Abdominal Mass

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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
hemi-scrotum with a mass that appears to be originating at the level of the
external inguinal ring. With the patient completely relaxed, the
physician is able to reduce the mass by pushing it back through the external
inguinal ring. With the mass reduced, the physician instructs the
patient to perform a Valsalva maneuver, upon which a protrusion is felt at the
external inguinal ring. Once the mass is reduced, the testicle
appears normal in size and consistency.
Question 1 of 4
Which of the following is the most likely diagnosis?
/ A. Hydrocele
/ B. Femoral hernia
/ C. Inguinal hernia
/ D. Testicular cancer
/ E. Varicocele
Explanation - Q: 1.1 Close
The correct answer is C. This patient has a reducible inguinal hernia. A

hernia is a protrusion of a structure, usually intestine, through tissue that
normally contains it. Inguinal hernias are either direct or indirect. Indirect
inguinal hernias occur through the internal inguinal ring in a protrusion of
peritoneum along the spermatic cord in the internal spermatic fascia. Direct
inguinal hernias occur through the floor of the inguinal canal, separate from
the spermatic cord as a result of breakdown of the transversus abdominis
aponeurosis and transversalis fascia. If the mass, i.e., hernia, is easily
returned back to its normal position, then it is called reducible. If the mass is
not reducible, then this is called incarcerated. And, if the mass becomes
incarcerated and develops compromised blood supply, it is termed
strangulated. Strangulated hernias require emergent repair because the
intestinal contents will necrose and cause the patient to become sick. As long
as the mass is reducible, surgical repair can be performed on an outpatient
basis.
A hydrocele (choice A) is a fluid collection contained within the tunica

vaginalis that surrounds the testicle. It presents as a painless swelling of the
scrotum, which transilluminates light when it is placed against the mass. A
hydrocele cannot be reduced.
Femoral hernias (choice B) are more common in women, presenting as

swellings in the upper part of the thigh. The neck of the hernia sac lies at the
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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Question 2 of 4
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
The correct answer is B. Although it is now possible to perform inguinal

hernia repairs laparoscopically, the traditional approach is through an incision
over the inguinal canal. At the time of surgery, the inguinal canal is opened
via sharp dissection through the external oblique aponeurosis (the anterior
wall of the inguinal canal). The ilioinguinal nerve is then encountered as it
runs on the anterior aspect of the spermatic cord. If not properly identified at
time of surgery it is possible to transect the ilioinguinal nerve or to "trap" it
during closure. If the ilioinguinal nerve is transected or entrapped in closure,
the patient will complain of numbness over the nerve's distribution, i.e., the
upper medial aspect of the thigh and the anterior portion of the scrotum on
the affected side.
The iliohypogastric, lateral femoral cutaneous, obturator, and pudendal

nerves are not encountered during traditional inguinal hernia repair.
The iliohypogastric nerve(choice A) is derived from L1 (as is the ilioinguinal

nerve) and runs with the ilioinguinal nerve as they both pierce the transversus
abdominis muscle near the anterior superior iliac spine. They then pass
through the internal and external oblique muscles to supply the skin of the
suprapubic and inguinal regions and the abdominal musculature. The
iliohypogastric sends a lateral branch to the skin of the gluteal region and
then continues on, to pass through the superficial inguinal ring.
The lateral femoral cutaneous nerve (choice C) originates from L2 and L3

and is a direct branch of the lumbar plexus. It enters the thigh deep to the
lateral end of the inguinal ligament near the anterior superior iliac spine and
supplies the skin on the anterior and lateral aspects of the thigh.
The obturator nerve(choice D) is the nerve of the adductor muscles of the

thigh. It arises from the lumbar plexus (L2, L3, L4), enters the pelvis minor,
and then leaves the pelvis via the obturator foramen. The obturator nerve
also sends a small cutaneous branch to the medial aspect of the mid thigh.
The pudendal nerve (choice E) arises from the sacral plexus (S2, S3, S4),
accompanies the internal pudendal artery, and leaves the pelvis between the
piriformis and coccygeus muscles. The nerve hooks around the sacrospinous
ligament to enter the perineum through the lesser sciatic foramen to supply
the muscles of the perineum, including the external anal sphincter, and then
ends as the dorsal nerve of the penis or clitoris. It also supplies some
sensation to the external genitalia
Question 3 of 4
If a segment of terminal ileum becomes strangulated as a consequence of his
condition, it may become infarcted and necrotic due to
occlusion of a branch of which of the following vessels?
/ A. Celiac trunk
/ B. Inferior mesenteric artery
/ C. Middle colic artery
/ D. Right colic artery
/ E. Superior mesenteric artery
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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.
Question 4 of 4
Which of the following pathological processes might cause the patient's
underlying condition to occur in an infant?
/ A. Defect in the floor of the inguinal canal
/ B. Defect in the internal inguinal ring
/ C. Defect in the linea semilunaris
/ D. Patent processus vaginalis
/ E. Persistent lumen of the tunica vaginalis
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The correct answer is D. The pathologic process that causes hernias is

different in neonates and infants than in an adult. Embryologically, in the
seventh week, the testes begin descending from their location at the 10th
thoracic level into the scrotum. After the eighth week, a peritoneal evagination
called the processus vaginalis forms just anterior to the gubernaculum. The
gubernaculum is a condensation of peritoneum that attaches superiorly to the
gonad and inferiorly to the fascia that is developing between the external and
internal oblique muscles in the region of the labioscrotal swellings. The
processus vaginalis pushes out as a "sock-like" extension into the
transversalis fascia, the internal oblique muscle, and the external oblique
muscle, thus forming the inguinal canal. After the processus vaginalis has
evaginated into the scrotum, the gubernacula shorten and simply pull the
gonads through the canal. Within the first year after birth, the superior portion
of the processus vaginalis is usually obliterated, leaving only a distal remnant
sac, the tunica vaginalis, which lies anterior to the testis. During infancy, this
sac wraps around most of the testis. Its lumen is normally collapsed, but
under pathologic conditions it may fill with serous secretions, forming a
testicular hydrocele (choice E). If the processus vaginalis remains patent, a
connection between the abdominal cavity and scrotal sac will occur. Loops of
intestine may herniate into this processus, resulting in an indirect inguinal
hernia.
In adults, hernias are caused by a protrusion of a structure, usually intestine,

through a tissue that normally contains it. Direct inguinal hernias occur
through the floor of the inguinal canal separate from the spermatic cord
(choice A). Direct inguinal hernias occur because of a breakdown of the
transversus abdominis aponeurosis and transversalis fascia.
An indirect inguinal hernia occurs through the internal inguinal ring in a

protrusion of peritoneum along the spermatic cord in the internal spermatic
fascia. Therefore, a large indirect inguinal hernia will descend into the
scrotum along the spermatic cord (choice B).
Spigelian hernias are rare and occur due to a weakness in the linea
semilunaris (choice C), which is located at the lateral margin of the rectus
sheath.
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A 2-year-old child is seen for a welI-child visit in a pediatric clinic. Abdominal
examination demonstrates a palpable, non-tender mass on the
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 1 of 5
CT examination demonstrates an 8-cm diameter, roughly round, mass involving
the lower pole of the kidney. Which of the following is the
most likely cause of this mass?
/ A. Ewing sarcoma
/ B. Neuroblastoma
/ C. Renal cell carcinoma
/ D. Transitional cell carcinoma
/ E. Wilms tumor
The correct answer is E. Wilms tumor is an embryonal malignancy of the

kidney that most commonly affects children from birth to age 4, but can affect
children up to about age 15. This tumor is the second most common
extracranial solid tumor in children and tends to form large, round, solitary
masses of the kidney, although bilaterality and multicentricity may also occur.
Wilms tumors usually present with a palpable abdominal mass, with less
common presentations including abdominal pain, hematuria (indicating
invasion of the collecting system), hypertension, fever, nausea, and vomiting.
Ewing sarcoma (choice A) most commonly involves the long bones of older
children and young adolescents.
Neuroblastoma (choice B) may also effect very young children, and typically
arises in the adrenal gland. Extensions into the kidney can occur, but usually
involve the upper pole first.
Renal cell carcinoma (choice C) and transitional cell carcinoma (choice D)

would be much more likely to involve the kidney of an adult.
Question 2 of 5
If a CT guided biopsy of the mass were performed, which of the following
histological patterns would be most suggestive of the likely
diagnosis?
/ A. Cords of clear cells with rounded or polygonal shape and abundant clear
cytoplasm
/ B. Invasive papillary lesions with delicate connective tissue stalk covered with
epithelium resembling that lining the bladder
/ C. Small dark cells embedded in a finely fibrillar matrix with formation of
numerous rosettes
/ D. Triphasic pattern with tubule formation, spindle cells, and blastemal
elements
/ E. Uniform sheets of small round cells with scanty cytoplasm
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The correct answer is D. Adequate sampling of most Wilms tumors will

detect the three distinct growth patterns that are most characteristic of this
tumor: less cellular tumor areas containing spindle cells; densely cellular
(blastemal) areas with closely packed small cells with scanty cytoplasm and
darkly blue nuclei; and areas with production of more mature-appearing
epithelium that may form occasional tubules. The tissues present are similar
to those present in the developing kidney, and may also include primitive
glomeruli. Wilms tumors may additionally contain heterologous elements,
such as skeletal muscle, smooth muscle, squamous or mucinous epithelium,
adipose tissue, cartilage, bone, or neural tissue.
Choice A suggests renal cell carcinoma.
Choice B suggests transitional cell carcinoma.
Choice C suggests neuroblastoma.
Choice E suggests Ewing sarcoma; neuroblastoma and some lymphomas

may also sometimes have a similar appearance.
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Question 4 of 5
Sometimes this child's disease occurs in association with certain congenital
anomalies. Children with which of the following abnormalities at
birth should be monitored for the development of this disease?
/ A. Aniridia
/ B. Coarctation of the aorta
/ C. Cystic hygroma
/ D. Parathyroid hyperplasia
/ E. Simian crease
The correct answer is A. The WAGR syndrome includes Wilms tumor,

aniridia (lack or defect of the iris), genital anomalies (gonadal dysgenesis,
hypospadias, cryptorchidism, or other genitourinary anomalies), and mental
retardation. Wilms tumor can also occur as part of the Beckwith-Wiedemann
syndrome with hemihypertrophy, and the Drash syndrome with nephropathy
and ambiguous genitalia.
Coarctation of the aorta (choice B) and cystic hygroma (choice C) are

associated with Turner syndrome, which may predispose for later
development of ovarian cancer.
Parathyroid hyperplasia (choice D) can be a component of multiple

endocrine neoplasia (MEN).
Simian crease (choice E) suggests Down syndrome, which is associated with

an increased incidence of leukemia.
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Question 5 of 5
Abnormalities of which of the following chromosomes have been linked to this
disease?
/ A. 3
/ B. 5
/ C. 11
/ D. 15
/ E. 21
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
Which of the following is most likely pathogenetically related to this patient's
aortic disease?
/ A. Atherosclerosis
/ B. Cystic medial necrosis
/ C. Kawasaki disease
/ D. Mönckeberg arteriosclerosis
/ E. Syphilis
The correct answer is A. This patient has an abdominal aortic aneurysm

(AAA); these are most commonly the result of atherosclerosis. Hypertension
and cigarette smoking are also risk factors. AAA may be asymptomatic, or
may be associated with pain. Some aortic aneurysms are palpable as
pulsating masses in the abdomen. Abdominal aortic aneurysms typically
begin below the renal arteries and may extend well into the iliac system
bilaterally. Calcified atherosclerotic plaques on plain films of the abdomen can
be seen in the majority of cases. Rupture of an aortic aneurysm is usually
preceded by excruciating pain in the lower abdomen and back. The mortality
rate for abdominal aortic aneurysm repair performed electively is about 2-5%,
while that performed emergently after rupture of the aneurysm has begun is
50%. Many patients with atherosclerotic aneurysms also have severe
coronary artery disease, and repair of the coronary arteries may be needed
before the patient is subjected to the risk of aortic aneurysm repair.
Cystic medial necrosis (choice B) is a risk factor for dissecting aneurysms

that typically do not widen the lumen of the aorta.
Kawasaki disease (choice C) can cause small aneurysms of the coronary

arteries.
Mönckeberg's arteriosclerosis (choice D) can cause focal calcification of

