Angiography techniques — MCQs

10 questions

A 47-year-old woman comes to the emergency department after coughing up 2 cups of bright red blood. A CT angiogram of the chest shows active extravasation from the right bronchial artery. A coil embolization is planned to stop the bleeding. During this procedure, a catheter is first inserted into the right femoral artery. Which of the following represents the correct subsequent order of the catheter route?

A 62-year-old man comes to the physician because of a 5-day history of swelling in his left arm. Two months ago, he was diagnosed with a deep venous thrombosis in the left calf. He has had a 7-kg (15-lb) weight loss in the last 3 months. He has smoked 1 pack of cigarettes daily for the past 25 years. His only medication is warfarin. Physical examination shows warm edema of the left forearm with overlying erythema and a tender, palpable cord-like structure along the medial arm. His lungs are clear to auscultation bilaterally. Duplex sonography shows thrombosis of the left basilic and external jugular veins. Which of the following is the most appropriate next step to confirm the underlying diagnosis?

A 67-year-old woman presents with right leg pain and swelling of 5 days’ duration. She has a history of hypertension for 15 years and had a recent hospitalization for pneumonia. She had been recuperating at home but on beginning to mobilize and walk, the right leg became painful and swollen. Her temperature is 37.1°C (98.7°F), the blood pressure is 130/80 mm Hg, and the pulse is 75/min. On physical examination, the right calf is 4 cm greater in circumference than the left when measured 10 cm below the tibial tuberosity. Dilated superficial veins are present on the right foot and the right leg is slightly redder than the left. There is some tenderness on palpation in the popliteal fossa behind the knee. Which of the following is the best initial step in the management of this patient’s condition?

A 56-year-old man with substernal chest pain calls 911. When paramedics arrive, they administer drug X sublingually for the immediate relief of angina. What is the most likely site of action of drug X?

On cardiology service rounds, your team sees a patient admitted with an acute congestive heart failure exacerbation. In congestive heart failure, decreased cardiac function leads to decreased renal perfusion, which eventually leads to excess volume retention. To test your knowledge of physiology, your attending asks you which segment of the nephron is responsible for the majority of water absorption. Which of the following is a correct pairing of the segment of the nephron that reabsorbs the majority of all filtered water with the means by which that segment absorbs water?

A 67-year-old man presents to his primary care provider with bloody urine. He first noticed the blood 1 week ago. He otherwise feels healthy. His past medical history is significant for type 2 diabetes mellitus for 18 years, for which he takes insulin injections. He has smoked 30–40 cigarettes per day for the past 29 years and drinks alcohol socially. Today his vital signs include: temperature 36.6°C (97.8°F), blood pressure 135/82 mm Hg, and heart rate 105/min. There are no findings on physical examination. Urinalysis shows 15–20 red cells/high power field. Which of the following is the next best test to evaluate this patient’s condition?

A 43-year-old man presents with acute-onset left flank pain for the past 6 hours. He describes the pain as severe, intermittent, colicky, and “coming in waves”, and he points to the area of the left costovertebral angle (CVA). He says he recently has been restricting oral liquid intake to only 2 glasses of water per day based on the advice of his healer. He also reports nausea and vomiting. The patient has a history of hypertension, gout, and type 2 diabetes mellitus. He is afebrile, and his vital signs are within normal limits. On physical examination, he is writhing in pain and moaning. There is exquisite left CVA tenderness. A urinalysis shows gross hematuria. Which of the following is the next best step in the management of this patient?

A 55-year-old man comes to the emergency department because of left-sided chest pain and difficulty breathing for the past 30 minutes. His pulse is 88/min. He is pale and anxious. Serum studies show increased cardiac enzymes. An ECG shows ST-elevations in leads I, aVL, and V5-V6. A percutaneous coronary intervention is performed. In order to localize the site of the lesion, the catheter must pass through which of the following structures?

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?

Q10

A 45-year-old man comes to the physician for the evaluation of limited mobility of his right hand for 1 year. The patient states he has had difficulty actively extending his right 4th and 5th fingers, and despite stretching exercises, his symptoms have progressed. He has type 2 diabetes mellitus. He has been working as a mason for over 20 years. His father had similar symptoms and was treated surgically. The patient has smoked one pack of cigarettes daily for 25 years and drinks 2–3 beers every day after work. His only medication is metformin. Vital signs are within normal limits. Physical examination shows skin puckering near the proximal flexor crease. There are several painless palmar nodules adjacent to the distal palmar crease. Active and passive extension of the 4th and 5th digits of the right hand is limited. Which of the following is the most likely underlying mechanism of this patient's symptoms?

Angiography techniques US Medical PG Practice Questions and MCQs

Question 1: A 47-year-old woman comes to the emergency department after coughing up 2 cups of bright red blood. A CT angiogram of the chest shows active extravasation from the right bronchial artery. A coil embolization is planned to stop the bleeding. During this procedure, a catheter is first inserted into the right femoral artery. Which of the following represents the correct subsequent order of the catheter route?

A. Thoracic aorta, right superior epigastric artery, right bronchial artery
B. Thoracic aorta, right bronchial artery (Correct Answer)
C. Thoracic aorta, left ventricle, left atrium, pulmonary artery, right bronchial artery
D. Thoracic aorta, brachiocephalic trunk, right subclavian artery, right internal thoracic artery, right bronchial artery
E. Thoracic aorta, right subclavian artery, right internal thoracic artery, right bronchial artery

Explanation: ***Thoracic aorta, right bronchial artery*** - The **femoral artery** leads directly into the **aorta**. From the aorta, the catheter can be navigated to the **thoracic aorta**, where the **bronchial arteries** typically originate. - The **bronchial arteries** usually arise directly from the **descending thoracic aorta** (most commonly T5-T6 vertebral level) to supply the lung parenchyma and airways. *Thoracic aorta, right superior epigastric artery, right bronchial artery* - The **superior epigastric artery** is a terminal branch of the **internal thoracic artery**, supplying the anterior abdominal wall, and is not a direct path to the bronchial arteries. - Navigating from the superior epigastric artery to the main bronchial artery without passing through intermediary large vessels would be anatomically incorrect and impractical. *Thoracic aorta, left ventricle, left atrium, pulmonary artery, right bronchial artery* - This path describes the venous and then pulmonary circulation (right heart, lungs), which is incorrect for reaching the **arterial system** of the bronchial arteries. - A catheter inserted via the **femoral artery** remains within the arterial system and would not cross into the pulmonary circulation or the left heart chambers in this manner. *Thoracic aorta, brachiocephalic trunk, right subclavian artery, right internal thoracic artery, right bronchial artery* - This pathway involves ascending from the **thoracic aorta** to the **brachiocephalic trunk** and subsequently into the **right subclavian** and **internal thoracic arteries**, which is a route primarily to the upper limb and chest wall. - While the internal thoracic artery can sometimes have small anastomoses, it is not the primary or direct route for embolizing a bronchial artery, which typically originates directly from the descending thoracic aorta. *Thoracic aorta, right subclavian artery, right internal thoracic artery, right bronchial artery* - Similar to the previous incorrect option, this route involves navigating through the **subclavian** and **internal thoracic arteries**, which is an indirect and unnecessarily complex path to the bronchial arteries. - The **bronchial arteries** are direct branches of the **thoracic aorta**, making this a much more convoluted and less likely route for therapeutic embolization.

Question 2: A 62-year-old man comes to the physician because of a 5-day history of swelling in his left arm. Two months ago, he was diagnosed with a deep venous thrombosis in the left calf. He has had a 7-kg (15-lb) weight loss in the last 3 months. He has smoked 1 pack of cigarettes daily for the past 25 years. His only medication is warfarin. Physical examination shows warm edema of the left forearm with overlying erythema and a tender, palpable cord-like structure along the medial arm. His lungs are clear to auscultation bilaterally. Duplex sonography shows thrombosis of the left basilic and external jugular veins. Which of the following is the most appropriate next step to confirm the underlying diagnosis?

A. CT scan of the chest
B. X-ray of the chest (Correct Answer)
C. Transesophageal echocardiography
D. Serum antiphospholipid antibody level
E. Serum D-dimer level

