Abdominal anatomy

• Your 37-year-old male patient on your pulmonary therapy service has a history of asthma and is a chain smoker. By now, he has developed emphysema. When measuring peak flow, you note how he labors to exhale. Which of the following muscles are responsible for active expiration? • Answer Choices • 1 • External intercostal muscles • 2 • Internal intercostal muscles • 3 • Sternocleidomastoid muscle • 4 • Anterior serrati muscles • 5 • Scaleni muscles

: Internal intercostal muscles • uring forced expiration

A 44-year-old female presents to the emergency room with a two-day history of intermittent right upper quadrant abdominal pain, which is exacerbated by fatty and fried meals. The pain is sharp and radiates to her right arm and scapula. She indicates that she has had similar symptoms at least twice over the past year. On physical examination, she is overweight (BMI= 29) in mild distress. Her vital signs are temperature = 37.2° C, heart rate = 96 beats per minute, blood pressure = 168/84. Her lungs are clear to auscultation bilaterally, her heart is regular rate, and rhythm, her abdomen is non-distended, soft, and tender to palpation over the right upper quadrant. On palpation, and pressure of the right upper quadrant she stops breathing for a moment, and complains of pain (positive Murphy's sign). Her laboratory tests reveal normal white count and normal liver function tests. What is the most appropriate next step in the management of this patient? Answer Choices 1 Surgical consultation 2 Abdominal CT with intravenous contrast 3 Oral ursodeoxycholic acid (Actigall®) and follow up 4 HIDA scan 5 Abdominal ultrasound

Abdominal ultrasound Explanation The most common lesion affecting the gallbladder is gallstone disease. Gallstones can be found in 10% of the population in certain groups (i.e. Pima Indians as high as 50%) and 1 to 2% of these cases become symptomatic. Risk factors for the development of cholesterol stones are the classic four F's (Female, Fertile, Forty, Fat).

Early one afternoon, a male adolescent presents with abdominal pain, nausea, and vomiting. The pain has been worsening since the onset of symptoms in the morning. There is no known gastrointestinal disease in the history; no one in the immediate environment has one either. Physical examination finds no abdominal tenderness, but Psoas sign and tenderness on rectal examination are detected. Temperature and pulse are slightly elevated. Skin turgor is reduced, and there is a 10 mm Hg drop in postural blood pressure. Laboratory studies find 18,000 white blood cells per microliter. What is the most likely diagnosis? Answer Choices 1 Acute mesenteric lymphadenitis 2 Acute appendicitis 3 Salmonella gastroenteritis 4 Meckel's diverticulitis 5 Regional enteritis

Acute appendicitis Explanation The course and signs of the disease indicate appendicitis. The lack of abdominal tenderness and positive rectal examination indicate inflammation of retrocecal or pelvic appendix. Salmonella gastroenteritis would likely affect other persons in the child's environment. Regional enteritis is associated with a prolonged history. Acute mesenteric lymphadenitis poses a differential diagnostic challenge more frequently among children than adults. The diagnosis is impossible clinically, although the temperature tends to be higher and the pain is more diffuse. Culture of mesenteric nodes and serologic titers confirms Yersinia infection in some patients. Meckel's diverticulitis is rare, but it is impossible to distinguish from appendicitis. Considering the risk of perforation and limited observation, if unavoidable, overdiagnosis is preferred in cases of suspected appendicitis.

A 58-year-old man is seen in the hospital urgent care center complaining of a recent episode of rectal bleeding. A brief history reveals that his bowel patterns have been increasingly erratic over the past 6 weeks. He reports periods of 2-6 days without bowel movements followed by copious production of thin coils of stool. He has lost 10 pounds over the last month. His family history is significant for death due to colon cancer of his cousin. Physical exam reveals the patient is pale, febrile (temperature: 101F), the rectal exam is heme-positive with scant stool, and his prostate is soft and moderately enlarged. Question What is the most appropriate evaluation method in the diagnosis of colorectal cancer? Answer Choices 1 Abdominal plain film 2 Barium enema 3 Colonoscopy 4 Anoscopic examination 5 Exploratory laparotomy

Colonoscopy Explanation In the United States, colorectal cancer is the 3rd most common cancer occurring in both men and women. The key to a good prognosis is early detection of the cancer. The correct answer is colonoscopy. This patient presents with signs and symptoms consistent with colorectal cancer. The gold standard technique for examination of the colon and rectum is colonoscopy. To view a colonoscopic mass lesion, refer to the image. In symptomatic patients having a positive family history of colorectal cancer, colonoscopy is a useful imaging modality for the diagnosis of colorectal cancer. It has a diagnostic role by evaluating and detecting the cause of symptomatology or excluding the presence of malignancy by direct visualization. Colonoscopy has the advantage of direct bowel visualization, biopsy, and excision of lesions when present. In this case, Abdominal plain films would probably not provide as much information as the other imaging modalities would.

A 26-year-old, Filipino male, presents to the emergency room with a 7-hour history of abdominal pain that localized to the right lower quadrant. He also complains of nausea and vomiting. There is no history of diarrhea, constipation, chills, or fever. He has not eaten anything in the past 24 hours and has no appetite. He has an unremarkable past medical history and has had no operations. He has no allergies and does not take any medications. He does not smoke or drink. His vital signs are as follows: Temperature = 37.5 ° C, Heart Rate = 100, Blood Pressure = 124/82 and respiratory rate = 18. On physical examination, there is tenderness over the right lower quadrant, rectal exam is normal. The rest of the physical exam is within normal limits. The following laboratory data is available: Hb 14.4 gm/dl Hct 42.2 % WBC 15,0000 Neutrophils 70% BUN 24 mg/dl Creatinine 1.2 mg/dl Question Highlights What is the next immediate step in the management of this condition? Answer Choices 1 A STAT surgical consult 2 Intravenous antibiotics 3 A CT-Scan of the abdomen with and without contrast 4 An intravenous pyelogram 5 A Nephrology consult to rule out pyelonephritis

Correct Answer: A STAT surgical consult

A 52-year-old man presents with vomiting and epigastric distress for the past few hours. He has been drinking alcohol for over 20 years, and he has been a moderate-to-heavy drinker. 5 years ago, he was diagnosed with a "gastric/duodenal ulcer", for which he has been taking cimetidine and antacids. The pain now radiates towards the left along the costal margin. He has noticed his appetite has been reduced lately, and his stools are bulky and foul smelling. His friends have commented on his sickly look and weight loss. What is the most likely diagnosis? Answer Choices 1 Chronic pancreatitis 2 Acute recurrent pancreatitis 3 Myocardial infarction 4 Acute cholecystitis 5 Left sided ureteric colic

Correct Answer: Chronic pancreatitis Explanation Chronic pancreatitis is common in alcoholics when pancreatic proteins become denatured and cause destruction of glandular and ductal tissue in the pancreas. There is recurrent epigastric or upper abdominal colicky pain; it radiates towards the left, usually along left costal margin in the direction of the tail of the pancreas. There may be nausea and vomiting along with weight loss, appetite disturbance, and bowel disturbance. Due to fat malabsorption, the stools are bulky and foul smelling, which is called steatorrhea. There may be varying degrees of liver and gall bladder problems accompanying chronic pancreatitis. ERCP is the best diagnostic tool. Acute recurrent pancreatitis is usually a more acute event that is initiated by pathologic activity within the glandular/ductal system. Deep epigastric pain radiates to the back, and it is relieved by leaning forward. There may be an accompanying fever with a history of similar attacks in the past. An inferior MI can mimic this clinical picture, but pain direction, radiation, and EKG would be diagnostic. Acute cholecystitis is more common in women, and it can be excluded by direction and radiation of the pain leaning towards the right hypochondrium. In left ureteric colic, the pain would not present in the epigastrium; instead, it would be located more in the left lumbar region and flank, and it would radiate towards the scrotum on that side.

Question A 56-year-old man presents with abdominal pain, indigestion, weight loss, nausea, and vomiting, and gray colored stools for the past month. His past medical history is positive for alcoholism. Lab results demonstrate an elevated serum amylase and lipase, decreased trypsinogen, and a positive fecal fat test. What is the most likely diagnosis? Answer Choices 1 Acute pancreatitis 2 Chronic pancreatitis 3 Pancreatic carcinoma 4 Pacreatic abscess 5 Insulinoma

