Exam 3 Main Topics Condensed

Secretion of epinephrine

A 12-year-old boy suffers an enlarging neurogenic tumor in the right posterior mediastinum, as shown in the given lateral view radiograph. This growth causes multiple lesions of the right thoracic sympathetic trunk below the T5 chain ganglion. Which of the following functions is most likely compromised?

Spleen

A 13-year-old girl is brought to the ER after falling from a horse onto her left side. Her pulse is 120/min, blood pressure is 90/60 mm Hg, and respirations are 30/min. Physical examination reveals cold and clammy skin, bruising, and fractured 9th and 10th ribs on her left side at the posterior axillary line. Which of the following organs is most likely damaged in this patient?

The central abdominal pain resulted from afferent fibers from the appendix that entered the spinal cord at the T10 level.

A 14-year-old boy complained of vague central abdominal pain (periumbilical pain). When he felt severe pain in the right lower quadrant (RLQ) of his anterior abdominal wall, he called his physician. The boy's temperature was 38.3 °C and his pulse was 82. The physician noted that the boy's abdominal muscles in the RLQ were rigid and that there was severe rebound tenderness. A diagnosis of acute appendicitis was made. Which of the following statements about the boy's inflamed appendix is correct?

The parietal pleura, particularly its costal part, is very sensitive to pain.

A 14-year-old girl was taken to the family physician because she had a hacking cough and was bringing up blood-tinged sputum, and she had pain in her chest. After receiving laboratory and radiology reports, the physician diagnosed her illness as pleurisy (pleuritis) caused by pneumococcal pneumonitis. Which of the following statements is correct about pleural pain?

Inferior pancreaticoduodenal artery

A 16-year-old boy with a ruptured spleen comes to the emergency department for splenectomy. Soon after ligation of the splenic artery just distal to its origin, a surgical resident observes that the patient is healing normally. Normal blood flow would occur in which of the following arteries?

Ileocolic artery

A 19-year-old man with a ruptured appendix is sent to the emergency department for surgery. To cut off the blood supply to the appendix (if collateral circulation is discounted), a surgeon should ligate which of the following arteries?

Left colic flexure

A 19-year-old young woman with a long history of irritable bowel syndrome presents for the possibility of surgical resection of the gastrointestinal (GI) tract where the vagal parasympathetic innervation terminates. Which of the following sites is most appropriate for surgical resection?

Passes through the deep inguinal ring.

A 21-year-old man developed a hernia after lifting heavy boxes while moving into his new house. During the repair of his resulting hernia, the urologist recalls that the genitofemoral nerve:

Ascending and transverse colons

A 21-year-old man receives a penetrating knife wound in the abdomen and is injured in both the superior mesenteric artery and the vagus nerve. Which portion of the colon would most likely be impaired by this injury?

The heart occupies the middle mediastinum.

A 22-year-old man is taken to the emergency room after being stabbed in the right side of his chest. He presents with a right pneumothorax, including a collapsed right lung and mediastinal structures displaced to the left. Correct management of this situation assumes the attending physician understands which of the following is a normal condition of the mediastinum?

Spleen

A 22-year-old man who was thrown from his motorcycle complained of severe pain in the lower left side of his chest. He held his hand over his lower left ribs near the midaxillary line. A radiograph of his thorax revealed fractures of the 9th and 10th ribs. What internal organ would most likely be injured?

Above the upper border of the ribs

A 32-year-old patient has a tension pneumothorax that can be treated with needle aspiration. To avoid an injury of the intercostal neurovascular bundle, the needle may be inserted in which of the following locations?

Lungs

A 35-year-old man is suffering from an infected mediastinum (mediastinitis) after neck and chest injuries resulting from a head-on automobile collision. He has been intubated since the accident and on broad-spectrum intravenous antibiotics since admission; however, the infection continues to progress throughout the mediastinum. Which of the following structures is free from infection?

Phrenic nerve

A 35-year-old woman with a history of cholecystectomy arrives in the emergency department with intractable hiccups most likely caused by an abdominal abscess secondary to surgical infection. Which of the following nerves carries pain sensation caused by irritation of the peritoneum on the central portion of the inferior surface of the diaphragm?

