Clinical Anatomy Cases

By A/Prof. Ken Ashwell Mr Paul Halasz, Department of Anatomy, School of Medical Sciences, UNSW Special thanks to Dr Stephen Riordan, Prince of Wales Hospital, for providing many of the illustrations

Instructions
1. Please read the clinical case and view any illustrations. 2. Attempt the multiple choice questions. Select

the MOST correct answer. Note that in some

cases there may be several options correct, but one option will allow you to choose all of the correct options (e.g. all of the above are correct, both B and D are correct).

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Abscess of Greater Vestibular Gland gland)

(Bartholins

History A 26 year old women presents to her general practitioner with pain upon intercourse (dyspareunia). The pain appears to be localized to the right side of her vulva and she has noticed a painful swelling on the right side of the vaginal entrance. The woman has had approximately a dozen sexual partners over the last year, most of whom have not used condoms. Physical examination and investigations There is an acutely tender swelling in the right posterior third of the labia. Vaginal swabs reveal infection with Neisseria gonorrhoea. Subsequent events The woman is admitted to hospital, given a general anesthetic and undergoes a procedure to surgically drain a large abscess of Bartholins gland (greater vestibular gland) into the vagina. The abscess is incised and the margins of the incision are sewn to the vaginal epithelium, forming a pouch (marsupialisation). This allows drainage of the abscess contents into the vagina. When glandular function returns to normal, the normal glandular secretions will also continue to drain into the vagina. The woman recovers well with antibiotic treatment of her gonorrhoea.

Clinical anatomy questions 1. The greater vestibular glands lie: n A. deep to the anterior part of bulb of the vestibule o B. deep to the posterior part of the bulb of the vestibule n C. between the bulbospongiosus muscle and greater vestibular gland n D. deep to the vestibular fossa n E. none of the above are correct 2. The function of the greater vestibular gland is to: o A. secrete mucus to lubricate the vagina during sexual intercourse n B. provide nutrients for spermatozoa n C. expand during sexual arousal and open the vaginal introitus n D. provide secretions which control fungal populations in the vagina n E. provide secretions which facilitate flow of menstrual blood 3. Structures within the vaginal vestibule include all of the following EXCEPT: n A. the external urethral orifice n B. the vaginal orifice n C. the ducts of the greater vestibular glands o D. the prepuce of the clitoris n E. the vestibular fossa

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4. Blood supply to the region of the greater vestibular gland is derived from the: n A. external pudendal branch of the internal iliac artery n B. internal pudendal branch of the external iliac artery o C. internal pudendal branch of the internal iliac artery n D. internal pudendal branch of the obturator artery n E. inferior gluteal artery

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Acute appendicitis
History A 16 year old girl awoke one night at midnight with pain centred around her umbilicus. The pain came and went in waves and at this time did not radiate to any other part of the abdomen. After a few hours the girl vomited and became febrile (temperature up to 38.5oC). At about 5.00 am the pain shifted to the right iliac fossa and became constant in nature. At this time the girl was brought to the Accident and Emergency Department of her local hospital where she was admitted. Physical examination The examination upon admission revealed marked tenderness in the right iliac fossa with guarding (rigidity of abdominal wall muscles) and rebound tenderness (minimal pain upon gently pushing an examining hand into the right iliac fossa, but intense pain upon sudden withdrawal of the examining hand). Bowel sounds were reduced and the per rectal examination failed to reveal any abnormality. A provisional diagnosis of acute appendicitis was made. Subsequent events The girl was prepared for theatre and an appendicectomy was performed at 8.00 am. The abdominal wall was incised using a grid-iron incision centred at McBurneys point. The aponeuroses and muscle sheets of the anterolateral abdominal wall muscles were incised in the line of their fibres. The caecum was mobilised by incising the peritoneum along its lateral and inferior borders and exteriorized. The greater omentum was found to be partially adherent to the caecum and the two structures were carefully separated by incision. The inflamed appendix was

encountered, the appendicular vessels located and ligated, the appendix removed and its stump invaginated into the caecum. The girl subsequently recovered well. Clinical anatomy questions 1. Periumbilical pain could be due to disease in the: n A. rectum n B. 1st part of the duodenum n C. sigmoid colon n D. stomach o E. ileocecal region 2. The vermiform appendix is particularly prone to gangrene because: n A. it receives its blood supply from the lumbar arteries via attachments to the posterior abdominal wall n B. the appendicular vein may be obstructed in its drainage into the inferior vena cava o C. the appendicular vessels may be readily obstructed by thrombosis as they run along the wall of the appendix n D. the mesoappendix is prone to kinking n E. the appendicular artery is prone to atherosclerosis 3. Pain in the right iliac fossa could be due to: n A. a gall stone lodged in the hepatopancreatic ampulla n B. rupture of the spleen with bleeding onto the parietal peritoneum n C. perforated duodenal ulcer with a right paracolic gutter directing duodenal contents towards the right side of the abdomen n D. irritation of iliac fossa parietal peritoneum by an appendicular abscess o E. both C and D are correct

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4. Guarding (rigidity of the abdominal wall muscles) is due to: n A. irritation of the parasympathetic nerve fibres supplying gut segments n B. activation of sympathetic nerve fibres from the coeliac ganglion n C. tension on mesenteric supports resulting from gut inflammation o D. irritation of parietal peritoneum resulting in reflex activation of abdominal muscles n E. none of the above are correct 5. Spinal segments supplying the right iliac fossa are: n A. L1/L2 o B. T12/L1 n C. T10/T11 n D. T9/T10 n E. T8/T9 6. Favoured incision sites for appendicectomy include: n A. a midline incision in the hypogastrium n B. an oblique incision at a point two thirds of the way from the umbilicus to the right ASIS n C. a transverse incision beginning 2.5 cm superior to the ASIS and passing towards the midline n D. an incision at the middle of the left spinoumbilical line o E. both B and C are correct 7. Concerning the abdominal wall fascial layers, which would need to be opened in this patient: n A. there is a superficial fatty layer which is continuous with the deep fascia of the thigh o B. there is a deep fibrous fascial layer, which is continuous with the Colles fascia of the perineum

n C. the deep fibrous fascial layer is continuous with the superficial fat elsewhere in the body n D. the fascia of the abdomen is denser than that over the thigh n E. none of the above are correct 8. The most common position for the vermiform appendix is: n A. preilieal n B. retroileal o C. retrocolic or retrocaecal n D. pelvic n E. subcaecal 9. Locating the verniform appendix can be achieved by: n A. following appendices epiploicae to the caecoappendicular junction o B. following taenia coli of the caecum to the caecoappendicular junction n C. identifying the anterior and posterior frenula of the appendicular orifice by palpation n D. following the ileum to the appendicular origin n E. tracing the mesentery of the small intestine to the mesoappendix 10. The appendicular artery is usually a branch of: n A. the right colic artery n B. the left colic artery n C. the sigmoid artery o D. the ileocolic artery n E. the middle colic artery

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Carcinoma of the colon

History A 60 year old woman presented to her general practitioner complaining of bleeding per rectum associated with the passage of motions. This had become more noticeable over the last 2 months. She also admitted to easy fatigability and weakness and has had occasional episodes of feeling as if the bowel had not emptied properly when she passes a motion. She has no family history of any bowel disease.

Physical examination Pallor of the oral mucosa and nail beds suggestive of anemia was found. The abdominal examination revealed slight gaseous distension but no palpable masses. The per rectal examination and proctoscopy revealed a sessile (flat), hard, oval lesion with rolled edges and a central depression situated on the anterior wall of the rectal ampulla (Figure 1). The lesion was approximately 5 cm in diameter and blood was noted on the examining glove at the end of the per rectal examination. Full colonoscopy was performed and no other lesions were found to the distal ileum. Biopsies of the rectal mass showed adenocarcinoma (Figure 2). At the time of presentation the chest X-ray was normal.

Figure 1 flattened tumour on rectal mucosa

Figure 2 histology of adenocarcinoma Subsequent events The patient underwent a wide surgical resection of the lesion in the rectum with clearance of the draining lymph nodes. Care was taken during the surgery to avoid unnecessary

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palpation of the lesion and blood vessels supplying the area of affected bowel were divided and ligated early in the procedure. Histological assessment showed that the resection margins of the rectum were free of tumour. Several of the draining lymph nodes were positive for adenocarcinoma. The patient then completed a course of adjuvant radiotherapy and chemotherapy. However, she developed enlargement of the liver, abdominal distension and dyspnoea (breathlessness) over the subsequent 7 months. On examination at this time the patient had yellow skin (jaundice), a distended abdomen with an enlarged, hard, irregular liver and enlargement of the spleen as well as distended veins radiating from the umbilicus. A moderate amount of ascites (free fluid in the abdominal cavity) was apparent.