Explanation: **X-ray of the chest** - The patient presents with **recurrent deep venous thrombosis (DVT)**, specifically in an unusual location (upper extremity), combined with **unexplained weight loss** and a **significant smoking history**. These are strong indicators of an underlying malignancy. - A **chest x-ray** is a readily available and cost-effective initial screening tool to evaluate for **lung cancer**, which is common in smokers and can present with paraneoplastic phenomena like hypercoagulability (Trousseau phenomenon) leading to DVT. *CT scan of the chest* - While a **CT scan of the chest** is more sensitive than an X-ray for detecting lung masses, an **X-ray is the more appropriate initial step** for screening given the clinical context. - A **CT scan** would typically be performed after an abnormal chest X-ray or if clinical suspicion remains high despite a normal X-ray. *Transesophageal echocardiography* - **Transesophageal echocardiography (TEE)** is primarily used to evaluate **cardiac structures**, valve function, and to detect intracardiac thrombi or vegetations. - It is not indicated as a primary screening tool for an underlying malignancy or in the workup of a **venous thrombosis** not directly related to cardiac pathology. *Serum antiphospholipid antibody level* - **Antiphospholipid antibody syndrome** is a cause of recurrent thrombosis, but the patient's other symptoms (weight loss, smoking history, unusual DVT location) point more strongly towards an underlying malignancy. - While it might be considered in a broader workup for hypercoagulability, it is not the most immediate next step given the constellation of findings strongly suggestive of cancer. *Serum D-dimer level* - A **serum D-dimer level** is a marker of fibrin degradation and is useful for **excluding DVT/PE** in low-probability patients. - In this patient, a DVT has already been diagnosed by duplex sonography, so a D-dimer level would not provide additional diagnostic information regarding the presence of thrombosis, nor would it help in identifying the underlying cause of the recurrent thrombosis.

Question 3: A 67-year-old woman presents with right leg pain and swelling of 5 days’ duration. She has a history of hypertension for 15 years and had a recent hospitalization for pneumonia. She had been recuperating at home but on beginning to mobilize and walk, the right leg became painful and swollen. Her temperature is 37.1°C (98.7°F), the blood pressure is 130/80 mm Hg, and the pulse is 75/min. On physical examination, the right calf is 4 cm greater in circumference than the left when measured 10 cm below the tibial tuberosity. Dilated superficial veins are present on the right foot and the right leg is slightly redder than the left. There is some tenderness on palpation in the popliteal fossa behind the knee. Which of the following is the best initial step in the management of this patient’s condition?

A. International normalized ratio (INR)
B. Thrombophilia screen
C. Wells’ clinical probability tool (Correct Answer)
D. Computerized tomography (CT) with contrast
E. Activated partial thromboplastin time (aPTT)

Explanation: ***Wells' clinical probability tool*** - The patient presents with classic signs and symptoms of **deep vein thrombosis (DVT)**, including unilateral leg pain and swelling, dilated superficial veins, and tenderness. The Wells' clinical probability tool helps stratify the risk of DVT, guiding further diagnostic testing. - Using this validated clinical decision rule for risk assessment is the **best initial step** to determine the likelihood of DVT before proceeding with imaging studies (compression ultrasound) or D-dimer testing. - Based on the Wells' score, patients are categorized as low, moderate, or high probability, which then directs appropriate diagnostic testing and potential empiric anticoagulation. *International normalized ratio (INR)* - **INR** is used to monitor the effectiveness of **warfarin** therapy, an anticoagulant, and to assess liver function. - It is not an initial diagnostic tool for DVT; rather, it is used **after a DVT diagnosis** has been made and anticoagulation with warfarin has been initiated. *Thrombophilia screen* - A **thrombophilia screen** investigates underlying genetic or acquired clotting disorders. - This is typically performed **after a DVT diagnosis** in younger patients, those with recurrent DVT, or those with a family history of thrombosis, not as an initial diagnostic step unless there is strong suspicion for an underlying clotting disorder. *Computerized tomography (CT) with contrast* - A **CT with contrast** (specifically **CT venography**) can diagnose DVT, but it is not the **first-line imaging modality** for suspected DVT because of radiation exposure and contrast risks. - **Compression ultrasonography** is generally the preferred initial imaging study for DVT, especially after a risk assessment using the Wells' score. *Activated partial thromboplastin time (aPTT)* - The **aPTT** is a measure of the intrinsic and common pathways of coagulation and is used to monitor **unfractionated heparin** therapy. - It is not an initial diagnostic test for DVT; like INR, it is used **after diagnosis** for monitoring anticoagulant treatment.

Question 4: A 56-year-old man with substernal chest pain calls 911. When paramedics arrive, they administer drug X sublingually for the immediate relief of angina. What is the most likely site of action of drug X?

