Clinical Anatomy Questions Flashcards
(139 cards)
1
Q
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?
A
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.
2
Q
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?
A
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).
3
Q
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?
A
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.
4
Q
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?
A
Yes. Costal cartilage calcifies with age.
5
Q
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?
A
Sternum
6
Q
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?
A
Pectus excavatum and pectus carinatum are both caused by malformations in fusion of the two longitudinal portions of the sternum.
7
Q
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?
A
Lung cancer is impeding on the recurrent laryngeal nerve (hoarseness) and the phrenic nerve (diaphragm).
8
Q
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?
A
Just enough into the thorax so you are past the thoracic wall but before the parietal pleura of the lungs.
9
Q
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?
A
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.
10
Q
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?
A
The right cervical pleura causing a pneumothorax.
11
Q
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?
A
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.
12
Q
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?
A
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).
13
Q
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?
A
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.
14
Q
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?
A
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.
15
Q
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?
A
Right main bronchus
16
Q
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?
A
Carina. It is the extremely sensitive bifurcation of the bronchus.
17
Q
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?
A
Car accident = torn great vessel and hemorrhage into mediastinum. Smoker = malignant enlarged lymph nodes from cancer. Edema = congestive heart failure yields an enlarged heart.
18
Q
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?
A
Transverse pericardial sinus
19
Q
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?
A
He had a transmural MI which is now inflamed, causing pericarditis which makes the serous pericardium roughened and painful.
20
Q
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?
A
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.
21
Q
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?
A
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.
22
Q
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?
A
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.
23
Q
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?
A
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.
24
Q
Where are the three most common places you see coronary artery occlusion?
A
1) Anterior interventricular branch (40-50%) 2) RCA (30-40%) 3) LCX (15-20%)
25
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.
26
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.
27
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.
28
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.
29
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.
30
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.
31
Where do sympathetic nerve impulses enter the ganglia? Where do they exit the ganglia?
In the white and out the grey rami communicantes
32
You see a patient who had a broken spinal cord in the thoracic region. How is he still able to have bowel movements despite laceration of his vagal nerve?
Auerbach's myenteric and Meissner's submucosal plexuses. These are intrinsic enteric innervations that can act independently of the PNS.
33
A mother has a baby and you are waiting and waiting for it to pass poo. You check and do not see an imperforate anus. What is causing the symptoms in this baby?
Hirshprungs disease. They are missing terminal ganglia of the intrinsic enteric system (Myenteric and submucosal plexuses).
34
A patient comes to see you with blanching of the skin in her fingers when she is exposed to the cold. What do you expect her blood pressure to be?
High, Reynaud's is a result of hyperactivity of the sympathetic nervous system and will cause vasoconstriction and high blood pressure.
35
A 35 year old mom comes to see you because her husband just got a huge raise and she wants liposuction. After sucking all of the fat out of her stomach, you stitch up the incision you made in the subcutaneous layer of the lower abdomen. When stitching her up you include the membranous layer of the subcutaneous tissue for added strength. Where would fluid have a tendency to accumulate after you do this?
Between the superficial membranous layer (Scarpa's fascia) and the deeper aponeurosis of the external abdominal oblique.
36
A really fat guy comes to see you with multiple bumps protruding from his abdomen. You determine he has multiple abdominal hernias. In what locations is he likely to have hernias?
Epigastric (through the linea alba between xyphoid and umbilicus), Spigelian (along semi-lunar lines) and umbilical hernias.
37
A 14 year old female comes to the ED complaining of severe abdominal pain. Upon palpation, you note rebound tenderness and use ultrasound to confirm appendicitis. When removing her appendix, what incision will give her the best outcome for healing and how is this done?
The oblique "McBurney's" incision. It is made about 2.5 cm superiomedial to the ASIS on the spino-umbilical line. 1st you go through the external oblique, then the internal oblique, find the iliohypogastric nerve and finally through the transversus abdominus, splitting fibers as you go along. In this process, no musculo-aponeurotic fibers are cut and she will heal back to 100%.
38
You decide that a woman who has been laboring for the past 18 hours is going to need to have a c-section. What type of incision do you make and what nerves do you identify on your way?
Suprapubic incision, identifying and preserving the iliohypogastric and ilioinguinal nerves as you go.
39
A 94 year old male comes to see you for his yearly check-up. When examining his abdomen you notice prominent veins protruding about his abdomen. What does this tell you about the venous flow in this patient?
Flow to the heart from the inferior vena cava is deficient likely due to portal hypertension. The veins of the anterior abdominal wall anastamose with the para-umbillical veins that become varicose (caput medusae)
40
When doing your pediatrics rotation you examine a young boy who has an undescended testicle. Where is this testicle hiding? What is he at risk for later in life?
Inguinal canal. It is through this canal the testis normally descend. He is at greater risk for malignancy because it cannot be palpated during examination.
