Case Files Anatomy CCBS

[1.1] A 12-year-old boy is diagnosed with an upper brachial plexus injury after falling from a tree. He presents with his right upper arm at his side due to loss of abduction. Which of the following muscles are primarily responsible for abduction of the arm at the shoulder? A. Deltoid and biceps brachii B. Deltoid and supraspinatus C. Deltoid and infraspinatus D. Supraspinatus and infraspinatus E. Coracobrachialis and supraspinatus

[1.1] B. The deltoid and supraspinatus muscles, which are innervated by the axillary and suprascapular nerves, respectively, are the primary abductors of the arm at the shoulder.

[1.2] Injury to the lateral cord of the brachial plexus will also injure its continuation, the musculocutaneous nerve. Which of the following findings would you observe in a patient with this injury? A. Weakness of abduction of the arm at the shoulder B. Weakness of adduction of the arm at the shoulder C. Weakness of extension of the forearm at the elbow D. Weakness of flexion of the forearm at the elbow E. Weakness of supination of the forearm and hand

[1.2] D. Injury to the musculocutaneous nerve will result in loss or weakness of flexion at the elbow due to paralysis of the biceps brachii and brachialis muscles.

[1.3] A 22-year-old man is brought into the emergency department with a knife injury to the axilla. The physician suspects injury to the lower brachial plexus. Which of the following nerves is most likely to be affected? A. Axillary B. Musculocutaneous C. Vagus D. Radial E. Ulnar

[1.3] E. The C8 and T1 portions of the lower brachial plexus make up the majority of the ulnar nerve.

[10.1] When will a patient's ankle joint have the greatest stability? A. When the knee is flexed B. When the foot is dorsiflexed C. When the foot is plantarflexed D. When the foot is everted E. When the foot is inverted

[10.1] B. The talocrural or ankle joint proper has the greatest stability in dorsiflexion.

[10.2] You are concerned that your patient's medial deltoid ligament may have been torn from its proximal attachment. Which of the following would you palpate for tenderness? A. The medial aspect of the tibial shaft B. The lateral aspect of the fibular shaft C. The lateral malleolus D. The medial malleolus E. The calcaneus

[10.2] D. The four components of the deltoid ligament arise from the medial malleolus.

[10.3] Your female patient is unable to walk on her tip toes. You immediately suspect damage to which of the following nerves? A. Sural nerve B. Tibial nerve C. Common fibular nerve D. Superficial fibular nerve E. Deep fibular nerve

[10.3] B. Plantarflexion of the foot at the ankle is produced by the muscles in the calf, which are innervated by the tibial nerve

[11.1] A thoracic surgeon has entered the right pleural cavity and excised two suspicious lymph nodes at the hilum of the right lung for frozen-section pathological study. These nodes belong to which of the following lymph node groups? A. Parasternal B. Paratracheal C. Superior tracheobronchial D. Inferior tracheobronchial E. Bronchopulmonary

[11.1] E. The bronchopulmonary lymph node group is located at the hilum of each lung, and it receives lymph from the superficial and deep lymphatic plexuses.

[11.2] During a surgical procedure, a surgeon has reflected the fat pad containing the thymic remnants and notes a large venous structure crossing the midline from the left and apparently emptying into the SVC. This vessel is most likely which of the following? A. Right brachiocephalic vein B. Left brachiocephalic vein C. Left internal jugular vein D. Left subclavian vein E. Azygous vein

[11.2] B. The left brachiocephalic vein crosses the midline to unite with the almost vertical right brachiocephalic vein to form the SVC.

[11.3] A pediatric heart surgeon has just divided the sternum in a child to repair a cardiac malformation. A lobulated gland-like structure is seen immediately obscuring the heart. This is most likely which of the following? A. Lung B. Thyroid gland C. Thymus D. Lymph nodes E. Liver

[11.3] C. The anterior mediastinum lies immediately posterior to the sternum and contains the thymus in children.

[12.1] A 45-year-old woman is noted to have a 1.5-cm breast cancer located in the upper inner-quadrant of the right breast. Which of the following lymph nodes is most likely to be affected? A. Level 1 axillary node B. Level 2 axillary node C. Level 3 axially node D. Parasternal node E. Inferior phrenic node

[12.1] D. Cancers located in the medial breast usually drain to the parasternal nodes.

[12.2] A physician is performing a breast examination. In addition to the breast tissue on the chest, what other region is critical to complete the palpation of mammary tissue? A. Supraclavicular region B. Subclavicular region C. Axillaryregion D. Parasternal region

[12.2] C. The tail of Spence is located in the axillary area and contains mammary tissue.

[12.3]A 24-year-old woman has vaginally delivered an infant 2 days ago. She complains of breast engorgement and swelling in regions at about the level of the umbilicus and at the lateral abdomen. There seems to be some leaking from these areas of swelling. Which of the following is the most likely diagnosis? A. Bilateral lipoma B. Accessory breast tissue C. Ascites D. Cutaneous malignancy

[12.3] B. These areas likely are accessory breast tissue. The "milk line" extends from the axilla to the groin area, and accessory mammary tissue may be present anywhere along this line.

[13.1] As a pathologist, you are examining the heart of a victim of fatal trauma and note a tear at the junction of the SVC and the right atrium. This tear would likely damage which of the following? A. SA node B. AV node C. AV bundle D. Right bundle branch E. Left bundle branch

[13.1] A. The SA node or pacemaker lies within the right atrial wall, where it is joined by the SVC.

[13.2] As a pathologist, you must examine the AV bundle histologically. In which of the following tissue samples will you find the AV bundle? A. Right atrium B. Left atrium C. Interatrial septum D. Membranous interventricular septum E. Muscular interventricular septum

[13.2] D. The AV bundle is located in the membranous portion of the inter- ventricular septum.

[13.3] A 57-year-old man develops a myocardial infarction and is noted to have a heart rate of 40 beats/min. The cardiologist diagnoses an occlu- sion of the right coronary artery. Which of the following structures is most likely to be affected? A. AV node B. Bundle of His C. Purkinje fibers D. Mitral valve

[13.3] A. An inferior wall myocardial infarction involving the right coronary artery may affect the AV node, leading to bradycardia.

[14.1] As a surgeon exploring the thorax, you will be able to identify the right pulmonary artery in which of the following locations? A. Anterior to the ascending aorta and the SVC B. Anterior to the ascending aorta and posterior to the SVC C. Posterior to the descending aorta and the SVC D. Posterior to the ascending aorta and the SVC E. Posterior to the ascending aorta and anterior to the SVC

[14.1] D. The right pulmonary passes posteriorly to the ascending aorta and the SVC.

[14.2] As a radiologist examining a contrast study of the pulmonary vessels, you will note how many pulmonary veins entering the left atrium? A. Two B. Three C. Four D. Five E. Six

[14.2] C. Four pulmonary veins that carry oxygenated blood drain into the left atrium.

[14.3] A 44-year-old woman who has a DVT of the lower extremity suddenly gasps and collapses. She is found to be hypotensive. Resuscitative measures are attempted without success. Which of the following is the most likely diagnosis? A. Myocardial infarction B. Saddle embolus C. Right peripheral pulmonary embolus D. Embolic stroke

[14.3] B. The patient likely developed a saddle embolus that occluded blood flow to both pulmonary arteries and, in effect, stopped the circulatory system.

[15.1] You must remove fluid from the pleural cavity of your patient (thoracentesis). You decide to insert the aspiration needle over the top of a rib, into an intercostal space inferior to the lower border of the lung in the MAL at the end of a normal expiration. Which of the following is the highest level at which this procedure might safely be done without injuring the lung? A. Fourth intercostal space B. Fifth intercostal space C. Sixth intercostal space D. Seventh intercostal space E. Eighth intercostal space

[15.1] E. The lower border of the lung will lie at the level of the eighth rib in the MAL, so the needle can be safely inserted into the eighth intercostal space.

[15.2] While performing this thoracentesis procedure, the lowest level of the pleural cavity will lie at the level of which rib at the end of expiration in the MAL? A. Seventh B. Eighth C. Ninth D. Tenth E. Eleventh

[15.2] D.The lowest level of the pleural cavity in the MAL lies at the level of the 10th rib.

[15.3] While performing this procedure, the lower border of the lung will lie at the level of which rib in the MCL? A. Fifth B. Sixth C. Seventh D. Eighth E. Ninth

[15.3] B. The lower border of the lung at the MCL at the level of the sixth rib.

[16.1] As a cardiologist, you are concerned about blockage of the artery to the SA node in a patient. This artery typically arises from which of the following? A. RCA B. Right marginal artery C. Posterior interventricular artery D. Anterior interventricular artery E. Circumflex artery

[16.1] A. The SA node is typically supplied by the RCA.

[16.2] In a balanced coronary artery pattern, the blood supply to the majority of the interventricular septum is derived from which of the following? A. RCA B. AV artery C. Posterior interventricular artery D. Anterior interventricular artery E. Circumflex artery

[16.2] D. Usually, the anterior two-thirds of the interventricular septum is supplied by the AV artery, and the right and left bundle branches of the conduction system are generally supplied by the anterior interventricular artery.

[16.3] As a cardiologist, you are concerned about blockage of the artery to the AV node in a patient. This artery typically arises from which of the following? A. RCA B. Right marginal artery C. Posterior interventricular artery D. Anterior interventricular artery E. Circumflex artery

[16.3] A. The AV node is also supplied by the RCA.

[17.1] A surgeon entering the abdominal cavity through the abdominal wall will take care to avoid injury to the vessels and nerves within the wall. The main portion of these vessels and nerves will be found immediately deep to which of the following? A. Skin B. Superficial fascia C. External abdominal oblique muscle D. Internal abdominal oblique muscle E. Transversus abdominis muscle

[17.1] D. The main course of the intercostal vessels and nerves is deep to the internal abdominal oblique muscle in the neurovascular plane.

[17.2] As a surgeon performing an appendectomy, you encounter an artery and vein in the superficial fascia of the lower abdominal wall. These vessels are most likely which of the following? A. Superficial epigastric artery and vein B. Superficial circumflex iliac artery and vein C. Intercostal artery and vein D. Inferior epigastric artery and vein E. Superior epigastric artery and vein

[17.2] A. The superficial epigastric vessels lie within the superficial fascia.

[17.3] During surgery, you must incise the anterior rectus sheath between the xiphoid process and the umbilicus. In this region, the sheath is derived from the aponeurosis of which of the following? A. External abdominal oblique only B. Internal abdominal oblique only C. External and internal abdominal oblique D. Internal oblique and transversus abdominis E. Transversus abdominis only

[17.3] C. The superior three-fourths of the anterior rectus sheath is derived from the aponeuroses of the external and internal abdominal oblique muscles.

[17.4] During a laparoscopic procedure, you observe the inferior epigastric vessels ascending on the posterior surface of the rectus abdominis muscle. They suddenly disappear from view by passing superior to which of the following? A. Falx inguinalis B. Linea semilunaris C. Falciform ligament D. Arcuate line E. Transversalis fascia

[17.4] D. As the inferior epigastric vessels ascend on the posterior surface of the rectus abdominis muscle, they will pass superiorly to the arcuate line, anteriorly to the posterior rectus sheath.

[18.1] As a physician examining the inguinal region of a patient, the inguinal ligament will be a key landmark. This structure is a feature derived from which of the following? A. Superficial fascia B. Fascia lata of the thigh C. Aponeurosis of the external abdominaloblique D. Aponeurosis of the internal abdominal oblique E. Aponeurosis of the transversus abdominis

[18.1] C. The inguinal ligament is the inferior edge of the aponeurosis of the external abdominal oblique muscle.

[18.2] As you continue your examination to check for the presence of an inguinal hernia, you insert the tip of your finger into the superficial inguinal ring. This is an opening in which of the following? A. Superficial fascia B. Fascia lata of the thigh C. Aponeurosis of the external abdominal oblique D. Aponeurosis of the internal abdominal oblique E. Aponeurosis of the transversus abdominis

[18.2] C. The superficial inguinal ring is an opening in the aponeurosis of the external abdominal oblique muscle.

[18.3] You are in the process of repairing a direct inguinal hernia. Which of the following anatomical relations will you find during surgery? A. The hernia will enter the deep inguinal ring B. The hernia will enter the femoral ring C. The hernia will lie lateral to the inferior epigastric vessels D. The hernia will lie medial to the inferior epigastric vessels E. The hernia will lie inferior to the inguinal ligament

[18.3] D. Direct inguinal hernias occur through the inguinal triangle, and the inferior epigastric vessels form the lateral boundary of this triangle. Hence, these vessels are lateral to the hernia.

[19.1] Which of the following is the correct landmark for locating the normal position of the gallbladder during a physical examination? A. The lowest point of the left subcostal margin B. The junction of the left linea semilunaris with the subcostal margin C. The lowest point of the right subcostal margin D. The junction of the right linea semilunaris with the subcostal margin E. The junction of the right linea semilunaris with the subcostal plane

[19.1] D. The gallbladder is normally located at the junction of the right semilunar line with the right subcostal margin.

[19.2] During a surgical procedure in which you will remove the gallbladder, you will expect its blood supply, the cystic artery, to arise from which of the following arteries? A. Right hepatic artery B. Left hepatic artery C. Proper hepatic artery D. Common hepatic artery E. Right gastric artery

[19.2] A. The cystic artery typically is a branch of the right hepatic artery.

[19.3] During a surgical procedure in which you will remove the gallbladder, your index finger is placed into the epiploic foramen. Which of the following structures would be inferior to your finger? A. Caudate lobe of the liver B. First part of the duodenum C. Inferior vena cava D. Portal vein E. Hepatic artery

[19.3] B. The first part of the duodenum will lie inferior to a finger within the epiploic foramen.

[2.1] An 18-year-old patient has been improperly fitted with axillary-type crutches, which have put pressure on the posterior cord of the brachial plexus. Which of the following terminal nerves would most likely be affected? A. Axillary nerve B. Musculocutaneous nerve C. Median nerve D. Radial nerve E. Ulnar nerve

[2.1] D. The radial nerve is a direct continuation of the posterior cord and is affected by injuries to the posterior cord.

[2.2] A 24-year-old man is noted to have a midshaft humeral fracture after falling from a scaffold. Which of the following muscle tests would you perform to test the integrity of the radial nerve? A. Flexion of the forearm at the elbow B. Flexion of the hand at the wrist C. Extension of the hand at the wrist D. Abduction of the index, middle, ring, and little fingers E. Adduction of the index, middle, ring, and little fingers

[2.2] C. The radial nerve innervates the muscles of the posterior compartment, which contains the extensors of the wrist.

[2.3] A 45-year-old woman has a severe asthmatic exacerbation and requires an arterial blood gas specimen for management. If you are planning to draw the sample from the brachial artery, where should you insert the needle? A. In the lateral aspect of the arm, between the biceps and triceps brachii muscles B. Just lateral to the biceps tendon in the cubital fossa C. Just medial to the biceps tendon in the cubital fossa D. Just medial to the tendon of the flexor carpi radialis muscle at the wrist E. Just lateral to the tendon of the flexor carpi ulnaris muscle at the wrist

[2.3] C. The brachial artery lies superficial and just medial to the tendon of the biceps brachii in the cubital fossa.

[20.1] During a surgical procedure, you have elevated the transverse colon and note an artery in the transverse mesocolon. What is this vessel? A. Right gastro-omental artery B. Middle colic artery C. Inferior pancreaticoduodenal artery D. Right colic artery E. Left colic artery

[20.1] B. The middle colic artery courses through the transverse mesocolon to supply the transverse colon.

[20.2] During surgery you note a retroperitoneal artery crossing the right side of the posterior abdominal wall and supplying the ascending colon. Which vessel is this? A. Middle colic artery B. Left colic artery C. Ileocolic artery D. Right colic artery E. Sigmoidal artery

[20.2] D. The right colic artery supplies the ascending colon and is retroperitoneal.

[20.3] A 44-year-old accountant develops a bleeding ulcer around tax time. The gastroenterologist visualizes the ulcer in the proximal duodenum. A radiologist has been called to cannulate and embolize the artery supplying the ulcer. Which of the following arteries does the radiologist need to cannulate? A. Celiac artery B. SMA C. IMA D. Superior epigastric artery

[20.3] A. The superior pancreaticoduodenal artery is a terminal branch that arises from the celiac artery.

[21.1] You are at surgery for the removal of a suspected appendicitis, but the appendix is not visible. The appendix is likely to be which of the following? A. Anticecal B. Paracecal C. Paracolic D. Retrocecal E. Retrocolic

[21.1] D. The appendix is retrocecal in position in almost 66 percent of the population.

[21.2] Which of the following techniques could you use to precisely locate the appendix? A. Locate a region devoid of haustra B. Trace the right collect artery C. Trace the ileocolic artery D. Trace the teniae coli on the cecum E. Examine the pelvic cavity

[21.2] D. The three teniae coli converge at the base of the appendix on the cecum.

