Block 7 Anat TA's ingu rgn teste kidny & pst wall

1. A 23-year-old patient arrives at the emergency department complaining of nausea, vomiting, and severe right lower quadrant abdominal pain. On physical examination she has tenderness in the right lower quadrant with rebound tenderness. You suspect appendicitis. To further confirm his suspicions, you attempt to straighten the patients flexed thigh. The patient grimaces in pain. Inflammation of which of the following muscles is the most likely cause of this pain?

Adductor magnus

Biceps femoris

Gluteus maimus

Gracilis

Psoas Major

The psoas major lies in the retroperitoneum and comes into close contact with the appendix. Acute appendicitis can cause infection or sympathetic inflammation of the psoas muscle. When the legs are straightened, there is classically more pain as the psoas is stretched. There is also an obturator sign that can be used in conjunction with the psoas sign to confirm retrocecal appendicitis. These signs will be taught more in 4th semester.

Explanation

The psoas major lies in the retroperitoneum and comes into close contact with the appendix. Acute appendicitis can cause infection or sympathetic inflammation of the psoas muscle. When the legs are straightened, there is classically more pain as the psoas is stretched. There is also an obturator sign that can be used in conjunction with the psoas sign to confirm retrocecal appendicitis. These signs will be taught more in 4th semester.

2. A 74-year-old male is found to have enlarged superficial inguinal lymph nodes on general physical. What is one possibility as to the origin of this enlargement?

Cancer of the testis

Infection in the abdominal wall above the umbilicus

Infection of the lateral foot

Infection in the scrotal skin

The superficial inguinal lymph nodes receive afferent drainage from the skin of the scrotal sac. (A) The testes drain first to lumbar (retroperitoneal) lymph nodes. (B) The abdominal wall above the umbilicus drains to axillary lymph nodes. However, the abdominal wall below the umbilicus will drain to the superficial inguinal lymph nodes. (C) The lateral foot will drain first to popliteal lymph nodes and then to deep inguinal lymph nodes.

Explanation

The superficial inguinal lymph nodes receive afferent drainage from the skin of the scrotal sac. (A) The testes drain first to lumbar (retroperitoneal) lymph nodes. (B) The abdominal wall above the umbilicus drains to axillary lymph nodes. However, the abdominal wall below the umbilicus will drain to the superficial inguinal lymph nodes. (C) The lateral foot will drain first to popliteal lymph nodes and then to deep inguinal lymph nodes.

3. A 17-year-old male gymnast complains of falling on his bar, in a straddle position at practice one afternoon. He no longer has sensation to the anterior part of his scrotum. What nerve was injured which runs through the inguinal canal?

Ilioingunial

Iliohypogastric

Femoral branch of Genitofemoral

Femoral

The ilioinguinal nerve enters the inguinal canal midway and exits the superficial ring to provides sensation to the anterior pubis and scrotum as well as afferent fibers for the Cremasteric reflex.

Explanation

The ilioinguinal nerve enters the inguinal canal midway and exits the superficial ring to provides sensation to the anterior pubis and scrotum as well as afferent fibers for the Cremasteric reflex.

4. Your patient presents with complaints of "lower back pain", after reviewing some labs you determine that a biopsy of his kidney is required for a diagnosis. Considering the orientation of the kidney, what is the best approach to insert the needle?

Anteriorly

Directly posteriorly

Posterio-laterally

Laterally

The best method here would be between the posterior and anterior segments

Explanation

The best method here would be between the posterior and anterior segments

5. Mr. Charles was having renal surgery. When his surgeon clamped the renal artery, which suprarenal artery was affected?

Superior Suprarenal Artery

Middle Suprarenal Artery

Superior Mesenteric Artery

Inferior Suprarenal Artery

The Superior Suprarenal Arteries are supplied by the Inferior Phrenic Arteries. The Aorta supplies the middle suprarenal arteries.

Explanation

The Superior Suprarenal Arteries are supplied by the Inferior Phrenic Arteries. The Aorta supplies the middle suprarenal arteries.

6. A male patient presents with a mass felt on his scrotum. It has been enlarging over the past 3 months. What lymph nodes would most likely be inflamed first?

