Download 1. A 57-year-old male complains of intense chest pain, but tests rule

1. A 57-year-old male complains of intense chest pain, but tests rule
out any cardiac pathology. It was determined that the patient
suffers from an esophageal (hiatal) hernia in which the stomach
herniates through an enlarged esophageal hiatus. Muscle fibers
from which of the following parts of the diaphragm would border
directly on this hernia?
left crus
right crus
central tendon
costal fibers
sternal fibers
2. Sympathetic fibers in the greater splanchnic nerve arise from
neuron cell bodies found in the:
brainstem
celiac ganglion
chain ganglion
spinal cord
superior mesenteric ganglion
3. After successfully performing two adrenalectomies (removal of the
adrenal gland), the surgical resident was disappointed to learn that
he would be merely assisting at the next one. The chief of surgery
told him: "I'm doing this one, since the one on the right side may
be a little too difficult for you." The difficulty he envisioned stems
from the fact that the right suprarenal gland is partly overlain
anteriorly by the:
aorta
inferior vena cava
left hepatic vein
right crus of the diaphragm
right renal artery
4. During preparations to remove the left kidney from a 28-year-old
female patient, the surgeon asked an observing medical student
where best to ligate the renal vein. Upon hearing the reply: "as
close to the inferior vena cava as possible, leaving just enough
stump to ensure tight closure," the surgeon's eyebrow shot up. "Do
you mean to say you're willing to compromise the venous drainage
of the other structures that drain into the renal vein?" By this he
meant all of the following except:
diaphragm
pancreas
ovary
suprarenal gland
5. The celiac plexus of nerves may contain fibers derived from all of
the following sources except:
posterior vagal trunk
greater thoracic splanchnic nerve
lesser thoracic splanchnic nerve
lumbar splanchnic nerves
6. Which statement regarding the suprarenal glands is correct?
Its entire arterial supply is directly from the abdominal aorta.
Veins from both glands drain directly into the inferior vena cava.
The glands are localized in the pararenal space.
Cells that secrete epinephrine and norepinephrine are
innervated by preganglionic fibers from the greater thoracic
splanchnic nerve.
7. The nerve that innervates the cells of the suprarenal medulla
consists of fibers of the:
Greater thoracic splanchnic nerve
Lesser thoracic splanchnic nerve
Least thoracic splanchnic nerve
Anterior vagal trunk
Posterior vagal trunk
8. Regarding the diaphragm, which, is paired INCORRECTLY?
Vertebrocostal trigone - lateral arcuate ligament
Esophageal hiatus - right crus
Medial arcuate ligament - psoas muscle
Central tendon - aortic hiatus
Vena caval foramen - right phrenic nerve
9. The nerves that end on the secretory cells of the medulla of the
suprarenal glands are principally:
Preganglionic fibers from the greater thoracic splanchnic nerve
Postganglionic fibers from the celiac plexus
Postganglionic fibers from the aorticorenal ganglia
Preganglionic fibers from the lesser thoracic splanchnic nerve
Postganglionic fibers from the renal plexus
10.
The vagus nerve passes into the abdomen by passing
through the
Aortic hiatus
Esophageal hiatus
Caval foramen
Lateral arcuate ligament
Medial arcuate ligament
11.
With one exception, preganglionic sympathetic axons
synapse upon postganglionic sympathetic dendrites or cell bodies.
The exception to this general rule occurs within the:
Kidney cortex
Kidney medulla
Suprarenal medulla
12.
Suprarenal cortex
The pararenal fat in the kidney bed is an elaboration of:
Peritoneum
Extraperitoneal connective tissue
Transversalis fascia
Fusion fascia
13.
The cisterna chyli accompanies which structure as it passes
through the diaphragm?
Inferior vena cava
Esophagus
Greater thoracic splanchnic nerve
Aorta
14.
Blood from an injured kidney will seep through the perirenal
fat until it contacts the internal surface of the renal (Gerota's)
fascia. Without perforating this fascia the blood could then
continue to pass in what direction?
inferiorly toward the pelvis
laterally into the body wall
medially across the midline to the other kidney
superiorly into contact with the fascia of the diaphragm
15.
A 19-year-old male suffers a tear to the psoas major muscle
during the course of a football game. A scar, which formed on the
medial part of the belly of the muscle, involved an adjacent nerve,
immediately medial to the muscle. The nerve is called the:
femoral
genitofemoral
iliohypogastric
ilioguinal
obturator
16.
While recovering from an open abdominal hysterectomy (i.e.,
using a midline abdominal incision to gain entry to the pelvis), a
patient realizes that she has lost sensation to the skin of her
anterior thigh and cannot extend her knee. Retractors holding the
incision open and pressing against the posterior abdominal wall
most likely caused injury to which nerve?
