cranial to be a risk of injury. Both the subcostal nerve T12 (not listed as
choice) and the iliohypogastric nerves are likely cut during the Pfannerenstiel
incision. The ilioinguinal nerve (answer d)tends to course about an inch
superior to the inguinal ligament, thus usually would most likely not be cut.
The lateral (femoral) cutaneous nerve of the thigh (from L2 to L3) (answer e)
runs across the iliacus muscle and under the inguinal ligament well lateral to
the femoral sheath to serve the anterolateral aspect of the thigh, thus should
not be at risk.
375.The answer is b.(Moore and Dalley, pp 208–209, 275.)Rebound ten-
derness over McBurney’s point is the likely diagnosis for an appendicitis.
McBurney’s point is generally described at 1.5–2 in. superomedial on a line
drawn between the patient’s right (thus left and answer cis wrong) anterior
superior iliac spine and the umbilicus. This is the approximate location of the
ileocecal junction near where the appendix would lie deep to the anterior
abdominal wall. The history of first umbilical pain and nausea and vomiting
is consistent with appendicitis, not kidney stones (answers d and e).The
inguinal ligament courses between the anterior superior iliac spine and the
pubic tubercle, which is the lateral portion of the pubic crest. While kidney
stones are very painful they are not always associated with vomiting, nor does
the pain locate to either the umbilical region or McBurney’s point. Gallbladder
pain often presents with rebound tenderness at the right costal margin at the
mid-clavicular line (answer a).
376.The answer is d.(Moore and Dalley, p 288.)The likely cause of the
elevated bilirubin is a blocked pancreatic and bile duct at the duodenal
papilla. Pancreatic cancer (usually ductal adenocarcinoma) frequently
arises from the head of the pancreas where it blocks the normal flow of
bile out of the liver, via the hepatic duct and gallbladder, via the cystic
duct which join to form the (common) bile duct that passes through the
substance of the head of the pancreas where it joins the main pancreatic
duct just before forming the hepatopancreatic ampulla at the second por-
tion of the duodenum (see Moore & Dalley, p 283). As a consequence of
the blockage [not open hepatic duct (answer c)] of the normal exit of
bile from the body bilirubin levels increase and jaundice (yellowing)
develops. Blockage of the cystic duct (answer b)may just lead to a gall-
bladder enlargement/inflammation. Viral hepatitis (answer a)would
normally not be associated with pancreatic cancer. Gilbert syndrome
516 Anatomy, Histology, and Cell Biology