Iliac

Deep inguinal

Aortic

Pudendal

Superficial Inguinal

Cancer to the scrotum will travel to the superficial inguinal lymph nodes, but the testes will go to para-aortic (lumbar) lymph nodes. The testes follow the site from where they embryologically originated.

Explanation

Cancer to the scrotum will travel to the superficial inguinal lymph nodes, but the testes will go to para-aortic (lumbar) lymph nodes. The testes follow the site from where they embryologically originated.

7. A 26-year-old man presents to your office with an enlarged scrotum. You make the diagnosis of a hematocele and proceed with drainage of the testis to remove the excess fluid. Which of the following layers is the fibrous capsule of the testis that you'll want to avoid piercing while performing the drainage procedure?

Dartos layer

Parietal layer of the tunica vaginalis

Cremasteric fascia

External spermatic fascia

Tunica albuginea

The tunica albuginea is the tough fibrous layer that directly covers the testis.

Explanation

The tunica albuginea is the tough fibrous layer that directly covers the testis.

8. Occasionally, during a nephrectomy, the adrenal gland is spared. In order to accomplish this, the vascular supply to the gland must be preserved. The left adrenal vein can be identified by observing that it drain directly into which of the following veins?

Hemiazygous vein

Inferior vena cava

Left renal vein

Splenic vein

Superior mesenteric vein

The left adrenal vein drains into the left renal. The right adrenal vein drains directly into the IVC.

Explanation

The left adrenal vein drains into the left renal. The right adrenal vein drains directly into the IVC.

9. A 45-year-old male presents to the clinic with a bulging in his right groin. You place your finger on the superficial inguinal ring and when asking the patient to cough, you feel protrusion against your fingertip. Which is true of this hernia?

It is medial to the rectus abdominus

It is medial to the epigastric vessels

It is lateral to the epigastric vessels

It is "direct"

"Indirect" hernias protrude through the abdominal wall lateral to the epigastric vessels, the lateral border of Hasselbach's triangle. They most often pass into the inguinal canal and through it, exiting the superficial ring, allowing the physician to palpate it with a finger tip on the superficial inguinal ring. (A) Hernias originating medial to the rectus abdominus are umbilical and usually do not enter the groin area. (B, D) Both describe "direct" hernias.

Explanation

"Indirect" hernias protrude through the abdominal wall lateral to the epigastric vessels, the lateral border of Hasselbach's triangle. They most often pass into the inguinal canal and through it, exiting the superficial ring, allowing the physician to palpate it with a finger tip on the superficial inguinal ring. (A) Hernias originating medial to the rectus abdominus are umbilical and usually do not enter the groin area. (B, D) Both describe "direct" hernias.

10. Match the abdominal layer with it's corresponding layer in the scrotum:

Internal Oblique Fascia: Cremasteric Fascia

Transversalis Fascia: Cremasteric Fascia

External Oblique muscle: Dartos muscle

Transversalis Fascia:: Cremasteric muscle

Transversalis fascia becomes internal spermatic fascia. External oblique muscle becomes external spermatic fascia.

Explanation

Transversalis fascia becomes internal spermatic fascia. External oblique muscle becomes external spermatic fascia.

11. Which hernia passes deep to the internal spermatic fascia?

Indirect inguinal hernia

Direct inguinal hernia

Femoral hernia

Obturator hernia

Indirect inguinal hernias go through the deep inguinal ring, passing deep to the internal spermatic fascia. These hernias can enter the scrotum easily. Direct inguinal hernias are not covered by the internal spermatic fascia; they enter the inguinal canal next to the spermatic cord, and are less likely to enter the scrotum, but they still can in some cases.

Explanation

Indirect inguinal hernias go through the deep inguinal ring, passing deep to the internal spermatic fascia. These hernias can enter the scrotum easily. Direct inguinal hernias are not covered by the internal spermatic fascia; they enter the inguinal canal next to the spermatic cord, and are less likely to enter the scrotum, but they still can in some cases.