An abdominal computerised tomography scan and chest Xray revealed metastases (tumour spread) in the liver (Figure 3) and lungs. She died from liver failure and pneumonia 20 months after the initial presentation Clinical anatomy questions 1. Concerning the structure of the rectum: n A. the rectal ampulla lies superior to the transverse rectal folds n B. the rectal (anal columns) collectively constitute the pectinate line n C. the rectum has upper perineal and lower sacral curvatures o D. the rectum is usually considered to begin at SV3 n E. the anorectal junction lies at the level of SV4 2. Anterior relations of the rectum in females include all of the following EXCEPT the: o A. superior rectal artery n B. posterior fornix of the vagina n C. rectouterine pouch n D. posterior vaginal wall n E. posterior azygos artery of the vagina 3. Anterior relations of the rectum in males include all of the following EXCEPT the: n A. seminal vesciles n B. ampulla of the ductus deferens n C. rectovesical pouch o D. piriformis muscle n E. posterior median groove of the prostate

Figure 3 multiple secondary tumours in the liver

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4. Concerning peritoneal relations of the rectum: n A. the upper one third is covered by peritoneum on all four sides n B. the lower one third is covered by peritoneum on the anterior surface o C. the middle third is covered by peritoneum on its anterior surface n D. the upper third is covered by peritoneum only on its anterior surface n E. the middle third is covered by peritoneum on three sides 5. Concerning arterial supply to the rectum and anus: n A. the rectum is supplied by the superior mesenteric artery n B. the anus is supplied by branches from the obturator artery n C. the rectum is supplied by branches from the internal pudendal artery n D. the rectum receives most of its arterial supply from the median sacral artery o E. the rectum is supplied mainly by the terminal branch of the inferior mesenteric artery 6. Concerning venous drainage from the rectum and anus: n A. drainage from the anus is exclusively to the inferior rectal veins n B. the rectum drains mainly to the internal pudendal vein n C. inferior rectal veins are tributaries of the portal vein o D. superior and inferior rectal veins may anastomose at the level of the pectinate line n E. the superior rectal vein drains to the internal iliac vein 7. Concerning lymphatic drainage of the anorectal canal: n A. lymph from the rectum drains to inguinal nodes n B. lymph from the anal canal may drain to inguinal nodes

n C. lymph from the rectum drains directly to the external iliac nodes n D. lymph from the rectum drains along superior rectal vessels to the lumbar nodes o E. both B and D are correct 8. The surgeon would be careful to ligate vessels to the rectum early in the operation because: n A. this reduces swelling of the rectum during anastomosis of the cut bowel edges n B. this reduces the risk of peritoneal seeding from the tumour o C. this reduces the risk of tumour spread (metastasis) to the liver via the portal circulation n D. this reduces the high risk of arterial spread associated with this tumour n E. none of the above are correct 9. Enlargement of the spleen is likely to be due to: n A. seeding of the tumour via the peritoneal cavity n B. arterial spread of tumour via the coeliac trunk n C. lymphatic spread of tumour via the lumbar lymph nodes o D. elevated portal venous pressure due to spread of tumour to the liver n E. none of the above are correct 10. Enlargement of the veins draining from the umbilicus: o A. is known as the caput Medusae sign n B. is due to increased inferior vena caval pressure n C. is due to increased pressure in the azygos vein n D. is due to invasion of the internal iliac vein by tumour n E. none of the above are correct

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Carcinoma of the Kidney

History A 50 year old woman presented to her general practitioner complaining of blood in her urine (haematuria) which has been increasing in frequency and magnitude over the last three months. She also said she had been feeling vaguely unwell for about one month. On questioning, she also admitted to having experienced a dull ache in the right side of the abdomen, which was fixed in position Physical examination The womans blood pressure was slightly elevated at 140/90 mm Hg. Body temperature was normal. A firm immobile mass could be felt by bimanual palpation in the upper right abdomen at about the level of lumbar vertebrae 1 and 2. Investigations and subsequent events The blood film showed a slightly elevated number of white blood cells (leucocytosis). Abdominal X-ray revealed a distorted upper renal outline on the right side. A subsequent intravenous pyelogram showed a space-occupying lesion distorting the upper right calyceal system. A chest X-ray was normal. The woman was admitted to hospital immediately and prepared for nephrectomy (removal of the kidney). At operation, the surgeon took great care to clamp and ligate the renal vein early in the operation. The woman subsequently recovered well and had no recurrence evident at 5 year follow-up.

Clinical anatomy questions 1. The right kidney is usually located at vertebral levels: n A. T10 to T12 n B. T11 to L1 o C. T12 to L3 n D. L1 to L4 n E. L2 to L5 2. The right kidney sits slightly: o A. lower than the left kidney because of the liver n B. lower than the left kidney because of the transverse colon n C. higher than the left kidney because of the third part of the duodenum n D. higher than the left kidney because of the right colic flexure n E. lower than the left kidney because of the larger right suprarenal gland 3. An expanding lesion of the right kidney upper pole could press against: n A. the third part of the duodenum n B. the 10th rib n C. the body of the pancreas o D. the 12th rib n E. the body of the stomach 4. An expanding lesion of the upper pole of the left kidney could press against: o A. the spleen n B. the ileum n C. the pylorus of the stomach n D. the liver n E. the fundus of the stomach

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5. A carcinoma of the left kidney in a man could cause dilation of the veins draining the left testis (left varicocele) because: n A. tumour invading the left renal vein could obstruct the internal iliac vein n B. tumour invading the inferior vena cava could obstruct the external iliac vein n C. the testicular vein passes posterior to the left kidney n D. renal carcinoma often metastasises (spreads) to the left testis o E. the left testicular vein may be blocked by tumour invading the left renal vein 6. Concerning the arrangement of renal fascia: n A. the anterior layer attaches to the vertebral column o B. the anterior layer fuses with the connective tissue enclosing the aorta and IVC n C. the posterior layer passes anterior to the inferior vena cava n D. the anterior and posterior layers fuse inferiorly n E. none of the above is correct 7. Concerning the calyceal system of the kidney: n A. major calyces receive renal papillae n B. minor calyces extend into the renal cortex n C. there are about 4 minor calyces o D. minor calyces receive renal papillae n E. there are about 8 to 12 major calyces

8. Haematuria in this patient could have arisen from: n A. rupture of tumour vessels into the renal sinus o B. rupture of tumour vessels into the renal pelvis n C. rupture of tumour vessels into the subcapsular tissue n D. rupture of tumour blood vessels into the perinephric space n E. none of the above is correct

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Carcinoma of the larynx

History A 58 year old man presents to his general practitioner complaining of increasing throat pain and changes to his voice over the last 4 months. He finds that his voice often fails him when the weather is cold. He has also had occasional episodes of coughing up small flecks of blood (hemoptysis), particularly in the early morning. The man admits to having smoked heavily since his twenties (2 to 3 packets per day) and has been a heavy drinker (5 to 8 standard drinks a day) for most of that time as well. Physical examination The tissues of the throat were found to be soft and mobile. Enlarged lymph nodes were palpable in the deep upper and lower neck upon displacement of the sternocleidomastoid muscle. Laryngoscopy revealed extensive involvement of the right vocal cord and adjacent laryngeal mucosa by carcinoma. The tumour had invaded posteriorly and superiorly. Subsequent events The man was treated by total laryngectomy and cervical lymph node clearance. He was subsequently trained to speak using an artificial hand-held laryngeal device.

Clinical anatomy questions 1. A structure which would be invaded early by a tumour arising from the vocal fold would be: n A. the posterior cricoarytenoid muscle n B. the lateral cricoarytenoid muscle n C. the muscular process of the arytenoid cartilage o D. the vocal process of the arytenoid cartilage n E. the anterior arch of the cricoid cartilage 2. Concerning the lymphatic drainage of the larynx: n A. the larynx above the vocal folds drains directly to the supraclavicular fossa n B. the larynx above the vocal folds drains directly to the mediastinum o C. the larynx below the vocal folds drains directly to the lower deep cervical nodes n D. the larynx below the vocal folds drains to the upper deep cervical nodes n E. a carcinoma confined to the posterior vocal fold cannot drain to both upper and lower deep cervical nodes 3. Concerning lymph nodes in the neck: n A. deep lymph nodes include submental, submandibular and mastoid nodes n B. deep lymph nodes are arranged horizontally at the junction of the head and neck n C. superficial lymph nodes are arranged in a vertical chain along the internal jugular vein n D. superficial lymph nodes drain directly to the jugular trunk o E. none of the above are correct

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4. Concerning sensory innervation of the larynx: n A. the infraglottic laryngeal mucosa is supplied by the glossopharyngeal nerve n B. the laryngeal vestibule is supplied by the recurrent laryngeal nerve n C. the floor of the piriform fossa houses the external laryngeal nerve o D. the vestibular folds are supplied by the internal laryngeal nerve n E. none of the above are correct 5. Arterial branches to the larynx include: n A. a superior laryngeal artery accompanying the recurrent laryngeal nerve o B. an inferior laryngeal artery derived from the inferior thyroid artery n C. an inferior laryngeal artery arising from the costocervical trunk n D. a superior laryngeal artery from the internal carotid artery n E. none of the above are correct 6. If the tumour invaded superiorly from the vocal fold it is likely to involve all of the following EXCEPT: n A. the quadrangular membrane n B. the laryngeal saccule n C. the vestibular fold o D. the arch of the cricoid cartilage n E. the apex of the arytenoid cartilage

7. Posterior invasion by tumour is likely to involve all of the following EXCEPT: n A. the arytenoid cartilage n B. the intercartilaginous portion of the rima glottidis n C. the transverse arytenoid muscle n D. the oblique arytenoid muscle o E. the stalk of the epiglottis 8. Concerning the nerve supply of intrinsic musculature of the larynx: n A. the posterior cricoarytenoid muscle is supplied by the external laryngeal nerve n B. the transverse arytenoid muscle is supplied by the superior laryngeal nerve o C. the aryepiglotticus muscle is supplied by the recurrent laryngeal nerve n D. the cricothyroid muscle is supplied by the recurrent laryngeal nerve n E. both C and D are correct 9. Sudden obstruction of the airway at the vocal fold could be treated by: o A. a midline incision halfway between the cricoid cartilage and suprasternal notch with tracheostomy n B. penetration of the thyrohyoid membrane with insertion of a tube n C. a lateral incision between the thyroid cartilage and sternocleidomastoid muscle n D. transection of the mylohyoid muscle with insertion of an endotracheal tube n E. none of the above are correct

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10. Block dissection of the neck to remove cancer-involved lymph nodes is likely to involve the removal of: n A. the vagus, lingual and hypoglossal nerves n B. common carotid artery and cervical sympathetic trunk n C. cervical sympathetic trunk and hypoglossal nerve o D. structures between the platysma and pretracheal fascia n E. sternomastoid muscle and cervical sympathetic trunk

