grafts would be likely to have the highest patency
rates at 10 years? Select one answer only.
Left internal mammary« YOUR ANSWER
Long saphenous vein
Radial artery
PTFE graft
Cryopreserved allograft vein.
During the first year following a CABG up to 15% of vein grafts occlude. Between 1–6 years the
graft attrition is 1% to 2% per year and between 6–10 years it is 4% per year. By 10 years after
bypass surgery, only 60% are patent and only 50% are free of significant stenosis. The internal
thoracic (mammary) artery has a reported patency of up to 90% at 10 years.
The left internal thoracic artery is usually anastomosed to the left anterior descending artery (or
anterior interventricular artery). A number of studies have been carried out to assess the use of
alternative grafts for coronary bypass surgery, including PTFE and cryopreserved allograft veins
(CAVs). The results so far have been disappointing.
04. A 32-year-old man is brought in after a RTA in which he was doing 40 mph and collided with an
on-coming vehicle after he lost concentration momentarily. He was not wearing a seatbelt and a
sternal fracture is seen on imaging. There is concern about a myocardial contusion. What is the
best way to establish this diagnosis? Select one answer only.
ECG« YOUR ANSWER
Direct inspection of myocardium
Serial troponin levels and ECG« CORRECT ANSWER
Transoesophageal echo
Transthoracic echo.
Blunt cardiac injury, commonly seen in patients with decelerating trauma, can cause valvular
disruption, pericardial effusion, myocardial muscle contusion and cardiac chamber rupture.
Patients with myocardial contusion may complain of chest discomfort/pain and may be
hypotensive. However, cardiogenic shock is rarely seen with myocardial contusion alone.
-------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Dr Mohammed Shamsul Islam Khan, Medical Officer, Clinical Neuro-Surgery, National Institute of Neuro-Sciences and Hospital Sher-E-Bangla
Nagar, Dhaka-1207, Bangladesh. Mobile: +880 1713 455 662, E-mail:
, MyPasTest: MRCS A Online - Jan Exam 2015
02. Anatomy; Thorax(120Qs)
-----------------------------------------------------------------------------------------------------------------
A two-dimensional echocardiography may reveal an abnormal ventricular wall motion. The
electrocardiographic changes are variable: They include multiple premature ventricular
contractions, unexplained sinus tachycardia, atrial fibrillation, bundle branch block (usually right),
non-specific ST and T wave changes and features suggestive of frank myocardial infarction.
In current practice, the widespread availability of cardiospecific troponin I and troponin T assays Page |
has made it easier to detect myocardial injury, especially in patients with no major signs of cardiac 72
injury. Troponin I and troponin T have also facilitated the stratification of patients at risk for life
threatening complications.
Serial measurements of troponin I or T in combination with ECG have shown to be sufficient for
identifying the vast majority of patients at risk, thus avoiding extensive diagnostic screening.
Moreover, patients with normal troponin I or T concentrations and ECG may be safely discharged
after a period of observation.
Ref: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1767619/
05. A 64-year-old man is admitted with a tearing chest pain radiating through to his back. He is
haemodynamically stable and a CT angiogram shows a type A thoracic aneurysm with dissection.
Which of the following vessels normally arise from the aortic arch? Select one answer only.
Left subclavian artery« YOUR ANSWER (Correct)
Left vertebral artery
Right internal mammary artery
Right common carotid artery
Right subclavian artery.
The arch of the aorta commences from the manubriosternal joint and passes backwards over the
left bronchus to reach the body of T4 vertebra just to the left of the midline. The arch is crossed on
its left side by the phrenic and vagus nerves as they pass downwards in front of and behind the
lung root, respectively. The left vertebral artery and the right internal mammary artery come off the
left and right subclavian arteries, respectively.
06. Following excision of a left cervical rib a 28-year-old female is found to have a milky, white fluid
in her drain. What structure is most likely to have been damaged? Select one answer only.
Cisterna chyli« YOUR ANSWER
Hemiazygos vein
Left subclavican artery
Left subclavican vein
Thoracic duct« CORRECT ANSWER.
-------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Dr Mohammed Shamsul Islam Khan, Medical Officer, Clinical Neuro-Surgery, National Institute of Neuro-Sciences and Hospital Sher-E-Bangla
Nagar, Dhaka-1207, Bangladesh. Mobile: +880 1713 455 662, E-mail:
, MyPasTest: MRCS A Online - Jan Exam 2015
02. Anatomy; Thorax(120Qs)
-----------------------------------------------------------------------------------------------------------------
The thoracic duct leaves the cysterna chyli at the level of L1–L2, ascends into the thorax to the right
of the descending thoracic aorta, crosses the midline gradually to reach the left border of the
oesophagus (plane of Louis, T4), where it continues to run upwards, reaching the root of the neck.
It then curves behind the carotid sheath and arches over the left subclavian artery to drain into the
left brachiocephalic vein, although it can also drain into the other adjacent major veins. It carries
lymph from the lower limbs, abdominal and pelvic regions, left thorax, left head and neck plus the Page |
left arm. 73
07. A 27-year-old male is rushed into A&E after being involved in a RTA. From the history he was a
front seat passenger in a stolen car that crashed into a wall at approximately 70mph. He is
complaining of generalised pain and on examination prominent marks are seen corresponding to
his seatbelt. His trauma series chest x-ray shows an obliterated aortic knuckle and there is concern
about blunt aortic rupture. Which of the following imaging modalities is the gold standard in
diagnosing this? Select one answer only.
Aortography« YOUR ANSWER (Correct)
Contrast- enhanced CT of the chest
MRI
Transoesophageal echocardiography
Transthoracic echocardiography.
Traumatic aortic disruption, a time-sensitive injury, is a common cause of sudden death after an
automobile collision or a fall from great height. A complete tear through the tunica intima, media
and adventitia usually leads to rapid exsanguination and death. In aortic rupture survivors,
immediate death is prevented due to the vascular continuity maintained by a pseudoaneurysm
within an intact adventitial layer or a mediastinal haematoma.
A large mediastinal haematoma may shift the trachea to the right. This condition has a variable
course ranging from a relatively clinically silent period due to the contained rupture
(pseudoaneurysm), to rupture of the pseudoaneurysm, exsanguination and death. Radiographic
findings may include a widened mediastinum, obliteration of the aortic knuckle, deviation of the
trachea to the right, obliteration of the space between the pulmonary artery and the aorta
(obscuration of AP (aorto-pulmonary) window), depression of the left main stem bronchus,
deviation of the oesophagus (nasogastric tube) and fractures of the first or second rib or scapula.
False-positive and false-negative findings occur with each radiographic sign and, rarely (1–2%), no
mediastinal or initial chest X-ray abnormality is present in patients with great vessel injury.
Although transoesophageal echocardiography is a useful, the less invasive diagnostic tool,
aortography is the gold standard in the diagnosis of blunt aortic rupture. Helical contrast-enhanced
computed tomography (CT) of the chest is also an accurate screening method for patients with
suspected blunt aortic injury. However, a patient who is haemodynamically abnormal should not be
placed in a CT scanner.
In stable patients, if enhanced helical CT of the chest is negative for mediastinal haematoma and
aortic rupture, no further diagnostic imaging is necessary. If it is positive for blunt aortic rupture,
the extent of the injury can best be ascertained by aortography.
-------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Dr Mohammed Shamsul Islam Khan, Medical Officer, Clinical Neuro-Surgery, National Institute of Neuro-Sciences and Hospital Sher-E-Bangla
Nagar, Dhaka-1207, Bangladesh. Mobile: +880 1713 455 662, E-mail:
