Surface anatomy

Surface anatomy US Medical PG Question 1: A research team develops a new monoclonal antibody checkpoint inhibitor for advanced melanoma that has shown promise in animal studies as well as high efficacy and low toxicity in early phase human clinical trials. The research team would now like to compare this drug to existing standard of care immunotherapy for advanced melanoma. The research team decides to conduct a non-randomized study where the novel drug will be offered to patients who are deemed to be at risk for toxicity with the current standard of care immunotherapy, while patients without such risk factors will receive the standard treatment. Which of the following best describes the level of evidence that this study can offer?

• A. Level 1
• B. Level 3 (Correct Answer)
• C. Level 5
• D. Level 4
• E. Level 2

Surface anatomy Explanation: ***Level 3*** - A **non-randomized controlled trial** like the one described, where patient assignment to treatment groups is based on specific characteristics (risk of toxicity), falls into Level 3 evidence. - This level typically includes **non-randomized controlled trials** and **well-designed cohort studies** with comparison groups, which are prone to selection bias and confounding. - The study compares two treatments but lacks randomization, making it Level 3 evidence. *Level 1* - Level 1 evidence is the **highest level of evidence**, derived from **systematic reviews and meta-analyses** of multiple well-designed randomized controlled trials or large, high-quality randomized controlled trials. - The described study is explicitly stated as non-randomized, ruling out Level 1. *Level 2* - Level 2 evidence involves at least one **well-designed randomized controlled trial** (RCT) or **systematic reviews** of randomized trials. - The current study is *non-randomized*, which means it cannot be classified as Level 2 evidence, as randomization is a key criterion for this level. *Level 4* - Level 4 evidence includes **case series**, **case-control studies**, and **poorly designed cohort or case-control studies**. - While the study is non-randomized, it is a controlled comparative trial rather than a case series or retrospective case-control study, placing it at Level 3. *Level 5* - Level 5 evidence is the **lowest level of evidence**, typically consisting of **expert opinion** without explicit critical appraisal, or based on physiology, bench research, or animal studies. - While the drug was initially tested in animal studies, the current human comparative study offers a higher level of evidence than expert opinion or preclinical data.

Surface anatomy US Medical PG Question 2: A 42-year-old woman presents to the physician with symptoms of vague abdominal pain and bloating for several months. Test results indicate that she has ovarian cancer. Her physician attempts to reach her by phone multiple times but cannot reach her. Next of kin numbers are in her chart. According to HIPAA regulations, who should be the primary person the doctor discusses this information with?

• A. The patient's brother
• B. The patient's husband
• C. The patient's daughter
• D. All of the options
• E. The patient (Correct Answer)

Surface anatomy Explanation: ***The patient*** - Under **HIPAA**, the patient has the **right to privacy** regarding their protected health information (PHI). Therefore, the physician must make all reasonable attempts to contact the patient directly to convey their diagnosis. - Sharing sensitive medical information like a cancer diagnosis with anyone other than the patient, without their explicit consent, would be a **violation of HIPAA regulations**. *The patient's brother* - The patient's brother is not automatically authorized to receive her medical information, even if listed as **next of kin**, without the patient's explicit consent or a documented **healthcare power of attorney**. - Discussing the diagnosis with the brother without the patient's direct consent would be a **breach of patient confidentiality**. *The patient's husband* - Even a spouse does not automatically have the right to access a patient's **PHI** without the patient's express permission, according to **HIPAA**. - While often a trusted contact, without explicit consent, revealing the diagnosis to the husband would still violate the patient's **privacy rights**. *The patient's daughter* - Similar to other family members, the patient's daughter is not legally entitled to receive her mother's confidential medical information without explicit authorization or a medical **power of attorney**. - The physician's primary responsibility is to the patient herself, ensuring her **privacy** is maintained. *All of the options* - According to **HIPAA**, sharing the patient's diagnosis with any family member without her explicit consent would be a **breach of confidentiality**. - This option incorrectly assumes that **next of kin** automatically have the right to receive sensitive medical information.

Surface anatomy US Medical PG Question 3: A 41-year-old woman is brought to the emergency department with the acute-onset of severe abdominal pain for the past 2 hours. She has a history of frequent episodes of vague abdominal pain, but they have never been this severe. Every time she has had pain, it would resolve after eating a meal. Her past medical history is otherwise insignificant. Her vital signs include: blood pressure 121/77 mm Hg, pulse 91/min, respiratory rate 21/min, and temperature 37°C (98.6°F). On examination, her abdomen is flat and rigid. Which of the following is the next best step in evaluating this patient’s discomfort and stomach pain by physical exam?

• A. Auscultate the abdomen (Correct Answer)
• B. Elicit shifting dullness of the abdomen
• C. Perform light palpation at the point of maximal pain
• D. Attempt to perform a deep, slow palpation with quick release
• E. Percuss the point of maximal pain

Surface anatomy Explanation: ***Auscultate the abdomen*** - Auscultation is typically performed first in an abdominal exam to assess **bowel sounds** and identify any bruits, as palpation and percussion can alter bowel sound characteristics. - While the patient has **peritonitis (rigid abdomen)**, initial auscultation is still the logical starting point for a comprehensive physical examination. *Elicit shifting dullness of the abdomen* - **Shifting dullness** is used to detect **ascites**, which is not the primary concern given the acute onset of severe pain and rigid abdomen. - This maneuver typically comes later in the abdominal examination, after initial auscultation and palpation. *Perform light palpation at the point of maximal pain* - Given the patient's **rigid abdomen**, suggesting peritonitis, performing palpation (even light) at the point of maximal pain could cause significant discomfort and is secondary to initial auscultation in the *sequence* of physical exam. - While palpation is crucial, the standard order in an abdominal exam begins with auscultation to ensure unchanged bowel sounds. *Attempt to perform a deep, slow palpation with quick release* - This describes evaluating for **rebound tenderness**, a sign of peritonitis, which is indeed suggested by the rigid abdomen. - However, just like light palpation, this maneuver is performed *after* auscultation and is likely to cause significant pain in a patient with a rigid abdomen, making it not the very next best step. *Percuss the point of maximal pain* - Percussion is typically used to assess for **gas, fluid, or organ size/tenderness**, but it is performed after auscultation and before deep palpation in a standard abdominal exam. - In a patient with a **rigid abdomen**, percussion can also elicit severe pain, and it does not precede auscultation in the examination sequence.

Surface anatomy US Medical PG Question 4: A 52-year-old man with stage IV melanoma comes to the physician with his wife for a routine follow-up examination. He was recently diagnosed with new bone and brain metastases despite receiving aggressive chemotherapy but has not disclosed this to his wife. He has given verbal consent to discuss his prognosis with his wife and asks the doctor to inform her of his condition because he does not wish to do so himself. She is tearful and has many questions about his condition. Which of the following would be the most appropriate statement by the physician to begin the interview with the patient's wife?

• A. Have you discussed a living will or goals of care together?
• B. We should talk about how we can manage his symptoms with additional chemotherapy.
• C. Why do you think your husband has not discussed his medical condition with you?
• D. What is your understanding of your husband's current condition? (Correct Answer)
• E. Your husband has end-stage cancer, and his prognosis is poor.