41
Shortly after a baby girl was born it was determined that she had hemolytic disease. Where would you place a catheter for blood transfusion in this baby? What will this vessel later become?
Through the umbilical vein. It remains patent for some time after birth before becoming the round ligament of the liver.
42
What determines if a patient has a direct or an indirect inguinal hernia?
A direct hernia goes straight through a weak abdominal floor and medial to the inferior epigastric artery. An indirect hernia goes through a persistent tunica vaginalis, taking it all the way down the inguinal canal from the deep to the superficial rings. This occurs lateral to the inferior epigastric artery.
43
A mother brings her four year old boy in to see you who complains of lower abdominal and testicular pain. When palpating for hernias, you do not feel any masses, but the area is definitely swollen. What test could you do to determine what is causing this boy's condition?
Transillumination of the scrotum will illuminate red if the child has hydrocele of the spermatocord or hydrocel from a persistent tunica vaginalis.
44
A patient comes to the ED in horrible testicular pain. Examination reveals progressive swelling and edema. You pull out the ultrasound and start scanning. What are you looking for?
Torsion of the spermatic cord. This is a surgical emergency and should be the first thing you rule out.
45
A mother brings her newborn baby in to see you complaining that urine is leaking out of her baby's belly button. Which umbilical fold will need to be surgically ligated?
The Median Umbilical Fold. This fold contains the urachus, the fetal vessel that joins the bladder to the umbilicus.
46
A mother brings her newborn baby in to see you complaining of small amounts of blood leaking out of her baby's belly button. Which umbilical fold will need to be surgically ligated?
The Medial Umbilical Folds (2). These folds contain the umbilical arteries.
47
A patient comes to see after sustaining a stab would near the umbilicus. After a few minutes of bleeding he starts to develop testicular pain. Through what umbilical fold did the knife likely penetrate?
Lateral Umbilical Folds. These contain the inferior epigastric arteries which supply the cremaster muscle.
48
A patient comes to see you complaining of something "weird" on his "ballsack". After physical examination, you tell him it feels like he has a bag of worms on the inside of his scrotum. What is causing this patient's condition? Which side is probably worse?
This is varicocele. It is due to distention of the pampiniform veins, especially in the left side because the angle of drainage is sharp as it goes into the left renal vein and on to the IVC.
49
You see two patients in your oncology clinic. One has cancer in his testicles and the other in his scrotum. Where are you going to look for metastasis in each patient?
Scrotum = superficial inguinal lymph nodes. Testis = retroperitoneal lumbar lymph nodes -\> mediastinal and possibly even supraclavicular nodes.
50
A 22 year old female comes to see you complaining of severe abdominal pain. You determine that she has an infection in her peritoneum and that it traveled from her vagina. Trace the pathway the microbe took to get to her peritoneum. What protective mechanism has failed her.
Vagina, through the cervix and into the uterus. Through a uterine tube (fallopian tube) and into the peritoneum. Normally there is a mucous plug that blocks entry into the uterus.
51
Your neighbor calls you in the middle of the night because his daughter has lower right quadrant pain. By the time you get to their house she is curled up on the floor breathing rapidly and shallowly with a fever of 104 degrees. Why does this concern you?
He appendix has likely burst. She is curled up on the floor to loosen up abdominal muscles and allow for less pain as her abdomen swells. She breaths shallowly to decrease intra-abdominal pressure.
52
A patient complains of chronic abdominal pain in their lower right quadrant. They do not have rebound tenderness and have had their appendix taken out previously. What is likely causing her pain?
An adhesion from a prior surgery that has caused the intestine to become twisted around it.
53
You are doing rounds and see a patient recovering from peritonitis after a perforating ulcer through his duodenum. The nurse has him lying supine. Is this how you want him positioned?
No. You want him almost in a sitting position so exudate can drain down the paracolic gutters into the pelvis where fluid absorption is not as rapid as it is in the upper bowel.
54
A patient comes to see you with severe abdominal pain. Blood tests reveal pancreatitis. Where is a likely location of pancreatic fluid accumulation around the stomach?
Omental bursa. The area that separates the stomach from the pancreas.
55
An 18 year old male comes to the ED with a stab wound to the right abdomen. When you open him up you find massive hemorrhage to the peritoneal cavity. How might you determine if hemorrhage is coming from the liver?
Clamp the hepatic artery and see if bleeding stops.
56
A 64 year old male comes to the ED in hypovolemic shock from internal hemorrhage. He has an extensive history of alcoholism and a very cirrhotic liver. Where might you look first for hemorrhage?
Esophageal veins. When people have portal hypertension, venous flow is reverse and can cause esophageal varices. These are prone to rupture and can cause hemorrhage.
57
Through what portion of the stomach does gastric fluid leak through in patients with GERD?
