ECAD - ILAs & Weekly Quizzes - Exam 2

A 1-day-old male born at term via an uncomplicated vaginal delivery presents at morning rounds with complaints of a strange swelling at the umbilical region. There is no evidence of cyanosis, and he moves all his extremities well. Upon physical exam, the anterior abdominal wall shows a ventral defect with protruding gut segments covered by amnion. Which of the following is the most likely cause of this patient’s condition?

Persistence of physiological intestinal loop herniation

A 58-year-old male presents to the emergency department complaining of hematemesis (vomiting blood) and dizziness that began an hour ago. Physical exam reveals jaundice and a distended abdomen. POCUS exam reveals free fluid within the peritoneal cavity. The patient reports a history of chronic alcohol use and denies the use of other substances. Which of the following is the most likely cause of this patient’s presentation?

Cirrhosis

A 43 y/o male presents to the emergency department with acute abdominal pain. Patient history reveals the appearance of a notable bulge in his right groin over several weeks. Physical exam reveals moderate swelling in the upper right scrotum with palpable loops of bowel. Imaging confirms an intestinal herniation medial to the inferior epigastric vessels. Which of the following is the most likely cause of the presenting symptoms?

Direct inguinal hernia

A 54-year-old female presents to the clinic with a complaint of worsening yellowish skin over the past week. Physical exam reveals yellowed skin and sclera (whites) of the eyes. The patient reports nausea, steatorrhea (loose, oily feces) and itchy skin. She reports no associated pain. Lab results reveal abnormally low pancreatic enzymes. Ultrasound evaluation of the pancreas, liver, and biliary apparatus demonstrates a small tumor within the pancreatic head. An obstruction of which of the following structures is the most likely cause of this patient’s symptoms?

Hepatopancreatic ampulla

A 20-month-old male is brought to the office by his mother for evaluation of blood in his stool for the past week. She believes that the child experiences abdominal pain but no nausea or vomiting. The child sometimes passes stool laced with blood. His abdomen is soft and non tender on palpation. Stool sample reveals presence of blood. Ultrasound reveals a suspicious diverticular structure in the distal small intestine. Which of the following is the most likely cause of this patient's symptoms?

Persistence of proximal part of omphaloenteric duct

A 60-year-old male diagnosed with portal hypertension presents to the clinic complaining of fatigue and abdominal swelling. Physical examination reveals yellow tinge to the sclerae. Multiple venous enlargements are seen on the anterior abdominal wall radiating outwards from the umbilicus. Which of the following veins is contributing to the patient's venous distention around his umbilicus?

Paraumbilical

A 55-year-old male with colon cancer presents to the clinic for a follow-up visit after undergoing surgery to remove most of his descending and sigmoid colon. Due to metastases, the associated vasculature and lymph nodes were also removed. His incision appears pink and shows no signs of infection. Collateral circulation from which of the following blood vessels would most likely perfuse the remainder of the descending colon following this procedure?

Middle colic artery

A 33-year-old female presents to the emergency department after a motor vehicle collision in which she had to decelerate rapidly to avoid an oncoming vehicle. She subsequently hit a light-post head-on at high speed. Because of the rapid deceleration, mesenteric attachments of the abdominal viscera were torn, causing injury to the superior mesenteric artery. This injury would most likely compromise blood supply to which of the following organs?

Head of the pancreas

An uncomplicated surgical removal of the tagged structure (yellow) would typically result in which of the following?

Dilute bile

A 40-year-old male was admitted to the hospital with a massive hemorrhage from chronic duodenal ulcer rupture. The surgeon attempted to clamp the artery to arrest the bleeding.  Which of the following is the most likely vessel the surgeon accessed behind the 1st part of the duodenum?

Gastroduodenal artery

A 34-year-old unconscious male presents to the ED in respiratory distress ~ 20 minutes after a motorcycle accident. Physical examination reveals mild lacerations of the upper limbs, extensive bruising along the right thoracic and abdominal wall, multiple penetrating injuries to the abdomen, and a dramatically enlarged scrotum. No penetrating injuries or direct trauma is visible upon close inspection of the scrotum. Abdominal and pelvic radiographs demonstrate that significant air/gas is visible in the abdomen and scrotum. In this patient, air most likely entered the scrotum via what path?

