Clinical Anatomy Questions Flashcards
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?
Sternum
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.
Where do sympathetic nerve impulses enter the ganglia? Where do they exit the ganglia?
In the white and out the grey rami communicantes
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.
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).
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.
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.
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.
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%.
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.
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)
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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?
- Superior mesenteric vein to the inferior mesenteric vein
- Portal vein to the SVC
- Portal vein to the left renal vein
- Splenic vein to the left renal vein
- 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.
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?
- Short gastric arteries
- Dorsal pancreatic artery
- Inferior pancreaticoduodenal artery
- Left gastroepiploic artery
- Artery in the gastrorenal ligament
- 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)
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.
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.
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.
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.
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.
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
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.
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
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
What is your diagnosis of the image seen below?
A bicornate uterus
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
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?
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)
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.
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.