Correct Answer: Chronic pancreatitis Explanation Pancreatitisis an inflammation or infection of the pancreas. Chronic pancreatitis, which is the correct response, is caused by alcohol abuse, hemochromatosis (a condition of excess iron in the blood), and other unknown factors. Inflammation and fibrosis cause the destruction of functioning glandular tissue in the pancreas. This results in an inability to properly digest fat caused due to a lack of pancreatic enzymes. The production of insulin is also affected. Symptoms include abdominal pain (mainly in the upper abdomen), nausea, vomiting, weight loss, and fatty stools. Additional symptoms may include swelling (overall), stools (clay colored), and abdominal indigestion. Tests should include serum lipase (may be elevated), serum amylase (may be elevated), serum trypsinogen (may be low), and fecal fat test (shows fatty stools). Abdominal ultrasound and CT may show an enlarged pancreas. Treatment of chronic pancreatitis includes reducing pancreas stimulation, alleviating fat indigestion, reducing pain, and treating diabetes. A reduced-fat diet, vitamin supplementation, no alcohol or caffeine, and regulation of blood sugar levels are indicated in the treatment. The chief causes of acute pancreatitis in adults are gallstones, other biliary disease, and alcohol use. Viral infection (mumps, Coxsackie B, mycoplasma pneumonia, and Campylobacter), injury, pancreatic or common bile duct surgical procedures, and certain medications (especially estrogens, corticosteroids, thiazide diuretics, acetaminophen, tetracycline) are other causes. After the triggering event, the process continues with autodigestion that causes swelling, hemorrhage, and damage to the blood vessels. An attack may last for 48 hours. Symptoms include abdominal pain (mainly located in the upper abdomen) nausea, vomiting, weakness, sweating, anxiety, fever, clammy skin, and mild jaundice. General examination may show a low blood pressure and a heart rate above 90. Most cases resolve within a week with supportive measures, such as analgesics and fluid replacement. However, some cases can be life threatening. Pancreatic abscess occurs in 5 to 10% of people with acute pancreatitis. An abscess may be caused by inadequate drainage of a pancreatic pseudocyst, which is a complication associated with pancreatitis. Symptoms include fever, chills, abdominal pain, and abdominal mass. Physical exam will show signs of pancreatitis, and tests should include an abdominal CT and ultrasound. Treatment will include laparotomy with drainage and possible resection of dead tissue. Pancreatic cancer is the 4th most common cancer causing death in the U.S. The disease is more common in men, especially those between 60 and 70 years. The cause is unknown; however the incidence is greater in smokers. A high fat diet and chemical exposures may increase the risk. Symptoms include weight loss, abdominal pain, loss of appetite, jaundice, nausea, weakness, fatigue, vomiting, diarrhea, indigestion, back pain, stools (clay colored), pallor, and depression. Tests should include a pancreatic biopsy, an abdominal CT scan, and abdominal ultrasound. Only 20% of the tumors are operable at the time of diagnosis. Palliation is generally the treatment, along with chemotherapy and radiation. Insulinomas are generally benign tumors of the insulin-secreting cells of the pancreas, which secrete excess amounts of insulin. Risk factors include a prior history of multiple endocrine neoplasia Type I (MEN I). Symptoms include sweating, tremor, rapid heart rate, anxiety, hunger, dizziness, headache, clouding of vision, confusion, behavioral changes, convulsions, and loss of consciousness. Surgery is the treatment of choice to remove the tumor. If the tumor is not found during surgery, diazoxide may be given. A diuretic is always given with this medication to avoid retaining too much salt.

Question What is the most common cause of hemodynamically significant bleeding from the lower gastrointestinal tract? Answer Choices 1 Colonic diverticula 2 Colonic cancer 3 Colonic polyps 4 Vascular ectasia of the colon 5 Inflammatory bowel disease

Correct Answer: Colonic diverticula Explanation The most common cause of hemodynamically significant hemorrhage from the lower gastrointestinal tract is colonic diverticula, which accounts for about 25% of the cases. The bleeding is typically painless and associated with voluminous hematochezia. Colonic cancer and polyps together make up about 20% of the cases of hemodynamically significant bleeding from the lower gastrointestinal tract; inflammatory bowel disease and vascular ectasia are considerably less frequent causes.

Case Ico-delete Highlights A 65-year-old man presents with a 2-day history of diffuse, colicky abdominal pain originating in the RUQ (right upper quadrant). It is not aggravated by food or activity. There has been nausea, but there has not been any vomiting. His skin and eyes have turned yellow in the last several days. His urine has been dark brown, and his stools have been white and chalky. He stopped drinking alcohol about 2 years ago and has been sober since. There is no history of drug abuse. He smokes 2 packs of cigarettes a day. He had gallstones diagnosed at the time he stopped drinking, but he refused surgery. There is a history of previously diagnosed but untreated hypertension. He denies temperature elevation, but he has felt "warm". There was an episode of "shaking chills" earlier in the day. When he walks, he gets dizzy. Vital signs are: T=103 F (oral); P=115/min; BP=100/65 mmHg; R=32/min (labored); Pulse Ox=90% (room air). Question What is the most likely cause of this man's primary problem? Answer Choices 1 Common bile duct stones 2 Smoking 3 Renal calculi 4 Hypertension 5 Alcohol abuse

Correct Answer: Common bile duct stones Explanation The most common cause of cholangitis is common bile duct (CBD) stones with obstruction of the CBD. The subsequent development of edema together with the presence of stones produces biliary stasis. Regardless of the source or bacteria, when bacterial infection occurs, cholangitis occurs. Smoking, although not healthy, has yet to be reported as causing biliary stasis, a precursor of cholangitis. Renal calculi could mimic this patient's abdominal pain, but they are unlikely to produce jaundice. Finally, although malignant severe hypertension is associated with multiple end organ failure, the gallbladder has not been reported as one of the end organs. Liver failure is associated with jaundice and hypotension; it is usually a terminal event, a state this patient has yet to reach

• A 48-year-old Caucasian male is undergoing surgical intervention for the treatment of an incarcerated hernia. At laparotomy, the surgeon finds that the incarcerated viscous contains a segment of the bowel, including the appendix. The next step the surgeon should undertake is • Answer Choices • 1 • Remove the appendix during this operation because acute appendicitis is very common and this would avoid the patient a second surgery • 2 • Ask the anesthesiologist to allow the patient to wake up for a few minutes to ask the patient what he would like • 3 • Ask the intern or a senior resident to obtain consent from the family and only after signed consent has been obtained proceed with an appendectomy • 4 • Continue with surgical reduction of the hernia without an appendectomy • 5 • Remind the anesthesiologist the importance of performing this procedure under spinal anesthesia rather than general anesthesia such that an appropriate dialogue can be established with the patient and his preference requested

Correct Answer: Continue with surgical reduction of the hernia without an appendectomy • Explanation The surgical repair of a hernia is considered a clean operation because no viscus is entered. Any time the respiratory, GU, or GI tract is entered, the wound is considered to be clean contaminated and the infection rate increases from 2% to 10%. Thus, during the reduction of a hernia, the appendix should not be removed

A 42-year-old man presents with acute abdominal pain. He describes the pain as constant and severe. Upon further questioning, he affirms that the pain radiates to his back. He leans forward in attempt to alleviate the pain. On physical examination, his temperature is 101 F and his pulse is 94. His abdomen is tender, but there is no guarding or rigidity./span>. There is discoloration in the flanks and discoloration around his umbilicus. His lab results are as follows: Question What is the name of the discoloration around this patient's umbilicus? Answer Choices 1 Cullen's sign 2 Grey Turner's sign 3 Lisker's sign 4 Kehr's sign 5 Blumberg's sign

Correct Answer: Cullen's sign This patient has signs and symptoms of acute pancreatitis,which include non-colicky abdominal pain that radiates to the back and fever. An elevated amylase, an elevated serum lipase and hypocalcemia are all also consistent with pancreatitis. The most frequent underlying cause of pancreatitis is alcoholism or biliary disease. Cullen's sign is ecchymosis around the umbilicus that can sometimes be seen with acute pancreatitis. Grey Turner's sign is ecchymosis of the flanks that can sometimes be seen with acute pancreatitis. Lisker's sign is tibial bone tenderness that can sometimes be elicited with deep vein thrombosis. Kehr's sign is pain in the left shoulder secondary to splenic rupture. Blumberg's sign is abdominal rebound tenderness. This is an indication of peritoneal irritation. References:

A 50-year-old man presents with a lump in his groin for 2 weeks. He states he was lifting an air conditioner and he felt a pop in his groin and began to notice an outpouching in his lower abdomen that has become mildly tender over the last week. Resting and lying flat appears to help, and standing and lifting aggravates it. He denies any fevers, nausea, vomiting, or changes in bowel habits. Patient denies any previous abdominal surgeries or procedures. Upon examination, you identify a soft, reducible mass in the lower abdomen and hernia examination reveals a mass pushing against the side of your finger. You order an ultrasound of the lower abdomen and find the intestinal sac has traversed through a weakened area of the abdominal wall and through Hesselbach's Triangle. Question What type of hernia does this patient have? Answer Choices 1 Direct inguinal hernia 2 Femoral hernia 3 Indirect inguinal hernia 4 Umbilical hernia 5 Incisional hernia

Correct Answer: Direct inguinal hernia Explanation Direct inguinal hernia is correct because the direct inguinal hernia enters through the weakened abdominal fascia and into the anatomic region known as Hesselbach's Triangle. This area is bordered by the rectus abdominus, the inferior epigastric artery, and the inguinal ligament. Femoral hernias, indirect inguinal hernias, and umbilical hernias do not traverse through Hesselbach's triangle. There was no previous surgery for an incisional hernia to occur.

Case A 50-year-old man presents with a lump in his groin for 2 weeks. He states he was lifting an air conditioner and he felt a pop in his groin and began to notice an outpouching in his lower abdomen that has become mildly tender over the last week. Resting and lying flat appears to help, and standing and lifting aggravates it. He denies any fevers, nausea, vomiting, or changes in bowel habits. Patient denies any previous abdominal surgeries or procedures. Upon examination, you identify a soft, reducible mass in the lower abdomen and hernia examination reveals a mass pushing against the side of your finger. You order an ultrasound of the lower abdomen and find the intestinal sac has traversed through a weakened area of the abdominal wall and through Hesselbach's Triangle. Question What type of hernia does this patient have? Answer Choices 1 Direct inguinal hernia 2 Femoral hernia 3 Indirect inguinal hernia 4 Umbilical hernia 5 Incisional hernia

Correct Answer: Direct inguinal hernia Explanation Direct inguinal hernia is correct because the direct inguinal hernia enters through the weakened abdominal fascia and into the anatomic region known as Hesselbach's Triangle. This area is bordered by the rectus abdominus, the inferior epigastric artery, and the inguinal ligament. Femoral hernias, indirect inguinal hernias, and umbilical hernias do not traverse through Hesselbach's triangle. There was no previous surgery for an incisional hernia to occur.

