58
6 A 4-year-old male child is admitted to the hospital
with severe vomiting. Radiographic examination and history taking reveals that the boy suffers from an an- nular pancreas. Which of the following structures is most typically obstructed by this condition?
⃣ A. Pylorus of the stomach
⃣ B. First part of the duodenum
⃣ C. Second part of the duodenum
⃣ D. Third part of the duodenum
⃣ E. Jejunum
7 A 3-year-old male child is admitted to the pedi-
atric clinic. Diagnosis reveals that the intermediate portion of the processus vaginalis is not obliterated.
Which of the following conditions will most likely result from this?
⃣ A. Hypospadias
⃣ B. Sterility
⃣ C. Congenital hydrocele
⃣ D. Ectopic testis
⃣ E. Epispadias
8 Testicles are absent from the scrotum of a 1-year-
old male admitted to the pediatric clinic. The pediatri- cian examined the infant and palpated the testes in the inguinal canal. Which of the following terms is used to describe this condition?
⃣ A. Pseudohermaphroditism
⃣ B. True hermaphroditism
⃣ C. Cryptorchism
⃣ D. Congenital adrenal hyperplasia
⃣ E. Chordee
9 A 28-year-old woman who is 8 months pregnant
goes to the outpatient clinic for her prenatal checkup.
Ultrasound examination of the fetus reveals gastroschi- sis, with herniation of the small bowel into the amni- otic cavity. Failure of proper formation of which of the following structure(s) has resulted in this condition?
⃣ A. Head fold
⃣ B. Tail fold
⃣ C. Neural folds
⃣ D. Lateral folds
⃣ E. Amnion
10 Rotation of the stomach during development re-
sults in movement of the left vagus nerve from its original position. Through approximately how many degrees of rotation does the nerve move, and what is its fi nal position?
⃣ A. 90 ° to become the anterior vagal trunk
⃣ B. 90 ° to become the posterior vagal trunk
⃣ C. 270 ° to become the anterior vagal trunk
⃣ D. 270 ° to become the posterior vagal trunk
⃣ E. 180 ° to become the right vagal trunk
11 A newborn baby was diagnosed with eventration
of the diaphragm, wherein one half of the diaphragm ascends into the thorax during inspiration, but the other half contracts normally. What is the most likely cause of this condition?
⃣ A. Absence of a pleuropericardial fold
⃣ B. Absence of musculature in one half of the diaphragm
⃣ C. Failure of migration of the diaphragm
⃣ D. Failure of development of the septum trans- versum
⃣ E. Absence of a pleuroperitoneal fold
12 A 2-day-old newborn male is cyanotic after at-
tempts to swallow milk result in collection of the milk in his mouth. After 2 days he develops pneumonia. A tracheoesophageal fi stula is suspected. Which of the following structures has failed to develop properly?
⃣ A. Esophagus
⃣ B. Trachea
⃣ C. Tongue
⃣ D. Tracheoesophageal septum
⃣ E. Pharynx
13 A 3-day-old male newborn has diffi culties in
breathing. A CT scan of his chest and abdomen reveals the absence of the central tendon of the diaphragm.
Which of the following structures failed to develop properly?
⃣ A. Pleuroperitoneal folds
⃣ B. Pleuropericardial folds
⃣ C. Septum transversum
⃣ D. Cervical myotomes
⃣ E. Dorsal mesentery of the esophagus
14 A 2-day-old female infant with fever is examined
by the pediatric team. Imaging reveals malrotation of the small intestine without fi xation of the mesenteries.
The vessels around the duodenojejunal junction are obstructed and the intestine is at risk of becoming gan- grenous. Which of the following has occurred to cause the obstruction?
⃣ A. Diaphragmatic atresia
⃣ B. Subhepatic cecum
59
⃣ C. Midgut volvulus
⃣ D. Duplication of the intestine
⃣ E. Congenital megacolon
15 A 5-day-old male infant is diagnosed with
Hirschsprung disease. CT scan examination reveals an abnormally dilated colon. Which of the following is the most likely embryologic mechanism responsible for Hirschsprung disease?
⃣ A. Failure of neural crest cells to migrate into the walls of the colon
⃣ B. Incomplete separation of the cloaca
⃣ C. Failure of recanalization of the colon
⃣ D. Defective rotation of the hindgut
⃣ E. Oligohydramnios
16 A 1-day-old infant has a mass protruding through
her umbilicus. Physical examination reveals an umbili- cal hernia. A CT scan reveals that part of another organ is attached to the inner surface of the hernia. What portion of the gastrointestinal tract is most likely to be attached to the inner surface of the umbilical hernia?
