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Abdominal Mass
Abdominal Mass
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femoral ring, below and lateral to the pubic tubercle, distinguishing these from
inguinal hernias, which are above and medial to the tubercle.
A mass caused by testicular cancer (choice D) cannot be reduced either.
Patients will complain of a dull, heavy, aching feeling within the testicle. The
testicle itself is usually enlarged, hard, irregular, and nontender.
A varicocele(choice E) is caused by dilatation of the pampiniform venous
plexus of the spermatic cord. It is typically described as feeling like "a bag of
worms" on physical examination. The dilatation is more easily appreciated
with the patient standing or during the Valsalva maneuver.
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Which of the following nerves travels along the spermatic cord within the inguinal
canal and may be damaged during a surgical procedure to
correct this patient's condition?
/A. IIiohypogastric
/B. IIioinguinal
/C. Lateral femoral cutaneous
/D. Obturator
/E. Pudendal
Explanation - Q: 1.2
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Question 3 of 4
Explanation - Q: 1.3
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The correct answer is E. The small bowel is a derivative of the midgut and
therefore receives its blood supply from the superior mesenteric artery. This
artery emerges from the aorta 1 cm below the celiac trunk and passes ventral
to the left renal vein to give off 12 to 15 jejunal and ileal arteries. As these
arteries divide, they join with an adjacent branch to form arches. These
arches may then communicate to form an arcade. Straight arteries also
emerge from these arches to supply the bowel. Although there are variants,
the ileal artery is usually a branch of the superior mesenteric artery, which
supplies a branch to the terminal ileum.
The celiac trunk (choice A) provides branches to supply the stomach, liver,
pancreas, and duodenum. It is not responsible for supplying blood to the
terminal ileum.
The inferior mesenteric artery (choice B) provides branches that supply a
limited part of the transverse colon near the splenic flexure and the
descending and sigmoid colon.
The middle colic artery (choice C) is a branch of the superior mesenteric
artery. There are two branches, right and left. The right branch supplies the
right half of the transverse colon and the left branch supplies the left half of
the transverse colon.
The right colic artery (choice D) is also a branch of the superior mesenteric
artery. It is responsible for supplying the hepatic flexure as well as that part of
the ascending colon not supplied by the ileocolic artery.
A 36-year-old man presents to his physician complaining of right scrotal swelling.
He states that the swelling has been present for 1 week. He
initially noticed the swelling shortly after moving furniture for his new living room.
He denies any nausea, vomiting, change in bowel habits,
abdominal pain, or urinary tract symptoms. He has no other significant medical or
surgical history. On examination, he has an enlarged right
Explanation - Q: 1.4
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Ieft side of the abdomen. The mother had no idea the mass was present and the
pediatrician did not note the presence of the mass at the
child's 18-month welI-child visit. Physical examination is otherwise unremarkable.
Question 2 of 5
Explanation - Q: 2.2
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Explanation - Q: 2.5
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The correct answer is C. Inactivation of the WT-1 Wilms tumor gene (located
at 11p13, and thought to encode a DNA-binding protein important in fetal
kidney development) has been reported in the tumor cells from many Wilms
tumor cases. Also, the WAGR syndrome involves a deletion of chromosome
11p13 and the Beckwith-Wiedemann syndrome involves a rearrangement of
chromosome 11p15. The genetic basis of the Drash syndrome has not been
established. The other choices are distracters.
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A 67-year-old man with an 18-year history of type 2 diabetes mellitus presents for
a routine physical examination. His temperature is 36.9 C
(98.5 F), his blood pressure is 158/98 mm Hg and his pulse is 82/minute and
regular. On examination, the physician notes a nontender,
pulsatile, mass in the mid-abdomen. A plain abdominal x-ray film with the patient
in the lateral position reveals spotty calcification of a
markedly dilated abdominal aortic walI.
Question 1 of 5
Explanation - Q: 3.1
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Which of the following physiologic observations helps to account for the fact that
75% of the aneurysms of this patient's type are found in the
abdomen and only 25% principally involve the thorax?
