Block 7 Anatomy Wk 10 11 From Ta's W Xpl Prt 2

1.

During vaginal delivery, the doctor preformed a median episiotomy in which he cut too far posteriorly. Which structure did he most likely cut?

A.

Bulbospongiosis muscle
B.

External anal sphincter muscle
C.

Ischiocavernosis muscle
D.

Sacrospinous ligament
E.

Sphincter urethrae

Correct Answer
B. External anal sphincter muscle

Explanation
a complication of median episiotomy is fecal incontinence due to tearing of the external anal sphincter

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2.

You are examining your cadaver's uterus and notice that the fundus of the uterus appears to be slightly irregular in shape. You also notice that there is an enlarged rouge lymph node resting ontop of the fundus of the uterus. Two of your lab partners are arguing over which lymph node would most likely drain the lateral fundus of the uterus first. You step in and correct both of your lab partners by explaining that the lateral fundus of the uterus drains first into the following lymph nodes:

A.

Pararectal lymph nodes
B.

Common Iliac lymph nodes
C.

Para-aortic (lumbar) lymph nodes
D.

Deep Inguinal lymph nodes
E.

Superficial Inguinal lymph nodes

Correct Answer
E. Superficial Inguinal lymph nodes

Explanation
To answer this question you must understand the embryological relationship of fundus of the uterus to the round ligament and to the Labia Majora (thus, there are many high yield relationships within this question). First remember that the Labia Majora is a homologue to the male’s Scrotum, then remember that the Round Ligament of the uterus is essentially the female Gubernaculum. You recall that the gubernaculum testis aids in the descent of the male testes towards the scrotum during development; in females however, the round ligament originates from the fundus of uterus and inserts on the inner surface of the Labia Majora and does not change in length or aid in descent of any gonadal organs. Regardless, because the round ligament takes this origin and insertion, it provides a lymphatic network that leads directly to the labia majora from the fundus of the uterus. As you already know, the labia majora drains to the superficial inguinal lymph nodes. These relationships can be the focus of several different types of questions.

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3.

The deep circumflex Iliac Artery arises from and anastomoses with.

A.

External iliac Artery; Inferior Epigastric A
B.

Internal Iliac Artery; Lumbar Artery
C.

External Iliac Artery; Lateral Circumflex Artery
D.

Internal Iliac Artery; Inferior Epigastric Artery

Correct Answer
C. External Iliac Artery; Lateral Circumflex Artery

Explanation
External Iliac Artery; Lateral Circumflex Artery

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4.

A 40 year-old primagravida female presents to the hospital in labor. She’s too far along to administer a spinal block or caudal epidural, so the obstetrician administers local anesthetic around the Pudendal nerve. What anatomical landmark did she use for the block?

A.

Ischial Tuberosity
B.

Ischial Spine
C.

Pubic Symphisys
D.

Ischiopubic Ramus

Correct Answer
B. Ischial Spine

Explanation
A finger is inserted into the vagina to palpate the ischial spine, and anesthetic is injected through the skin or vaginal wall keeping the finger between the needle and baby’s head. The distal portion of the vagina is innervated by somatic pudendal nerve (S2-4).

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5.

Your patient just had a CT to confirm a uterine adenocarcinoma at the fundus of the uterus. If this was to spread through lymph, how would you go about your biopsy?

A.

Small incision just external to the saphenous opening of the deep fascia lata of the thigh
B.

Small incision deep to the saphenous opening of the fascia lata of the thigh
C.

Intrarectal biopsy of the internal iliac nodes
D.

Laparoscopic to get to the paraaortic lymph nodes

Correct Answer
D. Laparoscopic to get to the paraaortic lymph nodes

Explanation
Uterine adenocarcinoma begins in the endometrium and can spread to paraaortic or lumbar lymph nodes when it is near the fundus. Not to be confused with lymph drainage near the insertion of the round ligament to superficial inguinal nodes.

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6.

You finish your education, receive your MD and begin your residency in OB/GYN. A patient is being prepped for delivery and is discussing options for pain management. She has worries about nerve blocks affecting the ability for her uterus to contract. You tell her:

A.

"Spinal anesthesia is no good because although C fibers controlling pain are blocked first, larger alpha motor fibers might be blocked as well which would inhibit functional contractions of the uterus."
B.

"Caudal epidural block would work well, but because type C fibers relaying pain and postganglionic autonomic function are so sensitive there might be some overlap, and the sympathetic system might not be able to cause significant contractions."
C.

"We will bring in your anaesthesiologist to discuss this issue with you however your uterine contractions are hormonally stimulated and not due to nervous stimulation."
D.

“General anesthesia is the only option that will affect uterus contractions.”

Correct Answer
C. "We will bring in your anaesthesiologist to discuss this issue with you however your uterine contractions are hormonally stimulated and not due to nervous stimulation."

Explanation
During labor contractions are hormonally stimulated, however at other times there is autonomic control - for instance tocolytic therapy can involve B2 agonists to postpone labor. During labor, nerve blocks do not affect contractions of the uterus as the contractions are hormonally stimulated. Remember that small, myelinated, slow conducting fibers are blocked first by anesthetics like your type B and C fibers. Alpha motor are the least sensitive even though they are myelinated.

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7.

A 50 year old female presents to your office with complaints of abdominal pain and feeling of fullness. After further investigations you suspect an ovarian carcinoma. Which lymph nodes are likely involved?

A.

Superficial inguinal
B.

Internal Iliac
C.

Virchow's nodes
D.

Para-aortic
E.

Deep inguinal

Correct Answer
D. Para-aortic

Explanation
the gonads drain blood to the L renal vein and IVC, so they drain lymph to para-aortic lymph nodes.

