Review Questions Flashcards
A 48-year-old male with a history of alcoholism is brought into the ER with severe epigastric pain and hematamesis. Upon physical examination you find him to be jaundiced and tachycardic with low blood pressure. Other physical findings include ascites and splenomegaly; and tortuous dilated veins radiating from the umbilicus (caput medusae). The patient also tells you that he often has bloody stools, and a rectal examination indicates he has hemorrhoids.
- What is your Dx?
- What other abnormalities might be present in this patient?
- Suggest possible treatments for lowering the blood pressure in the portal system.
- Portal hypertension
- Esophageal varices, hemorrhoids, ascites
- Surgical shunting of portal system blood into a caval vein
A 45 year-old male with a long history of alcoholism is admitted to the hospital with jaundice. A radiographic study reveals ascites, portal hypertension and liver cirrhosis. Which of the following veins are likely to be responsible for the production of the ascites?
A.Paraumbilical veins
B.Esophageal anastamoses with azygos tributaries
C.Anastamosing vessels between parietal veins and veins of retroperitoneal intestine
D.Superior rectal and middle rectal veins
C. Anastamosing vessels between parietal veins and veins of retroperitoneal intestine
As seen in the radiograph, bowel loops are positioned centrally due to the presence of _______.
ascites
patient with cirrhosis is scheduled for liver transplant surgery. During the operation rounds, the transplant physician quizzes his students and asks which of the following statements is true of the liver:
A. Receives blood only from the hepatic arteries
B. Drains venous blood into the hepatic veins
C. Manufactures red blood cells in an adult
D. Blood supply to the quadrate lobe comes from the right hepatic artery
E. Functions to concentrate and store bile
B. Drains venous blood into the hepatic veins
Your patient develops a gastric ulcer that erodes away the posterior wall of his stomach. As gastric juices and stomach contents leak out of the stomach, where would they accumulate?
The ulcer then erodes the area posterior to the stomach. Which organ and blood vessel might be damaged by the stomach acid?
If the ulcer were posterior to the first part of the duodenum, which vessel might be damaged?
accumulation in the lesser sac
pancreas and splenic artery would be damaged by the acid
gastroduodenal artery is near the first part of the duodenum
A 55 year old male is admitted to the hospital because of severe weight loss over the preceding 6 months. A CT scan and other tests indicate that a tumor(arrows) is causing portal hypertension. Laboratory studies reveal that the patient has fat in the stool, malnutrition and liver hypoxia. At which of the following locations is the tumor most likely located?
A. Right lobe of liver
B. Left lobe of liver
C. Porta hepatis
D. Falciform ligament
E. Hepatogastric ligament
C. Porta hepatis
A 60 year old man is admitted to the emergency department with severe abdomional pain. An abdominal CT angiogram (below) shows a thrombus in an intestinal artery supplying a loop of intestine. Which of the following layers of peritoneum will the surgeon have to enter to access the affected vessel through an incision through the abdominal wall?
A. Parietal peritoneum and the greater omentum
B. Greater and lesser omentum
C. Lesser omentum and gastrosplenic ligament
D. Parietal peritoneum and the mesentery
E. Greater omentum and the gastrohepatic ligament
D. Parietal peritoneum and the mesentery
You perform a vagotomy (sectioning of the vagal trunks) to improve you patient’s gastric ulcer situation. How could this procedure reduce your patient’s symptoms?
Would the functioning of the descending colon be affected by this procedure?
The vagus nerve supplies parasympathetic innervation to the GI tract up to the proximal 2/3 of the transverse colon – secretion of acid is modulated by the parasympathetic system.
No – the pelvic splanchnic nerves supply parasypathetic innervation to the hindgut
Patients who have perforated gastric ulcers are often propped up in bed. In anatomical terms, explain the reason for a patient being placed in this position.
Suppose you detect a collection of infected material in the peritoneal cavity in the region of the anterior surface of the second part of the duodenum. Indicate the pathways along which the material may spread to reach the:
a) undersurface of the diaphragm
b) the pelvic cavity
Sit the patient up so that the stuff drains downwards.
To get to the udersurface of the diaphgragm, fluid would need to exit at the epiplioc foramen of Carl Winslow and into the hepatorenal recess (of Morrison).
To get to the pelvic cavity, fluid would need to exit the foramen, travel down the paracolic gutters and into the pelvis.
An arteriogram of a 75 year old patient shows that the celiac trunk is occluded by atherosclerotic plaque.
Name the branches of the celiac trunk and the organs that are normally supplied by this artery.
Which structures are supplied by the SMA and IMA?
