HBA THE BODY Trunk Examination - October 1, 2012

Transcription

1 HBA THE BODY Trunk Examination - October 1, On the right is a lettered list of different functional types of neurons. On the left is a list of structures. In the blank following each named structure, enter the letters of the types of axons within it. For any given blank, your list must be entirely correct to generate any credit. (4) (a) gray ramus communicans of S4 (b) white ramus communicans of T2 (c) a cervical sympathetic cardiac n. (d) the pelvic splanchnic n. from S4 A - somatic motor B - somatic sensory C - visceral sensory D - preganglionic sympathetic (e) the contribution to the greater splanchnic n. from T8 (f) the anterior cutaneous branch of the 10 th intercostal n. (g) the anterior vagal trunk (h) the lumbar splanchnic n. from the fused L3/L4 ganglion E - postganglionic sympathetic F - preganglionic parasympathetic G - postganglionic parasympathetic 2. A patient with esophageal carcinoma undergoes resection of a major portion of the esophagus, with replacement by a segment of small intestine. State if the following procedures/treatments must also be done, and give the reason for your answer. (1) (a) treating with a drug that suppresses stomach acid (b) incising the pyloric sphincter 3. Provide an anatomic explanation for the fact that damage to the inferior hypogastric plexus can lead to absence of ejaculation. (0.5) 4. What is the name for the large group of nodes to which most of the lymph from the breast drains? (4) What is the surgeon s name for the subset of this group in which a sentinel node is most likely to occur. If tumor progresses to the most medial nodes of the large group, it is necessary to detach pectoralis minor from its coracoid attachment in order to complete the nodal dissection. What structure often passing through this muscle must be preserved and what happens if you fail to do so? What other group of nodes receives significant lymphatic drainage from the breast and approximately what percentage of breast lymph goes to them. 1

2 5. The integrity of which named portion of the subdiaphragmatic nerve plexus is most crucial for the following? (If the subdiaphragmatic plexus is not concerned with the stated item, enter none.) (2) (a) penile erection (b) clitoral erection (d) voluntary control of urination (e) the urge to defecate 6. Ms. Jones presents with a hard but painless lump just above the left clavicle near the posterior border of sternocleidomastoid. You order an abdominopelvic CT and the report indicates a suspicious mass in the uterine wall. Give an anatomical explanation for a possible link between the lump in the neck and the uterine mass. If this is true, what name would give to the lump when discussing the case with an oncologist? (1) 7. Edema (swelling), pain, varicose veins, and skin ulcers, all symptoms of poor venous return, are substantially more common for the left lower limb than the right. Provide an anatomic explanation for this fact. (0.5) 8. The DIEP (Deep Inferior Epigastric Perforator) flap has become increasingly popular for reconstructing the breast following a mastectomy. In this procedure, the inferior epigastric artery and the skin that it supplies through perforating branches are harvested, while the muscle it supplies is left intact. After the surgery, what keeps this muscle alive? (1) The procedure involves partial transverse incisions through the muscle normally supplied by the inferior epigastric artery. How will this affect the innervation of this muscle? Give a reason for your answer. 9. While picking up debris from in his yard, N. K. feels a snap in his back. He experiences severe back pain that radiates down the back of his thigh and into the sole and lateral side of his foot. You suspect a slipped disc. What happens anatomically during a slipped disc? (3) In N. K. s case, you deduce that the nerve has been affected by disease of the disc. Describe a motor test that, if performed weakly, would verify your suspicion? 10. In some cases of inoperable pancreatic cancer, alcohol is injected around the celiac ganglia. The alcohol stops axonal functioning. Provide an anatomical explanation for how this might benefit the patient. (0.5) 2

3 11. Provide an anatomical explanation for the following: (3) (a) Blood from a leaking abdominal aortic aneurysm spreads throughout the retroperitoneal space, but blood from a lacerated kidney does not spread throughout the retroperitoneal space. (b) When clamping the thoracic aorta (through the left pleural cavity) for the purpose of directing more blood to the brain, the clamp is placed as close to the abdominal diaphragm as is possible. (c) Two days after having his aorta clamped as described in item (c) above, the patient complains of difficulty breathing associated with a pressure in his left chest, but he has no pain on breathing and no fever. A plain film of the chest shows considerable fluid accumulation in the left pleural cavity. What about the operation could account for this untoward event? 12. Provide the requested information for the right phrenic nerve. (2) (a) its relationship to the SVC (b) its relationship to the root of the right lung (c) its relationship to the r. atrium (d) the spinal nerves from which it arises (e) the structure(s) to which it is sensory (f) the structure(s) to which it is motor 13. Listed below are sites of arterial anastomoses. Write the names of arteries that actually participate in the anastomosis. (2.5) (a) fourth intercostal space - (b) between celiac trunk and SMA in the gastrocolic ligament - (c) along the uterine tube - (d) between the IMA and the internal iliac artery - (e) between the IMA and the SMA Cancer of the stomach may enter blood capillaries of the stomach and spread hematogenously, or it may enter lymphatic capillaries of the stomach and spread lymphatically, or it may simply travel along structures that directly connect the stomach to other organs. (1.5) (a) To which major organ will such cancer spread if moves inferiorly along a connecting structure: (b) To which major lymph nodes will such cancer spread: (c)to which major structure will such cancer first spread if it travels hematogenously: 3