Femoral
Genitofemoral
Iliohypogastric
Lateral femoral cutaneous
Obturator
17.
In the lumbar region, tuberculosis may spread from the
vertebrae into an adjacent muscle to produce an abscess. Pus
from the abscess may travel within the fascial sheath surrounding
the affected muscle. A patient presents with pus surfacing in the
superomedial part of the thigh. To which muscle did the
tuberculosis most likely spread?
Internal oblique
Obturator internus
Psoas major
Quadratus lumborum
Rectus abdominis
18.
The nerves of the lumbar plexus are arranged around
specific muscles of the posterior abdominal wall. Which of these
nerves lies immediately medial to the psoas major muscle?
Femoral
Genitofemoral
Ilioinguinal
Obturator
1. The correct answer is:
right crus
The right crus is the part of the diaphragm that takes origin from L1-L3. It
splits to enclose the esophagus. So, in the case of an esophageal
hernia, the herniating stomach would be entirely surrounded by the
fibers of the right crus. The left crus is the part of diaphragm that takes
origin from L1 and L2. It is smaller and shorter than the right crus, and it
intermingles with the right crus around the aortic hiatus. It does not
contribute to the esophageal hiatus. The central tendon is the tendon in
the middle of the diaphragm where all the fibers of the diaphragm attach.
It provides an opening for the inferior vena cava. Finally, sternal and
costal fibers refer to muscle fibers in the diaphragm that take origin from
the xyphoid process or the ribcage. This could not refer to the right crus,
since it originates on the lumbar vertebrae.
2. The correct answer is:
spinal cord
The sympathetic fibers in the greater thoracic splanchnic nerve are
preganglionic sympathetic fibers that have left the sympathetic chain and
are going to synapse in abdominal ganglia. These preganglionic
sympathetic fibers originate in the lateral horn of the spinal cord grey
matter. The celiac ganglia and the superior mesenteric ganglia are the
two ganglia where the fibers from the greater thoracic splanchnic nerve
can go to synapse. Finally, remember that these fibers did not originate
in the chain ganglia--the fibers from there are the postganglionic
sympathetic fibers.
3. The correct answer is:
inferior vena cava
Remember that the inferior vena cava is a little off center, on the right
side of the abdomen. This means that structures on the right might be
closely associated with this vessel, while structures on the left will need
to have longer venous channels to connect with the IVC and drain into it.
In the case of the suprarenal glands, you can see that the IVC is laying
over the right suprarenal gland and is very far from the left gland. (This
means that the right gland is draining directly into the inferior vena cava,
while the left gland is draining into the renal vein.) As far as the other
structures in the question go... The aorta lies fairly evenly between the
suprarenal glands--it is not overlying either gland. The left hepatic vein,
which drains blood from the liver to the inferior vena cava, is superior to
the kidneys and not really involved with this area. The right crus of the
diaphram is a set of fibers that splits to make the esophageal hiatus, and
the right renal artery is a branch off the aorta to the kidney which enters
the kidney below the level of the suprarenal gland.
4. The correct answer is:
pancreas
Since the inferior vena cava is on the right side of the abdomen,
structures on the left will need to have longer venous channels to
connect to the IVC and drain into it. Consequently, some of the paired
retroperitoneal structures that drain directly into the IVC on the right side
cannot do that on the left. Instead, they must drain into the renal vein,
which crosses over the aorta and under the superior mesenteric artery to
connect to the inferior vena cava. The left inferior phrenic vein, left
suprarenal vein, and left ovarian/testicular vein all drain into the left renal
vein (although their analogs on the right side drain directly into the IVC).
If the left renal vein was ligated as it crosses the aorta, blood from the
left diaphragm, ovary, and suprarenal gland would have to drain
posteriorly - into the left second lumbar vein, which connects to the
posterior aspect of the left renal vein. The pancreas drains into the portal
venous system and would not be affected by this ligation.
5.
The correct answer is:
lesser thoracic splanchnic nerve
The celiac plexus of nerves contains fibers from the greater thoracic
splanchnic nerves, which are synapsing in the celiac ganglia. This
plexus also contains vagal fibers. Even though the vagus does not
synapse in the celiac ganglia, it passes through the ganglia and
contributes to the celiac plexus. This allows the vagal fibers to travel on
arteries to reach their eventual targets. The lesser thoracic splanchnic
nerves are not part of the celiac ganglia--these nerves synapse in the
aorticorenal ganglia and contribute to the renal plexus. The first lumbar
splanchnic nerve may occasionally contribute to the celiac plexus.
6. The correct answer is: Cells that secrete epinephrine and
norepinephrine are innervated by preganglionic fibers from the greater
thoracic splanchnic nerve.