[21.3] A patient experiencing infraumbilical pain is likely to have a disorder of which organ? A. Appendix B. Ascending colon C. Ileum D. Stomach E. Sigmoid colon

[21.3] E. Infraumbilical pain typically arises from hindgut-derived structures such as the sigmoid colon.

[22.1] You are at surgery and are about to mobilize the second portion of the duodenum and the head of the pancreas. You note an artery and vein passing anteriorly to the uncinate process of the pancreas and the third portion of the duodenum. Which vessels are these? A. SMA and SMV B. Inferior mesenteric artery and vein C. Gastroduodenal artery and vein D. Superior pancreaticoduodenal artery and vein E. Middle colic artery and vein

[22.1] A. The SMA and SMV emerge from between the head and uncinate process of the pancreas to cross the uncinate process and the third portion of the duodenum.

[22.2] As you proceed to elevate the duodenum and pancreas, you note two veins posterior to the neck of the pancreas uniting to form a large vein that passes superiorly. Which large vein has been formed? A. Splenic vein B. IVC C. Portal vein D. Right gastric vein E. Middle colic vein

[22.2] C. The portal vein is formed by the union of the superior mesenteric and splenic veins posterior to the neck of the pancreas.

[22.3] As you continue, you also note a large, tortuous artery passing to the left along the superior border of the pancreas. This is likely to be which of the following? A. Left renal artery B. IMA C. Splenic artery D. Left gastroomental artery E. Left colic artery

[22.3] C. The splenic artery, the most tortuous artery of the body, is located along the superior border of the pancreas as it passes to the left toward the spleen.

[23.1] You are examining the liver during a surgical procedure. The gallbladder will be found in its fossa between which two anatomical lobes? A. Quadrate and left lobes B. Quadrate and caudate lobes C. Right and quadrate lobes D. Caudate and right lobes E. Caudate and left lobes

[23.1] C. The gallbladder is located between the right lobe and the quadrate lobe.

[23.2] If you ligated the right hepatic artery, the arterial supply to which of the following portions of the liver would remain intact? A. Right lobe only B. Right and quadrate lobes C. Left lobe only D. Left and quadrate lobes only E. Left, quadrate, and a portion of the caudate lobe

[23.2] E. The left hepatic artery supplies the left and quadrate lobes and a portion of the caudate lobe.

[23.3] Your patient who had cirrhosis has symptoms of esophageal varices. This is due to dilatation of the anastomosis between which of the following pairs of veins? A. Left gastric and the azygous veins B. Right gastric and the azygous veins C. Right gastric and the hemiazygous D. Left gastric and the hemiazygous E. Azygous and the hemiazygous

[23.3] D. Esophageal veins drain to the left gastric and the hemiazygous veins.

[24.1] Gastric contents exiting a posterior perforation of the stomach wall will accumulate in which of the following? A. The left paracolic gutter B. The left paravertebral gutter C. The right paravertebral gutter D. The omental bursa E. The hepatorenal recess

[24.1] D. The omental bursa lies immediately posteriorly to the stomach.

[24.2] Ligation of the common hepatic artery will eliminate the gastric blood supply through which of the following arteries? A. Left gastric and short gastric arteries B. Short gastric and right gastro-omental arteries C. Right gastro-omental and right gastric arteries D. Right gastric and left gastric arteries E. Left gastric and left gastro-omental arteries

[24.2] C. Blood flow through the right gastric and right gastro-omental arteries would be lost with ligation of the common hepatic artery.

[24.3] A surgical incision through the fundus of the stomach would require you to clamp which of the following? A. Right gastric artery B. Left gastric artery C. Right gastro-omental artery D. Left gastro-omental artery E. Short gastric arteries

[24.3] E. The short gastric arteries supply the fundus of the stomach.

[25.1] During the removal of a patient's kidney, you would observe which of the following as being most anterior within the renal sinus? A. Renal arteries B. Renal vein C. Major calyx D. Minor calyx E. Renal pelvis

[25.1] B. The renal veins lie most anterior within the renal sinus.

[25.2] You wish to examine the hilum of the right kidney during surgery. Which of the following structures must be elevated and reflected to do so? A. Stomach B. Suprarenal gland C. Ascending colon D. Duodenum E. Liver

[25.2] D. The duodenum lies immediately anteriorly to the hilum of the right kidney.

[25.3] To elevate the kidney within the renal fascia and the perirenal fat, the renal fascia must be reflected or incised from the fascia of which of the following muscles? A. Diaphragm B. Psoas muscle C. Quadratus lumborum muscle D. Transverses abdominis muscle E. Iliacus muscle

[25.3] B. The renal fascia is fused posteriorly to the fascia of the psoas muscle.

[26.1] As a surgeon about to remove the right adrenal gland, you examine the blood supply of the right adrenal gland and observe which of the fol- lowing? A. It receives its arterial blood supply from the aorta only B. Its central vein drains into the IVC C. Its central vein drains into the left renal vein D. It is in contact with the head of the pancreas E. It lies external to the renal fascia

[26.1] B. The central vein of the right suprarenal gland drains into the IVC, whereas that of the right gland drains into the left renal vein.

[26.2] After removal of a large portion of the stomach in a patient who has cancer, you are now examining the lymph nodes that receive lymph from the stomach. Which of the following structures receives lymph directly from the stomach? A. Cisterna chili B. Aorticorenalnodes C. Celiac nodes D. Superior mesenteric nodes E. Inferior mesenteric nodes

[26.2] C. Lymph nodes located along the several arteries that supply the stomach will have their lymph drain to the celiac nodes. Remember that the arteries that supply the stomach are all branches of the celiac artery.

[26.3] In a patient who has testicular cancer that has metastasized (spread) to the lymph nodes, which of the following would you expect to be involved first? A. Lumbar (aortic) nodes B. Aorticorenalnodes C. Inferior mesenteric nodes D. Common iliac nodes E. Internal iliac nodes

[26.3] A. Tumor cells from either gonad that metastasize through the lymphatics will metastasize to the lumbar (aortic) lymph group. Remember the origin of the gonadal arteries is the abdominal aorta.

[27.1] A 34-year-old woman who has diabetes develops a "boil" on the right labia majora. Which of the following lymph nodes is most likely to be enlarged in response to the infection? A. Internal iliac B. External iliac C. Superficial inguinal D. Obturator

[27.1] C. The primary drainage of the vulva is the superficial inguinal nodes.

[27.2] Which of the following structures divides the perineum into the genitourinary and anal triangles? A. Levator ani muscles B. Superficial transverse perineal muscle C. Line from the ischial tuberosities D. Anal verge

[27.2] C. A line between the two ischial tuberosities divides the perineum into the genitourinary triangle (anteriorly) and the anal triangle (posteriorly).

[27.3] A 24-year-old woman is undergoing a vaginal delivery. A midline episiotomy is performed that incises into the perineal body. Which of the following muscles is most likely to be cut during this process? A. Superficial transverse perineal muscle B. Levator ani muscle C. Puborectalis muscle D. Pubococcygeus muscle

[27.3] A. The muscles that attach to the perineal body are the bulbospongiosus, superficial and deep transverse perineal muscles, and the external anal sphincter.

[28.1] Which of the following is the male homologue of the female clitoris? A. Epididymis B. Vas deferens C. Penis D. Scrotum

[28.1] C. The penis in the male is the homologue to the clitoris in the female.

[28.2] The scrotum appears to have a slightly pigmented and wrinkled appearance. What is the explanation for this appearance? A. Hyperkeratinized squamous epithelium B. The tunica albuginea C. The dartos fascia D. The pampiniform plexus

[28.2] C. The dartos fascia, which consists of smooth muscle, gives the scrotum its characteristic slightly pigmented and wrinkled appearance.

[28.3] An 18-year-old man is noted to have probable testicular cancer. He undergoes surgery. After incising the scrotum, the surgeon contem- plates the approach to the parenchyma of the testes. Through which layer must the surgeon incise to reach the testicular parenchyma? A. Buck fascia B. Tunica albuginea C. Dartos fascia D. Scarpa fascia

[28.3] B. Each testis is surrounded by a thick capsule, the tunica albuginea.

[29.1] A 31-year-old woman is in her physician's office for a fitting for an intrauterine contraceptive device. The physician performs a pelvic examination to ensure that the device is placed in the correct direction. The physical examination shows that the uterine body is tipped toward the rectum and that the uterine fundus is tipped anteriorly. Which of the following describes the position of the uterus? A. Anteverted, anteflexed B. Anteverted,retroflexed C. Retroverted, anteflexed D. Retroverted, retroflexed

[29.1] C. "Version" refers to the relation between the uterus and the vagina, whereas "flexion" denotes the relation between the body and the cervix. Thus, this uterus is retroverted and anteflexed.