A 41-year-old man presents with acute hematemesis. Abdominal exam reveals distension, no rebound or guarding, hepatosplenomegaly, and dull fluid wave. What is the most likely source of the upper gastrointestinal bleeding (UGI)? Answer Choices 1 Mallory-Weiss tear 2 Perforated duodenal ulcer 3 Chronic gastritis 4 Arteriovenous malformation (AVM) 5 Esophageal varices

Correct Answer: Esophageal varices Explanation Bleeding from esophageal varices secondary to portal hypertension and obstruction of splenic blood flow is a common source of UGI bleeding presented to emergency departments. Mallory-Weiss tears and perforated duodenal ulcers may result in hematemesis, but they are associated with significant abdominal pain. Chronic gastritis is a common source of abdominal pain and may result in occult fecal blood. AVMs in the small intestine should be suspected in cases of hematochezia.

A 42-year-old man presents with severe abdominal pain in the mid-epigastric region. The pain began 3 days ago with an intensity of 10/10, concomitant nausea, and vomiting (on 2 occasions). The patient denies any significant past medical history. BP is 86/58, and pulse is 112; temp is 101.5° F. There is rebound tenderness in the midepigastric area; bowel sounds are absent, and there is a positive Cullen's sign. The rest of the physical exam is within normal limits. What are the 2 most common causes of acute pancreatitis? Answer Choices 1 Hyperlipidemia and hypercholesterolemia 2 Pancreatic cancer and chemotherapeutic drugs 3 Gallstones and alcohol abuse 4 Abdominal trauma and postoperative period 5 Peptic ulcer disease and cystic fibrosis

Correct Answer: Gallstones and alcohol abuse Explanation More than 70% of cases of acute pancreatitis are due to alcohol abuse or gallstones. Less common causes include postoperative pancreatitis, abdominal trauma, hyperlipidemia, certain drugs, hypercalcemia, peptic ulcer disease, uremia, cystic fibrosis, and viral infections. Complications such as adult respiratory distress syndrome, hemorrhagic pancreatitis, pancreatic abscess, pancreatic pseudocyst, and pancreatic ascites account for the 10% mortality rate associated with acute pancreatitis. Hemorrhagic pancreatitis can lead to retroperitoneal hemorrhage and widespread tissue necrosis, and it may require surgical intervention or peritoneal lavage. This retroperitoneal bleeding can be responsible for the discoloration or hematoma in the periumbilical area (Cullen's sign).

A 36-year-old software consultant presents with complaints of a burning sensation in his chest for the last two weeks. He has had similar symptoms in the past, on and off for about 6 months. His wife has noticed episodes of regurgitation and coughing at night. There is no dysphagia, weight loss, hematemesis, or melena. He has no other past medical history. He is a nonsmoker and does not drink alcohol. Family history is significant only for HTN in father. On exam, his BP is 120/80 mm of Hg, pulse 76/min, SPO2 92%, height 6'4, and weight 242 pounds. Physical exam is unremarkable. What would be the likely diagnosis? Answer Choices 1 Peptic ulcer disease 2 Gastroesophageal reflux disease 3 Esophageal stricture 4 Acute gastritis 5 Cholelithiasis

Correct Answer: Gastroesophageal reflux disease Explanation Gastroesophageal reflux disease, or GERD, is the most common cause of noncardiac chest pain. The classic symptoms are burning in the chest, especially at night; regurgitation; and dysphagia. Choking and coughing during sleep may also be seen. Symptoms of dyspepsia like pain or discomfort centered on the upper abdomen, belching, abdominal fullness, and satiety are common. Obesity, as in this patient, is an important aggravating factor. Other aggravating factors include caffeine, alcohol, and drugs like beta blockers, calcium channel blockers, and progesterone. Endoscopy is not necessary for diagnosis. It is only indicated in patients with long standing GERD to rule out Barrett's esophagus and for assessment of dysphagia. A barium esophagogram is done in case of dysphagia. Esophageal manometry is done in case of resistance to treatment, frequent relapses, and atypical symptoms, such as cough or asthma. Treatment should be initiated in mild to moderate GERD with H2 receptor blockers, which are effective in healing 70-80% cases. In severe cases, treatment should be with a proton pump inhibitor like omeprazole or lansoprazole for complete relief from symptoms. Peptic ulcer disease has similar symptoms of dyspepsia but is associated with nausea, vomiting, hemetemesis, melena, and occasionally acute bleeding from an ulcer with hypotension requiring emergent treatment. Endoscopy is indicated for diagnosis as well as treatment. H2 blockers or proton pump inhibitors can be used as first line of treatment. Esophageal stricture most commonly occurs in patients with long standing reflux esophagitis, as well as a variety of other clinical disorders like scleroderma, malignancy, nasogastric intubation, surgery, etc. Patients present with insidious onset of dysphagia, initially to solids, then to liquids with dyspepsia-like symptoms and regurgitation. A barium swallow should be done to assess the location and length of the stricture, since it is the least invasive and is 90-100% sensitive in detecting the subtle narrowings. Endoscopy and dilatation are the usual modes of treatment. Acute gastritis is an inflammation of the gastric mucosa usually caused by drugs like NSAIDS, alcohol, caustic ingestion, and infections like Helicobacter pylori. Symptoms include epigastric burning, nausea, vomiting, and, rarely, acute episode of gastrointestinal bleeding with hypotension and shock. Other regimens for this infection are also available. Diagnosis is based on endoscopic findings, and therapy includes removal of offending agents, proton pump inhibitors, and surface acting agents like sucralfate. If H.pylori is found to be the causative factor, then triple therapy with amoxicillin, metronidazole, and clarithromycin is used. Other regimens for this infection are also available. Fluid resuscitation and blood replacement may be needed in cases of shock. Cholelithiasis usually presents with acute epigastric or right upper quadrant pain radiating to the back and occasionally may be associated with symptoms of dyspepsia. There is right upper quadrant tenderness known as Murphy's sign. Liver enzymes and bilirubin may be raised. Ultrasound of the gallbladder is diagnostic, and treatment is surgical removal of gall bladder with complete resolution of symptoms. Surgery is recommended only in cases of symptomatic stones

A 72-year-old man has a history of medically-treated COPD for 20 years, chronic constipation, benign prostatic hypertrophy, and obesity; he presents to his primary care office with a "bulge" in his abdomen, which became noticeable 1 week ago following a coughing episode. He states that it enlarges when he coughs, sneezes, laughs, stands, and bends forwards; it lessens in size when he lays supine. He admits to a pressure sensation, but he denies any pain, nausea, vomiting, diarrhea, melena, hematochezia, a change in bowel or dietary habits, hematuria, flank pain, or dysuria. His physical exam demonstrates an obese body habitus, a barrel chest, and the following physical exam finding. Question What is a correct health maintenance strategy regarding this patient? Answer Choices 1 A consultation with a surgeon is unnecessary 2 Gradual weight gain techniques should be provided 3 Education on the side effects of chemotherapy; radiation should be offered 4 Daily use of a truss, binder, or strap provides definitive and effective treatment 5 He should avoid straining at defecation and lifting heavy objects

Correct Answer: He should avoid straining at defecation and lifting heavy objects Explanation This patient's most likely diagnosis is an umbilical hernia. Patients should be counseled to avoid those activities that increase intra-abdominal pressure (e.g., straining at defecation and lifting heavy objects). This may require restrictions on work or school-related activities. Weight loss should be encouraged; obesity and an overweight state contribute to hernia development. An umbilical hernia in an adult should be repaired expeditiously to avoid incarceration and strangulation. Repairs utilizing mesh result in the lowest recurrence rate. Even with asymptomatic hernias, repair at an early stage (before the hernia enlarges) is preferred. Referral to a general surgeon for discussion of the available types of hernia repair is therefore warranted. This patient's pathology is not consistent of an underlying malignancy; therefore, chemotherapy or radiotherapy is indicated in this patient's management plan. If a patient refuses operative repair or when there are absolute contraindications to operation, a truss should be fitted to provide adequate external compression over the defect in the abdominal wall. It should be taken off at night and put on in the morning before the patient arises. The use of a truss does not preclude later repair of a hernia, although it may cause fibrosis of the anatomic structures; therefore, subsequent repair may be more difficult. Trusses place pressure on the skin and bowel, induce related injury, and mask signs of incarceration and strangulation. Strapping, with or without a coin, is not indicated in the treatment of umbilical hernia, due to of problems with skin erosion and lack of effectiveness.

During a transvaginal sonographic examination a hypoechoic linear area is seen lateral and posterior to the right ovary. What structure is being seen? Answer Choices 1 Ovarian vessels 2 Iliac vessels 3 Uterine vessels 4 Appendix 5 Bowel

Correct Answer: Iliac vessels Explanation The iliac vessels are seen lateral and posterior to the ovaries. These pulsating long structures are easily identified with Doppler. Ovarian and uterine vessels would appear tortuous between the uterus and ovaries. The appendix can be seen when it is inflamed and has a hypoechoic rim with an echogenic center.