Cardiac sphincter. A weak sphincter is often the cause of pyrosis (heartburn)
58
Why might someone with a hiatal hernia suffer from pyrosis (heartburn)?
In sliding hiatal hernias, the diaphragm can no longer clamp down as strongly on the distal portion of the esophagus, allowing gastric juice to spill into it.
59
A mother brings her 2 month old infant to see you complaining of a distended stomach and vomiting after feeding. Spasmatic contraction of what portion of the stomach is likely to cause these symptoms?
Pylorus. It results in accumulation of food in the stomach because spastic contraction does not allow for food passage to the duodenum.
60
What is the difference between a gastric and a pyloric ulcer? Transection of what nerve would result in decreased incidence of either of these ulcers?
Gastric ulcers occur in the stomach, where pyloric ulcers occur in the pylorus or shortly further downstream in the duodenum. Transection of the vagus nerve decreases acid production, decreasing ulcer incidence.
61
What surrounding structures are at risk for damage when ulcers perforate through organ walls?
Gastric arteries, splenic arteries, pancreas, liver, gallbladder and gastroduodenal artery.
62
Blood clots to which blood vessels would result in necrosis and possible death of an intestinal segment?
Vasa recta. These come off of the arterial arcades which comes off of the superior mesenteric artery.
63
Diets high in fiber have been proven to reduce what abnormality in the colon?
Diverticula (out-pocketings of the colon mucosa)
64
A patient comes to the ED after a motorcycle accident with severe internal hemorrhage because he lacerated his spleen. Which ribs did he likely break to cause this laceration?
Left 9-12 ribs.
65
A patient with a history of gallstones presents to the ED with symptoms of pancreatitis. How could his history of gallstones be causing his current symptoms?
The gallbladder empties its contents into the cystic duct, which joins the hepatic duct to form the common bile duct. This duct joints the pancreatic duct and the hepatopancreatic ampulla where it empties into the duodenum. A gallstone blocking this ampulla results in bile backup into the pancreas and pancreatitis.
66
How could you image someone's gallbladder via endoscopy?
From the duodenum, enter the hepatopancreatic ampula via the major duodenal papilla and up the bile duct.
67
A 51 year old male comes to see you with jaundice, severe back pain and sudden weight loss. After several diagnostic tests, he is found to have pancreatic cancer. How is the cancer causing jaundice and why is his prognosis so poor?
Cancer of the pancreatic head compresses the bile duct, causing back up of bile and obstructive jaundice. His prognosis is poor because metastasis to the liver happens very early via the hepatic portal vein and adjacent lymph nodes are inaccessible.
68
Why is it possible to perform a hepatic lobectomy without excessive bleeding?
The right and left hepatic portal veins do not communicate with each other.
69
When performing a hepatic lobectomy, what vessels must the surgeon look out for due to possible hemorrhage?
Right, left and intermediate hepatic veins draining into inferior vena cava.
70
What are the blood vessels that branch off of the celiac trunk?
Splenic artery, left gastric artery, common hepatic artery (which gives rise to the gastroduodenal artery and the proper hepatic artery).
71
Why does the liver always show the first signs of increase in central venous pressure?
The hepatic veins and IVC lack valves, thus whenever central venous pressure increases, it goes straight to the liver.
72
A patient comes to see you complaining of dull flank pain when he extends his hip. His family has a history of polycystic kidney disease. What is likely causing this pain?
He has an inflamed kidney that is compressed by the psoas major when extension of the hip occurs. This test can also be utilized with injury to kidneys, cecum, appendix, colon and lumbar lymph nodes
73
A patient comes to see you complaining of hematuria, left flank pain, nausea, vomiting and left testicular pain. What is causing his problems?
Left renal vein entrapment by the superior mesenteric artery. The left renal vein traverses between the SMA and the aorta on its way to the IVC and can easily become entrapped. The left testicular vein drains into the left renal vein, thus the left testicular pain. Vomiting and nausea indicates possible entrapment of the duodenum which also traverses in the same place.
74
What is the medical term for a kidney stone?
Ureteric calculus
75
A 63-year-old man comes to the emergency department with back pain, weakness, and shortness of breath. On examination, he has an aneurysm of the abdominal aorta at the aortic hiatus of the diaphragm. Which of the following pairs of structures would most likely be compressed?
A) Vagus nerve and azygos vein
B) Esophagus and vagus nerve
C) Thoracic duct and vagus nerve
D) Azygos vein and thoracic duct
E) IVC and phrenic nerve
D. The azygos vein and thoracic duct travel through the aortic hiatus. The vagus nerve passes through the esophageal hiatus and the phrenic nerve may pass through the vena caval hiatus.
76
A 2-year-old boy presents with pain in his groin that has been increasing in nature over the past few weeks. He is found to have a degenerative malformation of the transversalis fascia during development. Which of the following structures on the anterior abdominal wall is likely defective?