[29.2] A 45-year-old woman is having significant uterine bleeding from uterine fibroids. The radiologist performs an embolization procedure of the uterine arteries. Through which of the following structures do the uterine arteries traverse? A. Transverse cervical (cardinal) ligaments B. Uterosacral ligaments C. Vesicouterine fold D. Anterior vaginal fornix

[29.2] A. The uterine arteries travel through the transverse cervical ligaments.

[29.3] A 20-gauge spinal needle is placed through the vagina to assess whether there is blood in the peritoneal cavity. Which of the following describes the most dependent part of the peritoneum or pelvis? A. Vesicouterine fold B. Pararectal space C. Paravesical space D. Rectouterine pouch (of Douglas)

[29.3] D. The most dependent region of the pelvis is the rectouterine pouch of Douglas. The procedure described is called a culdocentesis, in which the spinal needle is placed through the posterior vaginal fornix.

[3.1] A 23-year-old accountant trips over a briefcase and falls onto his outstretched hand. A carpal bone fracture is suspected. Which of the following bones is most likely fractured? A. Scaphoid B. Lunate C. Triquetrum D. Pisiform E. Capitate

[3.1] A. The scaphoid bone is the most frequently fractured carpal bone.

[3.2] You are examining a radiograph of a patient's wrist and note malalignment (dislocation) of one of the carpal bones. Which of the following is most likely to be the dislocated carpal bone? A. Scaphoid B. Lunate C. Triquetrum D. Capitate E. Hamate

[3.2] B. The lunate bone is the most frequently dislocated carpal bone.

[3.3] A patient with a severe tear of the medial collateral ligament of the wrist would likely display which of the following increased wrist movements? A. Flexion B. Extension C. Abduction D. Adduction E. Pronation

[3.3] C. The medial or ulnar collateral ligament limits abduction or radial deviation of the wrist, which would be increased if the ligament were severely torn.

[3.4] A 24-year-old male slips on a banana peel and falls onto his outstretched hand. Which of the following structures transmits the force from the radius to the ulna? A. Triangular fibrocartilage B. Interosseous membrane C. Scaphoid bone D. Ulnar collateral ligament E. Radial collateral ligament

[3.4] B. The interosseous membrane conducts force from the radius to the ulna when the force originates from the wrist.

[30.1] A 22-year-old woman is noted during surgery to have a 3-cm ectopic pregnancy involving the ampulla of the fallopian tube. Which of the following best describes this location of the tube? A. Portion within the muscle of the uterus B. Portion that is narrowest and mobile C. Portion that begins to widen distally and is the longest portion of the tube D. Portion with finger-like projections

[30.1] C. The ampulla of the tube, which is the most common location of ectopic pregnancies, is the part of the tube that begins to widen at the distal end of the tube.

[30.2] Bilateral oophorectomy is performed in a woman who had ovarian cancer. To accomplish this procedure, the ovarian arteries were ligated. Which of the following describes the anatomy of the ovarian vessels? A. Right ovarian artery arises from the right renal artery B. Right ovarian vein drains into the vena cava C. Left ovarian artery arises from the left internal iliac artery D. Left ovarian vein drains into the vena cava

[30.2] B. Both ovarian arteries arise from the abdominal aorta. The right ovarian vein drains to the vena cava, whereas the left ovarian vein drains into the left renal vein.

[30.3] A 3-cm ectopic pregnancy of the isthmus of the left tube is noted to have ruptured, leading to hemorrhage. The blood noted arises principally from which of the following? A. Uterine artery B. Ovarian artery C. Uterine and ovarian arteries D. Neither the uterine nor the ovarian arteries

[30.3] C. The uterine artery (ascending branch) and the ovarian artery anastomose to provide blood supply within the mesosalpinx to the tube.

[31.1] A 66-year-old man complains of difficulty voiding and is noted to have probable BPH. Which of the following prostatic lobes is likely to be responsible for these symptoms? A. Anterior lobe B. Posterior lobe C. Lateral lobe D. Middle lobe

[31.1] D. The middle lobe of the prostate is the part through which the urethra traverses and may be obstructed by BPH.

[31.2] A 48-year-old man is undergoing cystoscopic examination. As the cystoscope is placed into the urethra through the penile portion, which of the following tissues surrounds the urethra? A. Prostate B. Corpus spongiosum C. Seminal colliculus D. Sphincter urethrae muscles

[31.2] B. The longest portion of the urethra is the penile urethra, which traverses through the corpus spongiosum.

[31.3] A police detective takes a scraping of some stains to be examined for alkaline phosphatase to assess whether these might be ejaculate. What is the source of alkaline phosphatase in the semen? A. Prostatic gland B. Bulbourethral glands C. Seminal vesicles D. Seminal colliculus apparatus

[31.3] C. The seminal vesicles are the source of the alkaline phosphatase in the semen. The alkalinity helps to neutralize the acidity of the vagina.

[32.1] A 39-year-old woman complains of hematuria and significant flank tenderness. She has a history of kidney stones. A CT scan depicts the abdominal portion of the ureter lying anterior to a muscle. Which of the following is most likely to be the name of this muscle? A. Psoas B. Serratus anterior muscle C. Obturator muscle D. Rectus muscle E. External oblique muscle

[32.1] A. The abdominal ureter lies anterior to the psoas muscle.

[32.2] A dissection of the ureter is accomplished to excavate a large retroperitoneal mass. In isolating the ureter, the surgeon is attempting to ensure that the blood supply to the ureter is not disrupted. Which of the following best describes the arterial supply to the ureter? A. Ureteral artery arising from the abdominal aorta B. Ureteral artery arising form the external iliac artery C. Ureteral artery arising from the internal iliac artery D. No specific artery, but rather small branches from the nearby arteries

[32.2] D. The ureter does not have any specific artery supplying it, but rather has small branches from the nearby arteries such as the renal, gonadal, aorta, common and internal iliac, and vesical and uterine arteries.

[32.3] A 30-year-old woman is noted to have an absent kidney. Which of the following findings is she also likely to have? A. Absent unilateral ovary B. Unicornuate uterus C. Imperforate hymen D. Inguinal hernia

[32.3] B. The urinary and paramesonephric ducts are in close proximity anatomically and relationally during embryologic development. Thus, a congenital abnormality in the kidney or ureter often is associated with an abnormality of the ipsilateral tube, uterine horn, or cervix. The distal vagina, vulva, and ovary are of different embryonic origin.

[33.1] A 34-year-old woman is undergoing cystoscopic examination under spinal anesthesia. As the anesthesiologist places the needle into the subarachnoid space to inject the anesthetic agent, he goes through various layers. Which of the following describes the accurate sequence of layers from skin to subarachnoid space? A. Skin, supraspinous ligament, interspinous ligament, posterior longitudinal ligament, dura mater, subarachnoid space B. Skin, supraspinous ligament, interspinous ligament, dura mater, subarachnoid space C. Skin, supraspinous ligament, intertransverse ligament, arachnoid space, subarachnoid space D. Skin, interspinous ligament, anterior longitudinal ligament, dura mater, subarachnoid space

[33.1] B. The sequence of structures is skin, supraspinous ligament, interspinous ligament, dura mater, and subarachnoid space.

[33.2] A 45-year-old man complains of shooting pain down his right leg that worsens with sitting and coughing. He also has some numbness in the area. The physician tests sensation on the lateral thigh region. Which of the following nerve roots is being tested? A. L1andL2 B. L2andL3 C. L4andL5 D. S1 and S2 E. S3 and S4

[33.2] C. The lateral thigh is innervated by nerve root L5.

[33.3] A 50-year-old man who has diabetes is having difficulty voiding urine. On examination, he has decreased sensation of the perineal region. Which of the following reflexes is the most likely to be affected? A. Patellar tendon B. Achillestendon C. Cremaster D. Anal wink

[33.3] D. The sensory fibers affected are from S2 through S4, which innervate the perineal region and supply the afferent limb of the anal wink reflex.

Match the following anatomical spaces (A-D) to the descriptions of location. [35.1] Between the dura and the calvaria. A. Epidural B. Subdural C. Subarachnoid D. Intra-arachnoid

[35.1] A. The epidural space is between the fibrous dura and the periosteum of the calvaria.

Match the following anatomical spaces (A-D) to the descriptions of location. [35.2] Between the arachnoid and pia maters. A. Epidural B. Subdural C. Subarachnoid D. Intra-arachnoid

[35.2] C. The subarachnoid space is between the arachnoid and the pia maters.

