Review Test

Directions: Each of the numbered items or incomplete statements in this section is followed by
answers or by completions of the statement. Select the one-lettered answer or completion that is
best in each case.

1. During an outbreak of meningitis at a local 4. A 39-year-old woman with headaches pres-

college, a 20-year-old student presents to a ents to her primary care physician with a pos-
hospital emergency department complain- sible herniated disk. Her magnetic resonance
ing of headache, fever, chills, and stiff neck. imaging (MRI) scan reveals that the postero-
On examination, it appears that he may have lateral protrusion of the intervertebral disk
meningitis and needs a lumbar puncture or between L4 and L5 vertebrae would most likely
a spinal tap. Cerebrospinal fluid (CSF) is nor- affect nerve roots of which of the following
mally withdrawn from which of the following spinal nerves?
spaces? (A) Third lumbar nerve
(A) Epidural space (B) Fourth lumbar nerve
(B) Subdural space
(C) Space between the spinal cord and the pia (D) First sacral nerve
mater (E} Second sacral nerve

(E) Space between the arachnoid and dura 5. A57-year-old woman comes into her
maters physician’s office complaining of fever, nausea,
vomiting, and the worst headache of her
2. A 23-year-old jockey falls from her horse and life. Tests and physical examination suggest
complains of headache, backache, and weak- hydrocephalus (widening ventricles) resulting
ness. Radiologic examination would reveal from a decrease in the absorption of cerebro-
blood in which of the following spaces if the spinal fluid (CSF). A decrease of flow in the
internal vertebral venous plexus was ruptured? CSF through which of the following structures
(A) Space deep to the pia mater would be responsible for these findings?
(B) Space between the arachnoid and dura (A) Choroid plexus
maters (B) Vertebral venous plexus
(C) Subdural space
(D) Internal jugular vein
(E) Subarachnoid space (E} Subarachnoid trabeculae

3. A 42-year-old woman with metastatic breast 6. After a 26-year-old man’s car was broadsided
cancer is known to have tumors in the inter- by a large truck, he is brought to the emergency
vertebral foramina between the fourth and fifth department with multiple fractures of the
cervical vertebrae and between the fourth and transverse processes of the cervical and upper
fifth thoracic vertebrae. Which of the following thoracic vertebrae. Which of the following
spinal nerves may be damaged? muscles might be affected?
(A) Fourth cervical and fourth thoracic nerves (A) Trapezius
(B) Fifth cervical and fifth thoracic nerves
(C) Fourth cervical and fifth thoracic nerves (C) Rhomboid major
(D) Serratus posterior superior
(E} Third cervical and fourth thoracic nerves (E} Rectus capitis posterior major

43
44 BRS Gross Anatomy

7. A 27-year-old mountain climber falls from 11. An elderly man at a nursing home is known
a steep rock wall and is brought to the emer- to have degenerative brain disease. When cere-
gency department. His physical examination brospinal fluid (CSF) is withdrawn by lumbar
and computed tomography (CT) scan reveal puncture for further examination, which of the
dislocation fracture of the upper thoracic ver- following structures is most likely penetrated by
tebrae. The fractured body of the T4 vertebra the needle?
articulates with which of the following parts of (A) Pia mater
the ribs? (B) Filum terminale externum
(A) Head of the third rib (C) Posterior longitudinal ligament
(B) Neck of the fourth rib
(C) Tubercle of the fourth rib (E) Annulus fibrosus

(E} Tubercle of the fifth rib 12. A 27-year-old stuntman is thrown out of
his vehicle prematurely when the car used for
8. A young toddler presents to her pediatrician a particular scene speeds out of control. His
with rather new onset of bowel and bladder spinal cord is crushed at the level of the fourth
dysfunction and loss of the lower limb function. lumbar spinal segment. Which of the following
Her mother had not taken enough folic acid (to structures would most likely be spared from
the point of a deficiency) during her pregnancy. destruction?
On examination, the child has protrusion of (A) Dorsal horn
the spinal cord and meninges and is diagnosed (B) Ventral horn
with which of the following conditions?
(C) Lateral horn
(A) Spina bifida occulta (D) Gray matter
(B} Meningocele (E) Pia mater

