Download term 3 answers to questions - Hatzalah of Miami-Dade

TERM 3
ANSWERS TO QUESTIONS
Session 1 - Pelvis (Skeleton, Floor, Peritoneum), Rectum, Anal Canal & Ischioanal Fossa
Session 2 - Urinary System, Perineum, Male & Female Genitalia
Session 3 - Female Reproductive System
Session 4 - Anterior Abdominal Wall
Session 5 - Inguinal Canal And Spermatic Cord
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Session 1 - Pelvis (Skeleton, Floor, Peritoneum), Rectum, Anal Canal &
Ischioanal Fossa
1.
Upright: Anterior superior iliac spine and top of pubis. Horizontal: Tip of coccyx (approximately the
ischial spines) and top of pubis (pubic tubercle).
2.
Female.
3.
Centre of acetabulum.
4.
S4 (perineal branch) but also from inferior rectal and perineal branches of the pudendal nerve.
Coccygeus is supplied mostly by branches form S5.
5.
Obturator internus
6.
Perineal body, anococcygeal body and tip of coccyx.
7.
Puborectalis.
8.
Sacral promontory, arcuate lines, iliopectineal lines and pubic crests.
9.
True.
10. Into the pelvis.
11. That part of the trunk that lies below the pelvic floor.
12. Base: perineal skin. Medial: Anal canal and levator ani. Lateral: Ischial tuberosity and obturator
internus. Apex: white line origin of levator ani. Anterior: perineal body, urogenital diaphragm and the
anterior recess of the fossa. Posterior: Gluteus maximus, Sacrotuberous ligament and anococcygeal
body.
13. Inferior rectal.
14. The upper third of the rectum has peritoneum on its sides and anterior surfaces, whilst the middle
third has peritoneum only on its anterior surface. The lower third is below the peritoneum.
15. No. Fortunately, when the bladder fills it takes the peritoneum upwards with it and it is thus safe to
pass a catheter into the bladder through the lower anterior abdominal wall without risk of puncturing
the peritoneal cavity.
16. Level of S3 to level of puborectalis.
17. (a) correct.
18. Three folds of mucosa and circular muscle caused by the two convexities.
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19. Puborectalis.
20. Upper: columnar. Lower: stratified squamous. The pectinate (dentate) separates the two halves.
21. Twelve anal columns of Morgagni, valves of Ball, three mucosal cushions and supplied by
autonomic nerves.
22. Upper half.
23. Circular. It does not stop at the puborectalis but reaches down half way into the upper half of the anal
canal.
24. Deep, superficial and subcutaneous. Inferior rectal from pudendal nerve.
25. Parasympathetic.
26. Perineal nerve from pudendal nerve and its posterior scrotal branches. Also anterior branches of the
posterior femoral cutaneous nerve.
27. Superior rectal from inferior mesenteric artery, middle rectal from internal iliac and inferior rectal
from internal pudendal artery (internal iliac). All arteries to all layers.
28. Portal: superior rectal vein to inferior mesenteric. Systemic: middle (directly) and inferior (via
internal pudendal) rectal veins to internal iliac.
29. Yes it is true. Thus, haemorrhoids are enlargements of the anal cushions which are mostly capillary
structures. Bleeding from a portosystemic anastomosis in this area is from the submucosal venous
plexuses.
30. Male: prostate, bladder and seminal vesicles (if abnormal). Female: uterus. Also abnormalities in
recto-uterine pouch, ovaries and bladder.
31. No, they are stored in the sigmoid and descending colon and are only pushed down into the rectum
by the "mass movement" before an evacuation.
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Session 2 - Urinary System, Perineum, Male & Female Genitalia
1.
Mesonephric duct.
2.
The ureteric orifices.
3.
The ureters enter the bladder at an oblique angle and run through a submucosal tunnel before opening
into the bladder. This prevents reflux of urine.
4.
Male: inferior to vas. Female: Inferior to uterine artery.
5.
Superior and inferior vesical. Small contributions from obturator, inferior gluteal, uterine and vaginal
explain why the bladder can survive after the vesical arteries are ligated.
6.
In the male there is a single peritoneal pouch between the bladder and rectum called the rectovesical
pouch, whereas in the female there is a pouch in front of the uterus - the vesico-uterine pouch and a
pouch of Douglas behind which is the recto-uterine pouch.
7.
Anterior.
8.
Bladder neck muscles.
9.
Verumontanum.
10. Vas and duct of the seminal vesicle.
11. No.
12. S2,3,4 (pudendal nerve). Somatic.
13. Perineal membrane.
14. Deep transverse perinei.
15. Deep perineal pouch.
16. Ischio-anal fossa.
17. Bulbourethral glands (Cowper's glands).
18. Ischiocavernosus, bulbospongiosus, superficial transverse perinei, dartos and cremasteric muscles.
Crura of penis, urethra, corpus spongiosum, corpora cavernosum, perineal body, perineal vessels and
nerves and scrotum.
19. Scarpa's fascia, the deep layer of the superficial fascia of the abdomen, finishes at the level of the
pubis in the midline and extends into the scrotum as Colles' fascia and around the penis as Buck's
fascia.
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20. Genital branch (L2) of the genitofemoral nerve (L1,2)
21. Branches of the pudendal nerve (S2,3,4).
22. The internal pudendal artery arises from the internal iliac artery and passes out through the greater
sciatic foramen, below piriformis, and passes immediately over the tip of the ischial spine to enter the
lesser sciatic foramen. It then enters the pudendal canal (Alcock's canal) and runs forwards to the
urogenital diaphragm.