Match the following anatomical spaces (A-D) to the descriptions of location. [35.3] Between the dura and the arachnoid maters. A. Epidural B. Subdural C. Subarachnoid D. Intra-arachnoid

[35.3] B. The subdural space is between the dura and the arachnoid maters.

Match the following anatomical spaces (A-D) to the descriptions of location. [35.4] A 2-month-old baby is noted to have macrocephaly (large head) and developmental delay. On ultrasound, the baby has significant hydrocephalus. The pediatrician is suspicious of congenital stenosis of the aqueduct of Silvius. Which of the following are the most likely findings in this infant? A. Epidural B. Subdural C. Subarachnoid D. Intra-arachnoid

[35.4] C. The aqueduct of Silvius is between the third and fourth ventricles; thus, dilation of the lateral ventricles and the third ventricle is seen with aqueductal stenosis.

[36.1] Which of the following muscles is most important to allow air movement through the larynx? A. Posterior cricoarytenoids B. Lateral cricoarytenoids C. Cricothyroid muscle D. Infrahyoid muscles

[36.1] A. The posterior cricoarytenoid muscles are the only muscles that abduct the vocal folds and are necessary to widen the rima glottidis for breathing.

[36.2] A 33-year-old woman underwent partial thyroidectomy for hyperthyroidism in which the thyroid failed to take up radioactive iodine. She is noted to have some hoarseness of voice 1 month later. Which of the following is the most likely explanation? A. Endotracheal tube trauma to the vocal cords B. Injury to the cricoid cartilage C. Injury to the thyroid cartilage D. Injury to the recurrent laryngeal nerve

[36.2] D. Injury to the recurrent laryngeal nerve is common during thyroid surgery and may lead to the inability to tightly adduct the two vocal folds, resulting in hoarseness. In addition, the protective function of the rima glottidis may be lost, and food or liquid that does not go down the esophagus may flow into the trachea and cause a choking response.

[36.3] A 15-year-old boy is eating a fish dinner and inadvertently has a bone "caught in his throat." He complains of significant pain above the vocal cords. Which of the following nerves is responsible for carrying the sensation for this pain? A. Superior laryngeal nerve B. Recurrent laryngeal nerve C. Spinal accessory nerve D. Hypoglossal nerve

[36.3] A. The laryngeal mucosa above the vocal cords is innervated by the superior laryngeal nerve, whereas mucosa below the vocal cords is innervated by the recurrent laryngeal nerve.

[36.4] A 25-year-old woman underwent surgery for a thyroid nodule. Two months later, she complains of dryness of skin and muscle spasms. Which of the following is the most likely explanation? A. Low serum magnesium B. Low serum calcium C. Low serum potassium D. Low serum sodium E. Low serum glucose

[36.4] B. This patient likely has hypocalcemia due to excision of the parathyroid glands.

[37.1] A 47-year-old man complains of right arm weakness and difficulty speaking (expressive aphasia). Which of the following arteries is most likely affected? A. Vertebral B. Posterior cerebral C. Middle cerebral D. Anterior cerebral

[37.1] C. The middle cerebral artery supplies the temporal and parietal regions that contain Broca area (the speech center).

[37.2] A surgeon is performing a carotid endarterectomy in a 55-year-old man who has carotid artery occlusion. In approaching the internal carotid artery, the surgeon severs a nerve embedded in the carotid sheath. Which nerve was severed? A. Superior laryngeal B. Vagus C. Sympathetic trunk D. Ansa cervicalis E. Recurrent laryngeal

[37.2] D. The ansa cervicalis is a branch of the cervical plexus that inne vates the infrahyoid strap muscles. The superior root generally descends within the carotid sheath superficially to the internal jugular vein. Therefore, this nerve is at risk during surgical approaches to the internal carotid artery.

[37.3] A 44-year-old man falls from a tree and develops a severe scalp hematoma. The superficial temporal artery continues to bleed internally because the man takes warfarin sodium (Coumadin) for an artificial heart valve. Which of the following arteries may be ligated to control the bleeding? A. Internal carotid B. External carotid C. Occipital D. Maxillary

[37.3] B. The external carotid artery divides into two branches: the maxillary artery and the superficial temporal artery.

[38.1] A 2-year-old girl is diagnosed with torticollis involving the right SCM. Which of the following describes the most likely anatomical change? A. Head flexed forward in the midline B. Head rotated to the right C. Head rotated to the left D. Head extended in the midline plane

[38.1] C. With torticollis, the SCM is shortened, leading to the head being rotated toward the contralateral side.

[38.2] A 24-year-old football player receives a blow to the left skull, and the team physician finds weakness of the left SCM. Which of the following associated findings is most likely to be seen in this patient? A. Weakness of the masseter muscle B. Decreased sensation of the ipsilateral face C. Decreased tearing from the ipsilateral eye D. Weakness of the trapezius muscle

[38.2] D. The SCM and the trapezius muscle are innervated by the spinal accessory nerve (CN XI), which is at risk in the posterior triangle of the neck.

[38.3] A clinician is palpating the anterior neck of a patient who has been involved in a motor vehicle accident and notes the laryngeal prominence. Which of the following describes the anatomical structure that corresponds to this prominence? A. Thyroid cartilage B. Cricoid cartilage C. Hyoid bone D. First tracheal ring

[38.3] A. The laryngeal prominence is produced by the superior border of the thyroid cartilage.

[39.1] A 57-year-old man is diagnosed with colon cancer. He is noted to have a probable metastatic mass in the neck at the thoracic duct. Where is the metastasis likely to be located? A. Right supraclavicular region B. Right subclavicular region C. Left supraclavicular region D. Left subclavicular area

[39.1] C. The thoracic duct drains into the left subclavian vein. Malignant metastasis is often diverted to the supraclavicular nodes, where it proliferates.

[39.2] A 65-year-old woman is noted to have cancer of the vulva. It is noted that the cancer has spread to the lymph nodes in the femoral triangle. Which of the following best describes the location of the lymph nodes? A. Immediately lateral to the femoral nerve B. Immediately medial to the femoral nerve C. Immediately medial to the femoral artery D. Immediately medial to the femoral vein E. Immediately lateral to the femoral vein

[39.2] D. The relations of the structures in the groin can be remembered by the mnemonic NAVEL: Nerve, Artery, Vein, Empty space, Lymph node.

[39.3] What is the mechanism that propels lymph through the lymphatic vessels? A. Cardiac contractility B. Gravity C. Peristalsis D. Compression

[39.3] D. Compression is the primary way that lymph moves through the lymphatic vessels.

[4.1] You are examining an axial (cross-section) magnetic resonance imaging (MRI) scan of the wrist and have identified the carpal tunnel. Which of the following is the structure that forms the anterior wall of the tunnel? A. Palmar aponeurosis B. Volar carpal ligament C. Flexor retinaculum D. Extensor retinaculum E. Deep fascia

[4.1] C. The flexor retinaculum or transverse carpal ligament forms the anterior boundary of the carpal tunnel.

[4.2] As you are explaining carpal tunnel syndrome to a woman who has the condition, shown where the median nerve is located just as it is about to enter the tunnel. Where is the median nerve located? A. Just lateral to the flexor carpi radialis tendon B. Must medial to the flexor carpi radialis tendon C. Just medial to the flexor palmaris longus tendon D. Just lateral to the flexor carpi ulnaris tendon E. Just medial to the flexor carpi ulnaris tendon

[4.2] B. The median nerve lies just medial to the tendon of the flexor carpi radialis at the wrist.

[4.3] If the median nerve were severed in an industrial accident at the wrist, which of the following muscles would still retain their function? A. Flexor pollicis brevis B. Abductor pollicis brevis C. Opponens pollicis D. Lumbricals of the index and middle fingers E. Lumbricals of the ring and little fingers

[4.3] E. The lumbricals to the ring and little finger are innervated by the ulnar nerve.

[40.1] A 44-year-old man complains of difficulty hearing from the right ear and headaches. He also has weakness of the facial muscles. Which of the following is the most likely explanation? A. Peripheral CN VII palsy B. PeripheralCNVIIIpalsy C. Cerebellar pontine angle lesion D. Trigeminal ganglion lesion

[40.1] C. When multiple nerves are affected, it is unlikely to be a peripheral disorder. Cranial nerves VII and VIII exit in close proximity from the pons. A schwannoma involving the cerebellopontine angle can affect both cranial nerves.