Patent process vaginalis

A 23-year-old male undergoes routine evaluation 1-week after an emergency appendectomy. Physical examination reveals a "classic" and healing surgical incision site in the right inguinal region. Upon palpation of the anterior abdominal wall, suprapubic sensory loss is noted just superior to the pubic bone. An injury to which of the following nerves best explains this patient's presentation? (Image attached)

Ilioinguinal nerve

Which of the following arteries will be involved in forming the shortest anastomosing route to serve as an alternate channel to maintain hepatic arterial circulation should there be a blockage at the site indicated by the arrow? 

Left gastric artery

The tagged site is most prone to which of the following conditions?

Direct hernia

After entering the rete testes, which of the following structures will a sperm cell pass through next?

Efferent ductules

A 35-year-old female presents to the ED ~8 hours after a bicycle accident with the complaint of severe abdominal pain and dyspnea. The patient was struck by a slow-moving car on her left side, but went about her day with only minor initial discomfort. Approximately 3 hours post-accident, the patient noticed breathlessness and abdominal pain that have continued to worsen. Physical examination reveals abdominal guarding, contusions on the left anterolateral abdomen from rib 9 to just superior to the pelvis. Her symptoms are partially relieved by standing and exacerbated by lying down. In addition, the patient's blood pressure is within normal levels, but her resting heart rate is faster than normal. Focused ultrasonographic assessment identifies significant fluid in the pelvis. Plain film abdominopelvic radiographs are unremarkable, but are of limited diagnostic value given restricted patient positioning. An injury to what organ best explains this patient's presentation? 

Spleen

A 46-year-old male presents to the emergency department with the complaint of severe abdominal pain. Physical examination indicates the patient is experiencing generalized, but intense epigastric pain. Patient history reveals that he underwent a successful appendectomy from the right lower quadrant when he was 12 years old. Over the course of the next 3 hours, the patient's pain intensifies and localizes to the right upper quadrant. Involvement of which of the following organs is most consistent with this patient's presentation?

Gallbladder

If this artery were obstructed, blood could bypass the blockage and serve the proximal lesser curvature via an anastomosis with what vessel? 

Right gastric artery

Hypertension in the tagged vessel due to liver disease would most likely be associated with elevated pressure in which of the following vessels?

Right gastroomental vein

If an arterial occlusion occurred at this site, the structures it typically serves distal to the obstruction would most likely receive blood from what artery?

Right gastroomental artery

An injury to this muscle would primarily weaken what action in the afflicted individual? 

Flexion of thigh

A 44-year-old male with history of chronic alcoholic liver disease presents to the ER with hematemesis (blood vomiting).  On physical examination, the patient has poor built, presents with accumulation of fluid in the peritoneal cavity (ascites), internal haemorrhoids and has engorged veins radiating outwards from his umbilicus on his anterior abdominal wall.  Which of the following veins you suspect has abnormally raised pressure?

Portal vein

Which of the following gastrointestinal segments is distal to the tagged structure?

Sigmoid colon

A fracture involving the tagged area most likely results in injury to which of the following structures?

Tag: Lesser sciatic foramen

Pudendal nerve

A 13-year-old female presents to the clinic for an annual sports physical examination. The patient appears in excellent health, but has the complaint of intermittent sharp, localized pain that is associated with a small lump inferior to the umbilicus. Palpation reveals an ~2-cm mass inferior to the umbilicus protruding through a gap in the linea albea. Which of the following conditions is most likely displayed by this patient?

Umbilical hernia

An ulceration and associated perforation at the indicated site would permit gut contents to accumulate within what space? 

Lesser peritoneal sac

A neonate is born with coils of intestine protruding through a patent umbilical ring at the umbilicus. On closer inspection, the herniated contents are seen to be in the mid-line, covered with amnion with the umbilical cord attacked on the hernial sac.  Which of the following would best describe the condition? 

Omphacele

The tagged structure is derived from which of the following embryological structures? 

dorsal mesentery of esophagus

A 34-year-old male presents to the emergency department with pelvic trauma following a motor vehicle collision. Pelvic imaging indicates there are bilateral pelvic fractures across his ischiopubic rami. Physical examination reveals loss of sensation to the perineum. Moreover, injury has been remarkably restricted to the contents of the right and left pudendal canals. In this case, which of the following would remain unaffected?