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Carcinoma of the Thyroid

History A 60 year old woman presents to her general practitioner complaining of a mildly painful lump in her throat, which has been increasing in size over the last 2 months. She also admits to some hoarseness of her voice, which she has noticed for about the last 3 weeks. She had not received any radiotherapy to the neck previously and there was no family history of thyroid problems. Physical examination and investigations A lump was found in the lower left anterior triangle of the neck. The lump was about 4 cm in diameter, firm and tender to the touch. It was found to be: fixed on swallowing (i.e. did not move when the patient swallowed). There were some enlarged firm lymph nodes found in the left side of the neck. Indirect laryngoscopy revealed that the left vocal cord was flaccid and immobile in the midline. Thyroid hormone levels were normal. Subsequent events The woman was referred to a surgeon, admitted to hospital and immediately prepared for surgery. The thyroid gland was removed along with associated cervical lymph nodes. The sternocleidomastoid muscle was preserved. Frozen section analysis of the tumour showed undifferentiated carcinoma of the thyroid. Postoperatively, the woman recovered well in the short term. She received extensive radiotherapy to the neck and mediastinum and chemotherapy. At 4 months after presentation the woman was found to have metastatic tumour in the lung fields. The tumour involvement of the lungs gradually became more extensive

and the woman died of pneumonia at 4 years after initial presentation. Clinical anatomy questions 1. Concerning the structure of the thyroid gland: n A. it lies level with the 3rd to 5th cervical vertebrae n B. it has two lobes connected by an isthmus n C. it weighs about 70 g in a normal person n D. the bases of the thyroid lobes lie level with the 4th or 5th tracheal cartilages o E. both B and D are correct 2. Concerning the lymphatic drainage of the thyroid gland: n A. lymph drains upward to the paratracheal nodes n B. lymph drains downward to the lower deep cervical nodes o C. lymph from the lobes drains upward to the lower deep cervical nodes n D. lymph from the isthmus drains to the deep cervical nodes n E. none of the above is correct 3. Concerning the venous drainage of the thyroid gland: n A. the inferior thyroid vein usually drains into the internal jugular vein n B. the superior thyroid vein usually drains into the external jugular vein o C. the superior and middle thyroid veins usually drain into the internal jugular vein n D. the inferior thyroid vein usually drains into the external jugular vein n E. the middle thyroid vein usually drains into the external jugular vein

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4. Posterior relations of the thyroid gland include all of the following EXCEPT the: n A. larynx n B. pharynx n C. oesophagus n D. parathyroid glands o E. sternothyroid muscle 5. Concerning the fascia of the neck: o A. the pretracheal layer is attached to the oblique line of the thyroid cartilage n B. the prevertebral layer surrounds the thyroid gland n C. the pretracheal layer extends above the hyoid bone n D. the prevertebral layer covers the floor of the anterior triangle of the neck n E. none of the above is correct 6. Concerning the arterial supply of the thyroid gland: n A. the superior thyroid artery is usually a branch of the internal carotid artery o B. the inferior thyroid artery is usually a branch of the thyrocervical trunk n C. the superior thyroid artery is usually a branch of the thyrocervical trunk n D. the inferior thyroid artery is usually a branch of the external carotid artery n E. the inferior thyroid artery is usually a branch of the internal carotid artery

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Cardiac valvular and coronary artery disease

History A 50 year old man presents to his general practitioner complaining of occasional chest pain on exertion. The pain is experienced mainly in the central retrosternal region, but sometimes radiates into the left arm as far as the elbow. It lasts only a few minutes, is crushing in nature and is relieved by rest. The man admits to having smoked 40 cigarettes per day for the last 25 years and has been treated for elevated blood pressure for the last 5 years. The man had had rheumatic fever at age 8, which, he has been told by other doctors, has left him with a heart murmur. His father died from a stroke at age 65, while his mother died from a heart attack at age 68. Physical examination The man is overweight. The pulse was regular in rhythm (80 bpm). Blood pressure was 135/90. There was no evidence of cardiac failure (i.e. no oedema, no elevation of jugular venous pressure, no enlargement of the liver). The apex beat was palpable in the 5th left intercostal space in the midclavicular line. Auscultation of the chest revealed a harsh midsystolic murmur, which was most audible at the 2nd right intercostal space, but radiated down to the left sternal edge and could also be heard faintly in the carotid arteries. Subsequent events Plain chest X-ray revealed mild calcification of a valve positioned behind the middle of the sternal body. Exercise ECG revealed changes with exertion and coronary artery angiography revealed partial obstruction to the proximal left coronary artery, anterior interventricular artery,

circumflex artery, right marginal artery and posterior septal artery. The man was subsequently operated on for a coronary artery bypass graft, using lengths of the internal thoracic artery. Clinical anatomy questions 1. Concerning the nerve supply of the heart: n A. pain fibres usually accompany the vagus nerve n B. sympathetic fibres usually arise from T5 and T6 segments of the spinal cord n C. the cervicothoracic ganglion is the only sympathetic ganglion contributing to cardiac supply n D. cardiac cholinergic innervation is exclusively to the ventricles o E. none of the above are correct 2. Radiation of cardiac pain into the left arm probably involves which spinal segment? n A. C5 n B. C6 n C. C7 n D. C8 o E. T1 3. The normal position of the apex beat is: n A. 5th left intercostal space in the mid-axillary line n B. 6th left intercostal space in the mid-clavicular line o C. 5th left intercostal space in the mid-clavicular line n D. 4th left intercostal space in the mid-clavicular line n E. none of the above are correct

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4. A shift of the apex beat to the left could result from: n A. enlargement of the left atrium n B. a tension pneumothorax on the left side n C. enlargement of tracheobronchial lymph nodes o D. enlargement of the left ventricle n E. none of the above are correct 5. A mid-systolic murmur best heard in the 2nd right intercostal space most likely arises from the: n A. pulmonary valve o B. aortic valve n C. mitral valve n D. tricuspid valve n E. patent ductus arteriosus 6. Inflammation of the endocardium or endothelium due to rheumatic heart disease could cause narrowing of the aortic valve orifice by: n A. causing the supraventricular crest to adhere to the conus arteriosus n B. causing left ventricular chordae tendineae to shorten n C. causing adhesion of the aortic valve lunules to the endothelium of the aortic sinuses o D. causing adhesion of aortic valve lunules to each other n E. none of the above are correct 7. The left coronary artery: n A. always has a diagonal branch o B. usually has circumflex and anterior interventricular (descending) branches n C. usually passes anterior to the pulmonary trunk n D. usually gives off a posterior septal artery n E. usually supplies a smaller myocardial volume than the right coronary artery

8. The right coronary artery: o A. usually supplies the sinuatrial node n B. often gives off an anterior interventricular artery n C. usually passes between the pulmonary trunk and left auricle n D. gives off a conus branch to the aortic vestibule n E. none of the above are correct 9. Vessels which might be used for coronary artery bypass grafting include all of the following EXCEPT: n A. right gastroepiploic artery n B. internal thoracic artery n C. great saphenous vein o D. inferior thyroid artery n E. all of the above could be used 10. The internal thoracic artery usually arises from the: n A. thyrocervical trunk n B. brachiocephalic trunk o C. subclavian artery n D. external carotid artery n E. arch of aorta

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Cholelithiasis with acute cholecystitis

History A 45 year old woman presented to the Accident and Emergency Department of her local hospital complaining of a 24 hour history of pain in the upper right side of the abdomen. The woman also complained of pain in the upper right scapula and had experienced nausea and some vomiting. The woman admitted that she had had previous similar attacks of pain, which had passed off after a few days. Physical examination The woman was febrile (38.5oC). Tenderness and guarding were present in the right upper quadrant of the abdomen. When the patient was asked to breath deeply while the doctor palpated the right subcostal region, the patient complained of increased tenderness and suddenly stopped her inspiration (Murphys sign). No abnormal masses were palpable. Bowel sounds were normal. Subsequent events An ultrasound examination revealed that gallstones were present in the womans gall bladder, which appeared thickwalled.

Ultrasound showing a thick-walled gallbladder (compatible with chronic cholecystitis) containing gallstones A small amount of peri-cholecystic fluid was noted. The radiologist who performed the ultrasound examination also commented that the right upper quadrant tenderness was maximal when the ultrasound probe was positioned over the surface markings of the gall bladder. Despite treatment with antibiotics, the womans condition deteriorated over the next three days, with elevated temperature (spiking to 39.5oC) and chills. At 4 days after the initial presentation the patient experienced sudden spread of the pain and tenderness to a wider region of the abdomen. A free perforation of the gall bladder was suspected and mild jaundice of the sclera was noted at this time. The patient was immediately prepared for theatre, where perforation of a gangrenous gall bladder was confirmed and cholecystectomy was performed.

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Gangrenous gall bladder wall The woman was found to have a multitude of small stones in the gall bladder and had a dilated common bile duct (duct greater than 0.7 cm in diameter). This finding, along with the pre-operative development of jaundice, led the surgeon to suspect that some stones may have entered the lower parts of the biliary tree and an exploration of the bile duct for stones was performed. A stone was found to have lodged at the lower end of the common bile duct and was removed. A subsequent operative cholangiography showed no further gallstones in the bile duct.