Branches of celiac trunk are: left gastric artery; splenic artery –> left gastroepiploic; common hepatic, proper hepatic and right gastric artery, gastroduodenal, and right gastroepiploic artery. These supply foregut structures (lower esophagus –> 2nd part of duodenum), spleen, and liver.
SMA supplies the midgut (3rd part of duodenum –> proximal 2/3 of transverse colon)
IMA supplies the hindgut (distal 1/3 of transverse colon –> rectum)
Which structure is retroperitoneal in position and receives blood from the splenic artery?
C – the pancreas is secondarily retroperitoneal and receives branches from the splenic artery
-the spleen is intraperitoneal
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?
A. Left and right suprarenal veins
B. Left and right colic veins
C. Left and right gastroepiploic veins
D. Left and right ovarian veins
E. Left and right hepatic veins
E. Left and right hepatic veins
A patient with diverticulosis of the sigmoid colon presents for follow-up to his primary care physician with ongoing complaints of left lower quadrant pain and occasionally bloody stools. Which of the following is true of the sigmoid colon?
A. Receives its blood from the superior mesenteric artery
B. Is drained by systemic veins
C. Receives parasympathetic fibers from the vagus nerve
D. Has teniae coli and epiploic appendages
E. Is a retroperitoneal organ
D. Has teniae coli and epiploic appendages
A twenty-six year old female arrives in the ER after being hit by a motor vehicle while crossing the street. The patient’s only complaints are abdominal tenderness and left shoulder pain. Her abdomen is tender on palpation of the left upper quadrant, with a faint tire mark over that area; in addition you detect crepitus (indicating fractured ribs) over the 9th,10th, and 11th ribs on the left side. You order a diagnostic CT scan to assess her injury.
- What type of injury do you suspect?
- What other structures lie within this quadrant and are at risk for injury?
- Suppose you had to remove the spleen. What is the major arterial supply of the spleen? What other major branches arise from this artery?
- Ruptured spleen
- Stomach, splenic flexure of the colon, tail of the pancreas, left kidney and adrenal gland
- Splenic artery, left gastro-epiploic artery and short gastric arteries
Name three signs of a splenic rupture.
- Hypotension
- LUQ pain
- Referred pain to left shoulder (phrenic nerve C3, 4, 5)
A 29 year old man who has been diagnosed with acute appendicitis exhibits a “positive psoas sign”.
What is a “psoas sign” and why would some types of appendicitis produce it?
What other type of pathology might produce a psoas sign? Where might one feel a mass with this type of pathology?
Psoas sign is pain upon extending the thigh due to inflamed psoas major muscle or appendicitis (appendix is just anterior to the psoas major).
Tuberculosis which invades the lumbar spine; inflamed appendix, pancreas, sigmoid colon can produce a positive psoas sign.
A 45-year-old man complains of heartburn, substernal pain and the feeling of regurgitation after he eats. What might be the cause of his symptoms?
GERD
A 32 year old woman is admitted to the hospital for the delivery of her baby. Her obstetrician decides to perform an emergency Cesaerian section. A Pfannensteil incision is used to reach the uterus by making a transverse section through the external rectus sheath about 2 cm above the pubic symphyses. Which of the following nerves is most at risk when this incision is made?
A. T10
B. T11
C. Iliohypogastric
D. Ilioingiuinal
E. Lateral femoral cutaneous
C. Iliohypogastric
A 53 year old male is admitted to the ER with severe upper abdominal pain. Gastroscopy reveals a tumor in the antrum of the stomach. A CT is ordered to evaluate lymphatic enlargement of the stomach and other nodes. Which of the following lymph nodes is most likely to be involved in a malignancy of the stomach?
A. Superficial inguinal
B. Lumbar
C. Celiac
D. Superior mesenteric
E. Inferior mesenteric
C. Celiac
A mother brings her 2-week old baby to the pediatrician because he exhibits “projectile vomiting” of curdled milk (milk mixed with gastric acid) stained with bile. You suspect an obstruction somewhere along the baby’s GI tract. An X-ray shows a “double-bubble” sign in which both the stomach and part of the duodenum is extended.
- What do you suspect could be the problem with this child?
- Which other abnormal conditions might explain his problems?
Obstruction of the duodenum beyond the hepatopancreatic ampulla: annular pancreas or SMA syndrome or duodenal atresia.
check the double-bubble sign in the photo…
A 4 day old infant vomits the contents of his stomach but the vomitus does not contain bile. There is no evidence that he is choking. Which of the following conditions will best explain his symptoms?