Internal urethral sphincter

Injury to this structure may result in its inability to secrete what fluid during sexual activity?

Lubricating mucus

A 33-year-old male presents for a routine post-operative examination 2 weeks after pelvic surgery. The patient sustained blunt trauma to the posterior pelvis with significant sacral trauma. Following reconstructive surgery, which of the following would indicate an injury to the pelvic splanchnic nerves?

Inability to dilate helicine arteries

A significant injury to this muscle would hinder its ability to:

Fix the perineal body

Mistakenly severing this structure during surgery would result in damage to which of the following structures contained within it? 

Ovarian vessels

A rupture of the tagged site would permit urine to extravasate into what space or potential space? 

Retropubic space

A 46-year-old female presents to the Obstetrics and Gynecology Office with the complaint of a tender lump on the right side, near the opening of her vagina. Physical examination reveals a palpable lump ~ 2cm in diameter, located posterolateral to the vaginal orifice. The surrounding tissue is red and upon gentle pressure, purulent discharge exudes from the lump into the posterior part of the vestibule. The patient has a mildly elevated temperature. The examination is otherwise unremarkable. The most likely cause of this physical presentation is what?

Infection of Greater vestibular gland

Injury to this nerve would leave which of the following muscles affected?

External anal sphincter

A surgeon examining a patient with right upper quadrant pain would most likely exclude which of the following from the list of differential diagnoses?

Splenic rupture

A 27-year-old female presents to the OB/Gyn clinic with complaints of pain, irregular menstrual periods, and excess hair growth on her body. Follow-up testing reveals the patient suffers from polycystic ovarian syndrome (PCOS), a condition involving the follicles of the ovary. Abnormal systemic hormone causes this patient’s ovarian follicles to continue to develop, but not mature. An ultrasound scan reveals increased numbers of follicles with a large antrum. Pain due to this patient’s condition is most likely to be carried by what nervous fibers or to what region?

Referred pain to lower abdominal wall

Which of the following arteries are unaffected when a blood clot enters the tagged vessel?

(Tag: Anterior division of the internal iliac artery)

Superior gluteal artery

A 43-year-old female presents for a routine evaluation prior to a voluntary radical nephrectomy, for donation to a family member. The patient's pre-operative plain film abdominal x-ray demonstrates a potential anomaly. The follow-up magnetic resonance arteriogram confirms what anomaly or variant in this patient? (Image attached)

Accessory renal arteries

A routine physical examination of a neonate reveals ambiguous external genitalia: a fused labial or scrotal sac without descended testes and a large clitoris or small penis. A quick chromosomal analysis revealed 46XX. Results from metabolic, genetic, and urologic evaluations are forthcoming. However, which of the following conditions is a likely cause of these physical findings in advance of the results?

Congenital adrenal hyperplasia

A 16-year-old male presents to his primary care doctor with a 6-month history of kidney stones. Before referring to a urologist, the PC orders a plain-film X-ray study to assess the location of other potential kidney stones. Radiology reports a left kidney with 3 calculi (stones)in the left renal pelvis, but no evidence of a right kidney in the right upper quadrant or in the pelvic brim. The patient denies any prior surgical history. What is the most likely cause of this finding?

Failure of uteric bud to induce Metanephron formation

A duplication of the tagged structure would result from developmental malformation of what developing structure?

Paramesonephric ducts

A 17-month-old baby boy presents to clinic with a slight fever and a suspected urinary infection. His mother states that his urine has a strong odor, and his diapers are constantly soaked all the way up to his umbilicus. What persistent developmental structure could be responsible for the infection and umbilical wetness?

Urachus

An infant with an XY chromosomal complement who presents with well-developed male external genitalia and a fully developed uterus is most likely to suffer from which of the following developmental failures?

Mullerian inhibiting substance deficiency

A 47-year-old overweight female presents with RUQ pain.  Ultrasound demonstrates multiple gallstones. The common bile duct is not well visualized due to the patient’s obesity.  Which diagnostic imaging test would best delineate the common bile duct to exclude an impacted stone?

MRCP

In the interpretation of an abdomen image (attached), in which of the following categories would the liver (13) be included?

Soft tissue/fluid

A 59-year-old man is diagnosed with prostate cancer following a digital rectal examination. The cancer cells may invade the urethra by spreading through the prostatic ducts. Which part of the prostatic urethra is likely the first location to be invaded by the cancer cells?