⃣ A. Anal canal
⃣ B. Appendix
⃣ C. Cecum
⃣ D. Ileum
⃣ E. Stomach
17 A 38-year-old pregnant woman is admitted to the
emergency department with severe vaginal bleeding.
Ultrasound examination confi rms the initial diagnosis of ectopic pregnancy. Which of the following is the most common site of an ectopic pregnancy?
⃣ A. Uterine tubes
⃣ B. Cervix
⃣ C. Mesentery of the abdominal wall
⃣ D. Lower part of uterine body overlapping the internal cervical os
⃣ E. Fundus of the uterus
18 A 23-year-old woman is admitted with severe ab-
dominal pain, nausea, and vomiting. History taking shows that the pain is acute and has been constant for 4 days. The pain began in the epigastric region and radi- ated bilaterally around the chest to just below the scapu- lae. Currently the pain is localized in the right hypo- chondrium. A CT scan examination reveals calcifi ed stones in the gallbladder. Which of the following nerves is carrying the afferent fi bers of the referred pain?
⃣ A. Greater thoracic splanchnic nerves
⃣ B. Dorsal primary rami of intercostal nerves
⃣ C. Phrenic nerves
⃣ D. Vagus nerves
⃣ E. Pelvic splanchnic nerves
19 A 32-year-old male is admitted to the emergency
department with groin pain. Examination reveals that the patient has an indirect inguinal hernia. Which of the following nerves is compressed by the herniating struc- ture in the inguinal canal to give the patient pain?
⃣ A. Iliohypogastric
⃣ B. Lateral femoral cutaneous
⃣ C. Ilioinguinal
⃣ D. Subcostal
⃣ E. Pudendal
20 A 54-year-old male is admitted to the emergency
department with severe upper abdominal pain. Gastros- copy reveals a tumor in the antrum of the stomach. A CT scan is ordered to evaluate lymphatic drainage of the stomach. Which of the following lymph nodes is most likely to be involved in a malignancy of the stomach?
⃣ A. Celiac
⃣ B. Superior mesenteric
⃣ C. Inferior mesenteric
⃣ D. Lumbar
⃣ E. Hepatic
21 During a scheduled laparoscopic cholecystectomy
in a 47-year-old female patient, the resident acciden- tally clamped the hepatoduodenal ligament instead of the cystic artery. Which of the following vessels would most likely be occluded in this iatrogenic injury?
⃣ A. Superior mesenteric artery
⃣ B. Proper hepatic artery
⃣ C. Splenic artery
⃣ D. Common hepatic artery
⃣ E. Inferior vena cava
22 A 45-year-old male was admitted to the hospital
with groin pain and a palpable mass just superior to the inguinal ligament. The patient was diagnosed with an inguinal hernia and a surgical repair was performed.
During the operation the surgeon found a loop of intes- tine passing through the deep inguinal ring. Which of the following types of hernia was this?
⃣ A. Direct inguinal
⃣ B. Umbilical
⃣ C. Femoral
⃣ D. Lumbar
⃣ E. Indirect inguinal
60
23 A 55-year-old man was admitted to the hospital
with severe abdominal pain. Gastroscopy and CT scan examinations revealed a perforating ulcer in the poste- rior wall of the stomach. Where would peritonitis most likely develop initially?
⃣ A. Right subhepatic space
⃣ B. Hepatorenal space (of Morison)
⃣ C. Omental bursa (lesser sac)
⃣ D. Right subphrenic space
⃣ E. Greater sac
24 A 58-year-old male alcoholic is admitted to the
hospital after vomiting dark red blood (hematemesis).
Endoscopy reveals ruptured esophageal varices, result- ing from portal hypertension. Which of the following venous tributaries to the portal system anastomoses with caval veins to cause the varices?
⃣ A. Splenic
⃣ B. Left gastroomental
⃣ C. Left gastric
⃣ D. Left hepatic
⃣ E. Right gastric
25 A 45-year-old male entered the emergency depart-
ment with a complaint of severe abdominal pain. During physical examination it is observed that his cremasteric refl ex is absent. Which of the following nerves is respon- sible for the efferent limb of the cremasteric refl ex?
⃣ A. Ilioinguinal
⃣ B. Iliohypogastric
⃣ C. Genitofemoral
⃣ D. Pudendal
⃣ E. Ventral ramus of T12
26 The decision is made by emergency department
surgeons to perform an exploratory laparotomy on a 32-year-old female with severe abdominal pain. Where would the incision most likely be made to separate the left and right rectus sheaths?