1. Superficial inguinal ring
2. Deep inguinal ring
3. Inguinal ligament
4. Sac of direct inguinal hernia
5. Anterior wall of the inguinal canal
2. Deep inguinal ring lies in the transversalis fascia. The superficial inguinal ring lies in the aponeurosis of the external abdominal oblique which also forms the inguinal ligament and anterior wall of the inguinal canal. The sac of a direct inguinal hernia is formed by the peritoneum.
77
A 29-year-old man comes to a local hospital with duodenal peptic ulcer and complains of cramping epigastric pain. Which of the following structures harbors the cell bodies of abdominal pain fibers?
1. Lateral horn of the spinal cord
2. Anterior horn of the spinal cord
3. Dorsal root ganglion
4. Sympathetic chain ganglion
5. Celiac ganglion
Dorsal root ganglion = sensory pain fibers
Lateral horn of the spinal cord = sympathetic preganglionic cell bodies
Anterior horn of the spinal cord = efferent somatic cell bodies
Sympathetic chain ganglion = sympathetic postganglionic cell bodies for blood vessels, sweat glands, and hair follicles
Celiac ganglion = sympathetic postganglionic cell bodies for visceral organs (stomach and intestines)
78
How would gallstone ulceration through the body of the gallbladder differ from an ulceration through the fundus?
The fundus is in contact with the transverse large intestine and will be pooped out. The body is in contact with the duodenum and could cause intestinal obstruction if it gets caught up at the ileocecal valve.
79
During an annual health examination of a 46-year-old woman, a physician finds hypersecretion of norepinephrine from her suprarenal medulla. Which of the following types of nerve fibers are most likely overstimulated?
1. Preganglionic sympathetic fibers
2. Postganglionic sympathetic fibers
3. Somatic motor fibers
4. Postganglionic parasympathetic fibers
5. Preganglionic parasympathetic fibers
1. Preganglionic sympathetic fibers. The adrenal gland is the only organ that receive signals from a preganglionic sympathetic nerve fibers.
80
Absence of what types of fibers results in Hirchsprung's disease?
Postganglionic parsympathetic fibers. This dilates the colon and does not allow for bowel secretion.
81
A pediatric surgeon is resecting a possible malignant mass from the liver of a neonate with cerebral palsy. The surgeon divides the round ligament of the liver during surgery. A fibrous remnant of which of the following fetal vessels is severed?
1. Ductus venosus
2. Ductus arteriosus
3. Left umbilical vein
4. Right umbilical vein
5. Umbilical artery
3. Left umbilical vein.
Ductus venosus = ligamentum venosum
Ductus arteriosus = ligamentum arteriosum
Right umbilical vein = degenerated in early embryo
Umbilical artery = medial umbilical ligament
82
A 27-year-old woman has suffered a gunshot wound to her midabdomen. After examining the patient’s angiogram, a trauma surgeon locates the source of bleeding from pairs of veins that typically terminate in the same vein. Which of the following veins are damaged?
1. L and R ovarian veins
2. L and R gastroepiploic veins
3. L and R colic veins
4. L and R suprarenal veins
5. L and R hepatic veins
5. L and R hepatic veins both drain into the inferior vena cava.
The right gastroepiploic vein drains into the superior mesenteric vein, the left one drains into the splenic vein. The right gonadal and suprarenal veins drain into the IVC, whereas the left ones drain into the left renal vein. The right colic vein ends in the superior mesenteric vein, but the left one terminates in the inferior mesenteric vein.
83
A 43-year-old man complains of abdominal pain just above his umbilicus. On examination, a tumor is found anterior to the IVC. Which of the following structures would most likely be compressed by this tumor?
1. Sympathetic trunk
2. Left 3rd lumbar artery
3. Left renal artery
4. Cisterna chyli
5. 3rd part of duodenum
5. Third part of the duodenum is the only structure that crosses anteriorly to the IVC
84
A 33-year-old man with a perforated gastric ulcer complains of excruciating pain in his stomach. It is observed that the pain comes from peritoneal irritation by gastric contents in the lesser sac. Which of the following nerves contain sensory nerve fibers that convey this sharp, stabbing pain?
1. Vagus nerves
2. Greater splanchnic nerves
3. Lower intercostal nerves
4. White rami communicantes
5. Grey rami communicantes.
3. Lower intercostal nerves = pain sensation originating from peritoneal irritation by gastric contents in the lesser sac
## Footnote
Vagus nerves = sensory fibers associated with reflexes in the gastrointestinal (GI) tract
Greater splanchnic nerves and white rami communicantes = pain (general visceral afferent [GVA]) fibers from the wall of the stomach and other areas of the GI tract.
The gray rami communicantes = no sensory fibers, contains sympathetic postganglionic fibers.