Drains bile into the second part of the duodenum.

A 41-year-old woman is brought to the emergency department by her family because of acute onset of right upper quadrant pain, nausea, and vomiting. For this case, it is important to remember that the bile duct:

Elastic tissue in the lungs and thoracic wall

A 43-year-old female patient has been lying down on the hospital bed for more than 4 months. Her normal, quiet expiration is achieved by contraction of which of the following structures?

Loss of sensation in the fibrous pericardium and mediastinal pleura

A 44-year-old man with a stab wound was brought to the emergency department, and a physician found that the patient was suffering from a laceration of his right phrenic nerve. Which of the following conditions has likely occurred?

Pectoral group of axillary lymph nodes

A 45-year-old woman consulted her physician about a painless lump in the right upper outer quadrant of her breast. During palpation of her axilla, the physician detected enlarged, firm lymph nodes. A mammogram showed a malignant breast tumor. In which of the following groups of axillary lymph nodes would most of the cancer cells initially lodge?

Descending aorta

A 45-year-old woman presents with a tumor confined to the posterior mediastinum. This could result in compression of which of the following structures?

Lymph nodes

A 46-year-old postal worker was exposed unknowingly to the powdered form of bacteria Bacillus anthracis (anthrax). He comes to the ER with flu-like symptoms, including fever, chills, fatigue, headache, chest pain, and shortness of breath. A chest X-ray shows an abnormally wide space between the lungs. Enlargement of which of the following structures is the most likely cause of the widened mediastinum in this patient?

A large gallstone lodged in the Hartmann pouch (abnormal sacculation of gallbladder neck) that obstructed the cystic duct and caused inflammation and dilation of the gallbladder.

A 49-year-old woman complained of recurrent attacks of right upper quadrant pain in her abdomen. During palpation of the fundus of the gallbladder at the junction of the 9th costal cartilage and the semilunar line, the physician detected gallbladder tenderness. The patient also complained of pain in her right shoulder and back.. A diagnosis of inflammation of the gallbladder (cholecystitis) was made. Which of the following statements most likely explains the cause of pain in the woman's shoulder and back?

The hernia bulges forward through the posterior wall of the inguinal canal.

A 50-year-old man presents with multiple symptoms suggestive of an abdominal hernia. Which of the following is most indicative of a direct inguinal hernia?

Inferior vena cava (IVC)

A 52-year-old woman presents with severe upper right quadrant abdominal pain. She is jaundiced, obese, and has a history of gallstones. Further examination indicates acute cholecystitis, and she undergoes an open abdominal cholecystectomy (removal of gall bladder). During the surgery, the doctor inserts her index finger into the omental (epiploic) foramen to palpate the structures in the hepatoduodenal ligament. Which of the following structures lies immediately posterior to her finger?

Cancer cells entering the lymphatic vessels from the descending colon reach the inferior mesenteric nodes.

A 53-year-old woman consulted her physician about pain in the left lower quadrant of her abdomen. The physician asked her about her bowel movements. She said they were irregular and that she had difficulty evacuating her stool (feces). She said that her stool was usually blood stained. Radiographic images revealed a tumor, which was later determined to be a cancer of the descending colon. Which of the following statements about the descending colon is correct?

Superior mesenteric artery

A 54-year-old man comes to a hospital with abdominal pain, jaundice, loss of appetite, and weight loss. On examination of his radiograms and CT scans, a physician finds a slowly growing tumor in the uncinate process of the pancreas. Which of the following structures is most likely compressed by this tumor?

Caput medusae and hemorrhoids caused by portal hypertension

A 54-year-old man with a long history of alcohol abuse presents to the emergency department with rapidly increasing abdominal distention most likely resulting from an alteration in portal systemic blood flow. Which of the following characteristics is associated with the portal vein or the portal venous system?

Blood flow to the descending colon via the left colic artery is affected.

A 55-year-old man has a 90% occlusion of the inferior mesenteric artery due to atherosclerotic plaque formation at the origin of the vessel. Which of the following is the most likely outcome of this condition?

In a sliding hiatus hernia, the abdominal part of the esophagus, cardia, and parts of the funds of the stomach slide superiorly through the esophageal hiatus.