(usually medium-sized) arteries, but is not associated with aneurysm
formation.
Syphilis (choice E) is a now rare cause of aortic aneurysms that typically

involve the aortic root and ascending aorta.
Question 2 of 5
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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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
an average daily pressure is taken, the abdominal aorta tends to have a
significantly higher pressure than does the thoracic aorta.
Diastolic pressure (choice A) is actually greater in the thoracic aorta

compared to the abdominal aorta in the supine position. However, the systolic
blood pressure is greater in the abdominal aorta.
A negative intrathoracic pressure (choice B) would tend to increase

transmural pressure across the wall of the thoracic aorta, and thereby
increase wall tension and promote the development of aneurysms.
Blood flow (choice C) in the abdominal aorta is less than that in the thoracic
aorta, because some blood leaves the aorta through its thoracic branches.
Higher turbulence (choice E) tends to predispose for atherosclerosis, and the

flow in the abdominal aorta, with its many branches, tends to be more
turbulent than that in the thoracic aorta; this problem is exacerbated as
atherosclerotic disease advances.
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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
The correct answer is C. This recommendation is made because larger

aneurysms have a much greater chance of rupture, and emergency repair
carries a high mortality rate. For aneurysms larger than 5 cm, the risk of
rupture is 5-10% per year
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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The correct answer is B. Cholestyramine and colestipol are bile acid

sequestrants that bind bile acids in the intestine, thereby interrupting
enterohepatic circulation of bile acids. This has an indirect effect to enhance
LDL clearance and lower lipids in the blood.
Atorvastatin (choice A) and lovastatin (choice E) are lipid-lowering drugs

that competitively inhibit HMG-CoA reductase, an early step in cholesterol
biosynthesis.
Clofibrate (choice C) and gemfibrozil (choice D) are fibric acid derivatives

that may increase the activity of lipoprotein lipase.
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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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What effect does the aneurysm have on wall stress?
/ A. Wall stress decreases 10 fold
/ B. Wall stress decreases 2.5 fold
/ C. Wall stress decreases 5 fold
/ D. Wall stress increases 10 fold
/ E. Wall stress increases 2.5 fold
/ F. Wall stress increases 5 fold
The correct answer is E. According to the Law of LaPlace for a cylindrical

structure such as the aorta: wall stress (s) = (P x r)/w. Because P and w are
shown in the table to be unaffected by the aneurysm and because radius is
increased by 2.5 fold at the site of the aneurysm, it is clear that wall stress
has increased by 2.5 fold at the site of the aneurysm. This relationship
between vessel radius and wall tension can explain why the probability of
rupture increases as the aneurysm becomes larger.
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 1 of 5
The worms are most likely which of the following?

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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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
The correct answer is B. This is the correct description of fertilized Ascaris

eggs. Both fertilized and somewhat more elongated unfertilized eggs may be
seen; fertilized eggs may contain multiple cells under the thick wavy shell.
Choice A describes the eggs of the trematode (fluke) Schistosoma mansoni.
Choice C describes the eggs of Trichuris trichiura.
Choice D describes the eggs of the cestodes (tapeworms) Taenia saginata

and Taenia solium.
Choice E describes the larvae of Strongyloides stercoralis. Strongyloides

stercoralis has a rapid life cycle in its host. It is the only nematode whose
diagnostic form is a larva, not an egg.
hooks.
Question 3 of 5
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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The correct answer is E. It is easy for medical students, residents, and

physicians to neglect parasitic diseases because they assume that the
American population is not likely to have them. However, it is thought that
more than 4 million individuals in the Untied States, most of whom are
immigrants from developing countries, are infected with Ascaris species,
predominately Ascaris lumbricoides. Most of these people have
asymptomatic infections. Ascaris can also be acquired in rural areas of the
Southeastern United States, where it is endemic. Worldwide, 1.4 billion
people are estimated to be infected.
hooks.
Question 4 of 5
Which of the following medications would be the most appropriate
pharmacotherapy for this patient?
/ A. Bithionol
/ B. Mebendazole
/ C. Metronidazole
/ D. Niclosamide
/ E. Praziquantel
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The correct answer is B. Mebendazole is a systemically absorbed broad-

spectrum 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.
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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
The correct answer is C. Ascaris infection is acquired by ingestion of the

eggs, usually from contaminated soil. The ingested eggs hatch in the
duodenum to produce larvae, which cross the small intestinal wall to enter the
blood stream. They then pass through the heart to lodge in the lungs. They
leave the lung capillary bed to enter the airspaces. They then ascend the
bronchial tree into the oropharynx, where they are again swallowed. This
time, they return to the small intestine where they develop into mature worms
that can live in the host for up to two years. A gravid female worm may
produce up to 250,000 eggs daily, which are shed in stool. The passage of
the larvae through the lungs often produces cough and/or wheezing, and
may, in severe cases, produce fever, dyspnea, fleeting patchy pulmonary
infiltrates (Loeffler pneumonitis with prominent eosinophilia), and rarely
hemoptysis.
Passage through the heart (choice A) is usually asymptomatic, as the larvae

are small.
A single adult worm, but not usually larval forms, can migrate into the biliary
tree (choice B), leading to biliary colic, cholangitis, or gallstone formation;
obstructive jaundice uncommonly occurs.
The pancreas (choice D) and stomach (choice E) are not common sites for
complications of ascariasis.