12. When assessing the renal vasculature in the body which statement is correct?

Renal artery is anterior to the renal vein

Renal artery is posterior to the renal vein and anterior to the renal pelvis

The left renal artery travels further than the right renal artery

The renal pelvis is anterior to the renal vein

Anterior to posterior is renal vein, renal artery, renal pelvis. Remember “VAP” (anterior to posterior) = Renal Vein, Renal Artery, Renal Pelvis

Explanation

Anterior to posterior is renal vein, renal artery, renal pelvis. Remember “VAP” (anterior to posterior) = Renal Vein, Renal Artery, Renal Pelvis

13. A young man while doing a monthly testicular self-exam feels an unusual lump. He goes to his doctor since he is concerned. If the lump turns out to be a metastatic cancer, to which lymph nodes will it likely first metastasize?

Superficial Inguinal nodes

Deep Inguinal nodes

Lumbar nodes

External Iliac nodes

Sacral nodes

The testes start their development under the diaphragm. While the testes are descending they drag their lymph vessels (along with their nerves, arteries, and veins) with them. So lymph drains to the lumbar (para-aortic) lymph nodes.

Explanation

The testes start their development under the diaphragm. While the testes are descending they drag their lymph vessels (along with their nerves, arteries, and veins) with them. So lymph drains to the lumbar (para-aortic) lymph nodes.

14. A young man in his 20's presents with a mass on the right superior posterior part of his scrotum. He complains of loss of sensation in the posterior area of his scrotum where the mass is located. The nerve responsible for the sensation of the posterior scrotum is a direct branch from what nerve?

Femoral n.

Genitofemoral n.

Pudendal n.

Rectal n.

Pudendal nerve is responsible for posterior sensation on the scrotum. Ilioingiunal nerve is responsible for anterior sensation on the scrotum.

Explanation

Pudendal nerve is responsible for posterior sensation on the scrotum. Ilioingiunal nerve is responsible for anterior sensation on the scrotum.

15. A patient complains his physician that he can no longer feel the outer portion of her thigh. He states that he does tend to wear tight pants. What nerve is most likely damaged and what are the nerve roots of this nerve?

Lateral Cutaneous nerve of thigh; L2-L3

Genitofemoral nerve; L1-L2

Lateral Cutaneous nerve of thigh; L1-L2

Obturator Nerve; L2-L4

Genitofemoral nerve; L2-3

The nerve that is most likely damaged is the lateral cutaneous nerve of the thigh. The nerve roots of this nerve are L2-L3. It is important to know the other nerves of the posterior abdominal wall. Subcostal nerve: T12, Genitofemoral: L1-L2; Ilioinguinal: L1, iliohypogastric: L1, Obturator nerve: L2-L4

Explanation

The nerve that is most likely damaged is the lateral cutaneous nerve of the thigh. The nerve roots of this nerve are L2-L3. It is important to know the other nerves of the posterior abdominal wall. Subcostal nerve: T12, Genitofemoral: L1-L2; Ilioinguinal: L1, iliohypogastric: L1, Obturator nerve: L2-L4

16. A 42-year-old male presents to his physician with a mass protruding from his low abdominal/groin region. On further examination, when the mass was compressed back into the abdominal cavity, a pulsation was noted on the lateral aspect of the Physicians finger. Which of the following characteristics of the hernia is most consistent with the following description?

The hernia protruded through the deep and superficial inguinal rings

The hernia was found next to other structures of the femoral ring

The herniation was caused by wearing excessively tight hip-hugger jeans

This answer choice describes the boundaries of Hesselbach's triangle. It is important to consider that these questions can be written in a confusing manner, 1: consider where the pulsation is in respect to the physicians finger or 2: consider where the herniation is in respect to the inferior epigastric artery. The incorrect answer choices describe: (a) indirect inguinal hernias, (b) femoral hernia [remember NAVEL for the relationship of the structures] and (d) Calvin Klein syndrome!

Explanation

This answer choice describes the boundaries of Hesselbach's triangle. It is important to consider that these questions can be written in a confusing manner, 1: consider where the pulsation is in respect to the physicians finger or 2: consider where the herniation is in respect to the inferior epigastric artery. The incorrect answer choices describe: (a) indirect inguinal hernias, (b) femoral hernia [remember NAVEL for the relationship of the structures] and (d) Calvin Klein syndrome!