An obstetrician administers a pudendal nerve block to his patient in labor by injecting the nerve as it enters the pudendal (Alcock's) canal. The patient, however, continues to complain of extreme pain, gesturing to the anterior part of her perineum, as her contractions continue. What additional nerve or nerves does the obstetrician need to anesthetize? Answer Choices 1 Ilioinguinal and genitofemoral nerves 2 Iliohypogastric and inferior rectal nerves 3 Posterior labial nerves 4 Perineal nerve 5 Dorsal nerve of the clitoris

Correct Answer: Ilioinguinal and genitofemoral nerves Explanation Genital branches of the ilioinguinal nerve (L1), supplying the perineum through the inguinal canal, and the genitofemoral nerve (L1-2), supplying the perineum from the inferior anterior abdominal wall, are injected along the lateral margins of the labia majora. This injection also anesthetizes the small perineal branch of the posterior cutaneous nerve of the thigh, also innervating this region. The iliohypogastric nerve (T12, L1) does not supply the perineum and the inferior rectal nerve is a branch of the pudendal nerve (S2-4), already blocked. The perineal nerve and dorsal nerve of the clitoris are branches of the pudendal nerve. The posterior labial nerves are branches of the perineal nerve.

A 26-year-old African-American male presents to the students' health center, where you are covering for your colleague. The patient tells you that the other physician he saw two weeks ago, diagnosed him with a left inguinal hernia, and he finally decided to undergo surgical repair. He asks about the potential risks of surgical intervention, and you tell him that there is poor association between this type of operation and which one of the following side effects? Answer Choices 1) Decreased sensation to the anterior-medial aspect of the left thigh 2) Atrophy and necrosis of the left testicle 3) Recurrence of the hernia 4) Impotence 5) Recurrent inguinal pain

Correct Answer: Impotence Explanation Surgical repair is a mainstay in the management of hernias. As surgical intervention involves manipulation of the spermatic cord, damage to the testicular artery, ilioinguinal nerve, and other sensory nerves of the groin are a possibility. Thus, potential complications during surgery include damage to the testicular artery and necrosis of the involved testicle, damage to the ilioinguinal nerve, and decreased sensation to the anterior and medial aspect of the thigh. Hernias may recur with a rate that is highly variable on the technique used for the repair. Impotence is not a risk of this operation.

Which one of the following statements about pancreas is true? Answer Choices 1 The inferior pancreatico-duodenal artery is given off from the inferior mesenteric artery, or from the left side of the aorta, between one and two inches above its division into the common iliacs. It distributes branches to the head of the pancreas and to the transverse and descending portions of the duodenum. 2 In structure the pancreas is a compound racemose gland resembling the salivary glands, differing in that it is softer and looser in its texture and that it is not enclosed in a distinct capsule but is surrounded by areolar tissue which dips into its interior and connects together its various lobules. It is long and irregularly prismatic in shape, compared to a human or dog's tongue: its right extremity (the head) being broad and connected by a slight constriction (the neck) to a gradually tapering left extremity (the tail). It is situated transversely across the posterior wall of the abdomen at the back of the epigastric and left hypochondriac regions. 3 Delta cells (D-cells) of the Islets of Langerhans occupy the center of each islet and make up about twenty per cent of all islet cells. These cells release serotonin from secretion granules of various sizes. Serotonin is an amino acid derivative with many effects and numerous sources in the nervous system and blood. For example, basophils and mast cells promote tissue inflammation by releasing serotonin. 4 The pancreas is innervated by the nerves derived from the pneumogastric and sympathetic nerves which accompany the vessels and ducts to the interlobular spaces. Here the myelinated fibers are distributed almost exclusively to the coats of the blood vessels, while the non-myelinated enter the lobules and ramify between the cells.

Correct Answer: In structure the pancreas is a compound racemose gland resembling the salivary glands, differing in that it is softer and looser in its texture and that it is not enclosed in a distinct capsule but is surrounded by areolar tissue which dips into its interior and connects together its various lobules. It is long and irregularly prismatic in shape, compared to a human or dog's tongue: its right extremity (the head) being broad and connected by a slight constriction (the neck) to a gradually tapering left extremity (the tail). It is situated transversely across the posterior wall of the abdomen at the back of the epigastric and left hypochondriac regions.

Which of the following muscles or muscle groups are used during expiration by a patient experiencing severe dyspnea associated with emphysema? Answer Choices 1 Internal intercostals 2 Trapezius 3 Sternocleidomastoid 4 Pectoralis major 5 Scalenus group

Correct Answer: Internal intercostals

Case A 68-year-old woman presents with a 4-hour history of severe left-sided abdominal pain. The pain was initially associated with several episodes of diarrhea with some hematochezia. Since then, she has had a few more stools, but she has not seen any more frank blood. Her pain is somewhat improved from what it was at the onset. Past medical history is positive for renal lithiasis and atrial fibrillation. Current medications are digoxin and aspirin. She is a recovering alcoholic who last had a drink 15 years prior. She recently returned home from a trip to Mexico; she was visiting relatives for 2 months. On exam, you see a well-nourished woman in extreme discomfort. Auscultation of her lungs reveals good breath sounds bilaterally; her heart has an irregularly irregular rhythm with a rate of 92; there is a soft II/VI systolic murmur. Her abdomen is mildly obese and tender on the left side; there is no appreciable mass or rebound. There is no flank tenderness. Rectal exam reveals guaiac positive mucus mixed with flecks of bright red blood. 12 hours after presentation, her left upper quadrant pain is still present; however, it is much improved, and she had only 2 more stools with small flecks of blood in them. Question What is the most likely diagnosis? Answer Choices 1 Left ureteral lithiasis 2 Diverticulitis 3 Infectious colitis 4 Small bowel ischemia 5 Ischemic colitis

Correct Answer: Ischemic colitis Explanation This is a classic presentation of ischemic colitis. Ischemic colitis occurs when there is obstruction of the colonic blood supply, causing ischemia with inflammation and ulceration of the colonic mucosa. The area of the splenic flexure is most at risk for ischemia because it is the watershed area of the arterial supply to the colon. Ischemic colitis is most commonly seen in elderly individuals. These patients typically present with an acute onset of pain associated with bloody diarrhea, and they have an area of tenderness corresponding to the ischemic segment of colon. Patients may experience recurrent bouts of ischemic colitis. Sigmoidoscopy makes the diagnosis in 85% of patients; 15% will have ischemia in areas proximal to the reach of a sigmoidoscopy. The majority of these patients will improve with supportive care (hydration and prophylactic antibiotics, in case of bacterial transmigration). However, some patients have much more severe disease, which may even require emergency colectomy. The most important condition to differentiate from ischemic colitis is that of small bowel ischemia. Small bowel ischemia can lead to gangrene of the intestine. Most commonly, these patients have developed occlusion of some of the distribution of the superior mesenteric artery, either from acute thrombosis in an area of atherosclerosis, or from embolic disease. These patients classically have pain out of proportion to their exam, at least early in the process, and they do not usually have an area of localized tenderness on palpation. These patients can have leukocytosis on the level of 20,000 to 30,000/μL, and they may exhibit a lactic acidosis and elevated amylase levels. Their stool is usually positive for occult blood, but frank blood is only rarely seen. Early diagnosis is very important, although often difficult, and urgent surgery is the only treatment. Renal or ureteral lithiasis can cause severe abdominal pain, and these patients can have diarrhea as well, but it should not cause hematochezia or localized anterior abdominal tenderness. Diverticulitis is more common on the left, which is the case with this patient's pain, but it typically does not cause hematochezia. Additionally, the sudden onset of very severe pain would not be typical of diverticulitis. Infectious colitis can cause abdominal pain and hematochezia, but the improvement in her pain over such a short time period would be atypical for an enterotoxic infection. Infection should be considered in this patient because of her recent travel history.

Which of the following statements regarding nephrons is true? Answer Choices 1 85% of all nephrons in the kidney are juxtamedullary nephrons 2 Only the cortical nephrons can form concentrated urine 3 Juxtamedullary nephrons have their loops of Henle in the medulla of the kidneys 4 Nephrons have an afferent arteriole which supplies them with blood, and an efferent vein which drains them 5 The vasa recta arises from the afferent arteriole and covers the loops of Henle in cortical nephrons only

Correct Answer: Juxtamedullary nephrons have their loops of Henle in the medulla of the kidneys Explanation Eighty-five percent of all nephrons are cortical nephrons, which do not concentrate urine. Concentration of the urine is accomplished by the loops of Henle of the juxtamedullary nephrons which lie in the medulla of the kidney. The vasa recta arises from the efferent arteriole and only in juxtamedullary nephrons.

Sensations of the lateral aspect of the thigh from the hip to the knee have been lost. There is likely a problem with the: Answer Choices 1 Lateral femoral cutaneous nerve 2 Intermediate femoral cutaneous nerve 3 Medial femoral cutaneous nerve 4 Posterior femoral cutaneous nerve

Correct Answer: Lateral femoral cutaneous nerve

• The tendinous median raphe between the two rectus abdominous muscles running from the xiphoid process to the pubic symphysis is termed the • Answer Choices • 1 • Linea alba • 2 • Linea semilunaris • 3 • Linea semicircularis • 4 • Lacunar ligament • 5 • Cooper's ligament

Correct Answer: Linea alba

Neoplastic tumors sometimes grow in to blood vessels. One mechanism of metastasizing is via the blood stream when neoplastic cells leave the original tumor and spread throughout the body. These cells usually get caught in the first capillary bed downstream, which works like a filter. Assuming this happened in the inferior mesenteric vein. Where would you expect to find metastases? Answer Choices 1 Pancreas 2 Lungs 3 Brain 4 Liver 5 Gallbladder

Correct Answer: Liver Explanation The venous blood from the inferior mesenteric vein flows into the portal vein. Therefore the first filter is the liver. Rephrasing the question reveals the only thing asked for was, "where does the venous blood from the inferior mesenteric vein pass the first capillary bed?" The answer is obviously the liver. The suggestion, all neoplastic growth with access to the inferior mesenteric vein metastasizes into the liver, is not intended. Other capillary beds performing filter functions are the lungs and the brain. Pancreas and gallbladder are usually unaffected by the mechanism described above