[40.2] An injury to the facial nerve (CN VII) as it leaves the stylomastoid foramen would disrupt which function? A. Taste to the posterior tongue B. Sensation to the cornea C. Sensation to the cheek D. Sensation to the anterior scalp E. Wrinkling the forehead

[40.2] E. Wrinkling the forehead is produced by contraction of the frontalis muscle, which is innervated by the facial nerve. The facial nerve is responsible for taste in the anterior two-thirds of the tongue, but the chorda tympani emerges before the main trunk exits through the stylomastoid foramen. Sensation of the cornea and sensation to the cheek are supplied by the trigeminal nerve.

[40.3] A 33-year-old woman suffered a skull fracture that led to a unilateral facial nerve palsy. Which of the following fractures was most likely responsible? A. Frontal calvaria B. Temporal bone fracture involving the squamous part C. Occipital fracture D. Basilar fracture involving the mastoid area

[40.3] D. The basilar fracture involving the mastoid region of the temporal bone may impinge on the facial nerve as it exits the stylomastoid foramen.

[41.1] A 56-year-old man had a stroke. Among other symptoms, a marked deficit in bite strength was observed on the affected side, indicating weakness in the muscles of mastication. Which of the following muscles is also innervated by the same nerve? A. Orbicularis oculi B. Platysma C. Anterior belly of digastric D. Stylohyoid E. Superior belly of omohyoid

[41.1] C. The anterior belly of digastric is innervated by CN V3, as are the muscles of mastication. The platysma and orbicularis oculi muscles are supplied by CN VII.

[41.2] A 45-year-old woman who has diabetes has developed shingles involving the right cornea. Through which nerve did the varicella virus most likely travel to the cornea? A. CNII B. CN III C. CN V D. CNVII

[41.2] C. The trigeminal nerve supplies sensory innervation to the cornea. Herpes simplex infections or varicella virus infections involving the face may travel through CN V to the cornea and endanger vision.

[41.3] Auricultemporal nerve. Match the following divisions (A-C) to the branches. A. CNV1 B. CN V2 C. CN V3

[41.3] C. CN V3 supplies the auriculotemporal, buccal, and mental nerves.

[41.4] Lacrimal nerve. Match the following divisions (A-C) to the branches. A. CNV1 B. CN V2 C. CN V3

[41.4] A. CN V1 supplies the lacrimal, supraorbital, and supra- and infratrochlear nerves.

[41.5] Supraorbital nerve. Match the following divisions (A-C) to the branches. A. CNV1 B. CN V2 C. CN V3

[41.5] A. CN V1 supplies the lacrimal, supraorbital, and supra- and infratrochlear nerves.

[41.6] Infraorbital nerve. Match the following divisions (A-C) to the branches. A. CNV1 B. CN V2 C. CN V3

[41.6] B. CN V2 supplies the infraorbital and zygomaticotemporal nerves.

[42.1] During a physical examination of a patient, you notice ptosis of the patient's left eye. This would indicate to you there is paralysis of which muscle? A. Orbicularis muscle B. Superior oblique muscle C. Inferior oblique muscle D. Inferior rectus muscle E. Levator palpebrae muscle

[42.1] E. Ptosis or drooping of the eyelid is due to paralysis of the levator palpebrae muscle. The orbicularis muscle closes the eyelid.

[42.2] While performing a physical examination, you test the function of the muscles attached to the eyeball, and thereby the integrity of their inner- vation. You would test the function of the superior oblique muscle by having the patient do which of the following? A. Look in toward the nose B. Look laterally C. Look in toward the nose and then upward D. Look in toward the nose and then down E. Look laterally and then down

[42.2] D. Turning the eyeball inward places the portion of the superior oblique between the trochlea and its insertion places the axis of the muscle in line with its axis of muscle pull. Because the muscle's insertion is on the posterior portion of the sclera, it will then turn the eye (pupil) down (depress).

[42.3] During this same physical exam, you ask the patient to look laterally with her right eye, and then upward. You have just tested the function of which muscle? A. Superior rectus muscle B. Superior oblique muscle C. Inferior oblique muscle D. Inferior rectus muscle E. Medial rectus muscle

[42.3] A. Turning the eyeball out places the axis of the superior rectus muscle parallel to its pull and the muscle will then turn the eyeball upward (elevate).

[43.1] Which of the following best describes the layers of scalp? A. Skin, aponeurosis, dense connective tissue, periosteum B. Skin, loose connective tissue, aponeurosis, periosteum C. Skin, dense connective tissue, aponeurosis, loose connective tissue, periosteum D. Skin, aponeurosis, loose connective tissue, muscle, periosteum

[43.1] C. The layers of the scalp can be remembered by the mnemonic SCALP: Skin, Connective tissue, Aponeurosis, Loose connective tissue, Periosteum.

[43.2] A 65-year-old woman complains of severe pain of the right side of the head. A vascular surgeon takes a biopsy of the artery deep to the temporalis muscle. Which of the following vessels did the surgeon most likely biopsy? A. Middle meningeal artery B. External carotid artery C. Ophthalmic artery D. Deep temporal artery

[43.2] D. The temporal artery is deep to the temporalis muscle and sometimes is associated with inflammation (temporal arteritis). Temporal arteritis or giant cell arteritis is associated with headache and multiple joint pain.

[43.3] A neurologist uses a pin to test the sensation to a 26-year-old man's scalp just near the hair line anteriorly. Which of the following nerves provides the innervation to the scalp in this region? A. CN V B. CNVII C. CNX D. Spinal nerve C2

[43.3] A. The anterior scalp is innervated by CN V, whereas the posterior scalp is innervated by spinal nerve C2.

[44.1] A 35-year-old man developed an intracranial hemorrhage when one of the meningeal arteries ruptured. Anatomically, where is the hematoma located? A. Immediately superficial to the dura B. Immediately deep to the dura C. Within the subarachnoid space D. Within the brain parenchyma

[44.1] A. Injuries to the meningeal arteries lead to epidural hematomas.

[44.2] A 1-month-old infant is seen in the emergency department due to lethargy and seizures. After careful questioning, it was discovered that the infant was shaken before the change in mental status. Which vessels are most likely to be injured? A. Meningeal arteries B. Meningeal veins C. Emissary veins D. Middle cerebral arteries

[44.2] C. Infants who are shaken are vulnerable to laceration of the emissary veins that are found below the dura. Thus, they often develop sub- dural hematomas.

[44.3] A 21-year-old man is brought into the emergency room after being hit in the head with a baseball bat. The neurosurgeon notes that the skull fracture and underlying hematoma seem to have occurred at the junction of the four major bones of the skull. Which of the following describes this region? A. Bregma B. Lambda C. Pterion D. Nasion

[44.3] C. The pterion is a landmark of the skull where the four major bones of the skull (frontal, parietal, temporal, and sphenoidal) come together. It is also the thinnest part of the skull

[45.1] A 22-year-old male is involved in a knife fight after a soccer game. He is brought to the emergency department. An 8-cm laceration that involves the right cheek, from his right ear to near the corner of his mouth, is noted. Which of the following structures is most likely injured? A. Parotid duct B. Submandibular duct C. Superficial temporal artery D. Lingual artery E. Mandibular branch of the facial nerve

[45.1] A. The buccal branch of the facial nerve and the parotid duct travel in the area of the cheek and can be located by a line drawn from the tragus of the ear (or the external auditory meatus) to the corner of the mouth.

[45.2] A 45-year-old woman is undergoing surgical resection of the salivary gland for probable cancer. After surgery, she notes that she cannot move her tongue well. Which of the following salivary glands is most likely involved in the surgery? A. Parotid B. Sublingual C. Submandibular D. Maxillary

[45.2] C. The hypoglossal nerve courses deep to the submandibular gland, and injury to this nerve weakens or paralyzes muscles of the tongue.

[45.3] A 16-year-old girl is brought into the physician's office because her mother suspects an eating disorder. The patient has bilateral swelling of the cheeks that are nontender. There are multiple dental caries. She appears to be of normal weight. Which of the following is the most likely diagnosis? A. Anorexia nervosa B. Bulimia C. Irritable bowel syndrome D. Facetious hyperphagia

[45.3] B. Enlargement of the parotid glands and multiple dental caries are common in individuals who have bulimia. Affected patients may be of normal weight or even slightly overweight, and their behavior is characterized by binges of eating and inducing vomiting or use of laxatives.

[46.1] A 53-year-old man is being examined for carotid bruits. The physician would like to auscultate the internal carotid artery. At what level does the carotid artery usually bifurcate into the internal and external carotid arteries? A. At the level of the cricoid cartilage B. At the level of the thyroid cartilage C. At the level of sternal notch D. At the level of the C8 vertebra

[46.1] B. The carotid artery bifurcates at the level of the thyroid cartilage.