A. Duodenal stenosis
B. Duodenal atresia
C. Hypertrophied pyloric sphincter
D. Tracheoesophageal fistula
E. Esophageal atresia
What if the infant exhibited signs of choking or aspiration pneumonia?
C. Hypertrophied pyloric sphincter
Choking or aspiration pneumonia could be due to:
●Esophageal Atresia (EA) – congenital malformation that represents the failure of the esophagus to develop a continuous passage into the stomach
●Tracheo-esophageal Fistula (TEF) – malformation where the trachea and esophagus fails to separate into distinct structures and a passage is created between them
A 47 year old obese man experiences nausea, vomiting, abdominal distension and stabbing pain after eating. It appears to be relieved when he leans forward or puts his knees to his chest.
A CT scan reveals a dilated superior mesenteric artery and you diagnose the patient with Superior Mesenteric Artery Syndrome.
Why would the SMA cause these symptoms? Which other problems might result from a dilated SMA?
SMA syndrome compresses the third part of the duodenum –> distension of the 1st and 2nd parts of the duodenum, nausea, comiting, etc.
Other symptoms like hematuria can result from compression of the left renal vein, which the left gonadal vein drains into –> edema of the left testicle or artery.
While on the pediatric surgery service, you are called to the neonatal intensive care unit to evaluate a thirty-six hour old infant. Auscultation reveals an absence of breath sounds on the left side of his chest, but you note apparent bowel sounds on the left side of the chest. The patient has no bowel sounds within his abdomen. The resident orders a chest x-ray, which demonstrates bowel within the thorax.
- What is your diagnosis?
- Where in the diaphragm does this type of pathology most often occur?
- What normal apertures are found in the diaphragm , and what structures pass through each aperture?
- Congenital diaphragmatic hernia
- Posteriolateral part of the diaphragm, usually on the left side
- IVC - T8
Esophagus, vagal trunks, branch of the left gastric artery - T10
Aorta, thoracic duct, azygos vein - T12
A 59-year-old man suddenly experiences an excruciating colicky pain across the upper part of her abdomen. Two days later the patient became jaundiced and it was noticed that the degree of jaundice varied from day to day. Radiographic studies reveal a tumor in the head of the pancreas. Which of the following structures is most likely being obstructed?
A. Proper hepatic artery
B. Accessory pancreatic duct
C. Common hepatic duct
D. Common bile duct
E. Cystic duct
What other symptoms might the patient exhibit eventually?
D. Common bile duct
Other symptoms: pancreatitis, steatorrhea
A forty year old slightly obese female presents to the ER with spasmodic, colicky pain in her right upper quadrant, with some right shoulder discomfort and accompanying nausea and vomiting. She is noticeably uncomfortable on deep inspiration, and palpation reveals an increase in pain while palpating the RUQ.
- What do you think is this patient’s problem?
- Which clinical diagnostic test would you use to confirm your diagnosis?
- Why might the patient experience right shoulder discomfort?
- During a laparoscopic procedure to remove the offending organ, the surgeon is responsible for dissecting out the cystohepatic triangle (of Calot) ; what are the borders of the triangle?
- Cholecystitis
- Ultrasound
- Inflamed gallbladder irritating the right hemidiaphragm
- Cyctic duct, hepatic duct, liver
During a laparoscopic cholecystectomy on a 67 year old female, which of the following arteries must be clamped to remove the gallbladder safely?
A. Common hepatic
B. Proper hepatic
C. Right hepatic
D. Left hepatic
E. Cystic
Which artery is this usually a direct branch from?
What is the landmark that surgeons use to locate this artery?
E. Cystic, a branch from right hepatic a.
The Triangle of Calot is the landmark
Your patient has a retroperitoneal infection. Which of the following organs would most likely be susceptible to the infection:
A. spleen
B. jejunum
C. duodenum
D. sigmoid colon
E. Transverse colon
C. Duodenum
A 43 year old female is diagnosed with midgut volvulus and intestinal ischemia. A laparotomy is performed to release the obstruction. Which of the following structures is used as a landmark to determine the position of the duodenojejeunal junction?
A. Vasa recta
B. Superior mesenteric artery
C. Inferior mesenteric artery
D. Ligament of Treitz
E. The proximal attachment of tenia coli
D. Ligament of Treitz
A patient arrives in your office complaining of sharp pain which began in the right postero-lateral abdominal wall and which now moves down into his groin. He also reports seeing a little blood in his urine this morning.
What might you suspect is going on with this patient?
What might you do to confirm your suspicion? What would the treatment be?
An intravenous pyelogram revealed that the calyces and pelvis of the right kidney were grossly dilated. Why?