Surface anatomy Explanation: ***What is your understanding of your husband's current condition?*** - This statement initiates the conversation by **assessing the wife's current knowledge** and emotional state, which is crucial for delivering sensitive and appropriate information. - It allows the physician to tailor the discussion to her specific understanding and concerns, ensuring that information is delivered compassionately and effectively. *Have you discussed a living will or goals of care together?* - This question is too abrupt and **premature** as an opening, as the wife is clearly distressed and unaware of the full severity of her husband's condition. - Discussions about end-of-life planning should only occur after the patient's wife has a clear understanding of the diagnosis and prognosis, and has processed this information. *Your husband has end-stage cancer, and his prognosis is poor.* - While factual, this statement is **too blunt and lacks empathy** for an opening, especially given the wife's emotional state and lack of prior knowledge. - Delivering such devastating news directly without first assessing her understanding or providing context can be traumatic and impede effective communication. *We should talk about how we can manage his symptoms with additional chemotherapy.* - This statement implies a focus on further aggressive treatment which may not be appropriate given the **new bone and brain metastases** and aggressive prior chemotherapy, suggesting a limited benefit of more chemotherapy. - It also **diverts from the primary need to discuss the overall prognosis** and the patient's rapidly declining condition, which the doctor has been asked to convey. *Why do you think your husband has not discussed his medical condition with you?* - This question is **accusatory** and places blame on either the patient or the wife, which is inappropriate and unhelpful in a sensitive medical discussion. - It shifts the focus away from providing medical information and empathy towards a speculative and potentially confrontational topic.

Surface anatomy US Medical PG Question 5: A 78-year-old man is brought in to the emergency department by ambulance after his wife noticed that he began slurring his speech and had developed facial asymmetry during dinner approximately 30 minutes ago. His past medical history is remarkable for hypertension and diabetes. His temperature is 99.1°F (37.3°C), blood pressure is 154/99 mmHg, pulse is 89/min, respirations are 12/min, and oxygen saturation is 98% on room air. Neurologic exam reveals right upper and lower extremity weakness and an asymmetric smile. Which of the following is the next best step in management?

• A. Alteplase
• B. MRI brain
• C. CT head (Correct Answer)
• D. Aspirin
• E. CTA head

Surface anatomy Explanation: ***CT head*** - A **non-contrast CT head** is the immediate priority to differentiate between ischemic and hemorrhagic stroke, which is critical for guiding subsequent treatment decisions. - Given the patient's acute neurological deficits (slurred speech, facial asymmetry, weakness) and vascular risk factors (hypertension, diabetes), **stroke is highly suspected**, and identifying intracerebral hemorrhage is crucial before considering thrombolytic therapy. *Alteplase* - **Alteplase** (tPA) is a thrombolytic agent used for acute ischemic stroke, but its administration is **contraindicated in hemorrhagic stroke**. - Initiating alteplase without first ruling out hemorrhage with a CT scan could lead to catastrophic bleeding. *MRI brain* - While an **MRI brain** can provide more detailed imaging of stroke, it is typically **not the initial imaging modality** in the emergency setting due to longer acquisition times and limited availability, especially when emergent differentiation between ischemic and hemorrhagic stroke is needed. - Its use is usually reserved for cases where the CT is inconclusive or for later evaluation. *Aspirin* - **Aspirin** is an antiplatelet agent used in the management of ischemic stroke, but it should **not be given until a hemorrhagic stroke has been ruled out** via CT head. - Administering aspirin in the context of an intracerebral hemorrhage could worsen bleeding. *CTA head* - A **CT angiography (CTA) head** is used to visualize the cerebral vasculature and identify large vessel occlusions, which can guide thrombectomy decisions in ischemic stroke. - However, performing a **non-contrast CT head is a prerequisite** to rule out hemorrhage before proceeding with CTA or any other advanced imaging or therapeutic interventions.

Surface anatomy US Medical PG Question 6: A 65-year-old man presents to the emergency department for sudden weakness. He was doing mechanical work on his car where he acutely developed right-leg weakness and fell to the ground. He is accompanied by his wife, who said that this has never happened before. He was last seen neurologically normal approximately 2 hours prior to presentation. His past medical history is significant for hypertension and type II diabetes. His temperature is 98.8°F (37.1°C), blood pressure is 177/108 mmHg, pulse is 90/min, respirations are 15/min, and oxygen saturation is 99% on room air. Neurological exam reveals that he is having trouble speaking and has profound weakness of his right upper and lower extremity. Which of the following is the best next step in management?