4 15. If you are visualizing the abdominal contents through a laparoscope, how can you distinguish colon from small intestine? (1) 16. Provide the anatomical explnation for why its is generally safe to tie off the left renal vein as it crosses over the descending aorta, but it is not safe to tie off the right renal vein anywhere along its course. (1) 17. On the right is a lettered list of arteries. On the left is a list of structures. In the blanks following each named structure on the left, enter the letters associated with the vessels that supply it. For any given blank, your list must be entirely correct to generate any credit. If an artery is the parent of another that actually provides blood to the named structure, include the parent as well as the actual supplier. (6) IN A LEFT CORONARY IN A RIGHT CORONARY A - right coronary a. DOMINANT HEART DOMINANT HEART B - left (main) coronary a. right atrium C - circumflex coronary a. right ventricle D - LAD (ant. interventric. a.) left atrium E - PDA (post. interventric. a.) left ventricle F - (acute) marginal a. AV node G - obtuse marginal aa. SA node H - diagonal aa. 18. On the drawing of the chest shown below are placed 8 possible locations of a stethoscope. In each case name the structure best heard. BE SPECIFIC (4)

5 19. You are assisting Dr. Sorrento at a surgery designed to remove a cancer of the descending colon. Once inside the peritoneal cavity, he will need to mobilize this portion of the bowel. What is the name of the structure along which he will make the incision in order to mobilize the descending colon. Why is this the preferred site for the incision? (1) 20. Name the structures in the hepatoduodenal ligament and describe their relationships to one another. (2.25) 21. Describe the surface anatomy of the superficial and deep inguinal rings. (4) What lies in the preperitoneal space immediately medial to the deep ring? Certain kinds of congenital inguinal hernias are more frequent in premature than full-term baby boys. Which kind and why? What is the most common type of hernia in women? What is the one kind of groin hernia that is equally or more common in women than in men, and why? 22. Both colon and rectal cancer may metastasize to the liver and/or the lung. Why is the presence of metastases in the lung without any in the liver more common in the case of rectal cancer than colon cancer? (0.5) 23. Provide an anatomical explanation for the fact that cancer of the head of the pancreas often reveals itself by painless jaundice whereas cancer of the tail does not. (3.25) Associated with the jaundice is dilatation of a structure that can be palpated. What structure is this and where should you place your fingers in order to feel it? Tumor of the body and tail of the pancreas is often inoperable because it engulfs neighboring arteries. Name the three arteries (excluding the aorta) most likely to be surrounded by such a tumor. If you decide to attempt surgery, once you have entered the peritoneal cavity, what should you do to see the body of the pancreas? 24. Where are Bartholin s glands located and where do they empty? (1) 5

6 25. What information do you hope to gain by performing a Pringle maneuver following liver trauma? In your answer, describe the possible results and how you interpret them. (1) 26. You wish to perform an epidural anesthesia that will eliminate the pain of labor and delivery. What is the last structure your needle pierces before it enters the epidural space? (4) What normally lies in the epidural space? You choose to perform this procedure at the same site as you would perform a spinal tap. Where is this and how do locate it? Which specific spinal nerves must be bathed in anesthetic if you are to be successful in eliminating the pain of the first stage of labor? What test can you perform to determine if you have been successful? What spinal nerves must be anesthetized if you are to eliminate the pain of cervical dilatation and perineal stretching? 27. State the surface anatomy of the following structures: (2) (a) aortic bifurcation (b) spleen (c) urinary bladder (d) aortic arch 28. Portal hypertension and thrombosis of the inferior vena cava will both produce signs that are visible on the anterior body wall. Briefly describe the sign that each pathology produces and how they are distinguished from each other. (1.5) 29. What is the most life-threatening consequence of portal hypertension and what anatomical facts underlie this risk?(1) 6

7 30. Name the structures that run between the layers of the lienorenal ligament. (1) 31. Name the structure that lies (2) (a) anterior to the lowest point of the posterior cul-de-sac (b) posterior to the lowest point of the posterior cul-de-sac (b) anterior to the lowest point of the anterior cul-de-sac (c) on the anterior aspect of the bifurcation of the common iliac artery (d) in a women, crossing the medial surface of the external iliac artery 1fb from its origin (d) surrounded by the corpus spongiosum (e) in a man, immediately inferior to the base of the bladder (f) in a man, anterior to the rectum immediately superior to the pelvic diaphragm 31. Below are presented two axial CTs at the level of S5. In both cases the patient has received intravascular contrast. The female has also swallowed barium. Identify the indicated structures. (3) A B C D E F G H I J K L 7

8 32. Below are numbered sections from an MRA. Section 1 is the left-most; section 21 is the right-most section. (The sections are not equally spaced from left to right, An increment of 1 corresponds to 8 mm.) Sometimes the same structure has been labeled in more than one section; at other times a structure appearing in multiple sections is labeled only once. Identify the labeled structures, stating side (l. or r.) where appropriate. (5) A: B: C: D: E: F: G: H: I: J: K: L: M: N: O: P: Q: R: S: T: 8