/A. Diastolic pressure is greater in the abdominal aorta in the supine position
/B. Negative intrathoracic pressure reduces aortic wall tension in the thorax
/C. The average blood flow in the abdominal aorta is greater than that in the
thoracic aorta
/D. The average blood pressure in the abdominal aorta is higher than that in the
thoracic aorta
/E. The average degree of turbulence in the thoracic aorta is higher than that in
the abdominal aorta
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Explanation - Q: 3.2
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The correct answer is D. Increased blood pressure is a strong risk factor for
atherosclerosis, and humans pay a price for their erect sitting and standing
postures. In these postures, the abdominal aorta experiences the weight of a
column of blood added to the pressure produced by the heart. In the supine
posture, the pressures in the thoracic and abdominal aorta are similar. So, if
A 67-year-old man with an 18-year history of type 2 diabetes mellitus presents for
a routine physical examination. His temperature is 36.9 C
(98.5 F), his blood pressure is 158/98 mm Hg and his pulse is 82/minute and
regular. On examination, the physician notes a nontender,
pulsatile, mass in the mid-abdomen. A plain abdominal x-ray film with the patient
in the lateral position reveals spotty calcification of a
markedly dilated abdominal aortic walI.
Question 3 of 5
The patient is taken to surgery and the abdominal aorta and proximal common
iliac arteries are replaced with a graft. Which of the following
aneurysm diameters is usually considered the threshold above which elective
surgery is recommended, unless contraindicated by other
disease?
/A. 1 cm
/B. 2 cm
/C. 6 cm
/D. 10 cm
/E. 15 cm
Explanation - Q: 3.3
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carries a high mortality rate. For aneurysms larger than 5 cm, the risk of
rupture is 5-10% per year
A 67-year-old man with an 18-year history of type 2 diabetes mellitus presents for
a routine physical examination. His temperature is 36.9 C
(98.5 F), his blood pressure is 158/98 mm Hg and his pulse is 82/minute and
regular. On examination, the physician notes a nontender,
pulsatile, mass in the mid-abdomen. A plain abdominal x-ray film with the patient
in the lateral position reveals spotty calcification of a
markedly dilated abdominal aortic walI.
Question 4 of 5
Following surgery, the patient is placed on a low-fat diet to reduce the risk of
continued progression of his atherosclerotic disease. A bile
acid sequestrant is added to interrupt enterohepatic circulation of bile acids.
Which of the following agents was most likely prescribed?
/A. Atorvastatin
/B. Cholestyramine
/C. CIofibrate
/D. Gemfibrozil
/E. Lovastatin
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Explanation - Q: 3.4
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A 67-year-old man with an 18-year history of type 2 diabetes mellitus presents for
a routine physical examination. His temperature is 36.9 C
(98.5 F), his blood pressure is 158/98 mm Hg and his pulse is 82/minute and
regular. On examination, the physician notes a nontender,
pulsatile, mass in the mid-abdomen. A plain abdominal x-ray film with the patient
in the lateral position reveals spotty calcification of a
markedly dilated abdominal aortic walI.
Question 5 of 5
The table shows values of vessel radius (r), intraluminal pressure (P), and wall
thickness (w) for both the normal aorta and an aortic aneurysm.
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Explanation - Q: 4.1
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The correct answer is B. Ascaris lumbricoides is the only parasitic worm that is
likely to cause intestinal obstruction, and then only if the worm burden is high. The
description given of the worms in the case presentation is typical. All of the other
worms listed in the choices are also nematodes or roundworms.
Ankylostoma duodenale(choice A) is a small (approximately 1 cm) hookworm that
inhabits the small intestine and clings to the mucosa.
Enterobius vermicularis(choice C) is the pinworm. This is an approximately 1 cm
long worm that inhabits the large bowel (and appendix); the female deposits eggs on
the perianal skin.