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8.

A 40 year old woman visits her gynecologist. She has a history of several pregnancies, which were delivered vaginally. Her gynecologist tells her she is in high risk of prolapse because the angle between the uterus and vagina is:

A.

Anteverted
B.

Anteflexed
C.

Retroverted
D.

Retroflexed

Correct Answer
C. Retroverted

Explanation
this position is in line with the vagina, so highest risk of uterine prolapse.

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9.

Prom is coming up and a teenage boy decides that he needs to “pop” the hideous pimple just lateral to his chin. The popped pimple gets infected, which lymph node is draining the lesion?

A.

Submental lymph nodes
B.

Submandibular lymph nodes
C.

Pharyngeal lymph nodes
D.

Lingual lymph nodes

Correct Answer
B. Submandibular lymph nodes

Explanation
Submental lymph nodes drain chin and central lower lip, while submandibular nodes drains most of the central face.

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10.

A man has cancer and the metastasized tumor cells occlude the superior rectal artery. However, the man is not in any immediate danger due to collateral circulation through an artery which directly branches off what other artery?

A.

Inferior mesenteric
B.

Posterior internal iliac
C.

Anterior internal iliac
D.

Inferior gluteal

Correct Answer
C. Anterior internal iliac

Explanation
Middle rectal artery usually branches off the anterior division of internal iliac artery.

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11.

A man has a tumor growing on his spinal column causing compression of some spinal nerve roots. The doctor wants to elicit a reflex to determine which nerve roots are involved. If the doctor were to elicit the anal reflex, what nerve roots would he be testing?

A.

S2-S4
B.

L4-L5
C.

S1-S2
D.

S4-S5

Correct Answer
A. S2-S4

Explanation
Pudendal nerve innervates the external anal sphincter.

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12.

Ned hears the joke: A pirate walks into a bar with a ship’s steering wheel hanging out of his pants. The bartender asks him what it’s for. He replies “Arrrrgh, it’s driving me nuts!” Ned laughs so hard he pees a little. What muscle has failed to prevent this embarrassing incident?

A.

External urethral sphincter
B.

Internal urethral sphincter
C.

Trigone
D.

Detrusor

Correct Answer
A. External urethral sphincter

Explanation
External urethral sphincter, innervated by somatic pudendal nerve, prevents micturition until the proper time and place.

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13.

59-year-old woman comes to a local hospital for uterine cancer surgery. As the uterine artery passes from the internal iliac artery to the uterus, it crosses superior to which of the following structures that is sometimes mistakenly ligated during such surgery?

A.

Ovarian artery
B.

Ovarian ligament
C.

Uterine tube
D.

Ureter
E.

Round ligament of the uterus

Correct Answer
D. Ureter

Explanation
ureter passes under uterine artery.

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14.

A 37-year-old man is suffering from carcinoma of the skin of the glans penis. Cancer cells are likely to metastasize directly to which of the following lymph nodes?

A.

External iliac nodes
B.

Internal iliac nodes
C.

Deep Inguinal nodes
D.

Aortic (lumbar) nodes
E.

Common iliac nodes

Correct Answer
C. Deep Inguinal nodes

Explanation
glans penis drains to deep inguinal lymph nodes.

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Block 7 Anatomy Wk 10 11 From Ta's W Xpl Prt 2

During vaginal delivery, the doctor preformed a median episiotomy in which he cut too far posteriorly. Which structure did he most likely cut?

The deep circumflex Iliac Artery arises from ______ and anastomoses with______.

A 40 year-old primagravida female presents to the hospital in labor. She’s too far along to administer a spinal block or caudal epidural, so the obstetrician administers local anesthetic around the Pudendal nerve. What anatomical landmark did she use for the block?

Your patient just had a CT to confirm a uterine adenocarcinoma at the fundus of the uterus. If this was to spread through lymph, how would you go about your biopsy?

You finish your education, receive your MD and begin your residency in OB/GYN. A patient is being prepped for delivery and is discussing options for pain management. She has worries about nerve blocks affecting the ability for her uterus to contract. You tell her:

A 50 year old female presents to your office with complaints of abdominal pain and feeling of fullness. After further investigations you suspect an ovarian carcinoma. Which lymph nodes are likely involved?

A 40 year old woman visits her gynecologist. She has a history of several pregnancies, which were delivered vaginally. Her gynecologist tells her she is in high risk of prolapse because the angle between the uterus and vagina is:

Prom is coming up and a teenage boy decides that he needs to “pop” the hideous pimple just lateral to his chin. The popped pimple gets infected, which lymph node is draining the lesion?

A man has cancer and the metastasized tumor cells occlude the superior rectal artery. However, the man is not in any immediate danger due to collateral circulation through an artery which directly branches off what other artery?

A man has a tumor growing on his spinal column causing compression of some spinal nerve roots. The doctor wants to elicit a reflex to determine which nerve roots are involved. If the doctor were to elicit the anal reflex, what nerve roots would he be testing?

Ned hears the joke: A pirate walks into a bar with a ship’s steering wheel hanging out of his pants. The bartender asks him what it’s for. He replies “Arrrrgh, it’s driving me nuts!” Ned laughs so hard he pees a little. What muscle has failed to prevent this embarrassing incident?

59-year-old woman comes to a local hospital for uterine cancer surgery. As the uterine artery passes from the internal iliac artery to the uterus, it crosses superior to which of the following structures that is sometimes mistakenly ligated during such surgery?

A 37-year-old man is suffering from carcinoma of the skin of the glans penis. Cancer cells are likely to metastasize directly to which of the following lymph nodes?

The deep circumflex Iliac Artery arises from and anastomoses with.