Left - operative cholangiogram showing a lucency in the common bile duct (arrow) compatible with a gallstone; Right magnetic resonance cholangiogram showing similar feature (arrow indicating gallstone) Despite the perforation of the gall bladder, the woman recovered well postoperatively with on-going antibiotic therapy. Clinical anatomy questions 1. Relations of the gall bladder include: n A. the 1st part of the duodenum anteriorly n B. the 3rd part of the duodenum posteriorly n C. the cystic duct inferiorly n D. the transverse colon posteriorly o E. the porta hepatis posteriorly

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2. Surface markings of the gall bladder are given by: n A. the lower trisection of the right spinoumbilical line n B. the right 12th rib o C. the angle between the right costal margin and the linea semilunaris n D. the transpyloric plane 2 cm to the right of the midline n E. none of the above are correct

5. Concerning the structure of the gall bladder: n A. Hartmanns pouch is present in all healthy gall bladders n B. the fundus opens directly into the cystic duct n C. skeletal muscle lines the gall bladder wall o D. Hartmanns pouch may lodge gall stones in cholelithiasis n E. the gall bladder neck lies inferior to the body 6. Close relations into which an inflamed gall bladder might ulcerate include: n A. the transverse colon n B. the 1st part of the duodenum n C. the 3rd part of the duodenum n D. the liver o E. A, B and D are all correct 7. Venous drainage from the gall bladder is via: n A. the right gastric vein n B. the cystic vein to the portal vein o C. small veins passing directly into the liver bed n D. the prepyloric vein into the right gastroepiploic vein n E. none of the above are correct 8. The immediate relations of the bile duct include: n A. the portal vein anteriorly n B. the inferior vena cava directly posteriorly n C. the common hepatic artery to the right in the lower hepatoduodenal ligament n D. the hepatic artery proper to the left in the lower hepatoduodenal ligament o E. the hepatic artery proper to the left in the upper hepatoduodenal ligament

3. Gangrene of the gall bladder is rare because: n A. the gall bladder often has a long mesentery n B. most gall bladder blood supply is from the liver bed n C. acute cholecystitis rarely causes thrombosis of the cystic artery o D. the gall bladder receives blood from both the cystic artery and liver bed n E. both C and D are correct 4. Haemorrhage during gall bladder surgery may be controlled by: n A. compressing the splenic artery in the anterior wall of the epiploic foramen n B. compressing the cystic artery in the posterior wall of the epiploic foramen o C. squeezing the hepatic artery in the upper part of the hepatoduodenal ligament n D. compressing the gastroduodenal artery in the greater omentum n E. both B and C are correct

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9. A gall stone impacted in the hepatopancreatic ampulla may be removed by: n A. incising the supraduodenal part of the bile duct n B. incising the peritoneum along the lateral duodenal margin to expose the retroduodenal bile duct o C. incising the sphincter of Oddi via an approach through the second part of the duodenum n D. entering the pancreatic duct system via the minor duodenal papilla n E. none of the above are correct 10. A perforated gall bladder is likely to discharge its contents directly into: n A. the lesser sac o B. the right paracolic gutter n C. left part of the greater sac n D. the pouch of Douglas n E. the epiploic foramen

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Duodenal ulcer
History A 48 year old man presents to the Accident and Emergency Department of his local hospital complaining of vomiting copious amounts of blood (haematemesis) over the last 6 hours. He also admits to having had a 5 month long history of upper abdominal pain arising at night. The pain has mainly been in the midline of the epigastrium but also radiates through to the posterior abdominal wall and is relieved by eating. The man smokes 10 cigarettes a day and drives a taxi for a living. Physical examination The man weighed 84 kg and was 1.73 m high. Blood pressure was low at 110/60 and pulse rate was 110 bpm. There was noticeable pallor of the conjunctiva and nail beds. There was mild tenderness to the epigastrium, but no other obvious physical abnormality upon examination of the abdomen. Apart from the elevated pulse rate and low blood pressure, cardiovascular and respiratory examinations were normal. Shortly after admission the man began to pass black tarry stools (melaena). Subsequent events Blood was taken for grouping and cross-matching, white cell count, hemoglobin estimation and red cell analysis. The man was resuscitated with intravenous fluids whilst awaiting the full blood count and availability of blood for transfusion. Urgent upper gastrointestinal endoscopy was performed and revealed ulceration of the first part of the duodenum, with evidence of recent bleeding

Endoscopic view of the duodenal ulcer with a large adherent blood clot.

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Endoscopic view of the duodenal ulcer without blood clot. Blood transfusion was commenced. Shortly afterwards, the man began to complain of a sudden onset of generalized abdominal pain. This was associated with marked rebound tenderness (i.e. an examining hand could be gently pushed into the abdomen without pain, but when the hand was suddenly removed the man experienced severe pain) and guarding (rigidity of the abdominal wall muscles). Bowel sounds were absent and a plain abdominal X-ray revealed the presence of free gas under the diaphragm.

Chest X-ray showing free gas beneath the diaphragm. The man was operated on for repair of a perforation of the first part of the duodenum. He recovered well. Subsequent testing for gastric infection with Helicobacter pylori, an important cause of peptic ulceration, proved positive

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2. Posterior relations of the 1st part of the duodenum include all of the following EXCEPT the: n gastroduodenal artery n portal vein n bile duct o splenic artery n proximal posterior superior pancreaticoduodenal artery 3. The 1st part of the duodenum is characterized by: n A. rugae in its most proximal part n B. plicae circulares throughout its length o C. a smooth proximal portion n D. a distal part free of plicae circulares n E. none of the above are correct 4. Haematemesis can also be due to: n A. ruptured oesophageal varices n B. penetration of an ulcer on the posterior stomach wall into the splenic artery n C. gastric cancer n D. hiatus hernia o E. all of the above are correct 5. Pain sensation from the 1st part of the duodenum is conveyed through the: n A. coeliac ganglion and least splanchnic nerve to the T8 segment of the spinal cord o B. coeliac plexus and greater splanchnic nerve to the T8 segment of the spinal cord n C. coeliac plexus and greater splanchnic nerve to the T10 segment of the spinal cord n D. coeliac ganglion and greater splanchnic nerve to the T8 segment of the spinal cord n E. none of the above are correct

Histology of Helicobacter pylori adjunct to surface gastric epithelium. Antibiotic therapy led to eradication of this bacterium and he experienced no further peptic ulceration. Clinical anatomy questions 1. Posterior relations of the stomach include all of the following EXCEPT the: o inferior vena cava n posterior gastric artery n splenic artery n body of pancreas n left suprarenal gland

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6. Likely causes of melaena would include: n A. haemorrhoids n B. fistula-in-ano n C. rectal carcinoma o D. gastric ulcer n E. both C and D are correct 7. A perforation through the anterior wall of the first part of the duodenum will: n A. involve the inferior vena cava n B. discharge gastric contents into the lesser sac n C. open into the epiploic foramen n D. penetrate the head of the pancreas o E. none of the above are correct 8. A perforation through the posterior wall of the first part of the duodenum will: n A. involve the hepatopancreatic ampulla o B. probably open into the epiploic foramen n C. discharge stomach contents directly into the greater sac n D. involve the accessory pancreatic duct n E. none of the above are correct

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Erectile problems
History A 55 year old man presented to his general practitioner complaining of difficulties obtaining and maintaining an erection sufficient to have intercourse with his wife. The man has been a smoker (20 cigarettes a day) for the last 20 years and admitted to enjoying a few drinks of an evening (4 standard drinks). The man could not recall waking with an erection in the last three months. Physical examination The mans weight was 88 kg and his height was 165 cm, giving a BMI of 32. Blood pressure was elevated at 150/90. The penis was normal to palpation (i.e. no scar tissue) and the testes were of normal size and consistency. Peripheral pulses (posterior tibial, dorsalis pedis) were somewhat reduced. A per rectal examination failed to detect any abnormality of the prostate. Investigations and subsequent events Fasting blood sugar levels were found to be slightly elevated (8.4 mM). Liver function tests were normal. Blood lipids were abnormal, with elevated low density lipoproteins, elevated cholesterol and triglycerides and low levels of high density lipoproteins. The man was placed on a weight reduction regime, and advised to give up smoking and reduce alcohol intake to one standard drink per day. He was also given a course of injectable vasodilator agents (combination therapy with papaverine, chlopromazine, atropine and prostaglandin E1), which he can insert into the corpora cavernosa prior to intercourse. This regime gave the man a reliable erection, which allowed him to continue with a normal sex life.

The mans blood sugar level continued to be closely monitored. Clinical anatomy questions 1. Arterial supply to the penis is derived from the: n A. obturator artery n B. superior gluteal artery n C. inferior gluteal artery o D. internal pudendal artery n E. middle rectal artery 2. Venous drainage from the deep dorsal vein of the penis is into the: n A. external iliac vein o B. prostatic plexus of veins n C. great saphenous vein n D. inferior gluteal vein n E. none of the above are correct 3. Concerning the internal structure of the penis: n A. the superficial layer of the tunica albuginea surrounds only the corpora cavernosa o B. the deep layer of the tunica albuginea is more rigid than the superficial n C. the deep dorsal vein lies within the deep layer of the tunica albuginea n D. the dorsal nerve lies medial to the dorsal artery n E. none of the above are correct

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4. Ligaments which support the penis during erection include: n A. a fundiform ligament attached to the pubic symphysis n B. a suspensory ligament arising from the umbilicus o C. a suspensory ligament which inserts into the median penile septum n D. a fundiform ligament which inserts into the median penile septum n E. a suspensory ligament which embraces the penile shaft 5. Arteries, which are commonly obstructed by atherosclerosis, thereby causing symptoms and signs include all of the following EXCEPT: n A. the coronary arteries o B. the pulmonary artery n C. the cerebral arteries n D. the penile arteries n E. the femoral and popliteal arteries 6. During erection: n A. sympathetic stimulation causes vasodilation of penile veins n B. parasympathetic stimulation directly causes dilation of penile veins n C. sympathetic stimulation dilates the penile arteries n D. adrenaline release causes vasodilation of penile arteries o E. parasympathetic stimulation causes dilation of penile arteries

7. Possible causes of impotence (erectile dysfunction) include: n A. excessive adrenaline release due to anxiety and stress n B. vasodilation of penile arteries due to stress n C. excessive leakage from the cavernous spaces to penile veins n D. autonomic nerve damage due to diabetes mellitus o E. A, C and D are all correct 8. Treatments of impotence could include all of the following EXCEPT: o A. injection of vasodilators into the corpus spongiosum n B. injection of vasodilators into the corpora cavernosa n C. constriction of penile vein outflow n D. insertion of flexible prostheses in place of the corpora cavernosa n E. insertion of inflatable prostheses in place of the corpora cavernosa