Strongyloides stercoralis(choice D), or threadworm, is a 2.5 mm worm that lives in
the crypts of the small bowel and may cause chronic infection due to autoinfection. It
is the only nematode capable of increasing its numbers in a host. In
immunocompromised hosts, it can cause life-threatening disseminated infection.
Trichuris trichiura(choice E), or whipworm, is a 3-5 cm worm that lives on the
colorectal mucosa.
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A 3-year-old girl is seen in the emergency department with acute abdominal pain.
She has a 5-day history of vomiting and abdominal
distension. She has not passed stool during this time, and during the past day,
has been vomiting bilious materiaI. On physical examination,
she is lethargic, with a firm and tender abdomen, and peritoneal signs are
present. She is immediately referred for laparotomy for suspected
diagnoses of intussusception vs. volvulus. At surgery, approximately 20 cm of
small intestine is found to be markedly distended, and is
resected. The section contains a tightly knotted ball of nematodes that are about
15 to 35 cm in length. The worms have tapered ends without
hooks.
Question 2 of 5
Which of the following best describes what would have been seen under the
microscope if the patient's stool had been analyzed for ova and
parasites?
/A. Large oval eggs with a lateral spine
/B. Large round to oval eggs, with a thick mammillated shells
/C. Lemon-shaped eggs, with bipolar plugs,
/D. Round eggs and proglottids filled with eggs
/E. Small larvae
Explanation - Q: 4.2
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If this child acquired her infection in the United States, in what region of the
nation does she most likely reside?
/A. Desert Southwest
/B. Midwest
/C. Northeast
/D. Pacific Northwest
/E. Southeast
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Explanation - Q: 4.3
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A 3-year-old girl is seen in the emergency department with acute abdominal pain.
She has a 5-day history of vomiting and abdominal
distension. She has not passed stool during this time, and during the past day,
has been vomiting bilious materiaI. On physical examination,
she is lethargic, with a firm and tender abdomen, and peritoneal signs are
present. She is immediately referred for laparotomy for suspected
diagnoses of intussusception vs. volvulus. At surgery, approximately 20 cm of
small intestine is found to be markedly distended, and is
resected. The section contains a tightly knotted ball of nematodes that are about
15 to 35 cm in length. The worms have tapered ends without
hooks.
Question 4 of 5
Explanation - Q: 4.4
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The correct answer is B. Mebendazole is a systemically absorbed broadspectrum anthelminthic agent effective against Ascaris species, hookworm,
tapeworm, liver fluke, and pinworms.
Bithionol (choice A) is used to treat infections caused by Fasciola hepatica, a
tissue fluke.
Metronidazole (choice C) is used to treat infections caused by anaerobic
organisms, including the intestinal protozoa, Giardia lamblia, and Entamoeba
histolytica.
Niclosamide (choice D) is not available in the United States. It can be used to
treat tapeworm infections caused by T. saginata and D. latum. It is less
expensive than praziquantel.
Praziquantel (choice E) has broad-spectrum activity against most trematodes
and cestodes, with the exception of F. hepatica.
A 3-year-old girl is seen in the emergency department with acute abdominal pain.
She has a 5-day history of vomiting and abdominal
distension. She has not passed stool during this time, and during the past day,
has been vomiting bilious materiaI. On physical examination,
she is lethargic, with a firm and tender abdomen, and peritoneal signs are
present. She is immediately referred for laparotomy for suspected
diagnoses of intussusception vs. volvulus. At surgery, approximately 20 cm of
small intestine is found to be markedly distended, and is
resected. The section contains a tightly knotted ball of nematodes that are about
15 to 35 cm in length. The worms have tapered ends without
hooks.
Question 5 of 5
Part of the life cycle of this patient's parasite is a filarial stage in which larva,
hatched in the duodenum, penetrate the wall of the small
intestine. The passage of migrating larvae most commonly produces
symptomatic disease in which of the following organs?
/A. Heart
/B. Liver
/C. Lungs
/D. Pancreas
/E. Stomach
Explanation - Q: 4.5
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