17. A fit 40-year-old man feels a severe pain in his abdominal lower right quadrant after a day of heavy lifting at the gym. He goes to see his doctor who diagnoses him with a hernia and recommends surgery. During surgery, the doctor finds a hernial sac in the inguinal region projecting through the abdominal wall just above the inguinal ligament and lateral to the inferior epigastric vessels. This type of hernia can be specifically diagnosed as a:

Femoral hernia

Congenital hernia

Indirect femoral hernia

Indirect inguinal hernia

Direct inguinal hernia

Indirect inguinal hernias leave the abdominal cavity LATERAL to the inferior epigastric vessels and enter the inguinal canal through the deep inguinal ring as opposed to direct inguinal hernias which leave the abdominal cavity MEDIAL to the inferior epigastric vessels.

Explanation

Indirect inguinal hernias leave the abdominal cavity LATERAL to the inferior epigastric vessels and enter the inguinal canal through the deep inguinal ring as opposed to direct inguinal hernias which leave the abdominal cavity MEDIAL to the inferior epigastric vessels.

18. Which of the following displays correctly the artery from which their respective suprarenal artery arises?

Renal artery--> superior suprarenal artery, aorta---> middle suprarenal artery, inferior phrenic artery --> inferior suprarenal artery,

Aorta-->superior suprarenal artery, renal artery--> middle suprarenal artery, inferior phrenic--> inferior suprarenal artery

Aorta--> superior suprarenal artery, inferior phrenic artery--> middle suprarenal artery, renal artery --> inferior suprarenal artery

Inferior phrenic artery--> superior suprarenal artery, renal artery--> middle suprarenal artery, aorta--> inferior suprarenal artery

Inferior phrenic artery--> superior suprarenal artery, aorta--> middle suprarenal artery, renal artery--> inferior suprarenal artery

The suprarenal (adrenal) glands are supplied by 3 arteries. The superior suprarenal artery comes off the inferior phrenic artery. The middle suprarenal artery comes directly off the aorta and the inferior suprarenal artery comes off the renal artery.

Explanation

The suprarenal (adrenal) glands are supplied by 3 arteries. The superior suprarenal artery comes off the inferior phrenic artery. The middle suprarenal artery comes directly off the aorta and the inferior suprarenal artery comes off the renal artery.

19. A 17-year-old, male presents to your clinic with a disturbing mass in the inguinal region. Past medical history reveals that the patient is following an excessive weight lifting regimen to try out for his varsity football team next fall. Physical examination shows a scrotal mass, 3 cm in width, 2 cm in thickness, and 5 cm in length. In order to diagnose this condition, you insert your index finger into the superficial inguinal ring and ask the patient to cough to the side. Upon coughing, the protruding mass is palpated at the tip of your finger. At this point in time, you highly suspect:

Femoral Hernia

Direct Femoral Hernia

Indirect Inguinal Hernia

Indirect Femoral Hernia

Direct Inguinal Hernia

This presentation is very common in young adolescent males after exerting themselves in a gym setting. Excessive weight lifting can not only stunt physiological growth during pubescent years but can also induce inguinal hernias; the most common hernias in males (femoral hernias are more common in females). To diagnose the hernia, a physician may place their index finger through the superficial inguinal ring and ask the patient to cough. If indeed the patient has an indirect inguinal hernia, you will most likely feel the mass at the tip of your finger. This due to the fact that as indirect inguinal hernia progresses, it first penetrates the deep inguinal ring and traverses the inguinal canal before it exits the superficial inguinal ring. A direct inguinal hernia however will not enter the inguinal canal through the deep inguinal ring and will simply protrude through weak fascia in the anterior abdominal wall. Furthermore, direct inguinal hernias are located MEDIAL to the inferior epigastric vessels and indirect inguinal hernias are located LATERAL to the inferior epigastric vessels. Please refer back to Hesselbach's Triangle for further clarification.