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Inguinal canal
History A 60 year old man came to his general practitioner complaining of a swelling in his left groin. The man has been a 40 cigarettes a day smoker since age 20 and now has chronic bronchitis. He complains of a dragging pain in his lower groin which radiates downwards into his left scrotum. The man says that the swelling bulges when he coughs or picks up heavy objects, but that he is still able to push the thing back in when his abdomen is relaxed (e.g. by lying on his back). Physical Examination The patient was found to be 1.70 m tall, weighing 95 kg, giving a BMI (body mass index) of about 33. Blood pressure was slightly elevated at 140/90. There was an elliptical swelling in the lower left abdomen, which appeared to come down the inguinal canal. The swelling was fluctuant and bulged noticeably when the man coughed. The swelling extended along the spermatic cord and into the scrotum itself. When the hernia was reduced (return of the sac contents to the abdominal cavity) and an examining finger was inserted into the superficial inguinal ring, it was found that the hernia pressed against the lateral side of the examining finger every time the patient coughed. It was also noted that with reduction of the hernial sac and application of pressure to the abdominal wall immediately above the femoral artery, the hernial sac could be prevented from emerging whenever the man coughed. Subsequent Events The man had no private health insurance and was placed on a waiting list for repair of his inguinal hernia. Several

months after the initial consultation, the man presented to the Accident and Emergency Department of his local hospital with a red and painful hernial sac, which he could not reduce. The man had vomited several times during the last 12 hours and had not passed feces or bowel gas in the last 36 hours. He complained of colicky abdominal pain in the hypogastrium, which progressively became continuous in nature. The man was prepared for theatre where a length of necrotic bowel was removed from the hernial sac. A temporary colostomy was also installed. Several weeks after this last incident the man was able to return to a reasonably normal life after final repair of the bowel had been completed. Clinical Anatomy Questions 1. The surface marking for the superficial inguinal ring may be found: n A. 1 cm superior to the femoral artery n B. 1 cm superior and medial to the pubic tubercle o C. 1 cm superior and lateral to the pubic tubercle n D. halfway between the anterior superior iliac spine and the pubic tubercle n E. 1 cm inferior to the femoral artery pulse 2. The deep inguinal ring (internal ring) may be found: o A. 1 cm above the palpable femoral artery pulse n B. 1 cm superior and 1 cm lateral to the pubic tubercle n C. 1 cm above the femoral vein n D. 1 cm medial to the femoral artery pulse n E. at the root of the scrotum

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3. Concerning the structure of the inguinal canal: n A. it is usually about 8 cm long n B. the conjoint tendon and transversalis fascia form its anterior wall n C. the inguinal ligament contributes to its roof o D. anterior relations include the external oblique aponeurosis and internal oblique laterally n E. both B and D are correct 4. Contents of the inguinal canal include: n A. the ilioinguinal nerve only in males n B. the round ligament and iliohypogastric nerve in women n C. the spermatic cord and lateral femoral cutaneous nerve in men n D. the iliohypogastric and ilioinguinal nerve in both sexes o E. the spermatic cord and ilioinguinal nerve in men 5. Concerning inguinal hernias: n A. indirect inguinal hernias always enter the canal through a weakened conjoint tendon. n B. direct inguinal hernias often descend into the scrotum n C. inguinal hernias often emerge inferior and lateral to the pubic tubercle n D. direct inguinal hernias can be controlled by pressure applied to the deep inguinal ring o E. none of the above are correct 6. The spermatic cord contains all of the following EXCEPT the: n A. nerve to the cremaster o B. ilioinguinal nerve n C. pampiniform plexus n D. testicular artery n E. artery of the ductus deferens

7. Concerning the fascia of the spermatic cord: n A. the external spermatic fascia is derived from the internal oblique aponeurosis n B. the internal spermatic fascia is derived from the transversalis fascia o C. the cremasteric fascia is derived from the internal oblique aponeurosis n D. the conjoint tendon contributes to the external spermatic fascia n E. the internal spermatic fascia also incorporates the cremaster muscle 8. Colicky pain in the hypogastrium could arise from the: n A. ascending colon n B. caecum n C. right colic flexure o D. sigmoid colon n E. anus 9. The inferior epigastric artery: n A. forms the lateral border of the deep (internal) inguinal ring n B. forms the medial border of the superficial inguinal ring n C. contributes to the medial umbilical ligament o D. forms the medial border of the deep inguinal ring n E. none of the above are correct 10. Concerning obstruction of the large bowel: n A. it can be caused by rotation of the sigmoid colon around the axis of the sigmoid mescocolon n B. it is unlikely to cause inability to pass bowel gas n C. it is unlikely in direct inguinal hernia n D. it is unlikely to cause abdominal distension o E. both A and C are correct

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Malignancy of the lung

History A 55 year old man presented to his general practitioner complaining of a cough with blood-stained sputum for a period of 2 months. The man admitted to smoking two packets of cigarettes a day since the age of 15. On questioning the man also admitted to increasing breathlessness over the last month. Physical examination The mans fingers showed nicotine staining and early clubbing. The man was afebrile. Sputum examination revealed blood staining as streaks, but no evidence of infection was found. Palpation, percussion and auscultation of the back of the chest were normal. Reduced breath sounds were noted in the upper left chest adjacent to the first rib and in the supraclavicular fossa. A tentative diagnosis of carcinoma of the lung was made. Investigations Chest X-ray showed increased opacity adjacent to the upper left mediastinal shadow (see illustration). A bronchoscopy with sampling for cytology was performed which confirmed the tentative diagnosis. Subsequent developments Two months after the initial presentation the man developed pain in the anterior shoulder and medial aspect of the left arm which radiated down to the fifth digit. The man also complained of weakness in the hand itself and examination confirmed that the small muscles of the hand were indeed weak and wasted.

Three months after the initial presentation, the man developed drooping of the upper left eyelid, a constricted left pupil, an apparently sunken or depressed left eyeball and reduced sweating on the left side of the head. The left arm now showed mild swelling and anesthesia of the left medial forearm and elbow. The patient also complained of further increases in breathlessness and changes in his voice over the last few weeks. Laryngoscopy revealed that the left vocal fold was immobile in the midline, while the right vocal fold moved freely with inspiration. At 4 months after presentation the man became febrile with yellow-green sputum and was admitted to hospital with left upper lobe pneumonia. Chest X-ray performed at 4 months after presentation revealed pneumonia in the left upper lobe and erosion of the first rib. This infective episode resolved adequately with antibiotics, but the man progressively declined in health, dying of pneumonia 8 months after the initial presentation.

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Clinical Anatomy Questions 1. Relations of the apex of the left lung include all of the following EXCEPT: n A. stellate ganglion n B. left recurrent laryngeal nerve n C. neck of left first rib n D. left subclavian artery o E. left C5/6 trunk of the brachial plexus 2. The spinal segment supplying the 5 digit of the hand is: n A. C5 n B. C6 n C. C7 o D. C8 n E. T1 3. Drooping of this mans upper eyelid is due to paralysis of the: n A. orbicularis oculi muscle n B. levator labii superioris muscle o C. superior tarsal muscle n D. frontalis muscle n E. superior rectus muscle 4. Horners syndrome can be due to damage to: n A. the recurrent laryngeal nerve n B. the stellate ganglion n C. the hypoglossal nerve n D. the superior cervical ganglion o E. both B and D are correct
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5. The paralysis of the small muscles of the hand could be due to damage to the: n A. C4 spinal segment n B. C6 spinal segment n C. C7 spinal segment o D. C8 spinal segment n E. T2 spinal segment 6. The dry face of Horners syndrome is due to paralysis of: n A. parasympathetic supply to the lacrimal gland n B. sympathetic supply to the lacrimal gland n C. parasympathetic supply to sweat glands o D. sympathetic supply to the sweat glands n E. none of the above are correct 7. The recurrent laryngeal nerve supplies the: n A. cricothyroid muscle n B. posterior cricoarytenoid muscle n C. laryngeal mucosa above the vocal fold n D. lateral cricoarytenoid muscle o E. both B and D are correct 8. Mediastinal structures which could be invaded from the left lung apex include: n A. the azygos vein n B. the superior vena cava n C. the inferior vena cava o D. the left brachiocephalic vein n E. the brachiocephalic trunk

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9. Pleural effusion fluid in the costodiaphragmatic recess could be sampled by a needle inserted into the: n A. 9th interspace in the midclavicular line n B. 11th interspace in the midaxillary line o C. 9th interspace in the midaxillary line n D. 6th interspace at the left sternal edge n E. none of the above are correct 10. Swelling of this patients left arm could be due to: n A. involvement of the axillary artery by tumour n B. involvement of the axillary lymph trunk n C. damage to the C8 nerve trunk n D. obstruction of the axillary vein o E. both B and D could be correct

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Obstructed Delivery
Previous history and examination A 30 year old nulliparous woman is pregnant. At the initial presentation to her clinician at about 6 weeks gestation it was noted that she was 150 cm tall. Examination revealed that the subpubic angle was narrow and the sacral promontory was palpable by the tip of an examining middle digit inserted per vaginam. There is no family history of problems with diabetes or hypertension. Fetal growth has been assessed regularly during the pregnancy and lies at the upper limit of normal. Physical examination At 36 weeks of pregnancy, the fundus of the uterus is found to be at the level of the xiphisternum. The fetal lie (long axis of the fetus) is parallel to that of the mother with the fetal head as the presenting part (i.e. head lowermost). The occiput of the fetus is facing towards the mothers back (occipitoposterior), but the fetal head has not engaged in the superior pelvic aperture. Subsequent events Throughout the last four weeks of pregnancy, the fetal head has failed to engage in the pelvis, remaining above the plane of the pelvic brim. The attending obstetrician suspects that there might be problems with cephalopelvic disproportion (fetal head too large for the pelvic cavity) and an occipitoposterior fetal position, but a decision is made to closely monitor a trial of labour once contractions begin. At the onset of labour the fetal head engaged with the pelvis (i.e. entered the true pelvic cavity), but continued in the occipitoposterior orientation. The normal maternal lumbar lordosis means that fetuses in this position often extend their

head while entering the birth canal and present the military (head erect like a soldier) or occipitofrontal diameter to the pelvic aperture. The woman and fetus were closely monitored during the trial of labour, with regular observations of the position and flexion of the fetal head. Progress was slow, so the attending obstetrician decided to use forceps to rotate the fetal head. The woman received an epidural anaesthetic, an episiotomy incision was made in the perineum and the fetal head was rotated to the occipito-anterior position with the aid of Kiellands forceps. After this intervention a healthy infant was delivered. Clinical anatomy questions 1. The height of the woman is significant because: n A. short women tend to have large subpubic angles n B. short women tend to have small subpubic angles n C. short women tend to have a more protruding sacral promontory o D. short women tend to have a smaller true conjugate diameter of the pelvis n E. none of the above are correct 2. The normal subpubic angle (i.e. the angle between the ischiopubic rami) in women is about: n A. 40 to 45 degrees n B. 50 to 55 degrees n C. 60 to 65 degrees n D. 70 to 75 degrees o E. 80 to 90 degrees