85
What nerve is responsible for the cremaster reflex?
Genitofemoral. It has an afferent fiber (femoral branch) that carries the sensation and an efferent fiber (genital branch) that causes the contraction.
86
A 21-year-old man receives a penetrating knife wound in the abdomen and is injured in both the superior mesenteric artery and the vagus nerve. Which portion of the colon would most likely be impaired by this injury?
1. Ascending and descending colons
2. Transverse and sigmoid colons
3. Descending and sigmoid colons
4. Ascending and transverse colons
5. Transverse and descending colons
4. Ascending and transverse colons = receives blood from the superior mesenteric artery and parasympathetic nerve fibers from the vagus nerve.
Descending and sigmoid colons = receive blood from the inferior mesenteric artery and the parasympathetic nerve fibers from the pelvic splanchnic nerve arising from sacral spinal nerves (S2–S4).
87
A 42-year-old man with portal hypertension secondary to cirrhosis of the liver and subsequent massive ascites presents to the emergency department. He refuses to have a transjugular intrahepatic portosystemic shunt (TIPS) procedure and prefers surgery. Which of the following surgical connections is involved in the most practical method of shunting portal blood around the liver?
1. Superior mesenteric vein to the inferior mesenteric vein
2. Portal vein to the SVC
3. Portal vein to the left renal vein
4. Splenic vein to the left renal vein
5. Superior rectal vein to the left colic vein
Portal hypertension can be reduced by diverting blood from the portal to the caval system. This is accomplished by connecting the splenic vein to the left renal vein or by creating a communication between the portal vein and the IVC. All of the other choices drain into the portal vein in the first place.
88
A 78-year-old man is suffering from ischemia of the suprarenal glands. This condition results from rapid occlusion of direct branches of which arteries?
The suprarenal gland receives arteries from three sources. The superior suprarenal artery arises from the inferior phrenic artery, the middle suprarenal artery arises from the abdominal aorta, and the inferior suprarenal artery arises from the renal artery.
89
A radiograph of a 32-year-old woman reveals a perforation in the posterior wall of the stomach in which the gastric contents have spilled into the lesser sac. The general surgeon has opened the gastrosplenic ligament to reach the lesser sac and notes erosion of the ulcer into an artery. Which of the following vessels is most likely involved?
1. Splenic artery
2. Gastroduodenal artery
3. Left gastric artery
4. Right gastric artery
5. Gastroepiploic artery
The left gastroepiploic artery runs through the gastrosplenic ligament, and hence, it is the artery most likely injured. The splenic artery is found in the gastrorenal ligament. The right and left gastric arteries run within the lesser omentum. The gastroduodenal artery descends between the duodenum and the head of the pancreas.
90
A 35-year-old woman with a history of cholecystectomy arrives in the emergency department with intractable hiccups most likely caused by an abdominal abscess secondary to surgical infection. Which of the following nerves carries pain sensation caused by irritation of the peritoneum on the central portion of the inferior surface of the diaphragm?
1. Vagus nerve
2. Lower intercostal nerves
3. Phrenic nerve
4. Subcostal nerves
5. Greater splanchnic nerve
The diaphragm receives somatic motor fibers solely from the phrenic nerves. The peritoneum on the central part of the diaphragm receives sensory fibers from the phrenic nerve, and the peripheral part from the lower intercostal nerves. The subcostal nerve supplies the peritoneum inferior to the diaphragm. The vagus and greater splanchnic nerves do not carry pain fibers from the peritoneum.
91
A 16-year-old boy with a ruptured spleen comes to the emergency department for splenectomy. Soon after ligation of the splenic artery just distal to its origin, a surgical resident observes that the patient is healing normally. Normal blood flow would occur in which of the following arteries?
1. Short gastric arteries
2. Dorsal pancreatic artery
3. Inferior pancreaticoduodenal artery
4. Left gastroepiploic artery
5. Artery in the gastrorenal ligament
3. Inferior pancreaticoduodenal artery is the only one that is not a branch off the splenic artery (it's a branch off of the superior mesenteric artery)
92
What nerve is most likely to be injured during an appendectomy performed at McBurney's point?
Ileohypogastric, it runs between the internal oblique and transverse abdominal muscles near the McBurney’s point, the point at the junction of the lateral one-third of the line between the anterior superior iliac spine and the umbilicus.
93
While examining radiographs and angiograms of a 52-year-old patient, a physician is trying to distinguish the jejunum from the ileum. He has observed that the jejunum has:
1. Fewer plicae circulares
2. Fewer mesenteric arterial arcades
3. Less digestion and absorption of nutrients
4. Shorter vasa recta
5. More fat in its mesentery
The jejunum has fewer mesenteric arterial arcades but longer vasa recta than the ileum. The plicae circulares are tall and closely packed in the jejunum and are low and sparse in the ileum, and the lower part of the ileum has no plicae circulares. More digestion and absorption of nutrients occurs in the jejunum than in the ileum, and less fat is found in the mesentery of the jejunum.