⃣ A. Midaxillary line
⃣ B. Arcuate line
⃣ C. Semilunar line
⃣ D. Tendinous intersection
⃣ E. Linea alba
27 After a “tummy-tuck” (abdominoplasty) procedure
is performed on a 45-year-old man, which of the follow- ing layers of the abdominal wall will hold the sutures?
⃣ A. Scarpa’s fascia (membranous layer)
⃣ B. Camper’s fascia (fatty layer)
⃣ C. Transversalis fascia
⃣ D. Extraperitoneal tissue
⃣ E. External abdominal oblique fascia
28 A 49-year-old man presents with acute abdominal
pain and jaundice. Radiographic studies reveal a tumor in the head of the pancreas. Which of the following structures is most likely being obstructed?
⃣ A. Common bile duct
⃣ B. Common hepatic duct
⃣ C. Cystic duct
⃣ D. Accessory pancreatic duct
⃣ E. Proper hepatic artery
29 A 44-year-old man is admitted to the emergency
department with excessive vomiting and dehydration.
Radiographic images demonstrate that part of the bowel is being compressed between the abdominal aorta and the superior mesenteric artery. Which of the following intestinal structures is most likely being compressed?
⃣ A. Second part of duodenum
⃣ B. Transverse colon
⃣ C. Third part of duodenum
⃣ D. First part of duodenum
⃣ E. Jejunum
30 During the surgical repair of a perforated duode-
nal ulcer in a 47-year-old male patient, the gastroduo- denal artery is ligated. A branch of which of the follow- ing arteries will continue to supply blood to the pancreas in this patient?
⃣ A. Inferior mesenteric
⃣ B. Left gastric
⃣ C. Right gastric
⃣ D. Proper hepatic
⃣ E. Superior mesenteric
31 A 70-year-old man is admitted to the emergency
department with severe diarrhea. An arteriogram re- veals 90% blockage at the origin of the inferior mesen- teric artery from the aorta. Which of the following ar- teries would most likely provide collateral supply to the descending colon?
⃣ A. Left gastroepiploic artery
⃣ B. Middle colic artery
⃣ C. Sigmoid artery
⃣ D. Splenic artery
⃣ E. Superior rectal artery
61
32 A 24-year-old woman has a dull aching pain in
the umbilical region, and fl exion of the hip against re- sistance (psoas test) causes a sharp pain in the right lower abdominal quadrant. Which of the following structures is most likely infl amed to cause the pain?
⃣ A. Appendix
⃣ B. Bladder
⃣ C. Gallbladder
⃣ D. Pancreas
⃣ E. Uterus
33 A 35-year-old male is admitted to the hospital
from the emergency department because of excruciat- ing pain in the back and left shoulder. A CT scan re- veals an abscess in the upper part of the left kidney, but no abnormality is detected in the shoulder region.
The shoulder pain may be caused by the spread of the infl ammation to which of the following neighboring structures?
⃣ A. Descending colon
⃣ B. Diaphragm
⃣ C. Duodenum
⃣ D. Liver
⃣ E. Pancreas
34 A 62-year-old man is admitted to the hospital
with dull, diffuse abdominal pain. A CT scan reveals a tumor at the head of the pancreas. The abdominal pain is mediated by afferent fi bers that travel initially with which of the following nerves?
⃣ A. Greater thoracic splanchnic
⃣ B. Intercostal
⃣ C. Phrenic
⃣ D. Vagus
⃣ E. Subcostal
35 A 52-year-old male with a history of smoking and
hypercholesterolemia is diagnosed with severe athero- sclerosis affecting the arteries of his body. Laboratory examination reveals extremely low sperm count. Which of the following arteries is most likely occluded?
⃣ A. External iliac
⃣ B. Inferior epigastric
⃣ C. Umbilical
⃣ D. Testicular
⃣ E. Deep circumfl ex iliac
36 In a routine visit to the outpatient clinic for his
annual checkup, a 42-year-old male is informed that radiographic examination has given strong evidence that he has a malignancy of his scrotum. Which of the
following nodes are the fi rst lymph nodes that drain the affected area?
⃣ A. Superfi cial inguinal
⃣ B. Internal iliac
⃣ C. Lumbar
⃣ D. Presacral
⃣ E. Axillary
37 A 35-year-old male is admitted to the hospital
with an indirect inguinal hernia. During an open her- nioplasty (in contrast to a laparoscopic procedure), the spermatic cord and the internal abdominal oblique muscles are identifi ed. Which component of the sper- matic cord is derived from the internal abdominal oblique muscle?