• A. Thrombolytics
• B. Noncontrast head CT (Correct Answer)
• C. CT angiogram
• D. MRI of the head
• E. Aspirin

Surface anatomy Explanation: ***Noncontrast head CT*** - A **noncontrast head CT** is the most crucial initial step in managing acute stroke symptoms because it can rapidly rule out an **intracranial hemorrhage**. - Distinguishing between ischemic stroke and hemorrhagic stroke is critical, as the management strategies are vastly different and administering thrombolytics in the presence of hemorrhage can be fatal. *Thrombolytics* - **Thrombolytics** can only be administered after an **intracranial hemorrhage** has been excluded via noncontrast head CT. - Administering thrombolytics without imaging could worsen a hemorrhagic stroke, causing significant harm or death. *CT angiogram* - A **CT angiogram** is used to identify large vessel occlusions in ischemic stroke and is typically performed after a noncontrast CT rules out hemorrhage. - This imaging is crucial for determining eligibility for **endovascular thrombectomy** but is not the very first diagnostic step. *MRI of the head* - An **MRI of the head** is more sensitive for detecting acute ischemic changes but takes longer to perform and is often not readily available in the acute emergency setting. - It is not the initial imaging of choice for ruling out hemorrhage due to its longer acquisition time compared to CT. *Aspirin* - **Aspirin** is indicated for acute ischemic stroke but should only be given after an **intracranial hemorrhage** has been ruled out. - Like thrombolytics, aspirin could exacerbate a hemorrhagic stroke and is thus deferred until initial imaging is complete.

Surface anatomy US Medical PG Question 7: A 57-year-old man presents to the emergency department for weight loss and abdominal pain. The patient states that he has felt steadily more fatigued over the past month and has lost 22 pounds without effort. Today, he fainted prompting his presentation. The patient has no significant past medical history. He does have a 33 pack-year smoking history and drinks 4 to 5 alcoholic drinks per day. His temperature is 99.5°F (37.5°C), blood pressure is 100/58 mmHg, pulse is 100/min, respirations are 17/min, and oxygen saturation is 98% on room air. On physical exam, you see a patient who is very thin and appears to be pale. Stool fecal occult blood testing is positive. A CT scan of the abdomen is performed demonstrating a mass in the colon with multiple metastatic lesions scattered throughout the abdomen. The patient is informed of his diagnosis of metastatic colon cancer. When the patient conveys the information to his family he focuses his efforts on discussing the current literature in the field and the novel therapies that have been invented. He demonstrates his likely mortality outcome which he calculated using the results of a large multi-center study. Which of the following is this patient most likely demonstrating?

• A. Intellectualization (Correct Answer)
• B. Dissociation
• C. Rationalization
• D. Optimism
• E. Pessimism

Surface anatomy Explanation: ***Intellectualization*** - This defense mechanism involves **focusing on the intellectual aspects** of a stressful situation, using logical reasoning and factual analysis to avoid experiencing distressing emotions. - The patient demonstrates this by discussing **literature, novel therapies, and mortality statistics** regarding his metastatic colon cancer. *Dissociation* - **Dissociation** involves a mental process that causes a lack of connection in a person's thoughts, memory, and sense of identity. - This patient is actively engaging with the information, not disconnecting from it. *Rationalization* - **Rationalization** is creating logical but false explanations for unacceptable thoughts, feelings, or behaviors to justify them. - The patient is not trying to justify his actions or feelings, but rather to understand his disease intellectually. *Optimism* - **Optimism** is a disposition to look on the favorable side of events or conditions and to expect the most favorable outcome. - While hope for novel therapies could be seen as optimistic, his detailed calculation of mortality outcomes is a realistic, rather than purely optimistic, approach. *Pessimism* - **Pessimism** is a tendency to see the worst aspect of things or believe that the worst will happen. - The patient is engaging with the facts of his diagnosis, even calculating his mortality outcome, which is not necessarily a pessimistic but rather a realistic and intellectual approach.

Surface anatomy US Medical PG Question 8: An 82-year-old right-handed woman is brought in by ambulance after being found down in her home. On presentation, she is found to be awake but does not follow directions or respond to questions. She is able to speak and produces a fluent string of nonsensical words and sounds. She does not appear to be bothered by her deficits. Subsequent neurologic exam finds that the patient is unable to comprehend any instructions and is also unable to repeat phrases. CT scan reveals an acute stroke to her left hemisphere. Damage to which of the following structures would be most likely to result in this pattern of deficits?