A 23-month-old boy presents with a sudden onset of bright red blood in his bowel movements. He is afebrile and does not seem to be in any pain. A technetium-99m pertechnetate scan after enhancement with cimetidine shows a 'hot spot' in the area of his ileum. Question What is the most likely cause? Answer Choices 1 Bleeding arteriovenous ileal malformation > 1 cm 2 Ileal bleeding secondary to factor VIII deficiency (hemophilia) 3 An ileal polyp 4 Intussusception 5 Meckel diverticulum

Correct Answer: Meckel diverticulum Explanation This patient is most likely suffering from a common congenital abnormality of the development of the ileum called a Meckel's diverticulum. In the embryo, the vitelline duct is a communication between the yolk sac and the lumen of the gastrointestinal tract at the midgut. Normally, it degenerates completely, but the persistence of a portion of the vitelline duct leads to the development of a cul-de-sac on the ileum (Meckel's diverticulum). This congenital birth defect follows a rule of 2s. It occurs in 2% of the population, but only 2% show symptoms. It is usually located about 2 feet from the ileocecal valve and is about 2 inches long. It can contain 2 types of ectopic tissue: gastric or pancreatic. It usually presents by 2 years old. The presence of ectopic gastric mucosa in the diverticulum can lead to secretion of stomach acid downstream from the duodenum, which has bicarbonate-secreting submucosal Brunner glands to neutralize gastric acid. Ectopic gastric tissue in the ileal diverticulum can lead to ulceration and bleeding of the adjacent ileal mucosa. Vascular malformations, intussusception, and coagulation disorders are more likely to manifest themselves in the first year of life. Cow's milk colitis is a problem of the first year of life and spontaneously resolves by the end of that year for most children. NEC is a problem of the stressed, usually premature, newborn. Rectal polyps are likely to present in older children, as is HSP. Babies and older children can have gastric bleeding from gastritis or gastric ulcers. Duodenal ulcers are much more common in older children.

A 1-year-old boy presents with a 1-week history of bloody diapers. The child has been crying almost constantly. On clinical exam, there is abdominal tenderness. Guaiac test is positive, hematocrit is 39.0, and hemoglobin is 13.0. What is the most likely diagnosis? Answer Choices 1 Diverticulitis 2 Meckel's diverticulum 3 Peutz-Jeghers syndrome 4 Ulcerative colitis 5 Crohn's disease

Correct Answer: Meckel's diverticulum The Meckel diverticulum appears to be a remnant of developmental structures that were not fully reabsorbed. It is a common congenital abnormality that consists of a small pouch called a diverticulum located off the wall of the small bowel. Symptoms generally occur during the 1st few years of life. Symptoms include passing of blood either with or without stool and abdominal discomfort ranging from mild to severe. Tests should include stool smear for occult blood (stool guaiac), hematocrit, hemoglobin, and technetium scan to demonstrate diverticulum. Surgery to remove the diverticulum is recommended if bleeding develops. Iron replacement may be needed to correct anemia. If bleeding is significant, blood transfusion may be necessary. Diverticulitis is inflammation of an abnormal pouch (diverticulum) in the intestinal wall, usually found in the large intestine (colon). Small protruding sacs of the inner lining of the intestine (diverticulosis) may occur in any part of the intestine. They occur with increasing frequency after the age of 40. Diverticulitis is an inflammatory condition where gross or microscopic perforation (hole) of the diverticula has occurred. A low-fiber diet may be a contributing factor to the development of diverticula. Symptoms include left lower abdominal pain, constipation or diarrhea, chills, fever, swallowing difficulty, stools (clay colored or bloody), nausea and vomiting, heartburn, cough, and breath odor. Tests should include colonoscopy, sigmoidoscopy, barium enema, rectal examination (showing bleeding), abdominal palpation (showing left lower quadrant mass), and stool hemoccult test (revealing blood). Treatment should include increasing the bulk in the diet with high-fiber foods and bulk additives. Peutz-Jeghers syndrome is transmitted as an autosomal dominant trait. Pigmented spots, brownish or bluish gray, develop from infancy through childhood around the lips, gums, and mucus membranes in the mouth. Symptoms include crampy abdominal pain, vomiting, occasional gross blood in the stool, and intussusception (a telescoping of one portion of the intestine into another). Intestinal polyps also develop that can be detected with special studies. Diagnostic tests include X-ray of abdomen (shows polyposis), occult blood in stool, CBC, serum iron, serum, total iron binding capacity, and biopsy of polyps. Treatment includes surgery to remove polyps that cause chronic problems. Iron replacement therapy (iron supplements) helps counteract blood loss. Periodic studies are recommended to watch for malignant changes in polyps. Crohn's disease (also called ileitis or enteritis) causes inflammation in the small intestine. The most common symptoms of Crohn's disease are abdominal pain (often in the lower right area) and diarrhea. Rectal bleeding, weight loss, decreased appetite, and fever may also occur. Bleeding may be serious and persistent, leading to anemia. Tests should include CBC (increased white count), upper GI, and colonoscopy. The goals of treatment are to control inflammation, relieve symptoms, and correct nutritional deficiencies. Surgery is indicated to relieve chronic symptoms that do not respond to treatment. Ulcerative colitis is chronic, episodic, inflammatory disease of the large intestine and rectum characterized by bloody diarrhea. Ulcers form in the inner lining, or mucosa, of the colon or rectum, often resulting in diarrhea, blood, and pus. The inflammation is usually most severe in the sigmoid and rectum and usually diminishes higher in the colon. It may affect any age group, although there are peaks at ages 15 to 30 and then again at ages 50 to 70. Symptoms include diarrhea of between 10 and 25 times a day (in which blood and pus may be present), abdominal pain and cramping that usually subsides after a bowel movement, abdominal sounds (borborygmus, a gurgling or splashing sound heard over the intestine), fever, weight loss, stools (foul smelling), and tenesmus (pain while passing stool). Tests include colonoscopy with biopsy, and barium enema. The goals of treatment are to control the acute attacks and prevent recurrent attacks. Corticosteroids are prescribed to reduce inflammation. Sulfasalazine may decrease the frequency of attacks. Surgery may be indicated in refractory disease.

An 88-year-old male complaining of abdominal pain enters the emergency room with his wife. A mini-mental status exam reveals pronounced forgetfulness and confusion. The patient is discovered to have acute appendicitis requiring immediate surgery. He is unable to understand the situation and cannot provide informed consent. Question What further action should the physician take? Answer Choices 1 Do not perform surgery 2 Have another doctor confirm the necessity of surgery 3 Obtain a court order to perform surgery 4 Obtain consent from his wife to perform surgery 5 Try to persuade the patient to consent to surgery

Correct Answer: Obtain consent from his wife to perform surgery Explanation In cases in which an emergency exists, the patient is incompetent to give consent, and the withholding of treatment would be potentially life-threatening, the physician must seek out close relatives of the patient to supply consent. The physician should proceed with treatment, assuming the patient would want the treatment had he or she understood the situation. Not performing surgery could cost the patient's life. Having another doctor confirm the necessity of surgery is favorable (if done immediately) but not mandatory and does not change the patient's consent status. Obtaining a court order is not necessary with the patient's wife immediately accessible. Trying to persuade the patient to consent to surgery would not only waste time and prove futile but might agitate the patient as well.

Case An 8-year-old girl is admitted to the hospital with right lower quadrant pain. She states that the pain began about 2 days ago as a dull ache around her umbilicus. She woke up this morning with sharp pain in the lower right quadrant, nausea, loss of appetite, and fever. Question What is the most common complication of the patient's most likely condition? Answer Choices 1 Perforation 2 Sepsis 3 Intestinal blockage 4 Appendiceal abscess 5 Pylephlebitis

Correct Answer: Perforation Explanation The most common complication of appendicitis is perforation, which causes the infection to spread outside the appendix. Other complications include peritonitis, sepsis, and intestinal blockage. Appendicitis is an inflammation of the appendix. Appendicitis is a common infection of the abdomen that can lead to surgical intervention. The appendix is attached to the first part of the colon, called the cecum. It is a blind pouch and is actually called the vermiform appendix (which means "worm-like appendage"). The appendix is part of the immune system and contains lymphatic tissue. The appendix produces mucus, and as objects (usually stool) enter the appendix they can become trapped. In addition, mucus can thicken and accumulate. As a result, the appendix can become blocked by the resulting fecalith. After the appendix becomes blocked, bacteria can increase in numbers and cause infection. The infection can spread from the appendix out into the abdomen. The appendix can rupture, and the spread of infection starts as an abscess around the appendix. Occasionally, the body can contain the infection and resolve. Differential diagnosis includes kidney disease, pelvic inflammatory disease, gall bladder disease, right-sided diverticulitis, and Meckel's diverticulitis. Symptoms of appendicitis include abdominal pain, loss of appetite, fever, nausea, vomiting, and fever. The main symptom is abdominal pain, which is poorly localized at first. Once the peritoneum becomes involved, the pain becomes more localized. It is usually located at McBurney's point. This is located 1/3 of the distance from the ASIS (anterior superior iliac spine) to the umbilicus. Diagnosis is usually made by taking a thorough history and performing a physical exam. Blood and urine samples should be taken, and elevated white blood cell count can often be seen. Urinalysis may show bacteria and red and white blood cells. An abdominal radiograph may show the presence of a fecalith, but may be negative in many patients. An ultrasound should also be done. Appendicitis is usually treated by surgery.