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Explanation - Q: 1.1 Close

The correct answer is C. This patient has a reducible inguinal hernia. A

A hydrocele (choice A) is a fluid collection contained within the tunica

Femoral hernias (choice B) are more common in women, presenting as

A mass caused by testicular cancer (choice D) cannot be reduced either.

A varicocele(choice E) is caused by dilatation of the pampiniform venous

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Explanation - Q: 1.2 Close

The correct answer is B. Although it is now possible to perform inguinal

The iliohypogastric, lateral femoral cutaneous, obturator, and pudendal

The iliohypogastric nerve(choice A) is derived from L1 (as is the ilioinguinal

The lateral femoral cutaneous nerve (choice C) originates from L2 and L3

The obturator nerve(choice D) is the nerve of the adductor muscles of the

Explanation - Q: 1.3 Close

The inferior mesenteric artery (choice B) provides branches that supply a

The middle colic artery (choice C) is a branch of the superior mesenteric

The correct answer is D. The pathologic process that causes hernias is

In adults, hernias are caused by a protrusion of a structure, usually intestine,

An indirect inguinal hernia occurs through the internal inguinal ring in a

Explanation - Q: 2.1 Close

The correct answer is E. Wilms tumor is an embryonal malignancy of the

Renal cell carcinoma (choice C) and transitional cell carcinoma (choice D)

Explanation - Q: 2.2 Close

The correct answer is D. Adequate sampling of most Wilms tumors will

Choice A suggests renal cell carcinoma.

Choice B suggests transitional cell carcinoma.

Choice C suggests neuroblastoma.

Choice E suggests Ewing sarcoma; neuroblastoma and some lymphomas

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Explanation - Q: 2.4 Close

The correct answer is A. The WAGR syndrome includes Wilms tumor,

Coarctation of the aorta (choice B) and cystic hygroma (choice C) are

Parathyroid hyperplasia (choice D) can be a component of multiple

Simian crease (choice E) suggests Down syndrome, which is associated with

The correct answer is C. Inactivation of the WT-1 Wilms tumor gene

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Explanation - Q: 3.1 Close

The correct answer is A. This patient has an abdominal aortic aneurysm

Cystic medial necrosis (choice B) is a risk factor for dissecting aneurysms

Kawasaki disease (choice C) can cause small aneurysms of the coronary

Mönckeberg's arteriosclerosis (choice D) can cause focal calcification of

Syphilis (choice E) is a now rare cause of aortic aneurysms that typically

Explanation - Q: 3.2 Close

Diastolic pressure (choice A) is actually greater in the thoracic aorta

A negative intrathoracic pressure (choice B) would tend to increase

Higher turbulence (choice E) tends to predispose for atherosclerosis, and the

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Explanation - Q: 3.3 Close

The correct answer is C. This recommendation is made because larger

The correct answer is B. Cholestyramine and colestipol are bile acid

Atorvastatin (choice A) and lovastatin (choice E) are lipid-lowering drugs

Clofibrate (choice C) and gemfibrozil (choice D) are fibric acid derivatives

Explanation - Q: 3.5 Close

The correct answer is E. According to the Law of LaPlace for a cylindrical

Explanation - Q: 4.1 Close

Ankylostoma duodenale(choice A) is a small (approximately 1 cm) hookworm that

Enterobius vermicularis(choice C) is the pinworm. This is an approximately 1 cm

Strongyloides stercoralis(choice D), or threadworm, is a 2.5 mm worm that lives in

Trichuris trichiura(choice E), or whipworm, is a 3-5 cm worm that lives on the

Explanation - Q: 4.2 Close

The correct answer is B. This is the correct description of fertilized Ascaris

Choice A describes the eggs of the trematode (fluke) Schistosoma mansoni.

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