Explanation

This presentation is very common in young adolescent males after exerting themselves in a gym setting. Excessive weight lifting can not only stunt physiological growth during pubescent years but can also induce inguinal hernias; the most common hernias in males (femoral hernias are more common in females). To diagnose the hernia, a physician may place their index finger through the superficial inguinal ring and ask the patient to cough. If indeed the patient has an indirect inguinal hernia, you will most likely feel the mass at the tip of your finger. This due to the fact that as indirect inguinal hernia progresses, it first penetrates the deep inguinal ring and traverses the inguinal canal before it exits the superficial inguinal ring. A direct inguinal hernia however will not enter the inguinal canal through the deep inguinal ring and will simply protrude through weak fascia in the anterior abdominal wall. Furthermore, direct inguinal hernias are located MEDIAL to the inferior epigastric vessels and indirect inguinal hernias are located LATERAL to the inferior epigastric vessels. Please refer back to Hesselbach's Triangle for further clarification.

20. A physician is performing a physical on a male patient. He feels for the posterior part of the scrotum and identifies a 'cord-like' structure. What has he palpated?

A hydrocele

A normal spermatic cord

An infected spermatic cord

The pampiniform plexus

The vas deferens

It is normal to identify a tough cord like structure in this region as the vas deferens. The spermatic cord is not correct because it is found anteriorly, traveling through the inguinal canal. The pampinoform plexus is normally not palpable. In the case of nutcracker syndrome, it may be visible as varicose veins. This is known as 'bag of worms.' This is due to the SMA compressing the left renal vein (into which the left testicular vein drains).

Explanation

It is normal to identify a tough cord like structure in this region as the vas deferens. The spermatic cord is not correct because it is found anteriorly, traveling through the inguinal canal. The pampinoform plexus is normally not palpable. In the case of nutcracker syndrome, it may be visible as varicose veins. This is known as 'bag of worms.' This is due to the SMA compressing the left renal vein (into which the left testicular vein drains).

21. Your patient comes into the clinic with lost of sensation to the anterior part of his scrotum, what nerve root(s) was injured?

L1, L2

L2, L3

L1

L2, L3, L4

The ilioinguinal nerve supplies cutaneous sensation to the anterior scrotum.

Explanation

The ilioinguinal nerve supplies cutaneous sensation to the anterior scrotum.

22. Which of the following vessels comes AFTER the interlobar vein?

Efferent vein

Inferior vena cava

Renal vein

Interlobular vein

Arcuate vein

Segmental vein

The major veins follow the same order as the arteries, but in reverse order.

Explanation

The major veins follow the same order as the arteries, but in reverse order.

23. A 52-year-old man presents to your clinic with groin pain. The physical exam reveals a bulge in the groin inferior to the inguinal canal. You suspect a femoral hernia containing a loop of small intestine. Which of the following structures is located immediately medial to the hernia sac?

Femoral artery

Femoral nerve

Femoral vein

Inferior epigastric artery

Lacunar ligament

The femoral hernia exits through the femoral ring immediately inferior to the inguinal ligament. It enters the femoral canal in the “empty space” bounded medially by the lacunar ligament. The anterior border is the inguinal ligament, posterior border is the pubis, the lateral border is the femoral vein. Remember from first semester the NAVEL mnemonic that indicates the sequence of structures from lateral to medial in the femoral triangle: Femoral nerve, femoral artery, femoral vein, empty space, and lacunar ligament.

Explanation

The femoral hernia exits through the femoral ring immediately inferior to the inguinal ligament. It enters the femoral canal in the “empty space” bounded medially by the lacunar ligament. The anterior border is the inguinal ligament, posterior border is the pubis, the lateral border is the femoral vein. Remember from first semester the NAVEL mnemonic that indicates the sequence of structures from lateral to medial in the femoral triangle: Femoral nerve, femoral artery, femoral vein, empty space, and lacunar ligament.