⃣ A. External spermatic fascia
⃣ B. Cremaster muscle
⃣ C. Tunica vaginalis
⃣ D. Internal spermatic fascia
⃣ E. Dartos fascia
38 A 63-year-old man with a history of alcoholism is
brought to the emergency department with hemateme- sis (vomiting blood). Findings on endoscopic examina- tion suggest bleeding from esophageal varices. The varices are most likely a result of the anastomoses be- tween the left gastric vein and which other vessel or vessels?
⃣ A. Azygos system of veins
⃣ B. Inferior vena cava
⃣ C. Left umbilical vein
⃣ D. Superior mesenteric vein
⃣ E. Subcostal veins
39 A 34-year-old man is undergoing an emergency
appendectomy. After the appendectomy has been per- formed successfully, the patient undergoes an explor- atory laparoscopy. Which of the following anatomic features are the most useful to distinguish the jejunum from the ileum?
⃣ A. Jejunum has thinner walls compared with the ileum.
⃣ B. Jejunum has less mesenteric fat compared with the ileum.
⃣ C. Jejunum has more numerous vascular arcades compared with the ileum.
⃣ D. Jejunum has more numerous lymphatic folli- cles beneath the mucosa compared with the ileum.
⃣ E. Jejunum has fewer villi compared with the ileum.
62
40 After a mastectomy, a musculocutaneous fl ap is
used to restore the thoracic contour in a 34-year-old female patient. The ipsilateral (same side) rectus ab- dominis muscle was detached carefully from the sur- rounding structures and transposed to the thoracic wall. Which of the following landmarks is most often used to locate the inferior end of the posterior, tendi- nous layer of the rectus sheath?
⃣ A. Intercristal line
⃣ B. Linea alba
⃣ C. Arcuate line
⃣ D. Pectineal line
⃣ E. Semilunar line
41 An anteroposterior radiograph is taken of the
lumbar region in a 31-year-old female patient who had been treated for tuberculous spondylitis at vertebral levels T12-L1. The patient has been asymptomatic for 10 years. Which of the following is the most likely site of the calcifi ed tuberculous abscess?
⃣ A. Body of pancreas
⃣ B. Cecum
⃣ C. Fundus of stomach
⃣ D. Psoas fascia
⃣ E. Suspensory ligament of the duodenum
42 A 45-year-old female is admitted to the hospital
with symptoms of an upper bowel obstruction. Upon CT examination it is found that the third (transverse) portion of the duodenum is being compressed by a large vessel. Which of the following vessels will most likely be causing the compression?
⃣ A. Inferior mesenteric artery
⃣ B. Superior mesenteric artery
⃣ C. Inferior mesenteric vein
⃣ D. Portal vein
⃣ E. Splenic vein
43 A 61-year-old woman had been scheduled for a
cholecystectomy. During the operation the scissors of the surgical resident accidentally entered the tis- sues immediately posterior to the epiploic (omental) foramen (its posterior boundary). The surgical fi eld was fi lled immediately by profuse bleeding. Which of the following vessels was the most likely source of bleeding?
⃣ A. Aorta
⃣ B. Inferior vena cava
⃣ C. Portal vein
⃣ D. Right renal artery
⃣ E. Superior mesenteric vein
44 A 32-year-old woman was admitted to the hospi-
tal with a complaint of pain over her umbilicus. Radio- graphic examination revealed acute appendicitis. The appendix was removed successfully in an emergency appendectomy. One week postoperatively the patient complained of paresthesia of the skin over the pubic region and the anterior portion of her perineum. Which of the following nerves was most likely injured during the appendectomy?
⃣ A. Genitofemoral
⃣ B. Ilioinguinal
⃣ C. Subcostal
⃣ D. Iliohypogastric
⃣ E. Spinal nerve T9
45 Exploratory laparoscopy was performed on a
34-year-old male, following a successful emergency appendectomy. Which of the following anatomic relationships would be seen clearly, without dissec- tion, when the surgeon exposes the beginning of the jejunum?
⃣ A. The second portion of the duodenum is related anteriorly to the hilum of the right kidney.
⃣ B. The superior mesenteric artery and vein pass posterior to the third part of the duodenum.
⃣ C. The portal vein crosses anterior to the neck of the pancreas.
⃣ D. The second part of the duodenum is crossed anteriorly by the attachment of the transverse mesocolon.
⃣ E. The third part of the duodenum is related an- teriorly to the hilum of the left kidney.