94
A 26-year-old patient is admitted to a local hospital with a retroperitoneal infection. Which of the following arteries is most likely to be infected?
1. Left gastric artery
2. Proper hepatic artery
3. Middle colic arteries
4. Sigmoid arteries
5. Dorsal pancreatic artery
The pancreas is a retroperitoneal organ, except for a small portion of its tail. The dorsal pancreatic artery would be the infected artery because it arises from the splenic artery and runs retroperitoneally along the superior border of the pancreas behind the peritoneum. The other arteries run within layers of the peritoneum. The left gastric arteries run within the lesser omentum; the proper hepatic artery runs within the free margin of the lesser omentum; the middle colic artery runs within the transverse mesocolon; the sigmoid arteries run within the sigmoid mesocolon.
95
Where do the quadrate and caudate lobes of the liver drain bile? Where does blood come into the liver?
The quadrate lobe drains bile into the left hepatic duct. The caudate lobe drains into the left and right hepatic ducts. The liver receives blood from both the hepatic portal vein and the hepatic artery.
96
Because of an inflammatory bowel disease (Crohn’s disease) and a small bowel obstruction leading to bowel ischemia, an elderly woman requires bypass of her ileum and jejunum and is scheduled for a gastrocolostomy. The surgeon will ligate all arteries that send branches to the stomach. Which of the following arteries may be spared?
1. Splenic artery
2. Gastroduodenal artery
3. Inferior pancreaticoduodenal artery
4. Left gastroepiploic artery
5. Proper hepatic artery
Inferior pancreaticoduodenal artery. All others supply the stomach.
97
A 38-year-old woman with peptic ulcer disease of the stomach experiences severe abdominal pain. Which of the following nervous structures is most likely involved?
1. Greater splanchnic nerve
2. Ventral roots of the spinal nerve
3. Lower intercostal nerve
4. Vagus nerve
5. Gray rami communicantes
Greater splanchnic nerve. This carries pain fibers from the upper GI tract. The vagus nerve carries sensory reflexes, not pain fibers. The lower intercostal nerves carry GSA (general somatic afferent) fibers from the diaphragm, abodominal wall and peritoneum, but not the GI tract.
98
A 3-year-old boy is diagnosed as having a persistent processus vaginalis in its middle portion. Which of the following conditions is most likely to be associated with this developmental anomaly?
1. Gubernaculum testis
2. Direct inguinal hernia
3. Hematocele
4. Hydrocele
5. Cryptorchidism
Hydrocele. A persistent processus vaginalis in the middle portion will become a hydrocele. If the entire processus vaginalis persists, it becomes a congenital indirect inguinal hernia. Gubernaculum testis is the fetal ligament that connects the bottom of the fetal testis to the developing scrotum. Hematocele is an effusion of blood into the cavity of the tunica vaginalis. Cryptorchidism is failure of the testis to descend from the abdomen to the scrotum.
99
Where do portal-caval anastomoses occur?
Portal–caval anastomoses occur between the left gastric vein and esophageal vein of the azygos, the superior rectal and middle or inferior rectal veins, paraumbilical and superficial epigastric veins, and retrocolic veins and twigs of the renal vein.
100
Mrs. Jones is undergoing a routine colonoscopy for colon cancer prevention. The gastroenterologist finds a Meckel’s diverticulum. Where is this found and what is it?
It is a persistent remnant of the embryonic yolk sac, found 2 feet proximal to the ileocecal valve.
101
A 54-year-old man comes to a hospital with abdominal pain, jaundice, loss of appetite, and weight loss. On examination of his radiograms and CT scans, a physician finds a slowly growing tumor in the uncinate process of the pancreas. What artery is most likely compressed by this tumor?
Superior mesenteric. The uncinate process sits behind the superior mesenteric artery.
102
A 21-year-old man developed a hernia after lifting heavy boxes while moving into his new house. During the repair of his resulting hernia, the urologist recalls that the genitofemoral nerve:
1. Runs in front of the quadratus lumborum
2. Is a branch of the femoral nerve
3. Supplies the testis
4. Passes through the deep inguinal ring
5. Gives rise to an anterior scrotal branch
Passes through the deep inguinal ring = this is where the nerve divides and the genital branch enters the deep inguinal ring
## Footnote
Runs in front of the quadratus lumborum: it runs in front of the psoas muscle
Is a branch of the femoral nerve: it arises from the lumbar plexus
Supplies the testis: doesn't supply the testis
Gives rise to an anterior scrotal branch: ilioinguinal nerve supplies these
103
During surgical treatment of portal hypertension in a 59-year-old man with liver cirrhosis, a surgeon inadvertently lacerates the dilated paraumbilical veins. The veins must be repaired to allow collateral flow. Which of the following ligaments is most likely severed?