24. From which vertebral level does the testicular artery arise?

T12

L2

L3

L4

T12 is where the Celiac trunk branches. L3 is where the IMA branches. L4 is the bifurcation level of the aorta

Explanation

T12 is where the Celiac trunk branches. L3 is where the IMA branches. L4 is the bifurcation level of the aorta

25. What is true about the Greater Splanchnic Nerve?

Provides sympathetic innervation to the adrenal cortex

Receives contributions from spinal levels T4-T9

Fibers synapse in the celiac ganglia and contribute to the celiac plexus

Modulates the enteric nervous system of the midgut

The greater splanchnic nerve provides sympathetic innervation to the adrenal MEDULLA, and receives contributions from spinal levels T5-T9, and modulates the enteric nervous system of the foregut.

Explanation

The greater splanchnic nerve provides sympathetic innervation to the adrenal MEDULLA, and receives contributions from spinal levels T5-T9, and modulates the enteric nervous system of the foregut.

26. Which is true of a renal lobe?

It contains only medulla

It can be located between two interlobular arteries

It contains both medulla and cortex

It can be located between two arcuate arteries

A renal lobe is defined as the space between two interlobar arteries containing a medullary pyramid and the intervening cortex on either side. (A) A renal lobe contains both medulla and a small amount of cortex on either side. (B,D) A renal lobe is located between two interlobar arteries. Interlobular arteries demarcate a renal lobule. There is no defined/named space between two arcuate arteries.

Explanation

A renal lobe is defined as the space between two interlobar arteries containing a medullary pyramid and the intervening cortex on either side. (A) A renal lobe contains both medulla and a small amount of cortex on either side. (B,D) A renal lobe is located between two interlobar arteries. Interlobular arteries demarcate a renal lobule. There is no defined/named space between two arcuate arteries.

27. A stenosis of the left renal artery could potentially cause what?

Varicocele

High blood pressure

Renal calculi

Abdominal aortic aneurysm

A stenosis of the left renal artery can potentially cause high blood pressure. The left renal artery supplies blood to the left kidney, and if it becomes narrowed or blocked due to stenosis, it can lead to reduced blood flow to the kidney. This can trigger the renin-angiotensin-aldosterone system, which regulates blood pressure, causing an increase in blood pressure. Therefore, a stenosis of the left renal artery can result in hypertension.

Explanation

A stenosis of the left renal artery can potentially cause high blood pressure. The left renal artery supplies blood to the left kidney, and if it becomes narrowed or blocked due to stenosis, it can lead to reduced blood flow to the kidney. This can trigger the renin-angiotensin-aldosterone system, which regulates blood pressure, causing an increase in blood pressure. Therefore, a stenosis of the left renal artery can result in hypertension.

28. This structure provides an alternate path for blood from the right atrium by allowing flow between the venae cavae when one vena cava is blocked. At what level does it pass through the diaphragm?

T5

T8

T10

T12

The ayzgos vein accompanies the aorta to pass through the diaphragm at the level of T12

Explanation

The ayzgos vein accompanies the aorta to pass through the diaphragm at the level of T12

29. A 46 year-old-male is admitted to your clinic with generalized abdominal pain. On physical examination, you note a positive psoas sign. A CT scan confirms your diagnosis and the patient is sent for surgery immediately. The surgery was uneventful except for an abnormal cremasteric reflex. The nerve that was MOST likely damaged is:

Femoral n.

Illioinguinal n.

Genital Branch of Genitofemoral n.

Iliiohypogastric n.

Femoral Branch of Genitofemoral n.

The positive psoas sign and "positive CT scan" should have confirmed your suspicions of a case of retrocecal appendicitis.The illiohypogastric nerve along with the illioinguinal nerve are the two (2) most common surgically injured nerves when attempting to remove an inflamed appendix. However, an abnormal cremasteric reflex along with history of a surgical appendicitis removal indicates a possible afferent lesion, making the illioinguinal nerve the best answer.

Explanation

The positive psoas sign and "positive CT scan" should have confirmed your suspicions of a case of retrocecal appendicitis.The illiohypogastric nerve along with the illioinguinal nerve are the two (2) most common surgically injured nerves when attempting to remove an inflamed appendix. However, an abnormal cremasteric reflex along with history of a surgical appendicitis removal indicates a possible afferent lesion, making the illioinguinal nerve the best answer.

Block 7 Anat Ta's Ingu Rgn Teste Kidny & Pst Wall