A 35-year-old Hispanic man presents to your office but is too embarrassed to tell the nurse his chief complaint. You enter the room, and he admits to severe, intense itching around his anus that has been worsening the last several weeks. He further states that he has noticed increasingly severe and tearing pain in the anal area with each bowel movement. He would rank this pain as a 10/10 on a pain scale. This intense pain makes him not want to have any bowel movements. He admits to only 1 episode of a small amount of bright red blood on the toilet paper as well as on the stool itself. The patient denies fever, diarrhea, or ever being diagnosed with inflammatory bowel disease. Question Considering the findings in the patient above, what is best choice in diagnostic studies to assist in confirmation of diagnosis? Answer Choices 1 Physical examination 2 Digital rectal exam 3 Anoscopy 4 Sigmoidoscopy 5 Colonoscopy

Correct Answer: Physical examination Explanation Most likely this patient is suffering from an anal fissure. Anal fissures most often affect infants, as well as middle-aged individuals. The majority of fissures are considered primary and caused by local trauma such as passage of hard stool, prolonged diarrhea, vaginal delivery, or anal sex. Presentation of anal fissures is a tearing pain accompanying bowel movements as well as bright red rectal bleeding that is limited to a small amount noted on the toilet paper or surface of the stool. The patient described all of these components. Patients will also complain of perianal pruritus or irritation, which he also admits to experiencing. The best diagnostic approach to confirming an anal fissure is usually based on the history of pain with defecation, as well as simply the physical examination finding of a superficial tear noted in the anoderm; this type of tear, no matter if located posteriorly or laterally, is considered a pathognomonic feature of an acute anal fissure. The examiner should carefully spread the buttocks apart and examine the area gently. Digital rectal examination, or anoscopy, is not recommended for diagnosis of this condition due to the fact that patients will not be able to tolerate them due to the severe pain they will be experiencing from the anal fissure. Sigmoidoscopy or colonoscopy are both inappropriate diagnostic tools in this patient case scenario. These studies should only be considered if there is presence of otherwise unexplainable rectal or gastrointestinal bleeding. Either a sigmoidoscopy or a colonoscopy can assist in evaluating the corresponding source of bleeding.

Once the diagnosis of acute appendicitis is made, a patient is taken to the operating room. At laparotomy, the appendix is found to be normal. The next step the surgeon should undertake is • 1 • Call his lawyer as this is a clear case of malpractice • 2 • Close the abdomen without removing the appendix as this would decrease the risk for complications • 3 • Take a biopsy of the appendix, send it for immediate pathological examination, and if it is not inflamed, the appendix can be left in place • 4 • Immediately close the abdomen without removing the appendix and inform the family that the rate of negative diagnoses is about 20% • 5 • Proceed with the same surgical intervention as if the appendix had been clearly inflamed

Correct Answer: Proceed with the same surgical intervention as if the appendix had been clearly inflamed

A middle-aged woman presents with diarrhea and vomiting that started this afternoon. She does not remember eating any meat, chicken, pudding, or ice cream the day before. She lives alone and says she warmed up leftover rice for supper last night. She looks sick from vomiting, but she is not dehydrated. She has no fever, and her blood pressure and pulse are within normal limits. What would be the best next step? Answer Choices 1 Admit and observe 2 Start oral fluids and metronidazole 3 Reassure the patient and send home with oral rehydration 4 Send stool specimen to the lab and ask patient to come the next day for follow up 5 Admit for parenteral treatment

Correct Answer: Reassure the patient and send home with oral rehydration

Case A 43-year-old man presents with a "sore" near his rectum. He reports rectal pain with bowel movements; there is some anal discomfort with sitting and physical activity. He occasionally notes some drainage from the lesion and rectal pruritus. He denies anal intercourse, unusual travel, and other skin lesions. He has tried over-the-counter hemorrhoid treatments without relief. His past medical history is significant for Crohn's disease; he is not being treated for it currently. He has no known allergies and takes no medications. He is married/monogamous; he works as a bartender and denies the use of tobacco. He reports occasional alcohol use, but no drug use. On physical exam, a single 4mm pustule-like lesion is visualized on the perianal skin; it is located about 2 cm away from the anus. No other skin lesions are found. Rectal exam is normal. Question What is the most likely diagnosis? Answer Choices 1 Hemorrhoids 2 Herpes simplex 3 Lymphogranuloma venereum 4 Rectal fistula 5 Syphilitic chancre

Correct Answer: Rectal fistula Explanation This patient most likely has a rectal fistula. A fistula (or fistula-in-ano) is a communicating tract (usually from an anal crypt) to the skin surface, and it often develops from a rectal abscess. Rectal fistulas are more common in patients with Crohn's disease. Fistulas are associated with rectal pain, itching and tenderness. External hemorrhoids are a common condition and can be associated with anal pain, constipation and bright red rectal bleeding. Hemorrhoids are dilated blood vessels and appear as protrusions, either singly or several clustered together, such as a bunch of grapes. (Internal hemorrhoids would not be visualized on this patient without anoscopy or colonoscopy.) Genital herpes simplex lesions are caused by sexual transmission of herpes simplex virus types 1 or 2 (HSV-1 and HSV-2). The classic presentation is a tingling, burning, and/or painful sensation from 1 or more vesicular or ulcerated lesions on the genitals. This patient's single perianal pustule and history of Crohn's disease make fistula a much more likely diagnosis. Lymphogranuloma venereum (LGV) is a sexually transmitted disease; it presents with a primary painless lesion on the genitals/anus. LGV is rare is developed countries, with greater incidence in the tropics. This patient noted a painful lesion, making LGV unlikely. Similarly, a syphilitic chancre is the primary lesion of the sexually transmitted Treponema pallidum. It presents as a solitary, painless anogenital lesion.

A 79-year-old man who returned the previous day from a long plane trip is affected with a sudden shortness of breath and collapses. He is rushed to the hospital where it is determined that he has suffered a pulmonary embolism, resulting from a blood clot that has lodged in his lung and cut off a portion of its blood supply. Most commonly, embolism is caused by thrombi which arise from the lower extremities and travel to the lung via the heart. Which is the correct path that the thrombus travels through the heart to the lung? Answer Choices 1 Left atrium-left ventricle-aorta-bronchial artery 2 Right atrium-superior vena cava-bronchial vein 3 Left atrium-pulmonary vein-bronchial vein 4 Right atrium-right ventricle-pulmonary trunk-pulmonary artery 5 Right atrium-azygos vein-pulmonary vein

Correct Answer: Right atrium-right ventricle-pulmonary trunk-pulmonary artery

A 24-year-old man presented with complaints of fever with rigors and pain in the right upper abdomen. He also complains of pain over the right shoulder. After thorough examination and investigation, he was diagnosed with an amebic liver abscess. Which nerve mediates the pain in his right shoulder? Answer Choices 1 Axillary 2 Descending cervical nerve 3 Intercostobrachial 4 Right phrenic 5 Right sympathetic chain 6 Right vagus 7 Transverse cutaneous

Correct Answer: Right phrenic Explanation The phrenic nerve arises from the 3rd, 4th and 5th cervical nerves, that is, C3, C4 and C5. The phrenic nervesupplies motor, sensory and sympathetic fibers to the diaphragm.

Case A 46-year-old woman presents with nausea, vomiting, crampy abdominal pain, and loud bowel sounds for the past several hours. She denies weight loss. She has had 1 normal bowel movement since the symptoms began, but this did not help her symptoms. She has a past surgical history of an abdominal hysterectomy 7 years prior. On physical exam, she is afebrile, with hyperactive and high-pitched bowel sounds localized to the left upper quadrant. She also has mild, diffuse abdominal tenderness. Question Ico-delete Highlights What is the most likely diagnosis? Answer Choices 1 Small bowel obstruction 2 Whipple's disease 3 Diverticulitis 4 Acute paralytic ileus 5 Irritable bowel syndrome

Correct Answer: Small bowel obstruction explanation The correct answer is small bowel obstruction, as it typically presents with localized high pitched bowel sounds with crampy abdominal pain, nausea, and vomiting. The bowel sounds will diminish if complete obstruction occurs. Acute paralytic ileus typically presents with very diminished or no bowel sounds. Patients with diverticulitis often have more severe, localized abdominal tenderness on exam and typically present with fever and possibly peritoneal signs. Whipple's disease is an infectious disorder characterized by fever, lymphadenopathy, arthralgias, weight loss, and chronic diarrhea. Irritable bowel syndrome is not typically associated with nausea and vomiting, and the abdominal pain is relieved with defecation.

• Question • (1) A blood clot originating in the deep venous system of the leg is unlikely to be transported into the brain because, (2) before the blood returning to the heart reaches the arterial system, it passes the lungs, which filter out the blood clot. • Answer Choices • 1 • Statement (1) is correct and statement (2) is the correct reason for (1) • 2 • Statements (1) and (2) are correct, but (2) is not the explanation for (1) • 3 • Statement (1) is correct and statement (2) is false • 4 • Statement (1) is false and statement (2) is correct • 5 • Both statements are false •

Correct Answer: Statement (1) is correct and statement (2) is the correct reason for (1)

Question A 38-year-old man presents with a 2-day history of a mass and severe pain in his scrotum. Physical examination reveals that his right testicle appears much larger than his left. On palpation, you note a small hole in his inguinal canal, and you are unable to place the contents into the canal. The contents of the hernia appear ischemic. What is the best description of the hernia? Answer Choices 1 Reducible 2 Recurrent 3 Irreducible 4 Strangulated 5 Incarcerated

Correct Answer: Strangulated Explanation The clinical picture is suggestive of an inguinal hernia. The hernia has become ischemic, which is better known as a strangulated hernia. In a reducible hernia, the contents would be able to be placed back into the abdominal cavity with simple manipulation. A recurrent hernia is a hernia that has been previously repaired surgically and has now returned. There is no history of a previous hernia in this patient. An irreducible (also known as incarcerated) hernia is when the hernial contents cannot be returned to their normal site with simple manipulation. This type of hernia would cause edema and entrapment due to impaired venous return. An irreducible (also known as incarcerated) hernia is when the hernial contents cannot be returned to their normal site with simple manipulation. This type of hernia would cause edema and entrapment due to impaired venous return.