1. Leinorenal ligament
2. Leinogastric ligament
3. Gastrophrenic ligament
4. Ligamentum teres hepatis
5. Ligamentum venosum
The paraumbilical veins and the ligamentum teres hepatis are contained in the free margin of the falciform ligament.
104
A 43-year-old woman is admitted to a hospital because of deep abdominal pain in her epigastric region. On examination, it is observed that a retroperitoneal infection erodes an artery that runs along the superior border of the pancreas. What artery is likely injured?
Splenic
105
A 19-year-old young woman with a long history of irritable bowel syndrome presents for the possibility of surgical resection of the gastrointestinal (GI) tract where the vagal parasympathetic innervation terminates. What site is most appropriate for surgical resection?
Left colic flexure. The vagus nerve supplies parasympathetic nerve fibers to the GI tract and terminates approximately at the left colic flexure.
106
A 58-year-old man is admitted to a hospital with severe abdominal pain, nausea, and vomiting resulting in dehydration. Emergency CT scan reveals a tumor located between the celiac trunk and the superior mesenteric artery. Which of the following structures is likely compressed by this tumor?
1. Fundus of the stomach
2. Neck of the pancreas
3. Transverse colon
4. Hepatopancreatic ampulla
5. Duodenojejunal junction
The pyloric canal and the neck of the pancreas are situated anterior to the abdominal aorta between the origin of the celiac trunk and the superior mesenteric artery. The transverse colon passes anterior to the superior mesenteric artery and the third part of the duodenum. The other structures are not located in front of the aorta.
107
During development, the midgut artery appears to be markedly narrowed at its origin. Which of the following structures is derived from the midgut and may receive inadequate blood supply?
1. Gallbladder
2. Stomach
3. Ascending colon
4. Descending colon
5. Rectum
Ascending colon. The ascending colon is derived from the midgut. The gallbladder and stomach are derived from the foregut, and the descending colon and rectum are derived from the hindgut.
108
A 33 year old female comes in with a positive pregnancy test. During your examination you note that the shape of her pelvis may put her at risk for cesarian section. What pelvic shapes can cause this?
Gynecoid is the normal female type. Platypelloid or markedly android pelvises may present hazards with vaginal deliveries.
109
What distances do you measure when determining if a woman can safely deliver a baby vaginally or not?
Diagonal conjugate. The middle finger touches the sacral promontory and the distance is measured from there to the pubic symphysis. This distance should be 11cm.
Interspinous distance. The distance between the two ischial spines should be at least 3 fingers wide.
110
A 22 year old primigravida gave birth to a 17 pound child. She obviously tore some of her pelvic floot and experiences bladder incontinence. What muscles are most commonly torn in these scenarios?
The most medial parts of the levator ani (pubococcygeus and puborectalis).
111
What two procedures on the female reproductive system put the ureters at risk for ligation?
Ovariectomy and hysterectomy. The ureter runs very close to the uterine and ovarian arteries.
112
A patient comes to the operating room with severe pelvic hemorrhage after a car accident. The surgeon permanently ligates the internal iliac artery. What will happen to this patient?
Nothing more than decreased blood pressure beyond the ligation. The vessels in this region anastamose and maintain blood flow to the pelvic, gluteal and genital regions. Anastamoses include lumbar/iliolumbar, median sacral/lateral sacra, superior rectal/middle rectal and inferior gluteal/profunda femoris arteries.
113
A patient comes to see you describing an intense pain radiating from his loin to his groin. CT imaging is shown below. What is your diagnosis?
Ureteric Calculi
114
A 23 year old comes to see you after giving birth 2 weeks ago. She says something comes out of her vagina everytime she bears down. What is causing this and what is your diagnosis?
Cystocele. During childbirth, tearing of the perineal muscles or fascial support can result in collapse of the bladder onto the anterior vaginal wall. She is seeing the anterior vaginal wall herniate through the vestibule.
115
What is a good place to enter if you need to extract urinary calculi?
Just above the pubic symphysis. When the bladder is distended, it rises above the symphysis, between the peritoneum and anterior abdominal wall.
116
What structures can be palpated through the wall of the anterior inferior rectum?
Prostate, seminal vesicles, cervix, internal iliac lymph nodes, thickened ureters, and bony structures.
117
A 40 year old man is mad at his kids and storms into your office demanding a vasectomy. Where do you snip?
Superior portion of the scrotum
118
During a routine physical exam you note an abnormally shaped and firm prostate on a 60 year old male. What lymph nodes might you examine as you think about possible metastasis sites?
Internal iliac and sacral nodes
119
Why are UTIs capable of developing into peritonitis in females?