A. Pulmonary arteries
B. Large veins (Correct Answer)
C. Cardiac muscle
D. Large arteries
E. Arterioles

Explanation: ***Large veins*** - Drug X is most likely **nitroglycerin**, which is administered sublingually for rapid relief of angina. - Its primary mechanism of action involves **vasodilation of large veins**, leading to **decreased preload** and reduced myocardial oxygen demand. *Pulmonary arteries* - While nitroglycerin can cause some pulmonary vasodilation, its primary therapeutic effect in angina is not focused on the **pulmonary arteries**. - Medications targeting pulmonary arteries are typically used for conditions like **pulmonary hypertension**. *Cardiac muscle* - Nitroglycerin does not directly act on **cardiac muscle** to improve angina; its effects are primarily vascular. - It does not directly enhance contractility or directly reduce oxygen consumption at the myocardial cellular level. *Large arteries* - Nitroglycerin does cause some **arterial vasodilation**, but this effect is less prominent than its venodilating effect at typical anti-anginal doses. - Significant arterial dilation can lead to **hypotension**, which is a side effect, not the primary therapeutic mechanism for angina relief. *Arterioles* - Nitroglycerin causes **less vasodilation of resistance arterioles** compared to its venodilating effects. - While some arteriolar dilation occurs, it mainly contributes to a decrease in **afterload**, but the predominant effect for angina relief is preload reduction.

Question 5: On cardiology service rounds, your team sees a patient admitted with an acute congestive heart failure exacerbation. In congestive heart failure, decreased cardiac function leads to decreased renal perfusion, which eventually leads to excess volume retention. To test your knowledge of physiology, your attending asks you which segment of the nephron is responsible for the majority of water absorption. Which of the following is a correct pairing of the segment of the nephron that reabsorbs the majority of all filtered water with the means by which that segment absorbs water?

A. Distal convoluted tubule via passive diffusion following ion reabsorption
B. Distal convoluted tubule via aquaporin channels
C. Thick ascending loop of Henle via passive diffusion following ion reabsorption
D. Proximal convoluted tubule via passive diffusion following ion reabsorption (Correct Answer)
E. Collecting duct via aquaporin channels

Explanation: ***Proximal convoluted tubule via passive diffusion following ion reabsorption*** - The **proximal convoluted tubule (PCT)** is responsible for reabsorbing approximately **65-70% of filtered water**, making it the primary site of water reabsorption in the nephron. - This water reabsorption primarily occurs **passively**, following the active reabsorption of solutes (especially **sodium ions**), which creates an osmotic gradient. *Distal convoluted tubule via passive diffusion following ion reabsorption* - The **distal convoluted tubule (DCT)** reabsorbs a much smaller percentage of filtered water (around 5-10%) and its water reabsorption is largely **regulated by ADH**, not primarily simple passive diffusion following bulk ion reabsorption. - While some passive water movement occurs, it is not the main mechanism or location for the majority of water reabsorption. *Distal convoluted tubule via aquaporin channels* - While aquaporin channels do play a role in water reabsorption in the DCT, particularly under the influence of **ADH**, the DCT is not the segment responsible for the **majority of all filtered water absorption**. - The bulk of water reabsorption occurs earlier in the nephron, independently of ADH for the most part. *Thick ascending loop of Henle via passive diffusion following ion reabsorption* - The **thick ascending loop of Henle** is primarily involved in reabsorbing ions like Na+, K+, and Cl- but is largely **impermeable to water**. - Its impermeability to water is crucial for creating the **osmotic gradient** in the renal medulla, which is necessary for later water reabsorption. *Collecting duct via aquaporin channels* - The **collecting duct** is critically important for **regulated water reabsorption** via **aquaporin-2 channels** under the influence of **ADH**, allowing for fine-tuning of urine concentration. - However, it reabsorbs only a variable portion (typically 5-19%) of the remaining filtered water, not the **majority of all filtered water**.

Question 6: A 67-year-old man presents to his primary care provider with bloody urine. He first noticed the blood 1 week ago. He otherwise feels healthy. His past medical history is significant for type 2 diabetes mellitus for 18 years, for which he takes insulin injections. He has smoked 30–40 cigarettes per day for the past 29 years and drinks alcohol socially. Today his vital signs include: temperature 36.6°C (97.8°F), blood pressure 135/82 mm Hg, and heart rate 105/min. There are no findings on physical examination. Urinalysis shows 15–20 red cells/high power field. Which of the following is the next best test to evaluate this patient’s condition?