A resident was asked to examine an 84-year-old man with carcinoma of the scrotum. He finds an ulcerating growth on the scrotal skin on the right side. What group of lymph nodes must he examine while looking for spread of the carcinoma? Answer Choices 1 External iliac 2 Internal iliac 3 Superficial inguinal 4 Deep inguinal 5 Lumbar (para-aortic)

Correct Answer: Superficial inguinal

Which one of the following statements about the stomach is true? Answer Choices 1 Like most of the alimentary tract, the stomach has 4 coats: (i) a mucous membrane of average depth containing gastric, pyloric and cardiac glands, (ii) submucosal coat of areolar tissue containing many elastic fibers and fat, (iii) a muscular coat of interwoven longitudinal and circular fibers, and (iv) a serous coat consisting of mesothelium attached to the muscular coat by a loosely arranged connective tissue. 2 The arteries are derived from the celiac trunk. 1 of the 3 main branches of the trunk, the left gastric artery, arches upwards and to the left towards the esophageal hiatus in the diaphragm and then passes along the lesser curvature to anastomose with the right gastric artery, a branch from the common hepatic or hepatic artery. The fundus is supplied by several short gastric arteries arising from the splenic branch of celiac trunk and run between the layers of the gastrosplenic ligament. 3 Occasionally there may be a structure, called Meckel's diverticulum, on an average of about 3 1/2 feet blind tube, attached to and communicating with the lumen by 1 extremity, and unattached, or connected by the other extremity with the abdominal wall or some other portion of the intestine by a fibrous band. This represents the remains of the vitelline or omphalo-mesenteric duct, the duct of communication between the umbilical vesicle and the alimentary canal in early fetal life. 4 The arteries are the pyloric and pancreatico-duodenal branches of the hepatic and the inferior pancreatico-duodenal branch of the superior mesenteric. The veins terminate in the splenic and superior meseteric. The nerves are derived from the solar plexus. 5 Attached to the lesser curvature are small pieces of fat of unknown function called appendices epiploicae. They vary greatly in size in different parts of the alimentary canal and are often rudimentary or absent on the cecum, rectum, and appendix.

Correct Answer: The arteries are derived from the celiac trunk. 1 of the 3 main branches of the trunk, the left gastric artery, arches upwards and to the left towards the esophageal hiatus in the diaphragm and then passes along the lesser curvature to anastomose with the right gastric artery, a branch from the common hepatic or hepatic artery. The fundus is supplied by several short gastric arteries arising from the splenic branch of celiac trunk and run between the layers of the gastrosplenic ligament.

Which of the following is true regarding the blood supply of the large intestine? Answer Choices 1 The blood supply is derived from the inferior mesenteric artery only 2 The blood supply is derived from the inferior and superior mesenteric arteries 3 Ileocolic and middle colic artery are branches of inferior mesenteric artery 4 The sigmoid arteries are branches of the superior mesenteric artery 5 Superior mesenteric artery supplies the descending colon and rectum

Correct Answer: The blood supply is derived from the inferior and superior mesenteric arteries

• Which of the following statements about the colon is correct? • Answer Choices • 1 • It contains Peyers patches in the mucosa • 2 • It contains submucosal glands (Brunners glands) • 3 • The mucosa is thrown into circular folds, the plicae circulares • 4 • The longitudinal smooth muscle surrounding the large intestine is discontinuous and is organized into three bands • 5 • The mucosa contains multiple villi •

Correct Answer: The longitudinal smooth muscle surrounding the large intestine is discontinuous and is organized into three bands • Explanation The colon differs from the small intestine in several ways. The mucous membrane of the colon is smooth and it does not contain villi, and there are no folds (plicae circulares). Peyers patches are found in the lower ileum, and Brunners glands are found in the duodenum. The longitudinal smooth muscle in the muscularis layer of the colon is discontinuous and is organized into three longitudinal bands, the teniae coli.

Anatomic characteristics of the spleen include Answer Choices 1 The splenic artery is a terminal branch of the celiac trunk 2 The spleen lies in the retroperitoneal space 3 Blood supply to the spleen includes branches from the left renal artery 4 The spleen is wholly contained within the lesser sac

Correct Answer: The splenic artery is a terminal branch of the celiac trunk

Which of the following is true regarding the thoracic muscles Answer Choices 1 The external intercostal muscles attach to the lower margins of the ribs and pass downward and backward to the upper margins of adjacent ribs 2 The internal intercostal muscles are attached to the lower margins of the ribs and pass downward and forward to the upper margins of the adjacent rib 3 The subcostal muscles are best developed in the upper thorax 4 The transversus thoracis (sternocostalis) arise from the posterior surface of the xiphoid process and the sternum body and inserts into the second to sixth costal cartilage 5 The subcostal and transversus thoracis are in the same plane as the external intercostal muscles, being connected by fascia

Correct Answer: The transversus thoracis (sternocostalis) arise from the posterior surface of the xiphoid process and the sternum body and inserts into the second to sixth costal cartilage Explanation The external intercostal muscles attach to the lower margins of the ribs, the fibers passing downward and forward to the upper part of the adjacent rib.

A cystotomy is performed on a 63-year-old woman to remove a large (7 cm) stone from the bladder. The irritation and damage caused to the lining of the bladder by the stone may have resulted in hydronephrosis. What structure or arrangement is present in order to prevent urine reflux from the bladder into the ureters? Answer Choices 1 The ureters enter the bladder obliquely and form a flap valve so the valve closes as bladder pressures increase 2 Skeletal muscle sphincters within the wall of the ureters constrict as the bladder fills 3 Pressure in the ureters is greater than pressures within the full bladder 4 Rugae of the bladder wall cover the openings of the ureter as the bladder fills 5 Because the ureters enter the bladder superiorly, the bladder empties before urine can reflux into the ureters

Correct Answer: The ureters enter the bladder obliquely and form a flap valve so the valve closes as bladder pressures increase

Which structure or arrangement is present in order to prevent urine reflux from the bladder into the ureters? Answer Choices 1 The ureters enter the bladder obliquely, so that the openings close as pressures in the bladder increase 2 Smooth muscle sphincters within the wall of the ureters constrict as the bladder distends 3 Flow of urine from the kidney is under greater pressure than pressures within the bladder, thanks to the small lumen of the ureters 4 Rugae of the bladder wall cover the openings of the ureter under high pressures experienced during distension of the bladder 5 Because the ureters enter the bladder at its superior aspect, the bladder is usually emptied before urine can reflux into the ureters

Correct Answer: The ureters enter the bladder obliquely, so that the openings close as pressures in the bladder increase Explanation There are no sphincters in the ureters. Flow of urine from the kidneys is passive and under very low pressure. Rugae of the bladder disappear as the bladder distends. The ureters enter the bladder at its base.

Which of the following structures are in close apposition to the esophagus as it passes through the thoracic cavity? Answer Choices 1 Trachea, vertebrae, thoracic duct 2 Trachea, thymus gland, phrenic nerves 3 Trachea, vertebrae, thoracic duct, thymus 4 Larynx, thoracic duct, azygous vein, phrenic nerves 5 Trachea, vertebrae, phrenic nerves

Correct Answer: Trachea, vertebrae, thoracic duct

Case A 47-year-old Hispanic woman presents with a 2-month history of persistent abdominal pains. She becomes uncomfortable after eating, especially after consuming fats, eggs, chocolate, fried foods, fatty foods, and rich desserts. Her pains are primarily located in her right upper abdominal quadrant and often radiate to her right shoulder blade. Physical examination is essentially unremarkable at this time. Her blood pressure is 122/82 mm Hg, she has a pulse of 72 per minute, and a temperature of 98.6°F with respirations 16 per minute. Her abdominal examination reveals no tenderness, no guard, no rebound, and normally active bowel sounds. Her liver and spleen are not palpable. She has no readily palpable abdominal masses. She is not jaundiced. She has no scleral icterus. Question What test should be given in order to confirm the probable diagnosis? Answer Choices 1 Oral cholecystogram 2 X-ray abdomen 3 Ultrasound abdomen 4 CT scan abdomen 5 Biliary scintigraphy 6 MRI abdomen

Correct Answer: Ultrasound abdomen Explanation Based on the patient's history, cholelithiasis is suspected. This condition is more common in females of Caucasian or Hispanic descent than in others. The incidence increases with age. Most (80%) of the stones in the US are the cholesterol type. Bilirubin, pigment, and calcium stones constitute the other 20%. Cholelithiasis may be asymptomatic (the presence of gallstones without symptoms), symptomatic (biliary colic), or complicated (e.g. cholecystitis, choledocholithiasis, cholangitis). Ultrasonography is a safe, reliable, and non-invasive test that can be performed at the bedside and is also safe in pregnant women. It is quite sensitive and specific for stones larger than 2 mm. Only about 10-30% gall stones are radio-opaque and hence abdominal X-ray may not be so useful. The oral cholecystogram is the X-ray taken after administering contrast medium to the patient. Although it can identify gall bladder pathology, it requires preparation and is not as convenient as the ultrasound. CT scan is not the first choice in suspected gallstones, although it may prove useful in intrahepatic stones. Biliary scintigraphy is of value in cystic duct obstruction. MRI is also an excellent choice but is expensive, requires sophisticated equipment, and is not used as the first choice investigation in most centers. Symptomatic stones are treated with cholecystectomy. Asymptomatic stones may also require surgery under special circumstances such as large (>2 cm) stones, those with spinal cord injuries affecting the abdomen, and in calcified gall bladder.