The female genital tract communicates with the peritoneal cavity via the abdominal ostia of the uterine tubes.
120
A 29 year old female comes to the ER with her friend complaining of severe right lower quadrant pain. The pain is so severe that she has a vasovagal response and passes out. Her pre-med friend tells you that she thinks her appendix burst. After pulling out the ultrasound, you note that her appendix has already been taken out. What is another possible diagnosis?
This woman could have had a right ectopic pregnancy that burst and caused hemorrhage into the abdominopelvic cavity and resulting peritonitis.
121
A 23 year old female is pregnant and comes to see you at 8 weeks. She complains of lower quadrant pain and has a history of chlamydia infection that resulted in pelvic inflamatory disease. You tell her she was lucky to get pregnant in the first place, but has had an ectopic pregnancy due to adhesions blocking entry to the uterus. Where is the most common site of implantation in ectopic pregnancies?
Uterine tubal ampulla
122
What is your diagnosis of the image seen below?
A bicornate uterus
123
A 44 year old female comes to see you for a physical exam. She is battling liver cancer and has ascites. You note the extensive bloating and pressure in her abdomen. How might this condition be affecting her uterus?
Increased intra-abdominal pressure puts you at risk for uterine prolapes, and you are at higher risk if you have a retroverted uterus because it is sitting directly above the vaginal canal.
124
How does the anatomy of the uterus change over time?
Newborn = large from mom's hormones
Shrinks until puberty where it then grows again.
Changes in size each month as a gravid adult
Expands to the costal margin in pregnancy
Edematous after birth
Large and nodular in multiparous adult
Shrinks during menopause
125
A 28 year old female is diagnosed with cervical cancer. To what other organ can this cancer easily metastasize?
Bladder. There is no periteoneum that separates the two structures.
126
Why do newborns come out sideways as their shoulders exit the birth canal?
The vaginal stretchs most in the longitudinal plane and least in the transverse plane.
127
A woman comes to your clinic for a follow up visit after giving birth 2 weeks ago. She complains that urine is constantly dripping out of her vagina. What is going on?
She sustained a tear through the vaginal wall that formed a vesicovaginal fistula, allowing urine that should accumulate in the bladder to exit into the vagina.
128
A 38 year old patient comes to see you with pelvic inflammatory disease. Physical exam reveals distension in the peritoneal cavity and you tell her you will drain some fluid for her. How do you do this?
You perform a culdocentesis by passing the needle through the posterior fornix and into the recto-uterine pouch
129
During a labroscopic surgery you are looking to see if everything is good with the bladder, fundus of uterus, uterine tubes and ovaries. Can you see those in this image?
130
What are the different anesthetic blocks available to laboring women that can be given to lessen the pain but keep them awake?
Spinal (subarachnoid space at L3-L4 anesthetizes from the waist down). Pudendal (perineum and inferior 1/4 of vagina). Caudal (Cervix, superior vagina and pudendal nerve)
131
What structure is the final support of the pelvic viscera, which can result in cystocele, rectocele and enterocele if torn?
Perineal body. It links all of the muscles of the pelvic floor (puborectalis, pubococcygeus, ileococcygeus)
132
What structure is cut in an episiotomy?
Perineal body
133
What is the difference between external and internal hemorrhoids? Which ones are more painful to treat?
External = clot in external rectal venous plexus. More painful to treat because they are somatic.
Internal = smooth muscle layer breakdown. Less painful to treat because they are visceral.
134
You are doing rounds at the hospital and the resident decides to give you a right of passage by allowing you to catheterize someone's bladder. When doing so, where in the urethra do you need to be most gentle?
At the intermediate urethra. It is at this point the urethra is thin, unprotected, and makes a 90 degree turn.
135
What causes hypospadias?
Failure of the urogenital folds to fuse during development. This results in the external urethral orafice being located further down the body of the penis.
136
What ways can you fix erectile dysfunction?
If it is due to nerve damage (prostatic or cavernous plexuses) you can install an inflatable pump. If it is due to autonomic control or endocrine reasons you can give medication to stimulate vasodilation of the deep arteries of the penis and allow filling of the corpora cavernosa and corpus spongiosum.
137
What venous structures are highly susceptible to injury in a woman who has been sexually assaulted?
The highly vascular bulbs of the vestibule.
138
A woman decides that she wants a pudendal nerve and ilio-inguinal nerve block for childbirth. How do you go about blocking these nerves?
Pudendal: where the pudendal nerve crosses the sacrospinous ligament near the ischial spine. Ilio-inguinal: see below.
139
How do Kegel exercises help women in childbirth?
Normally the superficial transverse perineal muscle, bulbospongiosus and external anal spincter (all attached to the perineal body) are underdeveloped in women. Voluntarily stopping urination will strengthen these muscles and allow for control during childbirth.