23. Pudendal nerve. It can be blocked with local anaesthetic at this spot for obstetric anaesthesia.
24. Posterior: the lesser sciatic foramen. Anterior: the posterior aspect of the urogenital diaphragm.
25. Deep perineal pouch.
26. Corpus cavernosum.
27. Ilio-inguinal nerve (L1).
28. Prostatic, membranous, bulbar and pendulous.
29. Superficial perineal pouch.
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Session 3 - Female Reproductive System
1.
(c) anteflexed and anteverted.
2.
Are the following statements true or false?
(a) false.
(b) false.
(c) true.
(d) false
3.
The ovarian artery from the aorta at L2.
4.
The ureter passes below the uterine artery just lateral to the cervix and the lateral fornix of the vagina.
5.
Transverse cervical or cardinal (strongest). Pubocervical and uterosacral.
6.
Ovarian vessels, lymphatics and autonomic nerves.
7.
These ligaments, which are in continuity with each other, are the female equivalents of the
gubernaculum of the male.
8.
Posterior side of the broad ligament.
9.
Because they have no (or exceedingly thin) layer of peritoneum over the surface that allows the ova
to extrude.
10. Superficial inguinal glands. It might be possible for malignant cells from the uterus to travel to the
groin.
11. The ureters. Renal failure can occur like this.
12. The obturator nerve.
13. The fertilised ovum implants within the Fallopian tube instead of passing down into the uterus. There
is usually no obvious cause but any form of blockage of the tube could cause it.
14. Para-aortic at L1/2 level.
15. Sympathetic nerves from the T10 ganglion level refer their pain to the T10 dermatome which is periumbilical.
16. The distal tube and fimbria exit the broad ligament posteriorly and are often held in approximation to
the ovary by one of the fimbria being attached to it.
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17. Yes.
18. Bladder and urethra.
19. (a) Stratified squamous.
20. Which fornix of the vagina
(a) Posterior.
(b) Posterior.
(c) Lateral.
21. Peritonitis.
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Session 4 - Anterior Abdominal Wall
1.
(b) 8 ribs
2.
Last four ribs: latissimus dorsi. Ribs 5-8: serratus anterior.
3.
Anterior superior iliac spine and pubic tubercle.
4.
No. It has a free edge posteriorly.
5.
The anterior superior iliac spine and the umbilicus.
6.
Lacunar ligament. The femoral canal. Pectineal ligament.
7.
The pubic crest. Medial and lateral crus. Intercrural fibres.
8.
Anterior two thirds.
9.
Lateral two thirds.
10. (a) Conjoint tendon.
(b) Transversus abdominis.
(c) Ilio-inguinal nerve (L1)
(d) Direct inguinal hernia.
11. (c) Split to lie anterior and posterior
12. A transverse line, a few centimetres below the umbilicus, where the aponeurosis of the internal
oblique no longer splits to enclose the rectus muscle but, instead, passes anterior to the rectus muscle
as does also the transversus abdominis.
13. This is the midline junction of the left and right rectus sheaths.
14. It arises from the anterior two thirds of the iliac crest and the lateral half of the inguinal ligament.
Thus, it becomes the lateral border of the deep inguinal ring.
15. Anterior.
16. Between internal oblique and transversus abdominis.
17. Tendinous intersections.
18. Transversalis fascia and peritoneum.
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19. Flexes trunk.
20. The seventh. Yes, because the first intercostal nerve to appear in the abdomen will be the seventh.
Therefore the nerve supply to the anterior abdominal wall muscles is T7-12.
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Session 5 - Inguinal Canal And Spermatic Cord
1.
(a) 1cm above the mid point of the inguinal ligament.
(b) Transversalis.
(c) Transversus abdominis.
(d) Internal and external oblique.
(e) Inferior epigastric.
2.
Internal oblique and transversus abdominis in the form of the conjoint tendon.
3.
(a) The floor is the inguinal ligament
(b) The roof is curved fibres of the internal oblique muscle and the transversus abdominis muscle
(c) The lateral third of the anterior wall is the internal oblique and the external oblique. More
medially the anterior wall is the external oblique only
(d) The posterior wall is transversalis fascia and the conjoint tendon
4.
Through the deep inguinal ring.
5.
The conjoint tendon and its constituent muscles.
6.
Direct is medial and indirect is lateral to these vessels.
7.
You would reduce the hernia manually with the patient lying down. Then pressure is applied to the
deep ring (see question 1a above) and the patient is either stood up or asked to cough. If the hernia
appears, despite this pressure, then it is a direct hernia.
8.
(a) Yes.
(b) Yes.
(c) No.
(d) No.
(e) Yes.
(f) Yes.
(g)Yes.
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(h) No.
9.
(a) Yes.
(b) No.
(c) Yes.
(d) Yes.
(e) Yes.
(f) Yes.
(g) Yes.
10. Hydrocele.
11. Indirect inguinal hernia.
12. (a) Testicular (aorta), artery to vas (superior vesical) and cremasteric (inferior epigastric).
(b) Testicular, from vas, cremasteric.
(c) Ilio-inguinal, genitofemoral and sympathetics.
(d) Cremasteric and internal and external spermatic.
(e) Vas, processus vaginalis and lymphatics.
13. Peri-umbilical (T10) and not lateralised.
14. Tunica albuginea.
15. Paramesonephric duct.
16. Mesonephric duct.
17. No.
18. Medial: lacunar ligament. Lateral: femoral vein. Anterior: inguinal ligament. Posterior: pectineal
ligament. Lacunar ligament can be cut. The superior pubic vessels from the inferior epigastric on
their way to join the obturator vessels may lie anterior to the hernia and can easily be damaged.
19. To help you, here are other structures that are the same approximate length: the femur, the transverse
colon, teeth to cardia of stomach, spinal cord, thoracic duct! 45cm.
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