[46.2] A 64-year-old man is diagnosed with an acute stroke. His main deficit is a partial loss of his visual field. The neurologist diagnoses a lesion of the occipital lobe. Which of the following arteries is likely to be involved? A. Internal carotid B. External carotid C. Middle cerebral D. Posterior cerebral

[46.2] D. The occipital lobes are supplied by the posterior cerebral arteries, which are terminal branches of the basilar artery.

[46.3] A 35-year-old man complains of the worst headache of his life, grabs onto the back of his neck, and then slumps onto the floor. At the hos- pital, his CT findings are consistent with a subarachnoid hemorrhage. Which of the following is the most likely etiology? A. Carotid artery occlusion B. Vertebrobasilar artery occlusion C. Middle meningeal artery laceration D. Rupture of a berry aneurysm

[46.3] D. The most common causes of subarachnoid hemorrhage are rupture of a berry aneurysm in the circle of Willis and bleeding from an arteriovenous malformation.

[47.1] A 4-year-old boy was noted to have recurrent ear infections. He underwent placement of tubes in the tympanic membranes 3 days previously and currently complains of some difficulty in tasting candy. Which of the following is the most likely explanation? A. Disruption of CN VIII B. Disruption of the chorda tympani C. Effects of the anesthesia D. Effects of the endotracheal tube

[47.1] B. The chorda tympani, which a branch of CN VII, courses behind the tympanic membrane and occasionally can be injured during sur- gery for ear tubes. The chorda tympani innervates the anterior two- thirds of the tongue.

[47.2] A 5-year-old girl complains of severe pain from her right ear due to an acute otitis media. Which of the following nerves is most likely respon- sible for carrying the sensation of pain from the tympanic membrane? A. CNVII B. CNVIII C. CNIX D. CN X

[47.2] C. The glossopharyngeal nerve (CN IX) is the afferent nerve for the sensory input from the internal surface of the tympanic membrane and the tympanic cavity.

[47.3] A 3-year-old boy had there episodes of otitis media over the past year. His mother asks the doctor why children tend to develop more ear infections than adults. Which of the following is the most likely anatomical explanation? A. Changes in the eustachian tube B. Changes in the external pinna C. Changes in the external ear canal D. Changes in the stapedius ossicle

[47.3] A. The eustachian tube connects the middle ear to the oral cavity. The eustachian tube is shorter and more horizontal in a child than in an adult.

[48.1] A 24-year-old medical student has been diagnosed with sinusitis and asks her physician why there is nasal drainage during the night but not during the day. Which of the following is the best explanation? A. Location of the ostia within the sinus B. Location of the ostia within the nasal passage C. Disruption of the drainage due to mastication D. Diurnal mucus production increases at night

[48.1] A. The sinus most likely affected is the maxillary sinus. The ostia within the sinus are located superiorly in a location inefficient for gravity drainage. During sleep at night, the mucus flows out through the ostia.

[48.2] A 22-year-old college student is being seen for possible sinusitis. The physician sees purulent drainage arising from the superior nasal meatus. Which of the following sinuses is likely to be infected? A. Frontal B. Maxillary C. Sphenoidal D. Ethmoidal

[48.2] D. The posterior ethmoidal sinus drains into the superior nasal meatus.

[48.3] A 28-year-old neuroanatomy graduate student noted pain at the bridge of his nose and had been told that he had "sinus" infections. He was speculating about the afferent nerve supply from this area. Which of the following is the most accurate description of the sensory nerve innervation? A. Branches of CN III B. Branches of CN V C. Branches of CN VII D. Branches of CN IX

[48.3] B. The paranasal sinuses are innervated by branches of CN V.

[49.1] During a procedure to remove a palatine tonsil,theoperatingfieldwas suddenly filled with bright red blood. Which artery was inadvertently damaged? A. Tonsillar branch of facial B. Ascending pharyngeal C. Ascendingpalatine D. Descending palatine E. Lingual

[49.1] A. The tonsillar branch of the facial artery lies in the bed of the palatine tonsil and is susceptible to damage. Although the ascending palatine artery sends branches to the tonsil, it is not likely to be affected in a routine procedure.

[49.2] A patient has a mild chronic cough, but has clear lungs and no evidence of bronchitis. Her physician believes that the symptoms are due to postnasal drip brought on by allergy. Which nerve is responsible for the afferent limb of the cough reflex? A. CNV2 B. CN V3 C. CNVII D. CN IX E. CNX

[49.2] D. The cough reflex is stimulated by irritation of the laryngopharynx, which is innervated by CN IX. The trigeminal nerve (CN V1 and V2) innervates the oral and nasal cavities.

[49.3] Which structure passes through the gap between the superior and middle constrictor muscles? A. Recurrent laryngeal artery B. Internal laryngeal nerve C. Superior laryngeal artery D. Glossopharyngeal nerve E. Pharyngotympanic tube

[49.3] D. The glossopharyngeal nerve (CN IX) passes through the gap between the superior and middle constrictors, along with the sty- lopharyngeus muscle and stylohyoid ligament.

[5.1] You are evaluating a radiograph of the only bony articulation between the upper limb and the trunk. Which of the following joints are you evaluating? A. Glenohumeral B. Acromioclavicular C. Humeroclavicular D. Coracoclavicular E. Sternoclavicular

[5.1] E. The upper limb is attached to the trunk only at the sternoclavicular joint. The primary attachment is muscular.

[5.2] You are explaining the anatomy of the shoulder to a young athlete who has sustained an injury to one of his shoulders. You tell him the chief stability to this joint is from which of the following? A. Glenohumeral ligaments B. Acromioclavicularligament C. Rotator cuff muscles D. Coracoclavicular ligaments E. Coracohumeral ligament

[5.2] C. The primary stability to the glenohumeral joint is provided by the tendons of the rotator cuff.

[5.3] A college baseball pitcher has shoulder discomfort and you suspect a rotator cuff tear. You will most likely see damage to the tendon of which of the following muscles? A. Supraspinatus B. Infraspinatus C. Subscapularis D. Teres major E. Teres minor

[5.3] A. The tendon of the supraspinatus is typically damaged in a rotator cuff tear due to the narrow space between the head of the humerus and the acromion.

[50.1] A 24-year-old man is being evaluated for airway abnormalities. Palpation of the cricoid cartilage is normally at which vertebral level? A. C2 B. C4 C. C6 D. T1

[50.1] C. The cricoid cartilage is usually located at the C6 vertebral level.

[50.2] A 45-year-old woman is undergoing thyroid surgery for suspected thyroid cancer. The surgeon has taken a midline approach and encounters significant bleeding below the isthmus of the thyroid gland. Which of the following is the likely cause of the bleeding? A. Penetration into the trachea B. Superior thyroid artery C. Inferior thyroid artery D. Thyroid ima artery E. Inferior laryngeal artery

[50.2] D. In up to 12 percent of individuals, a small midline artery, called the thyroid ima artery, arises from the aortic arch or brachiocephalic trunk and reaches the thyroid isthmus inferiorly.

[50.3] A 54-year-old woman has undergone partial thyroid resection due to a nontender cold nodule that likely represents cancer. One week after surgery, she complains of twitching of the right arm and "spasms" of both hands. Which of the following is the most likely explanation? A. Anxiety after surgery B. Effects of anesthesia C. Parathyroid glands removed D. Vagal nerve injury

[50.3] C. The parathyroid glands are variably inside the thyroid gland. With resections of the thyroid, the small parathyroid glands may be affected, leading to decreased levels of calcitonin and, hence, hypocalcemia. The low calcium levels may cause clinical symptoms of muscle spasms, tetany, or even convulsions.

[50.4] An emergency cricothyroidotomy is thought to be warranted due to airway collapse and severe laryngoedema. Which of the following is the most accurate description of the location of the cricothyroid membrane? A. Immediately superior to the thyroid cartilage B. Immediately inferior to the thyroid cartilage C. Immediately inferior to the cricoid cartilage D. Just deep to the isthmus of the thyroid gland E. Immediately inferior to the hyoid bone

[50.4] B. The cricothyroid membrane is just inferior to the thyroid cartilage and superior to the cricoid cartilage.

[51.1] A 55-year-old man has become anemic and hypotensive due to severe anterior epistaxis. An ear-nose-throat surgeon has been called to address the bleeding. He states that he may need to occlude the major arterial supply. Which of the following arteries is most likely to be responsible? A. Ethmoidal B. Sphenopalatine C. Superior labial D. Greater palatine

[51.1] B. The major blood supply to the anterior septum is the sphenopalatine artery, a branch of which supplies the nasal septum. The sphenopalatine artery arises from the maxillary artery, which is a terminal branch of the external carotid artery.