A 55-year-old obese man with a history of heartburn, dyspepsia, and belching complained to his physician about epigastric pain. He said the pain was most severe after a heavy meal, especially when accompanied by several glasses of wine. A radiographic examination showed that part of his stomach herniated through the esophageal hiatus when he bent over or was supine. The physician diagnosed a sliding hiatus hernia. Which of the following statements about hiatus hernias is correct?

Vagus nerves

A 55-year-old woman develops a hiatal hernia in which the fundus of the stomach protrudes through the esophageal hiatus of the diaphragm into the thorax. Which of the following structures is/are at greatest risk of injury during surgical repair of this hernia?

In the superior mediastinum, the arch of the aorta lies on the anterior and left sides of the trachea.

A 56-year-old man presents with difficulty in breathing and other indications suggestive of a compressed trachea. In assessing the condition of the trachea, the physician should understand which of the following relations is correct?

Left colic vein

A 57-year-old patient has a tumor in the body of the pancreas that obstructs the inferior mesenteric vein just before joining the splenic vein. Which of the following veins is most likely to be enlarged?

Neck of the pancreas

A 58-year-old man is admitted to a hospital with severe abdominal pain, nausea, and vomiting resulting in dehydration. Emergency CT scan reveals a tumor located between the celiac trunk and the superior mesenteric artery. Which of the following structures is likely compressed by this tumor?

Diaphragmatic hernia

A 59-year-old woman is brought to the ER in respiratory distress after her abdomen impacted the steering wheel in a motor vehicle accident. Auscultation of the left chest reveals the absence of audible breath sounds, but the presence of bowel sounds is noted. The given chest X-ray reveals radiopacity in her lower left hemithorax and a rightward mediastinal shift. Which of the following diagnoses would best explain the patient's presentation?

Sympathetic supply to the ascending colon

A 60-year-old man is diagnosed with a posterior abdominal wall tumor that is causing lesions in the superior mesenteric plexus. Which of the following pathways is most likely affected?

Superior mediastinum

A 65-year-old man presents with a swollen neck, marked edema in both upper limbs, and engorged and prominent intercostal veins. Subsequent examination reveals a tumor in his right lung. The tumor is likely compressing structures in which of the following regions?

Metastasis of cancer cells to the bronchomediastinal and superior tracheobronchial lymph nodes

A 65-year-old man who is a heavy smoker tells his physician about a persistent cough and hoarse voice. He is mainly concerned about the blood that he often coughs up. A physical examination reveals that his left vocal fold is motionless and in the adducted position. A posteroanterior radiograph of his thorax reveals a large mass in his left lung. A pathological examination of the mass revealed a bronchogenic carcinoma. Which of the following occurrences is most likely to be the anatomical basis of the alteration of his voice and the immobility of his left vocal fold?

The parietal pleura is innervated by the intercostal nerves.

A 65-year-old woman visits her doctor complaining of a severe cough that elicits intense pain in her chest and that extends into the anterior abdominal wall. Thorough examination leads to a diagnosis of lobar pneumonia with pleurisy. Which of the following is true of the parietal pleura?

Right colic vein

A 67-year-old woman with a long history of liver cirrhosis was seen in the emergency department. In this patient with portal hypertension, which of the following veins is most likely to be dilated?

Right coronary

A 7-year-old boy with Down syndrome underwent surgery to repair a congenital ventricular septal defect. During this procedure, iatrogenic injury to the coronary artery supplying the conduction system of the heart, including the sinuatrial (SA) and atrioventricular (AV) nodes, occurred, resulting in a heart block. What artery was most likely damaged by the surgeon?

The left gastric vein

A 72-year-old alcoholic man is vomiting blood. He is shown to have ruptured esophageal varices secondary to portal hypertension. These varices result from dilatation of the esophageal systemic veins because they communicate with the elevated pressure in the portal venous system via tributaries of which vein?

Hemiazygos vein

A 78-year-old patient presents with an advanced cancer in the posterior mediastinum. The surgeons are in a dilemma as to how to manage the condition. Which of the following structures is most likely damaged?