A. Prostate-specific antigen
B. Urine cytology
C. Urinary markers
D. Biopsy
E. Contrast-enhanced CT (Correct Answer)

Explanation: ***Contrast-enhanced CT*** - This patient presents with **painless gross hematuria** and significant risk factors, including a 29-year history of **heavy smoking** and age, which raise suspicion for **urothelial carcinoma** (e.g., bladder cancer, renal cell carcinoma). - A **contrast-enhanced CT** of the abdomen and pelvis is the most appropriate initial imaging study to evaluate the entire urinary tract for masses, stones, or other structural abnormalities causing the hematuria. *Prostate-specific antigen* - This test is primarily used for **prostate cancer screening** and monitoring, and while prostate issues can cause hematuria, the absence of urinary obstruction symptoms and the patient's age and smoking history make other causes more likely. - An elevated **PSA** would not explain gross, painless hematuria in this context and would not be the initial diagnostic step for evaluating the urinary tract in general. *Urine cytology* - While urine cytology can detect **malignant cells**, its sensitivity for urothelial carcinoma is variable and often low, especially for low-grade tumors. - A negative cytology does not rule out cancer, and an imaging study is still necessary to **localize the source** of bleeding and assess for structural abnormalities. *Urinary markers* - Various **urinary markers** (e.g., BTA stat, NMP22) are available for bladder cancer detection, but they are generally less sensitive and specific than imaging or cystoscopy. - These markers are often used in conjunction with other tests or for surveillance, but not as the initial definitive test for **gross hematuria** in a high-risk patient. *Biopsy* - A biopsy is a **definitive diagnostic step** for confirming cancer but requires an identified lesion to target. - Before a biopsy can be performed, imaging (like CT) is needed to **locate any potential tumors** in the kidneys, ureters, or bladder that would then be amenable to biopsy (e.g., via cystoscopy with biopsy or renal biopsy).

Question 7: A 43-year-old man presents with acute-onset left flank pain for the past 6 hours. He describes the pain as severe, intermittent, colicky, and “coming in waves”, and he points to the area of the left costovertebral angle (CVA). He says he recently has been restricting oral liquid intake to only 2 glasses of water per day based on the advice of his healer. He also reports nausea and vomiting. The patient has a history of hypertension, gout, and type 2 diabetes mellitus. He is afebrile, and his vital signs are within normal limits. On physical examination, he is writhing in pain and moaning. There is exquisite left CVA tenderness. A urinalysis shows gross hematuria. Which of the following is the next best step in the management of this patient?

A. Non-contrast CT of the abdomen
B. Contrast CT of the abdomen and pelvis
C. Supine abdominal radiograph
D. Renal ultrasound
E. Non-contrast CT of the abdomen and pelvis (Correct Answer)

Explanation: **Non-contrast CT of the abdomen and pelvis** - **Non-contrast CT of the abdomen and pelvis** is the gold standard for diagnosing urolithiasis, providing high sensitivity and specificity for detecting stones, identifying their size and location, and assessing for hydronephrosis. - The patient's presentation with **acute-onset, severe, colicky flank pain**, nausea, vomiting, gross hematuria, and CVA tenderness is highly suggestive of **renal colic due to a kidney stone**. *Non-contrast CT of the abdomen* - This option is **insufficient** as kidney stones can be located in the ureters within the pelvis; a scan of the abdomen alone might miss stones in the distal ureter. - While a non-contrast CT is appropriate, the scope of only the abdomen is **incomplete** for evaluating the entire urinary tract that might be affected by stones. *Contrast CT of the abdomen and pelvis* - **Contrast-enhanced CT is generally not indicated** for the initial evaluation of suspected renal colic due to urolithiasis because it can obscure the visualization of urinary stones. - The use of contrast also carries risks such as **allergic reaction** and **contrast-induced nephropathy**, which are unnecessary in this acute, non-complicated setting. *Supine abdominal radiograph* - A supine abdominal radiograph (KUB) has **limited sensitivity** for detecting kidney stones, especially radiolucent stones (e.g., uric acid stones) or small stones. - It also provides **poor anatomical detail** and cannot assess for hydronephrosis or other complications as effectively as CT. *Renal ultrasound* - Renal ultrasound can detect **hydronephrosis** and some kidney stones but is less sensitive than CT for visualizing smaller stones, especially in the ureters. - Its diagnostic utility can be **limited by body habitus** and operator dependence, making it less reliable as a primary diagnostic tool for acute renal colic.

Question 8: A 55-year-old man comes to the emergency department because of left-sided chest pain and difficulty breathing for the past 30 minutes. His pulse is 88/min. He is pale and anxious. Serum studies show increased cardiac enzymes. An ECG shows ST-elevations in leads I, aVL, and V5-V6. A percutaneous coronary intervention is performed. In order to localize the site of the lesion, the catheter must pass through which of the following structures?