The suprarenal medulla is directly innervated by preganglionic
sympathetic fibers from the greater thoracic splanchnic nerve. These
preganglionic fibers synapse on the cells of the adrenal medulla, causing
the cells in the adrenal medulla to release norepinephrine and/or
epinephrine. The preganglionic fibers can synapse on these cells of the
adrenal medulla because they are modified nervous tissue. The
epinephrine and norepinepherine enters the blood stream to cause a
systemic response. The superior suprarenal arteries branch from the
inferior phrenic, the middle suprarenal artery is a direct branch of the
abdominal aorta, and the inferior suprarenal arteries are branches of the
renal artery. Although the vein from the right gland drains into the inferior
vena cava, the vein from the left suprarenal gland drains into the left
renal vein. Finally, the pararenal space is the space outside the renal
fascia, covered with the pararenal fat. The suprarenal gland is covered
by the renal fascia, so it's in the perirenal space, not in the pararenal
space.
7. The correct answer is:
Greater thoracic splanchnic nerve
The suprarenal medulla is directly innervated by preganglionic
sympathetic fibers from the greater thoracic nerve. These fibers synapse
on the cells in the adrenal medulla, causing a systemic sympathetic
response. Other preganglionic fibers from the greater thoracic nerve
synapse in the celiac ganglion; the postganglionic fibers from this
ganglion distribute along branches of the celiac trunk. The preganglionic
fibers from the lesser thoracic splanchnic nerve synapse in the
aorticorenal ganglion--postganglionic processes from this ganglion
supply vascular smooth muscle of branches of the renal artery and
suprarenal arteries. The preganglionic fibers of the least thoracic
splanchnic nerve synapse in the renal plexus.
The anterior vagal trunk has a gastric and hepatic branch, supplying
parasympathetic fibers to the stomach and liver. The posterior vagal
trunk supplies some parasympathetic fibers to the stomach, but it also
sends a celiac branch to the celiac plexus. The fibers from the posterior
vagal trunk which pass to the celiac plexus eventually distribute to the
organs of the abdomen, all the way to the last third of transverse colon.
8. The correct answer is:
Central tendon--aortic hiatus
The aortic hiatus is not in the central tendon of the diaphragm--the caval
opening, for the inferior vena cava, is found in the central tendon of the
diaphragm. The aortic hiatus is formed by the median arcuate ligament,
which unites the two crura of the diaphragm. The vertebrocostal trigone
is an area of the diaphragm superior to the lateral arcuate ligament.
Here, the diaphragmatic muscle is deficient and the trigone is closed
primarily by the inferior and superior fascia of the diaphragm. It is a
significant area for hernias. The esophageal hiatus is formed entirely by
the fibers of the right crus. The psoas major muscle passes behind the
medial arcuate ligament. Finally, the right phrenic nerve passes through
the central tendon of the diaphragm, near the vena caval foramen. See
Netter Plate 181 for a picture of all these structures and their
relationships.
9. The correct answer is:
thoracic splanchnic nerve
Preganglionic fibers from the greater
Preganglionic fibers from the greater thoracic splanchnic nerve directly
innervate the suprarenal medulla, causing a systemic sympathetic
response. Postganglionic sympathetic axons from the celiac plexus
distribute along branches of the celiac trunk to supply the vascular
smooth muscle of those arteries. Preganglionic fibers from the lesser
thoracic splanchnic nerve travel to the aorticorenal ganglia;
postganglionic fibers from the aorticorenal ganglia supply the vascular
smooth muscle of the branches of the renal arteries. The postgangionic
fibers from the renal plexus provide sympathetic innervation to smooth
muscle to the blood vessels supplying the kidney, renal pelvis and upper
ureter.
10. The correct answer is:
Esophageal hiatus
Remember back to the thorax--the vagus joins the esophageal plexus
and covers the esophagus. The anterior and posterior vagal trunks form
from the esophageal plexus-- they pass into the abdomen through the
esophageal hiatus, on the anterior and posterior surfaces of the
esophagus. The aortic hiatus is deep to the median arcuate ligament--it
transmits the aorta and the thoracic duct. The caval foramen is found in
the central tendon of the diaphragm; it transmits the inferior vena cava.
Psoas major is deep to the medial arcuate ligament, and quadratus
lumborum is deep to the lateral arcuate ligament.
11. The correct answer is:
Suprarenal medulla
The suprarenal medulla is directly innervated by preganglionic
sympathetic fibers from the greater thoracic splanchnic nerve. These
preganglionic fibers synapse on the cells of the adrenal medulla, causing
the cells in the adrenal medulla to release norepinephrine and/or
epinephrine. The preganglionic fibers can synapse on these cells of the
adrenal medulla because they are modified nervous tissue. The
epinephrine and norepinepherine enters the blood stream to cause a
systemic response.