Iliohypogastric nerve

A 9-year-old boy was admitted to the emergency department complaining of nausea, vomiting, fever, and loss of appetite. On examination, he was found to have tenderness and pain on the right lower quadrant. Based on signs and symptoms, the diagnosis of acute appendicitis was made. During an appendectomy performed at McBurney's point, which of the following structures is most likely to be injured?

Ascending colon

A 9-year-old girl has crashed into her neighbor's brick fence while riding her bike and is brought to the emergency department with a great deal of abdominal pain. Her radiogram and angiogram show laceration of the superior mesenteric artery immediately distal to the origin of the middle colic artery. If collateral circulation is discounted, which of the following organs may become ischemic?

The upper opening in the thoracic cage.

A medical resident is reviewing the case history of a 45-year-old man suffering thoracic outlet syndrome. In a clinical context, which of the following is the correct definition of the thoracic outlet?

Bifurcation of the trachea

A patient has a small but solid tumor in the mediastinum, which is confined at the level of the sternal angle. Which of the following structures would most likely be found at this level?

Has teniae coli and epiploic appendages.

A patient with diverticulosis of the colon presents for follow-up to his primary care physician with ongoing complaints of left lower quadrant pain and occasionally bloody stools. His physician begins workup with appropriating test by recalling that the sigmoid colon:

The breast overlies the 2nd to the 6th ribs.

A physician conducts a breast examination of a 24-year-old woman. Which of the following features constitutes a normal condition?

Ribs 7 and 9

A thoracentesis is performed to aspirate an abnormal accumulation of fluid in a 37-year-old patient with pleural effusion. A needle should be inserted at the midaxillary line between which of the following two ribs so as to avoid puncturing the lung?

Ilioinguinal nerve

A young mother brings her 8-year-old daughter to a pediatrician for the first time because the girl has been complaining of a big lump and discomfort in her right groin area. The physician discovers what appears to be a complete indirect inguinal hernia on the right side. Which of the following structures is most likely to be compressed by the body of the hernial sac?

Superior rectal vein

A young woman with cryptogenic cirrhosis presents to the university hospital for an evaluation as a possible candidate for liver transplant. She has late-stage cirrhosis, and her liver-spleen scan shows a high degree of portal hypertension. The portal venous system includes which of the following veins?

Liver

Abdominal palpation is a common component of a general physical examination. Assuming examination of an adult woman of average body build and normal health, which of the following organs is palpable in the upper right abdominal quadrant?

It contains portions of the lungs

All of the following are true of the mediastinum except:

Muscles of the abdominal wall

An 18-year-old girl is thrust into the steering wheel while driving and experiences difficulty in expiration. Which of the following muscles is most likely damaged?

Midaxillary line—9th intercostal space

An 87-year-old woman with a history of metastatic adenocarcinoma of the breast presents with difficulty in breathing. A plain chest film reveals massive left pleural effusion, as noted in the photo. The physician chooses to drain the fluid with a thoracentesis. What is the proper location for placement of the cannula (hollow needle) to drain the pleural effusion?

Arch of the aorta

As part of an annual physical examination of a 57-year-old man, a physician orders a P-A (posteroanterior) radiograph of the thorax. Which of the following structures contributes to the left margin of the mediastinal shadow in this image?

The 6th, 8th, and 10th ribs

As part of an annual physical examination, a physician listens to the breath sounds of his 43-year-old male patient. During quiet midrespiration, the lower margin of the left lung normally crosses which of the following points?

The atrioventricular node lies in the interventricular septum

Cardiac ischemia can affect the heart's conduction system. Which of the following statements is incorrect pertaining to this system?

E (superior mesenteric artery)

Choose the appropriate lettered structure in the CT scan of the abdomen (see figure). Laceration of which structure decreases blood flow in the middle colic artery?

A (common hepatic artery)

Choose the appropriate lettered structure in this CT scan of the abdomen (see figure) at the level of the 12th thoracic vertebra. Which structure is divided into the proper hepatic and gastroduodenal arteries?