Suspect a kidney stone
Take a KUB X-ray or ultrasound. Tx is hydration, pain meds
Dilated kidney from obstruction of the ureter
The white arrow in the image below points to a kidney stone. Based on the anatomy shown in the radiograph, where is this stone located?
A. At the junction of the ureter and pelvis
B. In the middle of the abdominal ureter
C. In the ureter as it passes anterior to the common iliac artery
D. In the kidney
E. In the adrenal gland
D. In the kidney
A 30-year old man comes to your office with significantly elevated blood pressure, rapid heart rate, sweating and elevated metabolism. A CT scan shows a large mass just above his left kidney.
What is your diagnosis?
Phaeochromocytoma
Which of the following is incorrect pertaining to the structure indicated by the red arrow in the coronal CT shown below?
A. The right gland is exclusively supplied with blood via an artery that branches from the right renal artery
B. The diaphragm is posterior to both the right and left glands
C. The left gland is typically drained exclusively via a vein that empties into the left renal vein
D. Both left and right glands are retroperitoneal
E. Preganglionic sympathetic fibers reach the chromaffin cells in the medulla
A. The right gland is exclusively supplied with blood via an artery that branches from the right renal artery
You are on your Ob/Gyn rotation and are assisting in a delivery. The baby’s head has descending into the pelvic cavity (true pelvis). The head has already passed through the superior pelvic aperture (pelvic inlet); your job is to guide it through the inferior pelvic aperture (pelvic outlet).
- What are the boundaries of these two apertures? It looks like the baby’s head is quite large and might tear the vaginal opening.
- What ligaments support the bony pelvis and which structures form the floor of the pelvis?
Pelvic inlet boundaries: a plane from the sacral promontory to the superior pubis symphysis.
Pelvic outlet boundaries: tip of coccyx to lower pubic symphysis.
See pic for ligaments
A 27 year old man arrives in the ER after a motor vehicle accident. He is hypotensive and in extreme pain. His pelvic CT scan is shown below. What major complication are you concerned about?
Massive bleeding from rupture of internal iliac branches
A 43-year-old man is brought to the ER after being struck by a car. Radiographic imaging reveals a rotationally unstable pubic ramus fracture, which is depicted below. Which of the following structures is most likely damaged specifically by the fracture of the superior pubic ramus?
A. Sympathetic chain
B. Superior gluteal artery
C. Vas deferens
D. Piriformis muscle
E. Sciatic nerve
Which parts of the pelvis have been fractured?
C. Vas defrens
Superior and inferior pubic rami were fractured
You decided to perform a mediolateral episiotomy. What is an episiotomy?
Explain the difference between a mediolateral episiotomy and a median episiotomy.
Name the muscles that would be cut in each type.
An episiotomy is a surgical incision of the perineum and the posterior vaginal wall during second stage of labor to quickly enlarge the opening for the baby to pass through and decrease the degree of tearing of the muscles around the vaginal opening.
Mediolateral episiotomy avoids the perineal body and cuts through the bulbospongiosus muscle. A median episiotomy cuts the bulbospongiosus and the perineal body, where the superficial transverse perineal muscle attaches.
A 21-year-old woman asks about her first bimanual examination, and it is explained to her that the normal position of the uterus is:
A. Anteverted and retroverted
B. Retroverted and retroflexed
C. Anteflexed and retroverted
D. Anteverted and anteflexed
E. Retroflexed and anteverted
D. Anteverted and anteflexed
- Crus of penis
- Corpora cavernosa
- Corpus spongiosus
- Piriformis
- Levator ani: pubococcygeus
- Sphincter urethrae
- Deep transverse perineal muscle
- External anal sphincter
- Iliococcygeus muscle
- Bulbospongiosus
- Ischiocavernosus
- Pudendal nerve
- Superficial transverse perineal muscle
- Piriformis
- Coccygeus
- Levator ani
- Membranous urethra
- Obturator internus fascia
- Seminal vesicles
- Prostate
- Seminal vesicles
- Corpus spongiosum
- Corpus cavernosum
- Corpus cavernosum
- Corpus spongiosum
- Spongy urethra
- Membranous urethra
- Prostatic urethra
- Bulb of vestibule
- Ischiocavernosus
- Levator ani: pubococcygeus
- Bulb of vestibule
- Iliococcygeus
- External anal sphincter
- Deep transverse perineal muscle
- Bulbospongiosus
- Fascia of pelvic diaphragm
- Superficial transverse perineal muscle
Ischioanal fossa filled with fat
- Ureter
- Uterine artery
- Round ligament of the uterus