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3. The subpubic angle can be assessed most easily by: n A. pelvic radiography only n B. ultrasound of the maternal perineum o C. digital vaginal examination n D. palpating the distance between the ischial tuberosities n E. none of the above are correct 4. The significance of the subpubic angle for delivery is that: n A. the subpubic angle assists in rotation of the fetal head n B. the subpubic angle assists in extension of the fetal head n C. a narrow subpubic angle may interfere with external restitution (rotation) of the fetal head after delivery o D. a narrow subpubic angle interferes with extension of the fetal head under the pubic symphysis n E. both C and D are correct 5. If the sacral promontory is palpable per vaginam then the true pelvic conjugate (AP diameter of super pelvic aperture) may be less than: n A. 14.5 cm n B. 13.5 cm n C. 12.5 cm n D. 11.5 cm o E. 10.5 cm

6. Concerning pelvic types in women and their significance for parturition: o A. gynecoid pelves have a well-rounded brim, rounded sacral curve and parallel side walls n B. android pelves have a large pelvic brim with long anteroposterior diameter n C. the two commonest pelvic types in Australia are android and anthropoid n D. android pelves are the optimal shape for fetal head delivery n E. none of the above are correct 7. The commonest position of the fetal occiput at the onset of labour is towards: o A. the left maternal side n B. the right maternal side n C. the maternal pubic symphysis n D. the maternal sacral promontory n E. the right sacroiliac joint 8. The optimum attitude of the fetal head at the pelvic brim is to present the: n A. occipitofrontal diameter n B. verticomental diameter n C. submentobregmatic diameter o D. suboccipitobregmatic diameter n E. none of the above are correct

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9. Epidural anaesthesia can be easily delivered by a needle inserted through the: n A. sacral hiatus n B. space between the laminae of lumbar vertebrae 4 and 5 n C. dorsal sacral foraminae n D. ventral sacral foraminae o E. both A and B are correct 10. Episiotomy commonly involves an incision: n A. from the vaginal fourchette to the anal canal n B. through the perineal body n C. through the external anal sphincter o D. through the posterior fibres of the bulbospongiosus muscle n E. none of the above are correct

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Oropharyngeal carcinoma
History A 55 year old man presents to his general practitioner complaining of a sore throat which has lasted for over three months. He has also noticed some blood in his saliva over the last month. The man admits to having been a hard smoker (2 packets a day) and drinker (4 to 5 schooners per day) for most of his life. Physical examination The patients temperature was normal. His fingers showed heavy nicotine staining. When the man opened his mouth it was possible to see a large ulcer extending from the left palatine fossa over the palatopharyngeal arch anteriorly and onto the soft palate superiorly. The ulcer was bleeding slightly. Several of the mans teeth also showed evidence of tooth decay and the man had halitosis (bad breath). Palpation of the neck revealed hardening of the tissues of the neck on the left side below and behind the angle of the jaw. There were also several lymph nodes found on the left side of the neck in the anterior triangle of the neck. These were firm and enlarged and one of them was fixed to the underlying tissue. Subsequent events The man was prepared for theatre and a wide resection of the tumour performed, with clearance of the lymph nodes in the mans neck. The man recovered from the operation well and underwent a course of radiotherapy.

Clinical anatomy questions 1. Concerning the palatine tonsillar fossa: n A. it is bounded posteriorly by the palatoglossal arch n B. the medial surface presents several tonsillar crypts lined with respiratory epithelium n C. it is rarely the sight of inflammation o D. the lateral tonsillar surface is related to the pharyngobasilar fascia n E. none of the above is correct 2. Concerning the oropharynx: n A. it is related posteriorly to the 4th and 5th cervical vertebrae o B. it is bounded in front by the palatoglossal arches n C. it has sensory supply from the hypoglossal nerve n D. it is drained exclusively by the internal jugular vein n E. it contains the tubal elevation 3. The blood supply to the tonsil is usually derived from: o A. the tonsillar branch of the facial artery n B. the internal carotid artery n C. the tonsillar branch of the posterior auricular artery n D. the lingual artery n E. the superior thyroid artery 4. Lymph drainage from the tonsillar fossa and oropharynx would be to the: n A. superficial cervical nodes n B. lower deep cervical nodes o C. upper deep cervical nodes n D. submental nodes n E. paratracheal nodes

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5. Venous drainage from the tonsillar fossa is to the: o A. facial vein n B. lingual vein n C. cavernous sinus n D. inferior thyroid vein n E. none of the above is correct 6. A tumour invading laterally from the oropharynx would penetrate the following layers in order: n A. mucosa, fascial coat, muscular coat and fibrous coat o B. mucosa, fibrous coat, muscular coat and fascial coat n C. mucosa, muscular coat, fibrous coat and fascial coat n D. muscular coat, mucosa, fibrous coat and fascial coat n E. none of the above is correct 7. Concerning the structure of the soft palate: n A. it is covered chiefly by pseudostratified ciliated columnar epithelium n B. it has a palatine aponeurosis in its posterior one third o C. the palatine aponeurosis is formed by the expanded tendon of the tensor veli palatini n D. it has taste buds on its superior surface n E. both B and C are correct 8. The muscles of the pharynx likely to be invaded by the tumour as it spreads laterally include: o A. the superior constrictor of the pharynx n B. the hyoglossus n C. the posterior belly of the digastric n D. the middle constrictor of the pharynx n E. the inferior constrictor of the pharynx

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Rheumatic Heart Disease and Mitral Stenosis

History A 55 year old aboriginal man presents with shortness of breath increasing in severity over the last 2 years. Initially the shortness of breath was experienced only upon strenuous exercise, but now he finds difficulty in climbing even a small flight of stairs. He also admits to occasional severe bouts of breathlesssness and coughing with frothy pink sputum. On one occasion he had a small amount of frank blood in his sputum. Past history The man had had rheumatic fever at the age of 14, with involvement of the mitral valve noted at that time. The man had recovered from rheumatic fever, but a mild mitral valve murmur had persisted Physical examination The mans arterial pulse was normal in volume and regular. The apex beat was in a normal position but had a tapping quality. Mid-diastolic and presystolic thrills (palpable vibration) could be felt immediately medial to the apex beat. On auscultation a loud first heart sound was heard as well as an opening snap immediately after the second heart sound. Two murmurs were heard. One was a mid-diastolic murmur and the other was a presystolic murmur, both best heard at the apex. Investigations Anteroposterior and lateral chest X-rays revealed enlargement of the left atrium. Calcification of the mitral valve was also apparent. Echocardiography showed calcification of the mitral valve (as seen by the presence of

strong echoes) and tethering of the posterior leaflet of the mitral valve to the anterior leaflet, with the result that the posterior leaflet moved forwards with the anterior during diastole. Cardiac catheterization revealed that the pressure difference across the mitral valve was increased (30 mm Hg as opposed to a normal value of 12 mmHg). Pulmonary artery pressure was found to be twice as high as normal (45 mm Hg as compared to 25 mm Hg). Subsequent events The man received a porcine valve and recovered well. Clinical anatomy questions 1. The apex beat is normally located at: n A. 5th left intercostal space in the midaxillary line n B. 6th left intercostal space in the midaxillary line o C. 5th left intercostal space in the midclavicular line n D. 4th left intercostal space in the midclavicular line n E. 6th left intercostal space in the midclavicular line 2. The first heart sound is due to the: n A. opening of the atrioventricular valves o B. closure of the atrioventricular valves n C. opening of the aortic and pulmonary valves n D. closure of the aortic and pulmonary valves n E. inflow of blood into the ventricles during diastole

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3. The opening snap after the second heart sound is probably due to: n A. opening of the pulmonary heart valve against elevated pressure n B. opening of the tricuspid valve against elevated right ventricle pressure o C. opening of the calcified mitral valve n D. opening of the aortic valve due to increased cardiac output n E. none of the above is correct 4. A calcified mitral valve would be visible in an anteroposterior chest X-ray: n A. behind the sternum adjacent to the 3rd right costal cartilage n B. behind the sternum adjacent to the 2nd left costal cartilage n C. behind the sternum adjacent to the 3rd left costal cartilage o D. behind the sternum adjacent to the 4th left costal cartilage n E. behind the sternum adjacent to the 5th left costal cartilage 5. Murmurs arising from the mitral valve usually are best heard at: n A. the 2nd left intercostal space n B. the 2nd right intercostal space n C. the lower right sternal edge n D. the xiphisternum o E. the apex beat

6. Enlargement of the left atrium (auricular part) is likely to be visible in a PA chest X-ray as a bulge: n A. on the lower right border adjacent to the inferior vena cava n B. on the upper left border between the aortic knuckle and pulmonary trunk o C. on the upper left border between the pulmonary trunk and left ventricle n D. on the lower left border near the apex n E. on the upper border between the aorta and ligamentum arteriosum 7. Enlargement of the left atrium is likely to be visible on a lateral chest X-ray as a bulge: n A. on the anterior cardiac border above the right ventricle n B. on the posterior cardiac border immediately above the inferior vena cava n C. on the superior border near the aortic arch n D. on the inferior border anterior to the inferior vena cava o E. both A and B are correct 8. In the normal echocardiogram: n A. the anterior and posterior mitral valve leaflets move in the same direction o B. the mitral valve leaflets open rapidly in early diastole before returning to a partially closed position in mid-diastole n C. the heart can only be examined from the anterior chest wall n D. the mitral valve usually flutters during diastole n E. none of the above are correct

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Ruptured spleen
History and physical examination A 30 year old woman presents to the accident and emergency department of her local hospital complaining of abdominal and shoulder pain, mild nausea and vomiting. She was involved in a minor motor vehicle accident on the previous day. She had been sitting in the front passenger seat of a vehicle involved in a side-on collision and had been thrown against the left side of the car. On further questioning the woman said that her abdominal pain was worst in the upper left quadrant. She also had pain in her left shoulder and left neck region (Kehrs sign). On examination the woman was found to have a blood pressure of 110/60. The abdomen was tender over the left hypochondrium, with mild spasm of the abdominal muscles in that region and mild abdominal distension. The area over the 9th and 10th ribs on the left side was particularly tender and bruised. The pain in the left shoulder could be exacerbated by elevating the womans legs (Trendelenburg position). The area of splenic dullness (as assessed by percussion) was increased and a mass could be palpated in the left upper quadrant adjacent to the left costal margin. Investigations A plain X-ray of the abdomen showed that the shafts of ribs 9 and 10 on the left side were fractured. The gastric air bubble was displaced medially and the transverse colon was displaced inferiorly. The greater curvature of the stomach showed a serrated appearance and the splenic shadow was enlarged. The hematocrit was at the lower limit of normal.