12. The correct answer is:
Extraperitoneal connective tissue
Each kidney is embedded in two layers of fat, with a membrane (the
renal fascia), in between the layers. Inside the renal fascia, and directly
atop the kidney, is the perirenal fat. Outside the renal fascia, you will find
the pararenal fat, which is an elaboration of extraperitoneal connective
tissue. Although the kidney is not peritonealized, the peritoneum from
the posterior body wall lies over the anterior surface of the pararenal fat.
The kidney is not a secondarily retroperitoneal organ--it began
development in the retroperitoneum. So, it does not have a fusion fascia.
13. The correct answer is:
Aorta
In 25-50% of cases, the inferior portion of the thoracic duct includes a
dilated portion called the cisterna chyli. When present, all of the lymph
trunks draining the abdomen and lower limbs dump into it, as well as the
most inferior intercostal lymph trunks. When it is not present, these
trunks simply empty into the thoracic duct. So, the cisterna chyli is a
portion of the thoracic duct, and the thoracic duct passes through the
diaphragm with the aorta at the T12 level. The inferior vena cava passes
through the central tendon of the diaphragm at the T8 level. The
esophagus and vagal branches pass through the right crus of the
diaphragm at the T10 level. The greater thoracic splanchnic nerves pass
through the fibers of the left and right crus.
14. The correct answer is:
inferiorly toward the pelvis
The kidney is surrounded by a perirenal fatty capsule, the renal
(Gerota's) fascia and pararenal fat. The fat offers no resistance to
hemorrhage, but blood is contained in the renal fascia. This means that
blood would not flow toward the body wall, other kidney, or toward the
diaphragm. However, a kidney injury might involve part of the urinary
collecting system, and blood from such damage would travel into the
ureters and bladder.
15. The correct answer is:
obturator
The obturator nerve runs along the medial border of the psoas major
muscle, eventually passing through the obturator canal to innervate
muscles of the medial thigh. So, it might be damaged by an injury to the
medial portion of psoas major. The femoral nerve runs along the lateral
border of psoas major, where psoas major contacts iliacus. The
genitofemoral nerve pierces through psoas major at the level of L3 or L4.
The iliohypogastric and ilioinguinal nerves run under psoas major,
emerging at the lateral border of psoas major to run over quadratus
lumborum. The way to distinguish between these two nerves is to
remember that the iliohypogastric is superior to the ilioinguinal nerve.
16. The correct answer is:
Femoral nerve
During open abdominal surgeries (i.e., hysterectomy), retractor blades
are used to keep the abdominal cavity open. The blade may come to
rest on the femoral nerve as it lies between the iliacus and the lateral
side of the psoas major muscle. So, the femoral nerve can be easily
injured or crushed during abdominal surgery. If this nerve is injured, the
patient will experience some numbness on her leg, and she will be
unable to extend her knee. In this case, both the symptoms and the
history of abdominal surgery point to damage to the femoral nerve.
The genitofemoral nerve pierces the psoas major muscle before entering
the pelvis. The iliohypogastric nerve and lateral femoral cutaneous nerve
emerge at the lateral border of psoas major and then travel laterally. The
obturator nerve is at the medial border of psoas major. None of these
other nerves are in the right position to be injured by the retractor
blades. For a picture of these nerves of the lumbar plexus, see Netter
Plate 464.
17. The correct answer is:
Psoas major
This patient has Pott's disease, which is tuberculosis of the spine.
Tuberculosis of the spine frequently occurs in untreated tuberculosis in
young individuals, especially those on a poor diet. The tubercle bacilli
enter through the respiratory tract and pass from lungs to systemic
circulation. The bacilli tend to lodge in the bone marrow of the spine,
including the lumbar vertebrae. An infection in the lumbar vertebrae may
pass to the psoas major muscle, since psoas major takes origin from the
lumbar vertebrae. This infection can cause an abscess in psoas major,
which will be contained by the fascial sheath of the muscle. The psoas
major muscle arises from the bodies of the lumbar vertebrae, passes
under the inguinal ligament, and joins with the iliacus to insert on the
lesser trochanter of the femur as the iliopsoas tendon. Psoas major
passes through the superomedial part of the thigh, so an infection in this
muscle matches with the location of the pus. None of the other muscles
are closely associated with the lumbar vertebrae or found in the
superomedial thigh, so they could not have been ones infected.
18. The correct answer is:
Obturator
The obturator nerve lies along the medial border of the psoas major
muscle. The femoral nerve lies along the lateral border of the psoas
major muscle, between psoas major and iliacus. The genitofemoral
nerve pierces psoas major then lies on top of that muscle. The
ilioinguinal nerve emerges at the lateral border of psoas major, then
travels laterally.