Cardiac nerve branches of the cervical sympathetic ganglia

Diabetes mellitus is a disease characterized by elevated blood glucose levels (hyperglycemia). Persistent hyperglycemia is associated with degeneration of Schwann cells, followed by axonal damage. In the autonomic nervous system, the structures most susceptible to damage are the relatively smaller, nonmyelinated, postsynaptic axons. Which of the following structures are most likely to contain autonomic axons damaged secondary to diabetes mellitus?

Contraction of the arching fibers of the internal oblique and transversus abdominis muscles lowers the roof of the canal so that the canal is practically obliterated.

During a physical examination of the inguinal region, a physician asks his 35-year-old male patient to turn his head and cough. Which of the following is true of the inguinal canal when the patient coughs?

The diaphragm descends.

During a routine physical examination, a physician asks her 41-year-old female patient to breathe normally while she assesses the patient's respiration. Which of the following is true of the mechanics of inspiration during normal quiet respiration?

Lienorenal ligament

During a splenectomy, a surgeon carefully dissects the peritoneal ligament containing the splenic vessels at the hilum of the spleen. Which of the following peritoneal ligaments is being dissected by the surgeon?

Proper hepatic

During surgery to remove the gallbladder (cholecystectomy), a surgery resident damages the cystic artery before a clamp is properly placed. The attending physician applies pressure to the free edge of the hepatoduodenal ligament of the lesser omentum to control the bleeding until the damaged artery is clamped and ligated. Which of the following arteries was compressed by the attending physician?

Diaphragm

Familial dysautonomia is a rare genetic disorder of the autonomic nervous system. Problems include difficulty in feeding and respiration, vasomotor instability, insensitivity to pain, and ataxia (an unsteady gait). Patients with this syndrome have low numbers of autonomic neurons, probably related to defects in production and/or survival of the neural crest precursors of these neurons. Which of the following structures would not be affected by this disorder?

Fundic portion of the stomach

Following involvement in a car crash, a 20-year-old undergoes a splenectomy due to a lacerated spleen secondary to blunt abdominal trauma. During the procedure, the surgeon ligates the blood supply of the spleen at its hilum. Improper placement of the ligature may lead to damage to the arterial supply of which of the following structures?

Air in the esophagus

In the above axial CT of the superior mediastinum, what is the red arrow pointing to?

Tracheobronchial lymph node

In the above axial contrast enhanced CT of the superior mediastinum, the white arrow points to a cancer in the superior (upper) lobe of the right lung and the red arrows points to an abnormally enlarged structure. What is this structure?

Right gastric

In your 52-year-old patient with lower esophageal cancer, the surgeon performed a subtotal esophagectomy and attached the proximal stump of the thoracic esophagus directly to the stomach, which had been repositioned into the thorax ("gastric pull-through"). In order to do this, the surgeon had to ligate all of the major vessels supplying the stomach except the one that runs along the lesser curvature and typically arises from the proper hepatic artery. What is this artery?

Deep circumflex iliac artery

Initial examination of a newborn boy baby reveals a complete indirect inguinal hernia on the right side that is severely compressing the structures within the inguinal canal. Which of the following structures is most likely to be spared in this case?

Fist—lung; space between inner and outer balloon layers—pleural cavity; outer layer of balloon—parietal pleura

It is common to explain the relationships between the lung and surrounding structures by using the analogy of a fist inserted into a balloon. Accordingly, which of the following group of associations would be accurate?

Is initially to the ipsilateral anterior or pectoral group of axillary nodes

Lymphatic drainage of the breast is important because of its role in the metastasis of cancer cells. Which of the following is correct about the lymph drainage of the right breast?

Peau d' orange and interference with lymph drainage

The above image is a close up photograph of an abnormal breast. What is the name of this condition and its cause?

It is attached to the pubic crest and pectineal line.

The conjoint tendon is an important structure in that it reinforces the posteromedial wall of the inguinal canal immediately behind the superficial inguinal ring. Which of the following is true of the conjoint tendon?

The costal cartilages of the 7th-10th ribs and the ends of the cartilages of the 11th and 12th ribs.

The costal margin serves as a useful reference line for palpation of deeper lying soft structures. Which of the following defines the costal margin?

Transversalis fascia

The given photo shows a large left bulge in the inguinal canal and a swelling of the left scrotum in a newborn male. Ultrasound examination reveals a portion of the small intestine within the scrotal swelling. What is the deepest layer of the abdominal wall involved with this herniated bowel?