[51.2] An 18-year-old woman arrives in the emergency department complaining of persistent epistaxis. On examination, there is bleeding from the right nostril. Which of the following locations is the most likely source of the bleeding? A. Anterior nasal septum B. Posterior nasal septum C. Anteriorturbinate D. Posterior turbinate E. Nasal floor

[51.2] A. The most common location of epistaxis is the region of the anterior septum known as Kiesselbach plexus, which has a rich anastomosis of arteries.

[51.3] An 18 year old woman is thrown from her car during a motor vehicle accident and hits her head against the pavement. She has lost conscious- ness but currently is alert and has equally reactive pupils. She is well except for clear nasal leakage from the right nostril that has not abated over 24 hours. Which of the following is the most likely etiology? A. Sympathetic sinus drainage B. Allergic rhinitis from the airbag C. Damage to the cribriform plate D. Lacrimonasal fistula

[51.3] C. This patient likely has cerebrospinal fluid (CSF) rhinorrhea, which is not unusual after head trauma. The cribriform plate and meninges are disrupted, which allows CSF to leak through the nose. This predisposes to meningitis.

[52.1] A 67-year-old man developed a dental abscess that he ignored for 2 weeks. At that time, he began to have severe chest pain due to infec- tion of the mediastinum. Through which pathway did the infection most likely spread to the mediastinum? A. Masticator space B. Pretracheal space C. Retropharyngeal space D. Suprasternal space

[52.1] C. The major pathway between the infections of the neck and the chest is through the retropharyngeal space, which is a potential space between the prevertebral layer of fascia and the buccopharyngeal fascia surrounding the pharynx.

[52.2] A dentist uses local anesthesia to prepare for a procedure on a lower molar tooth. Which of the following nerves is the dentist blocking? A. Submental B. Maxillary C. Mandibular D. Vagus

[52.2] C. Dental anesthesia involving the lower molar teeth is called a lower mandibular block. The nerve affected is the inferior alveolar nerve branch of the mandibular nerve, which is a branch of V3.

[52.3] A 24-year-old male was involved in a knife fight in a bar. He appeared in the emergency department with a 2-cm laceration in the anterolat- eral neck. The wound was superficial, but the physician observed muscle fibers just deep to the superficial fascia. Which of the following muscles was observed? A. Platysma B. Sternocleidomastoid C. Omohyoid D. Trapezius E. Thyrohyoid

[52.3] A. The platysma muscle is a wide flat muscle that covers the anterolateral region of the neck.

[53.1] A 30-year-old woman under went blunt trauma to the left eye and found out that she was unable to secrete tears from that eye. Which of the following is the most likely location of the injury? A. Medial superior orbit B. Medial inferior orbit C. Lateral superior orbit D. Lateral inferior orbit E. Adjacent to nasal bridge

[53.1] C. The lacrimal gland, which produces tears, is located in the superior and lateral aspects of the orbit.

[53.2] A clinician places blue dye into the right eye to assess the patency of the tear duct system. Where should one look to see the eventual flow of the dye, assuming the lacrimal duct system is patent? A. Superior nasal meatus B. Middle nasal meatus C. Inferior nasal meatus D. Oral cavity E. Subclavian vein

[53.2] C. The tears flow through the puncta in the medial inferior aspect of the eyelid and travel through the lacrimal duct into the inferior nasal meatus.

[53.3] A 5-year-old boy is noted to have severe pain, swelling, and redness around his right eye. He has been diagnosed with periorbital cellulitis, with probable spread of the infection to the brain. Which of the following routes best describes the probable avenue of spread to the brain? A. Through the cribriform plate into the meningeal space B. Facial vein to ophthalmic vein to cavernous sinus into the dura space C. Frontal sinus into the sagittal sinus and into the subarachnoids pace D. Facial canal through the internal auditory meatus to the posterior cranial fossa

[53.3] B. Infections involving the periorbital space can penetrate through the ophthalmic vein into the cavernous sinus and into the dural space, leading to meningitis. Thus, prompt antibiotic therapy is critical with this infection.

[6.1] In a patient who has a posterior dislocation of the hip, which of the following ligamentous structures would be torn? A. Pubofemoral ligament B. Iliofemoral ligament C. Ischiofemoral ligament D. Lacunar ligament E. Sacrotuberous ligament

[6.1] C. Posterior dislocation of the hip would tear the ischiofemoral ligament, which reinforces the capsule of the hip posteriorly.

[6.2] A 54-year-old man has just dislocated his right hip. The physician is concerned about the integrity of the joint's blood supply. Which artery is the main blood supply to the hip joint? A. Lateral circumflex femoral B. Medial circumflex femoral C. Superficial circumflex iliac D. Deep circumflex iliac E. Perforating

[6.2] B. The chief blood supply to the hip is the medial circumflex femoral artery.

[6.3] A patient with the hip dislocation is also exhibiting weakness of extension of the thigh at the hip. This would indicate possible damage to which of the following? A. Femoral nerve B. Obturator nerve C. Common fibular portion of the sciatic nerve D. Tibial portion of the sciatic nerve E. Saphenous nerve

[6.3] D. Most of the extensor muscles of the hip (the hamstrings) are innervated by the tibial portion of the sciatic nerve. The gluteus maximus muscle, innervated by the inferior gluteal nerve, could still weakly extend the thigh at the hip.

[7.1] Your patient has sustained an external force to the knee. Which of the following ligaments has prevented abduction of the leg at the knee? A. Oblique popliteal B. Anteriorcruciate C. Posterior cruciate D. Lateral collateral E. Medial collateral

[7.1] E. Abduction of the leg at the knee is limited by the medial or tibial collateral ligament.

[7.2] In this same patient, which of the following ligaments prevented posterior displacement of the tibia on the femur? A. Oblique popliteal B. Anteriorcruciate C. Posterior cruciate D. Lateral collateral E. Medial collateral

[7.2] C. Posterior displacement of the tibia on the femur is limited by the PCL.

[7.3] You have examined a patient and find there is weakness in the ability to flex the knee. This indicates a problem with which of the following nerves? A. Femoral nerve B. Tibial nerve C. Common fibular nerve D. Deep fibular nerve E. Superficial fibular nerve

[7.3] B. The muscles that flex the knee are innervated by the tibial portion of the sciatic nerve.

[8.1] During an abdominal hysterectomy for a cancerous uterus, the obturator nerve was accidentally severed. This resulted in the patient losing which of the following actions? A. Extension of the leg at the knee B. Extension of the thigh at the hip C. Adduction of the thigh at the hip D. Flexion of the leg at the knee E. Dorsiflexion of the foot at the ankle

[8.1] C. The obturator nerve innervates the muscles of the medial compartment of the thigh which adduct the thigh at the hip.

[8.2] A patient comes to you complaining of his inability to stand on his tip toes. Which of the following nerve injuries is most likely to be involved? A. Femoral nerve B. Tibial nerve C. Common fibular nerve D. Deep fibular nerve E. Superficial fibular nerve

[8.2] B. The plantarflexors are located in the posterior compartment of the leg and innervated by the tibial nerve.

[8.3] A 32-year-old woman is brought into the emergency department, because she is unable to evert her foot at the ankle. Which of the following nerve injuries is most likely to be involved? A. Femoral nerve B. Obturator nerve C. Tibial nerve D. Deep fibular nerve E. Superficial fibular nerve

[8.3] E. The muscles of the lateral compartment of the leg evert the foot and are innervated by the superficial fibular nerve.

[9.1] As an orthopedic surgeon is operating in the posterior compartment of the thigh, care is taken to preserve the arterial blood supply to the muscles in that region. These are branches of which of the following arteries? A. Deep femoral artery B. Femoral artery C. Superior gluteal artery D. Inferior gluteal artery E. Obturator artery

[9.1] A. The blood supply to the posterior compartment of the thigh is from perforating branches of the deep femoral artery.

[9.2] A patient has sustained lower limb trauma that has damaged the posterior tibial artery. Therefore, you will be concerned about the blood supply to which of the following? A. Posterior thigh only B. Lateral compartment of the leg only C. Posterior compartment of the leg only D. Sole of the foot only E. Posterior compartment of the leg and the sole of the foot

[9.2] E. The posterior tibial artery provides the blood supply to the calf and sole of the foot.

[9.3] Which are the chief deep veins of the leg that are of concern for DVT? A. Small saphenous vein B. Great saphenous vein C. Deep femoral vein D. Anterior and posterior tibial veins E. Obturator vein

[9.3] D. The deep veins of the leg are the anterior and posterior tibial veins that accompany the arteries of the same name.