• While repairing a diaphragmatic hernia, you accidentally cauterize the vagus nerve as it passes through the diaphragm in to the abdominal cavity. Where the terminals of the vagus nerve tie into the stomach is known as • Answer Choices • 1 • Varicosity • 2 • Motor endplate • 3 • Diffuse junction • 4 • Synapse gap • 5 • Terminal cistern

Diffuse junction

Contraction of the heart begins on day Answer Choices 1 Ten to eleven of embryo development 2 Fifteen to sixteen of embryo development 3 Eighteen to Nineteen of embryo development 4 Twenty-one to twenty-two of embryo development 5 Twenty-five to twenty-six of embryo development

Explanation The cardiovascular system begins to develop toward the end the third week, and the heart starts to beat at 21 to 22 days

A 28-year-old man presents with a 2-week history of an inguinal lump. He states he was lifting a heater, felt a "pop" in his groin, and began to notice a bulge in his lower abdomen that recently became mildly tender. Resting or lying flat provides some relief, while standing or lifting aggravates it. He denies any fever(s), nausea, vomiting, or changes in bowel habits, as well as any previous abdominal surgeries or procedures. Upon examination, a palpable soft, reducible mass in the lower abdomen is found, and hernia examination reveals a mass pushing against your finger. You order an ultrasound of the lower abdomen and find the intestinal sac has traversed the deep inguinal ring. Question What type of hernia does this patient have? Answer Choices 1 Direct inguinal hernia 2 Femoral hernia 3 Indirect inguinal hernia 4 Umbilical hernia 5 Incisional hernia

Indirect inguinal hernia Explanation The correct answer is indirect inguinal hernia, as these hernias are characterized by the intestinal sac entering through the deep inguinal ring. Typically due to a congenital defect, there is incomplete obliteration of processes vaginalis. A direct inguinal hernia enters through the weakened abdominal fascia and into the anatomic region known as Hesselbach's Triangle. This area is bordered by the rectus abdominus, the inferior epigastric artery, and the inguinal ligament. Femoral hernias and umbilical hernias do not traverse through the deep inguinal ring, and femoral hernias occur lower on the body than inguinal hernias, near the leg crease. Umbilical hernias occur higher in the abdomen around the umbilicus. There was no previous surgery for an incisional hernia to occur.

A 68-year-old woman presents with a 4-hour history of severe left-sided abdominal pain. The pain was initially associated with several episodes of diarrhea with some hematochezia. Since then, she has had a few more stools, but she has not seen any more frank blood. Her pain is somewhat improved from what it was at the onset. Past medical history is positive for renal lithiasis and atrial fibrillation. Current medications are digoxin and aspirin. She is a recovering alcoholic who last had a drink 15 years prior. She recently returned home from a trip to Mexico; she was visiting relatives for 2 months. On exam, you see a well-nourished woman in extreme discomfort. Auscultation of her lungs reveals good breath sounds bilaterally; her heart has an irregularly irregular rhythm with a rate of 92; there is a soft II/VI systolic murmur. Her abdomen is mildly obese and tender on the left side; there is no appreciable mass or rebound. There is no flank tenderness. Rectal exam reveals guaiac positive mucus mixed with flecks of bright red blood. 12 hours after presentation, her left upper quadrant pain is still present; however, it is much improved, and she had only 2 more stools with small flecks of blood in them. Question What is the most likely diagnosis? Answer Choices 1 Left ureteral lithiasis 2 Diverticulitis 3 Infectious colitis 4 Small bowel ischemia 5 Ischemic colitis

Ischemic colitis This is a classic presentation of ischemic colitis. Ischemic colitis occurs when there is obstruction of the colonic blood supply, causing ischemia with inflammation and ulceration of the colonic mucosa. The area of the splenic flexure is most at risk for ischemia because it is the watershed area of the arterial supply to the colon. Ischemic colitis is most commonly seen in elderly individuals. These patients typically present with an acute onset of pain associated with bloody diarrhea, and they have an area of tenderness corresponding to the ischemic segment of colon. Patients may experience recurrent bouts of ischemic colitis. Sigmoidoscopy makes the diagnosis in 85% of patients; 15% will have ischemia in areas proximal to the reach of a sigmoidoscopy. The majority of these patients will improve with supportive care (hydration and prophylactic antibiotics, in case of bacterial transmigration). However, some patients have much more severe disease, which may even require emergency colectomy.

A 46-year-old male presents to the emergency room with a 6-hour history of acute onset of sharp right upper quadrant pain. He indicates he has had similar attacks in the past but they improve a few minutes after the onset. The onset of pain is usually triggered by fatty meals. He has been told he has gallstones but has been reluctant to have surgery. He has no history of alcohol drinking and no complaints of diarrhea. The pain is sharp and radiates to his right arm and scapula. On physical examination, he is an obese male (BMI = 33 kg/m2) in moderate distress lying in bed. His vital signs are temperature = 37.4° C, heart rate = 106 beats per minute, blood pressure = 140/86. His lungs are clear to auscultation bilaterally, his heart is tachycardic but regular, and his abdomen is non-distended, soft, and tender to palpation over the right upper quadrant. On palpation and pressure of the right upper quadrant, he stops breathing for a moment and complains of pain (positive Murphy's sign). Laboratory tests are obtained: White blood cell count 13,000 X 103/?L Hemoglobin = 15 mg/dL Hematocrit = 44% Platelets = 260 X 103/?L Amylase = 1140 IU/L (32-118 IU/L) Total bilirubin = 1.6 mg/dL (0.2-1.3 mg/dL) ALT = 28 IU/L (8-53 IU/L) AST = 35 IU/L (11-47 IU/L) Alkaline phosphatase = 114 (38-126 IU/L) Question What is the most appropriate next step in the management of this patient? Answer Choices 1 Right upper quadrant abdominal ultrasound 2 Surgical consultation 3 NPO and intravenous fluids 4 CT-scan of the abdomen with intravenous contrast 5 HIDA scan

NPO and intravenous fluids Explanation Gallstone pancreatitis is a common complication of cholelithiasis. In the present case, this is the most likely diagnosis as the patient has a history of biliary colic and documented gallstones. Without a history of alcoholic drinking, the clinical presentation, and the increased serum amylase, the diagnosis is gallstone pancreatitis.

A 35-year-old man presents with a groin mass. The patient states that the mass is painless; there is no known trauma to the region. The mass is present when the patient stands, and it disappears when the patient is lying flat. Past medical history is significant for obesity, hypertension, and hyperlipidemia. Past surgical history is significant for lipoma removal from the left shoulder. The patient denies tobacco use; he tells you that he drinks about 6 beers per week. Question What is the most significant risk factor for this patient's condition? Answer Choices 1 Obesity 2 Hypertension 3 Hyperlipidemia 4 Lipoma removal 5 Alcohol use

Obesity Obesity is the correct response. The patient has an inguinal hernia. Hernias are more likely to occur in conditions in which there is excess pressure on the abdomen. Obesity increases abdominal pressure; therefore, it increases the risk of hernia. Hypertension and hyperlipidemia are incorrect in responses. Neither of these conditions are associated with an increased risk of hernia development. Lipoma removal is an incorrect response. While previous surgery to the abdomen may increase the risk of hernia, surgery on the shoulder would not. Alcohol use is an incorrect response. Tobacco use increases the risk for hernia, but alcohol use does not.

A 24-year-old man presents with a 1-week history of shortness of breath and a nonproductive cough. On physical exam, he is tachycardic, tachypneic, and febrile. He has lost weight without a change in dietary habits. Auscultation of this chest reveals bibasilar crackles. A chest X-ray is ordered and demonstrates diffuse interstitial infiltrates. You collect an arterial blood gas, and the results show moderate hypoxemia. A metabolic panel is ordered, and the only abnormality is an isolated elevated lactate dehydrogenase (LDH) enzyme. Question What is the most likely diagnosis? Answer Choices 1 Bowen's disease 2 Streptococcal pneumoniae 3 Mycoplasma pneumoniae 4 Stevens-Johnson syndrome 5 Pneumocystis jiroveci

Pneumocystis jiroveci

• Which of the following is true regarding the peritoneal cavity? • Answer Choices • 1 • The hepatoduodenal ligament, which forms the free border of the lesser omentum, contains the common bile duct, the hepatic artery, and the portal vein • 2 • The anterior boundary for the epiploic foramen is the gastrolienal ligament • 3 • The falciform ligament extends from the posterior abdominal wall to the liver • 4 • The entrance into the lesser sac is through the gastric foramen

The hepatoduodenal ligament, which forms the free border of the lesser omentum, contains the common bile duct, the hepatic artery, and the portal vein

• A 38-year-old male patient is brought into the emergency room with acute subphrenic abdominal pain on the right side. Physical examination and an MRI test reveal an abscess of the liver in the right subphrenic space. The falciform ligament, separating the right and left subphrenic spaces, prevented the spread of infection to the left side of the body. What is the embryological origin of the falciform ligament? • Answer Choices • 1 • Ventral mesentery • 2 • Dorsal mesentery • 3 • Ventral mesocolon • 4 • Pleuroperitoneal membrane • 5 • Pleuropericardial membrane

Ventral mesentery