• A. Precentral gyrus
• B. Superior temporal gyrus (Correct Answer)
• C. Arcuate fasciculus
• D. Inferior frontal gyrus
• E. Watershed zone

Surface anatomy Explanation: ***Superior temporal gyrus*** - This patient presents with **fluent aphasia** (speaking nonsensical words), severely impaired **comprehension**, and impaired **repetition**. This triad is characteristic of **Wernicke's aphasia**. - **Wernicke's area**, responsible for language comprehension, is located in the **posterior part of the superior temporal gyrus** in the dominant hemisphere (typically left). *Precentral gyrus* - The **precentral gyrus** contains the **primary motor cortex** and its damage would primarily cause contralateral motor deficits (e.g., **hemiparesis** or **hemiplegia**). - This area is not directly involved in language comprehension or production of fluent but nonsensical speech. *Arcuate fasciculus* - Damage to the **arcuate fasciculus**, a white matter tract connecting Broca's and Wernicke's areas, results in **conduction aphasia**. - In **conduction aphasia**, comprehension and fluency are relatively preserved, but **repetition is severely impaired**. This patient also has impaired comprehension. *Inferior frontal gyrus* - The **inferior frontal gyrus** houses **Broca's area**, which is responsible for **language production and motor aspects of speech**. - Damage to this area typically causes **Broca's aphasia**, characterized by **non-fluent speech**, preserved comprehension, and impaired repetition. This patient has fluent speech. *Watershed zone* - **Watershed infarcts** occur at the borders between major arterial territories due to hypoperfusion, often leading to **transcortical aphasias**. - While transcortical sensory aphasia involves impaired comprehension and fluent speech, **repetition is preserved**, which is not the case here.

Surface anatomy US Medical PG Question 9: A 74-year-old male is brought to the emergency department 1 hour after he fell from the top of the staircase at home. He reports pain in his neck as well as weakness of his upper extremities. He is alert and immobilized in a cervical collar. He has hypertension treated with hydrochlorothiazide. His pulse is 90/min and regular, respirations are 18/min, and blood pressure is 140/70 mmHg. Examination shows bruising and midline cervical tenderness. Neurologic examination shows diminished strength and sensation to pain and temperature in the upper extremities, particularly in the hands. Upper extremity deep tendon reflexes are absent. Strength, sensation, and reflexes in the lower extremities are intact. Anal sensation and tone are present. Babinski's sign is absent bilaterally. Which of the following is most likely to confirm the cause of this patient's neurologic examination findings?

• A. CT angiography of the neck
• B. MRI of the cervical spine without contrast (Correct Answer)
• C. X-ray of the cervical spine
• D. CT of the cervical spine with contrast
• E. Cervical myelography

Surface anatomy Explanation: ***MRI of the cervical spine without contrast*** - This patient presents with symptoms consistent with **central cord syndrome**, characterized by greater weakness in the upper extremities than the lower extremities, often following a hyperextension injury in older adults with pre-existing cervical spondylosis. **MRI is the gold standard for visualizing soft tissue injuries**, including spinal cord compression, edema, or hemorrhage, which are typical causes of central cord syndrome. - Given the primary concern for spinal cord injury and the detailed neurological deficits indicating specific cord involvement, **MRI** offers the best resolution for evaluating the extent of cord damage, disc herniation, ligamentous injury, and pre-existing degenerative changes. *CT angiography of the neck* - **CT angiography** primarily evaluates the **vascular structures** of the neck (e.g., carotid and vertebral arteries) for dissection, stenosis, or occlusion. - While vascular injury could occur in trauma, the patient's neurological findings (disproportionate upper extremity weakness, pain and temperature sensation loss) point more directly to **spinal cord pathology** rather than isolated vascular compromise as the primary cause. *X-ray of the cervical spine* - **X-rays** are useful for initial screening of **bony fractures** and significant dislocations but offer limited information about soft tissues, such as the spinal cord, ligaments, or intervertebral discs. - They cannot adequately visualize the spinal cord damage responsible for the patient's specific neurological deficits, making it insufficient for confirming the cause of central cord syndrome. *CT of the cervical spine with contrast* - **CT scans** excel at visualizing **bony structures** and acute fractures, but even with contrast, they provide less detail of the **spinal cord parenchyma** and soft tissue ligaments compared to MRI. - **Contrast** is typically used to highlight vascular structures, inflammatory processes, or tumors, which are not the primary diagnostic concerns suggested by this patient's acute post-traumatic presentation of central cord syndrome. *Cervical myelography* - **Myelography** involves injecting contrast into the subarachnoid space, followed by X-ray or CT imaging, to outline the spinal cord and nerve roots. - While it can identify **spinal cord compression**, it is an **invasive procedure** with risks (e.g., headache, seizures) and has largely been replaced by the non-invasive and superior soft tissue imaging capabilities of MRI, especially in acute trauma.