Subsequent events The woman was immediately prepared for diagnostic laparotomy with a view to splenectomy (removal of the spleen). Abundant free blood was found in the upper left side of the abdomen and a rupture of the spleen was identified. The rupture extended through the splenic capsule and deep into the splenic pulp. Consequently a decision was made to remove the spleen. The spleen was mobilised and lifted out of the abdominal cavity. The splenic vessels were approached from behind the spleen and ligated as they entered the splenic hilum. Splenic peritoneal attachments were divided and the spleen removed. The women recovered well but her blood film over the following weeks to months showed transient elevation in granulocytes, followed by elevations in levels of lymphocytes and monocytes. Platelet levels were also increased for the next year (400,000/l). Clinical anatomy questions 1. The spleen lies parallel to the long axes of ribs: n A. 6, 7 and 8 n B. 7, 8 and 9 o C. 9, 10 and 11 n D. 10, 11 and 12 n E. 11 and 12 2. Visceral structures in immediate contact with the spleen include all of the following EXCEPT the: n A. fundus of the stomach n B. tail of the pancreas n C. upper pole of the left kidney n D. left colic flexure o E. left suprarenal gland

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3. Concerning the normal limits of splenic dullness as assessed by percussion: n A. it may extend forward to the anterior axillary line o B. it should not extend forward of the mid-axillary line n C. it may be detected at the left costal margin n D. it may extend into the epigastrium n E. none of the above is correct 4 The pain in the left shoulder and left neck could be due to: o A. irritation of the left diaphragmatic parietal peritoneum n B. irritation of the lesser omentum n C. irritation of the greater omentum n D. traction on the splenic pedicle due to enlargement of the spleen n E. irritation of the gastric mucosa by blood from the spleen 5. The serrated appearance of the greater curvature of the stomach could be due to: n A. dissection of blood into the phrenicolienal ligament n B. dissection of blood into the tail of the pancreas o C. dissection of blood into the gastrosplenic ligament n D. blood seeping into the stomach cavity n E. both C and D are correct 6. Concerning the arterial supply of the spleen: n A. the splenic artery courses along the posterior surface of the pancreas n B. the splenic artery is a branch of the gastroduodenal artery n C. the splenic artery gives off the right gastroepiploic artery o D. the splenic artery gives off the left gastroepiploic artery n E. both A and D are correct

7. Concerning the venous drainage of the spleen: n A. the splenic vein drains into the inferior mesenteric vein n B. the splenic vein follows a tortuous course along the superior pancreatic border n C. the splenic vein meets the superior mesenteric vein behind the pancreatic head n D. the splenic vein joins the portal vein in the hepatoduodenal ligament o E. the splenic vein joins the superior mesenteric vein behind the neck of the pancreas 8. Peritoneal attachments of the spleen include: n A. the phrenicolienal ligament derived from the ventral mesogastrium of the embryo n B. the hepatolienal ligament derived from the dorsal mesogastrium of the embryo n C. the gastrosplenic ligament enclosing the splenic artery n D. the gastrosplenic ligament enclosing the portal vein o E. none of the above is correct

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Testicular Tumour
History A 26 year old man presents to his general practitioner with a painless, firm enlarged left testis. The man first noticed the enlarged testis about 6 months ago, and the testis has been increasing in size steadily since then. He has also recently noticed some bilateral breast development (gynecomastia). Physical examination and investigation The left testis was found to be increased in size (measuring about 4.5 cm by 6.5 cm) relative to the right testis. There was a fluid filled enlargement (hydrocele) palpable within the scrotum, which could be revealed by transillumination with a torch. Gynecomastia was also present. A firm lymph node could be felt in the left supraclavicular fossa. Subsequent events The mans testis was removed through an inguinal incision and the spermatic cord transected at the level of the deep inguinal ring. Radical resection of the retroperitoneal lymph nodes was undertaken and frozen sections revealed some metastatic involvement already present. A testicular teratocarcinoma was diagnosed by histopathological examination. Radiotherapy was given to the abdominal, mediastinal and neck glands. The man also received chemotherapy. At a follow-up six months after surgery the man complained of progressive weight loss and anorexia. A chest X-ray revealed opaque secondary metastases in the lungs. An intravenous pyelogram showed that the upper ureter was deviated laterally by masses in the region of the upper lumbar lymph nodes.

The mans condition progressively deteriorated over the next two years, despite a repeat course of chemotherapy and radiotherapy and he died from pneumonia two and a half years after presentation. Clinical anatomy questions 1. Relations of the testis include all of the following EXCEPT: n A. the head of the epididymis superiorly o B. the testicular artery medially n C. the tail of the epididymis posteriorly n D. the sinus of the epididymis superiorly and laterally n E. the ductus deferens laterally 2. Concerning the internal structure of the testis: n A. the testis has a thick fibrous coat known as the tunica vaginalis n B. the testis is divided into about 10 lobules o C. vessels, ducts and nerves enter and leave via the mediastinum testis n D. each testicular lobule contains a single seminiferous tubule n E. about 100 efferent ductules leave the testis for the head of the epididymis 3. Contents of the spermatic cord may include all of the following EXCEPT: n A. the genital branch of the genitofemoral nerve n B. the cremasteric nerve n C. testicular artery o D. the ejaculatory duct n E. the pampiniform plexus (testicular vein)

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4. A hydrocele is excess fluid collected within the: n A. head of the epididymis n B. tunica albuginea n C. dartos muscle n D. external spermatic fascia o E. tunica vaginalis 5. The deep inguinal ring may be found: n A. 1 cm superior and lateral to the pubic tubercle n B. 1 cm medial to the anterior superior iliac spine o C. halfway between the pubic symphysis and the anterior superior iliac spine n D. 1 cm inferior to the femoral artery n E. 1 cm medial to the femoral artery 6. Lymphatic drainage of the testis is initially to the: o A. lateral and preaortic lymph nodes near the lumber vertebrae n B. superficial inguinal nodes n C. internal iliac lymph nodes of the pelvis n D. mediastinal lymph nodes of the thorax n E. external iliac lymph nodes of the pelvis 7. The seconday tumour in the lung could have reached that organ by following: o A. the left testicular vein to the left renal vein n B. the left internal iliac vein to the inferior vena cava n C. the left external iliac vein to the inferior vena cava n D. the inguinal lymph nodes to the cisterna chyli n E. the lumbar veins to the azygos venous system

8. Structures which could cause deviation of the ureter include of the following EXCEPT: n A. a tumour of the psoas major muscle n B. a congenitally aberrant renal artery n C. an aneurysm (dilation) of the common iliac artery bifurcation n D. an ovarian tumour o E. enlarged sacral lymph nodes

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Tetralogy of Fallot
History A baby boy only a few days old begins to show problems feeding and appears to tire easily at the breast. Over the subsequent weeks the baby has episodes of hypoxia (poor blood oxygenation) turning blue and lethargic, with occasional episodes of unconsciousness as well. Physical Examination When examined between bouts of hypoxia, the 4 week old infant was only mildly cyanosed (bluish colouration of the mucous membranes). The heart and liver were of normal size. A systolic murmur was found along the left sternal border and the pulmonary component of the second heart sound was decreased. There were no signs of heart failure at this stage. Investigations The infants chest X-ray revealed reduced vascularity of the lung fields, hypertrophy of the right ventricle, but little or no overall cardiac enlargement. The central pulmonary vessels (pulmonary arteries and pulmonary trunk) appeared small. The electrocardiogram at 4 weeks of age showed right ventricular hypertrophy (thickening of right ventricular myocardium). Cardiac catheterisation showed that the pressures within the two ventricles were similar and that there was a shunt of blood from the right to the left ventricle. Pressure within the body of the right ventricle was also found to be slightly higher than in the infundibulum. There was also some indication of pulmonary stenosis (narrowing) with a pressure difference across that valve (i.e. pressure higher in the infundibulum than in the pulmonary trunk. The pulmonary

artery and valve annulus were smaller than normal, but not severely so. The anterior descending coronary artery was also noted to arise from the right coronary artery and cross the right ventricular outflow tract. Subsequent events When the infant reached 4 months of age, the attending clinicians decided that the boy was fit enough to undergo corrective surgery. The infant was anaesthetised and placed on a total cardiopulmonary bypass. It was found that the infant had enlarged bronchial arteries arising from the descending aorta. The right ventricle was opened through a vertical incision and the fibrous and muscular obstruction of the right ventricle outflow tract was cut away (excised) to make an uninterrupted channel to the pulmonary valve. The pulmonary valve was found to be stenotic and was incised (cut through). A small patch of fibrous pericardium was used to enlarge the right ventricular outflow tract. The defect in the ventricular septum was repaired with a prosthetic patch. Finally the enlarged bronchial arteries were tied off. Clinical anatomy questions 1. The term systole usually refers to the: n A. period of atrial contraction n B. period of atrial relaxation o C. period of ventricular contraction n D. period of ventricular relaxation n E. none of the above is correct