46 A 30-year-old female patient complains that she
has been weak and easily fatigued over the past 6 months. She has a 3-month acute history of severe hypertension that has required treatment with antihy- pertensive medications. She has recently gained 4.5 kg (10 lb) and currently weighs 75 kg (165 lb). Her blood pressure is 170/100 mm Hg. Purple striae are seen over the abdomen on physical examination and she pos- sesses a “buffalo hump.” Fasting serum glucose con- centration is 140 mg/dl. A CT scan of the abdomen shows a 6-cm mass immediately posterior to the infe- rior vena cava. Which of the following organs is the most likely origin of the mass?
⃣ A. Suprarenal (adrenal) gland
⃣ B. Appendix
⃣ C. Gallbladder
⃣ D. Ovary
⃣ E. Uterus
63
47 An obese 45-year-old female patient with an ele-
vated temperature comes to the physician’s offi ce com- plaining of nausea and intermittent, acute pain in the right upper quadrant of the abdomen during the past 2 days. She has a 24-hour history of jaundice. She has a history of gallstones. Which of the following struc- tures has most likely been obstructed by a gallstone?
⃣ A. Common bile duct
⃣ B. Cystic duct
⃣ C. Left hepatic duct
⃣ D. Pancreatic duct
⃣ E. Right hepatic duct
48 A 67-year-old man has severe cirrhosis of the
liver. He most likely has enlarged anastomoses between which of the following pairs of veins?
⃣ A. Inferior phrenic and superior phrenic
⃣ B. Left colic and middle colic
⃣ C. Left gastric and esophageal
⃣ D. Lumbar and renal
⃣ E. Sigmoid and superior rectal
49 A 45-year-old male is admitted to the hospital
with a massive hernia that passes through the inguinal triangle (of Hesselbach). Which of the following struc- tures is used to distinguish a direct inguinal hernia from an indirect inguinal hernia?
⃣ A. Inferior epigastric vessels
⃣ B. Femoral canal
⃣ C. Inguinal ligament
⃣ D. Rectus abdominis muscle (lateral border)
⃣ E. Pectineal ligament
50 A 36-year-old man was brought to the emergency
department with a bullet wound to the abdomen. The bullet penetrated the anterior abdominal wall superior to the umbilicus. If the bullet passed directly posterior in the midline, which of the following structures was most likely to have been struck fi rst by the bullet?
⃣ A. Abdominal aorta
⃣ B. Transverse colon
⃣ C. Stomach
⃣ D. Gallbladder
⃣ E. Pancreas
51 A 48-year-old man has had three episodes of up-
per gastrointestinal bleeding from esophageal varices.
He has a history of chronic alcoholism but has recently been rehabilitated. Further evaluation shows ascites and splenomegaly. Which of the following surgical ve- nous anastomoses is most commonly used to relieve
these symptoms and signs before a liver transplant is attempted?
⃣ A. Left gastric to splenic vein
⃣ B. Right gastric to left gastric vein
⃣ C. Right renal to right gonadal vein
⃣ D. Splenic to left renal vein
⃣ E. Superior mesenteric to inferior mesenteric vein
52 A 55-year-old man is admitted to the hospital
with nausea, vomiting, and hematuria. A CT scan ex- amination reveals a neoplasm in the posterior surface of the inferior pole of the left kidney that has invaded through the renal pelvis, renal capsule, ureter, and fat.
To which of the following regions will pain most likely be referred?
⃣ A. Skin of the anterior and lateral thighs and femoral triangle
⃣ B. Skin over the gluteal region, pubis, medial thigh, and scrotal areas
⃣ C. Skin over the medial, anterior, and lateral side of the thigh
⃣ D. Skin over the pubis and umbilicus
⃣ E. Skin over the pubis, umbilicus, and posterior abdominal wall muscles
53 A 30-year-old female patient has complained of
weakness and fatigability over the past 6 months. She has a 3-month acute history of severe hypertension that has not responded to antihypertensive medications.
Fasting serum glucose concentration is 140 mg/dl. A CT scan of the abdomen shows a 6-cm mass in the adrenal gland affecting the secretory cells of the adre- nal medulla. Which of the following structures is most likely releasing products into the bloodstream to pro- duce the hypertension and other signs?
⃣ A. Preganglionic sympathetic axons in thoracic splanchnic nerves
⃣ B. Cells of neural crest origin that migrated to the adrenal medulla
⃣ C. Preganglionic parasympathetic branches of the posterior vagal trunk
⃣ D. Postganglionic parasympathetic branches of the left or right vagus nerves
⃣ E. Postganglionic fi bers from pelvic splanchnic nerves
54 A 48-year-old man is admitted to the hospital
with severe abdominal pain. Radiographic examination reveals a tumor in the tail of the pancreas. A diagnostic arteriogram shows that the tumor has compromised the blood supply to another organ. Which of the fol-