Surface anatomy US Medical PG Question 10: A 72-year-old male presents to a cardiac surgeon for evaluation of severe aortic stenosis. He has experienced worsening dyspnea with exertion over the past year. The patient also has a history of poorly controlled hypertension, diabetes mellitus, and hyperlipidemia. An echocardiogram revealed a thickened calcified aortic valve. The surgeon is worried that the patient will be a poor candidate for open heart surgery and decides to perform a less invasive transcatheter aortic valve replacement. In order to perform this procedure, the surgeon must first identify the femoral pulse just inferior to the inguinal ligament and insert a catheter into the vessel in order to gain access to the arterial system. Which of the following structures is immediately lateral to this structure?

• A. Lymphatic vessels
• B. Femoral vein
• C. Sartorius muscle
• D. Pectineus muscle
• E. Femoral nerve (Correct Answer)

Surface anatomy Explanation: ***Femoral nerve*** - The **femoral nerve** lies lateral to the **femoral artery** within the **femoral triangle**. - The order of structures from **lateral to medial** under the inguinal ligament is remembered by the mnemonic **NAVEL**: **N**erve, **A**rtery, **V**ein, **E**mpty space, **L**ymphatics. *Lymphatic vessels* - **Lymphatic vessels** and nodes are located most medially within the femoral triangle, medial to the femoral vein. - This position is not immediately lateral to the femoral artery. *Femoral vein* - The **femoral vein** is located immediately medial to the **femoral artery**. - It would not be found immediately lateral to the femoral artery. *Sartorius muscle* - The **sartorius muscle** forms the lateral boundary of the **femoral triangle** but is not immediately adjacent and lateral to the femoral artery within the triangle itself. - The femoral nerve is enclosed within the iliopsoas fascial compartment, which runs deep to the sartorius. *Pectineus muscle* - The **pectineus muscle** forms part of the floor of the **femoral triangle**, but it is deep to the neurovascular structures. - It is not immediately lateral to the femoral artery.

Surface anatomy Flashcard 1 of 7

Question: ID Spinal Cord Section: _____

Answer: Thoracic

Surface anatomy Flashcard 2 of 7

Question: ID Tract: _____

Answer: Spinothalamic tract

Surface anatomy Flashcard 3 of 7

Question: Structures of the _____ system include the hippocampus, amygdala, fornix, mammillary bodies, and cingulate gyrus

Answer: limbic

Surface anatomy Flashcard 4 of 7

Question: What action do the following muscles allow the hip to do?_____Iliopsoas (Iliacus + Psoas major / minor)Rectus femorisTensor fascia lataSartoriusPectineus

Answer: Hip flexion

Surface anatomy Flashcard 5 of 7

Question: ID Structure: _____

Answer: Medial lemniscus

Surface anatomy Flashcard 6 of 7

Question: ID Vessel: _____

Answer: Posterior inferior cerebellar artery

Surface anatomy Flashcard 7 of 7

Question: ID Gyrus: _____

Answer: Precentral gyrus