Prostatic sinus

A 65 year old male complained of a 6 month history of difficulty voiding and feeling that he could not empty his bladder completely. After voiding, he often felt the urge to urinate again. He had no complaints of urethral discharge or burning with urination. He has a history of two episodes of urinary tract infections during the previous year. Physical examination findings were unremarkable. An ultrasound showed an enlarged structure inferior to the bladder. What is the most likely cause of the patients presentation?

Enlarged median lobe of the prostate

A cystoscopy was performed to rule out bladder pathology. As the scope was passed through the penile urethra, which of the following tissues surrounded the scope?

Corpus spongiosum

A 30 year old primigravid female at 20 weeks gestation presents to her primary care physician for her routine prenatal visit. A transabdominal ultrasound shows no anatomic anomalies, normal amniotic fluid levels, visible fetal movements, heart motion, and a normal placenta. the fetus is determined to be male based on ultrasound findings. The primary duct responsible for the internal genital development in this fetus is also responsible for the development of the?

Seminal vesicle

A 16 year old male was involved in a motor vehicle collision. He complained of severe pain in his hip immediately after the accident and was transported to the emergency room. Examination revealed a palpable instability of the pelvis and visible blood at the urethral meatus. Digital rectal examination revealed a high-riding prostate gland and a sacral fracture. Radiographic studies confirmed multiple fractures of the bony pelvis, including a fracture of the sacrum, a fracture of the superior and inferior pubic rami. Bleeding from the urethral meatus is most likely secondary to an injury to which of the following structures?

Membranous urethra

A 16 year old male was involved in a motor vehicle collision. He complained of severe pain in his hip immediately after the accident and was transported to the emergency room. Examination revealed a palpable instability of the pelvis and visible blood at the urethral meatus. Digital rectal examination revealed a high-riding prostate gland and a sacral fracture. Radiographic studies confirmed multiple fractures of the bony pelvis, including a fracture of the sacrum, a fracture of the superior and inferior pubic rami. If the fracture involves the sacral canal at the S3 sacral vertebral level, which of the following structures is most likely affected?

Sacrococcygeal nerve roots

If a fracture involved the lower border of the greater sciatic foramen, which of these structures is most likely unaffected?

Superior gluteal nerve

A 59 year old male was admitted to the ED with complaints of nausea, vomiting, and hematuria (blood in urine) over the past two days. No significant findings were noted on general examination or examination of the abdomen. Radiological investigations revealed a calculus (stone) in the lower part of the left ureter. Pain arising from the calculus would most likely refer to what area of the body?

Root of the penis

A 61 year old female presented to her primary care physician with complaints of blood in her stools for the past 3 months. She has no complaints of nausea, vomiting, diarrhea, or painful defecation. Examination reveals no significant findings. A contrast CT scan revealed a mass, suspected to be malignant, in the anal canal above the pectinate line. there was no other pathology located in other parts of the GI tract. The lymphatic channels from the tumor would most likely metastasize to which of the following groups of lymph nodes first?

Internal iliac lymph nodes

A 32 year old female was admitted with labor pains during her 37 weeks of gestation. She was admitted and monitored for the progression of labor. An hour after admission, the obstetrician noticed fetal distress that necessitated an emergency C-section. The anesthetist planned to administer spinal anesthesia during the procedure. The anesthetic medication act primarily at which of the following locations to achieve the expected outcome?

Spinal cord

A 19 year old female consults her obstetrician at 7 weeks of gestation with complaints of vaginal spotting (streak of blood) and lower abdominal pain. Her medical history is significant for a pelvic infection approximately 3 years previously. On examination, she is afebrile, her blood pressure is 85/60 mmHg, heart rate is 110 beats/min. There is tenderness in the right iliac fossa, bowel sounds are normal. On pelvic examination, the external genitalia and uterus palpated as normal and there is right adnexal tenderness. A transvaginal ultrasonogram displays an empty uterus, free fluid in the cul-de-sac and an echogenic mass (9×10 cm) in the right ovary. An emergency laparotomy confirmed bleeding from a ruptured ovarian ectopic pregnancy necessitating right salpingooophorectomy (removal of ovary and part of the fallopian tube). Which of the following structures is clamped to block the arterial flow into the ectopic location?

Infundibulopelvic ligament