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2. The pulmonary component of the second heart sound would be best heard at: n A. the apex beat n B. the right sternal edge o C. the left second intercostal space n D. the right second intercostal space n E. the lower left sternal edge 3. Hypertrophy (increased thickness) of the right ventricle could lead to: n A. a boot-shaped heart as seen on a PA film n B. compression of the oesophagus o C. elevation of the anterior cardiac border as seen on a lateral X ray film n D. elevation of the aortic arch as seen on a lateral X ray film n E. depression of the apex as seen on a PA film 4. Shunting of blood from the right to the left side of the heart: n A. would occur when there is any septal defect n B. would arise only in atrial septal defect n C. occurs when there is a patent ductus arteriosus o D. would require elevated right ventricular pressure and a ventricular septal defect n E. does not cause cyanosis 5. The infundibulum: n A. is the entrance to the right ventricle n B. is also known as the supraventricular crest n C. is distal to the pulmonary valve n D. is traversed by the septomarginal trabecula o E. none of the above is correct

6. In normal individuals, the bronchial arteries: n A. arise from the pulmonary trunk o B. supply only the first few divisions of the bronchial tree n C. supply the vascular tree of the entire lung n D. arise from the internal thoracic arteries n E. may supply the coronary arteries with blood 7. Bronchial artery dilation in this infant is probably a consequence of: o A. the reduced pulmonary blood flow n B. increased pressure in the aorta n C. increased cardiac output from the left ventricle n D. hyperoxemia arising from shunting n E. none of the above is correct 8. Usually the anterior descending (anterior interventricular) artery arises from the: n A. circumflex artery n B. left marginal artery o C. left coronary artery n D. right coronary artery n E. posterior interventricular artery

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Urinary tract
History A 40 year old man awoke at 1 am with excruciating pain in the left side of the abdomen. The pain was initially confined to the loin region (upper posterior and lateral abdomen), but progressively shifted downwards, radiating to the iliac fossa. The pain came and went in waves (colicky in nature) and when present was so severe that the man cried out and writhed around in bed. The man also vomited at the height of each wave of pain. Believing that he was constipated, the man attempted to pass a motion, but succeeded only in passing a small volume of lightly blood-stained urine (hematuria). Drinking water appeared to exacerbate the pain. The man was driven to a nearby hospital by his wife. Physical Examination The man was found to be normal on physical examination. Bowel sounds were present and normal. Blood pressure was within the normal range. Urinalysis revealed red blood cells in the urine. A plain abdominal X-ray was taken, which failed to show any significant abnormality. Nevertheless a provisional diagnosis of ureteric calculus (stone) was made on the basis of the history and hematuria. Subsequent Events The man was treated with intramuscular pethidine and an antiinflammatory agent. By the following morning the pain was still present between pethidine doses, but had shifted further downwards, so that pain was found to be radiating to the pubic region and the scrotum.

Intravenous pyelogram taken 48 hours after the onset of symptoms. a) dilated calyceal system; b) contrast and urine extravasated from ureter; c) dilated ureter; d) calculus in terminal ureter emlarged view

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The man returned home to see his general practitioner who ordered an intravenous pyelogram (IVP). The IVP revealed a small calculus in the left ureter, a dilated ureter above the calculus and extravasation of contrast media from the upper ureter (see accompanying figure). Blood tests were also performed (calcium, phosphate, uric acid and plasma protein levels), but these did not reveal any significant abnormalities. After several days of anti-inflammatory suppositories, the mans pain had subsided to a dull ache radiating into the scrotum and a follow-up IVP revealed that the calculus was no longer present and that the ureter had returned to normal size. Clinical Anatomy Questions 1. The course of the abdominal ureter (which may be searched in an abdominal X-ray for the presence of a renal calculus) is usually: n A. down the line of the mammillary processes of the lumbar vertebrae n B. down the lateral margin of the quadratus lumborum muscle n C. down the line of the lateral surfaces of the lumbar vertebrae o D. down the tips of the lumbar vertebrae transverse processes n E. none of the above are correct 2. Concerning the course of the pelvic ureter: n A. it crosses the region of the pelvic sacral foraminae n B. it turns laterally at the level of the ischial spine o C. it turns medially at the level of the ischial spine n D. it passes through the bladder wall at right angles to the mucosa n E. both C and D are correct

3. The ureter is relatively narrowed or kinked and therefore prone to obstruction by calculi at the following sites: n A. the pelviureteric junction n B. the pelvic brim n C. the ischial spine n D. within the urinary bladder wall o E. A, B and D are all correct 4. Renal and ureteric calculi may be visible on plain abdominal radiographs because they often contain high levels of: n A. cystine n B. phosphate n C. uric acid o D. calcium n E. xanthine 5. Ureteric pain, which is referred to the groin and scrotum, suggests involvement of which spinal segment? n A. T10 n B. T11 n C. T12 o D. L1 n E. L2 6. The ureteric plexus, which provides innervation to the ureter, is derived from all of the following plexuses EXCEPT the: n A. renal n B. aortic n C. superior hypogastric n D. inferior hypogastric o E. coeliac

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7. The extravasating contrast medium is likely to have leaked into the: n A. peritoneal cavity n B. pararenal (paranephric) space o C. perirenal (perinephric) space n D. mesentery of the small intestine n E. suprarenal fascial compartment 8. Dilation of the ureter (hydroureter) could also result from: n A. obstruction of the pelvi-ureteric region n B. a tumour of the stomach fundus n C. a splenic artery aneurysm o D. a stricture at the course of the ureter through the bladder wall n E. an aberrant renal artery 9. Structures which are naturally visible in a plain abdominal and pelvic X-ray and which might be mistaken for a ureteric calculus include: n A. external iliac lymph nodes o B. pelvic phleboliths (calcified thomboses in pelvic veins) n C. calcified aneurysm of the median sacral artery n D. faeces in the rectal ampulla n E. both B and C are correct 10. Bladder calculi (i.e. stones forming in the urinary bladder) are likely to cause which of the following? n A. obstruction of the ureteric orifices n B. enlargement of the uvula of the urinary bladder n C. unilateral hydroureter o D. obstruction of the bladder neck n E. none of the above

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Uterine prolapse and fibroids

History A 49 year old woman presented to her general practitioner complaining of heavy but regular periods, which had increased in intensity over the last 5 months. She has also experienced colicky pain around the time of menstruation as well as a dull dragging pain in the pelvis. On questioning the woman also admitted to some urinary incontinence when she sneezes, coughs or laughs. She also has had occasional difficulties emptying the bowel, with the feeling that something is still in there after she has passed a motion. The woman has four children aged 15, 12, 10 and 9 years. All were delivered per vaginam, with minimal complications apart from episiotomy incisions. Physical examination Examination of the vulva revealed that the woman had mild prolapse of the bladder, with a cystocoele (posterior and inferior descent of the bladder to form a bulge of the anterior vaginal wall). The posterior vaginal wall also bulged forward as a rectocoele (a pocket of rectum evaginating anteriorly through the posterior vaginal wall). The vaginal cervix could be palpated 4 cm above the vaginal introitus. When the uterus was bimanually palpated, it was noted that the uterus was irregularly enlarged (about 10 cm from cervix to fundus) with multiple tumours of a variety of sizes present. Subsequent events The women was treated with a vaginal hysterectomy along with exposure of the bladder and firm tying of the pelvic fascia beneath the bladder neck and trigone. The rectocoele was also repaired by suturing of the perineum.

Pathological examination of the uterus revealed multiple fibromyomata (benign tumours of the uterus, commonly known as fibroids). Clinical anatomy questions 1. The most important structures directly supporting the uterus are the: o A. transverse cervical ligaments n B. levator ani muscle n C. round ligaments of the uterus n D. broad ligaments of the uterus n E. perineal body 2. The bladder and urethra are supported by: n A. the puborectalis muscle n B. tissue which is dependent on progesterone for its proper tone o C. pubovesical and pubourethral ligaments n D. the broad ligament n E. the round ligament 3. Factors which might exacerbate prolapse of the uterus include: n A. multiple childbirth n B. withdrawal of oestrogens at menopause n C. obesity n D. coughing from a respiratory tract infection o E. all of the above can be correct

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4. The normal position of the uterus is n A. anteverted and retroflexed n B. retroflexed and retroverted o C. anteverted and anteflexed n D. retroverted and anteflexed n E. none of the above are correct 5. An episiotomy which extends posteriorly and laterally from the fourchette is likely to cut through all of the following EXCEPT: o A. the external anal sphincter n B. the deep transverse perinei muscle n C. the posterior bulbospongiosus muscle n D. the ischioanal fossa n E. the superficial transverse perinei muscle 6. Urinary stress incontinence is likely to be due to: n A. loss of tone in the urachus n B. a cystocoele without descent of the internal urethral orifice o C. widening of the internal urethral orifice n D. weakening of the perineal body n E. deepening of the paravesical fossae 7. Normally the trigone of the bladder: o A. is related to the anterior vaginal wall n B. has a uvula in women n C. is related to the uterine fundus n D. has ureteric orifices at its inferior angles n E. none of the above are correct

8. Concerning the urethra in women: n A. it is about 8 cm long n B. it emerges anterior to the clitoris n C. its external orifice is flanked by the prepuce of the clitoris o D. it is attached to the anterior vaginal wall n E. it is flanked by the transverse cervical ligaments 9. Hazardous relations during vaginal hysterectomy include: n A. the superior gluteal artery crossing the transverse cervical ligament o B. the ureter crossing the uterine artery n C. the ureter crossing the uterosacral ligament n D. the uterine artery descending on the uterosacral ligament n E. the superior vesical artery crossing the round ligament 10. An enterocoele (loop of bowel herniating into the vagina) may arise at the posterior fornix of the vagina because: o A. the vaginal wall at this point consists of only epithelium, thin fascia and peritoneum n B. of increased rectal pressure due to constipation n C. of lateral pressure applied by strained uterosacral ligaments n D. a retroverted uterus exposes the pouch of Douglas to loops of intestine n E. none of the above are correct

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