A. Left coronary artery → left circumflex artery (Correct Answer)
B. Right coronary artery → posterior descending artery
C. Left coronary artery → left anterior descending artery
D. Right coronary artery → right marginal artery
E. Left coronary artery → posterior descending artery

Explanation: ***Left coronary artery → left circumflex artery*** - **ST-elevations** in leads I, aVL, and V5-V6 are indicative of a **lateral myocardial infarction**. - The **left circumflex artery** primarily supplies the lateral wall of the left ventricle. *Right coronary artery → posterior descending artery* - The **posterior descending artery** (PDA) typically supplies the inferior wall and posterior interventricular septum. - An occlusion here would cause **ST-elevations** in leads II, III, and aVF, which is not seen in this case. *Left coronary artery → left anterior descending artery* - The **left anterior descending** (LAD) artery supplies the anterior wall and apex of the left ventricle. - Occlusion of the LAD would typically cause **ST-elevations** in leads V1-V4, indicating an anterior MI. *Right coronary artery → right marginal artery* - The **right marginal artery** is a branch of the right coronary artery and supplies part of the right ventricle. - Occlusion here would primarily affect the **right ventricle**, and is not typically associated with the given ECG changes. *Left coronary artery → posterior descending artery* - While the **posterior descending artery** can sometimes originate from the left circumflex artery (**left dominant circulation**), it primarily supplies the inferior wall. - The observed ECG changes in leads I, aVL, and V5-V6 are characteristic of a **lateral wall infarct**, which is supplied by the left circumflex artery.

Question 9: 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)

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.

Question 10: A 45-year-old man comes to the physician for the evaluation of limited mobility of his right hand for 1 year. The patient states he has had difficulty actively extending his right 4th and 5th fingers, and despite stretching exercises, his symptoms have progressed. He has type 2 diabetes mellitus. He has been working as a mason for over 20 years. His father had similar symptoms and was treated surgically. The patient has smoked one pack of cigarettes daily for 25 years and drinks 2–3 beers every day after work. His only medication is metformin. Vital signs are within normal limits. Physical examination shows skin puckering near the proximal flexor crease. There are several painless palmar nodules adjacent to the distal palmar crease. Active and passive extension of the 4th and 5th digits of the right hand is limited. Which of the following is the most likely underlying mechanism of this patient's symptoms?

A. Ulnar nerve lesion
B. Ganglion cyst
C. Palmar fibromatosis (Correct Answer)
D. Tendon sheath tumor
E. Tenosynovitis

Explanation: ***Palmar fibromatosis*** - The patient's symptoms, including **painless palmar nodules**, skin puckering near the flexor crease, and inability to actively extend the 4th and 5th fingers (a classic presentation of **Dupuytren's contracture**), are indicative of palmar fibromatosis. - Risk factors like **male sex**, **age > 40**, **smoking**, **alcohol use**, **diabetes mellitus**, and a **family history** of similar symptoms are all present in this patient, strongly supporting the diagnosis. *Ulnar nerve lesion* - An ulnar nerve lesion would primarily cause **sensory deficits** (numbness/tingling in the 4th and 5th digits) and **motor weakness** in intrinsic hand muscles, leading to a **claw hand deformity**, not typically the presence of palmar nodules or skin puckering. - While it can affect the 4th and 5th digits, the mechanism of limitation would be due to muscle weakness rather than fixed contracture. *Ganglion cyst* - A ganglion cyst is a **fluid-filled sac** that typically presents as a smooth, mobile, sometimes painful lump, often on the dorsal aspect of the wrist or fingers. - It does not cause progressive finger contracture, skin puckering, or diffuse palmar nodules. *Tendon sheath tumor* - A tendon sheath tumor (e.g., giant cell tumor of the tendon sheath) is a **benign soft tissue mass** that presents as a firm, localized nodule, usually associated with a tendon. - While it can limit finger movement, it typically does so by mass effect and does not cause the characteristic diffuse fibrotic changes and skin puckering seen in Dupuytren's contracture. *Tenosynovitis* - Tenosynovitis is **inflammation of the tendon sheath**, often causing pain, swelling, and tenderness along the course of the tendon, and sometimes a "triggering" sensation with movement. - It does not typically manifest as painless, firm palmar nodules or progressive contracture with skin puckering.

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