Pectoralis major (accessory muscle for inspiration)

The image above shows a medial-lateral-oblique mammographic image of the right breast of a woman. Mammograms are a specialized form of radiography. The structure indicated by the letter "A" is which of the following?

It shows a patient who likely has a paralyzed right phrenic nerve

Which of the following is correct based on the above image, which was taken during inspiration?

Expiration is primarily a passive process

Which of the following is correct during normal (non-forced) respiration?

It provides a surgical cleavage plane between the thoracic wall and the costal parietal pleura

Which of the following is correct of the endothoracic fascia?

thoracic duct

Which of the following is found in the posterior mediastinum?

An intercostal space is numbered based on the superior rib

Which of the following is true pertaining to the ribs?

9

Which of the following ribs is considered typical?

Falciform ligament

Which of the following structures is a remnant of the embryonic ventral mesentery?

Immediately superior to the 10th rib at the midaxillary line

Which of the following would be the safest locations to insert a needle for thoracocentesis of the pleural cavity during expiration in an upright patient?

Directed obliquely to the right from the lower thoracic esophagus

While assisting in a bowel resection the surgeon asked you to extend the small bowel from its root. Where do you find the origin of the root of the mesentery?

The right external oblique and the left internal oblique

You are concerned as to whether your 67-year-old male patient's abdominal wall musculature is functioning correctly because he is prone to abdominal wall hernias. You do an electromyographic (EMG) exam to determine muscle activity. You ask him to try to rotate his trunk so as to bring his right shoulder to his left hip. The EMG should show most activity during this action in which of the following?

Hypertrophic pyloric stenosis

You are examining a 3-week-old male infant who shows projectile vomiting, dehydration, and lack of weight gain. You also feel an olive-shaped mass in the middle of his right upper quadrant. Sonography confirms your initial diagnosis as which of the following?

Between the left costal margin and the level of the L3/L4 intervertebral disk

You are sending your 45-year-old patient for a CT scan of her abdomen because she is having increasing postprandial pain in her upper left quadrant. This means that the pain is located where?

Superior mesenteric artery

You are viewing a CT arteriogram of your 56-year-old patient's hepatic blood supply. His common hepatic artery does not appear to have a branch supplying the right lobe of the liver. What is the most likely source of the right hepatic artery in this patient?

Ileum

You are working in the ED and a patient is admitted with a bullet wound in her lower right quadrant. Which of the following small bowel segments would be most likely to be injured?

Your finger compressed the inferior epigastric artery within the canal

You feel a hernia in a male patient and you use your finger to push the hernia contents back into the abdomen through the inguinal canal. In performing this procedure, which of the following is not correct?

The inflammation irritates the ilioinguinal nerve

Your 31-year-old patient has lower right quadrant pain that is originally thought to be appendicitis but CT showed to be pyelonephiritis (kidney infection). Which of the following is the most likely explanation for right lower quadrant pain with a kidney infection?

It is firmly fixed to the posterior abdominal wall by the its mesentery

Your 45-year-old patient is about to donate a kidney to her husband. The surgeon plans to harvest the left kidney. Which of the following is not true about this kidney?

All breast tissue superficial to the retromammary space

Your 51-year-old patient is scheduled for a simple mastectomy. This involves removal of which of the following?

Posterior to the superior mesenteric artery

Your 54-year-old patient had unexplained weight loss and vague abdominal and back pain. A CT scan showed that she has a tumor in the uncinate process of her pancreas. Where would the surgeon find this tumor?

Superior mesenteric artery

Your 55-year-old patient complains of slowly progressive postprandial abdominal pain and weight loss. A sagittal image from a CT arteriogram is shown above. The red arrows show stenosis of which artery?

Falciform

Your 56-year-old patient has peritonitis with pus in his subphrenic recess. The abscess in this space is separated into right and left abscesses by which of the following ligaments?

Right renal nodes

Your 67-year-old patient has a primary liver tumor and you are concerned about metastases via the lymphatic drainage of the liver. Which of the following group of lymph nodes do not typically receive lymph directly from the liver?