(D} Myeloschisis 13. A 24-year-old woman comes to a hospital to

(E) Syringomyelocele deliver her baby. Her obstetrician uses a caudal
anesthesia during labor and childbirth to block
9. A 34-year-old woman crashes into a tree the spinal nerves in the epidural space. Local
during a skiing lesson and is brought to a hos- anesthetic agents are most likely injected via
pital with multiple injuries that impinge the which of the following openings?
dorsal primary rami of several spinal nerves. (A) Intervertebral foramen
Such lesions could affect which of the following
muscles? (C} Vertebral canal
(A) Rhomboid major (D) Dorsal sacral foramen
(B) Levator scapulae (E) Ventral sacral foramen
(C) Serratus posterior superior
14. Ina freak hunting accident, a 17-year-old
(E} Latissimus dorsi boy was shot with an arrow that penetrated into
his suboccipital triangle, injuring the suboc-
10. During a domestic dispute, a 16-year-old cipital nerve between the vertebral artery and
boy receives a deep stab wound around the su- the posterior arch of the atlas. Which of the fol-
perior angle of the scapula near the medial bor- lowing muscles would be unaffected by such a
det, which injures both the dorsal scapular and lesion?
spinal accessory nerves. Such an injury could (A) Rectus capitis posterior major
result in paralysis or weakness of which of the (B) Semispinalis capitis
following muscles?
(A) Trapezius and serratus posterior superior (D) Obliquus capitis superior
(E) Obliquus capitis inferior
(C) Rhomboid minor and latissimus dorsi
(D) Splenius cervicis and sternocleidomastoid
(E) Levator scapulae and erector spinae
 (ETE Back 45
15. A 26-year-old heavyweight boxer was (D) Whiplash injury
punched on his mandible, resulting in a slight (E) Herniated disk
subluxation (dislocation) of the atlantoaxial
joint. The consequence of the injury was 20. A 37-year-old man is brought to the emer-
decreased range of motion at that joint. What gency department with a crushed second
movement would be most affected? cervical vertebra (axis) that he suffered after a
(A) Extension stack of pallets fell on him at work. Which of the
(B) Flexion following structures would be intact after the
(C) Abduction accident?
(D}) Adduction (A) Alar ligament
(B) Apical ligament
(C} Semispinalis cervicis muscle
16. Acrush injury of the vertebral column can
cause the spinal cord to swell. Which structure (E) Obliquus capitis inferior
would be trapped between the dura and the
vertebral body by the swelling spinal cord? 21. A middle-aged coal miner injures his back
(A) Anterior longitudinal ligament after an accidental explosion. His magnetic
(B} Alar ligament resonance imaging (MRI) scan reveals that his
(C) Posterior longitudinal ligament spinal cord has shifted to the right because the
lateral extensions of the pia mater were torn.
(E} Ligamentum nuchae Function of which of the following structures is
most likely impaired?
17. A 44-year-old woman comes to her physi- (A) Filum terminale internum
cian and complains of headache and backache. (B) Coccygeal ligament
On examination, she is found to have fluid
accumulated in the spinal epidural space be- (D) Choroid plexus
cause of damage to blood vessels or meninges. (E) Tectorial membrane
Which of the following structures is most likely
ruptured? 22. A 25-year-old man with congenital ab-
(A) Vertebral artery normalities at birth has a lesion of the dorsal
(B) Vertebral vein scapular nerve, making him unable to adduct
(C) External vertebral venous plexus his scapula. Which of the following muscles is
most likely paralyzed?
(E} Lumbar cistern (A) Semispinalis capitis

18. A 69-year-old man has an abnormally (C} Multifidus

increased curvature of the thoracic vertebral (D) Rotator longus
column. Which of the following conditions is (E) Iliocostalis
the most likely diagnosis?
(A) Lordosis 23. After an automobile accident, a back mus-
(B) Spina bifida occulta cle that forms the boundaries of the triangle of
(C) Meningocele auscultation and the lumbar triangle receives
(D} Meningomyelocele no blood. Which of the following muscles might
be ischemic?
(A) Levator scapulae
19. During a snowstorm, a 52-year-old man is (B}) Rhomboid minor
brought to the emergency department after a (C) Latissimus dorsi
multiple car accident. Which of the following (D) Trapezius
conditions is produced by a force that drives the (E) Splenius capitis
trunk forward while the head lags behind in a
rear-end automobile collision?
(A) Scoliosis
(B} Hangman fracture
(C) Meningomyelocele
46 BRS Gross Anatomy

24, A 38-year-old woman with a long history of 26. When the internal vertebral venous plexus
shoulder pain is admitted to a hospital for sur- is ruptured, venous blood may spread into
gery. Which of the following muscles becomes which tissue and space?
ischemic soon after ligation of the superficial
or ascending branch of the transverse cervical 27. Dorsal and ventral roots of the lower lum-
artery? bar and sacral nerves are lacerated. Which
(A) Latissimus dorsi structure is most likely damaged? (7
(B} Multifidus
28. The spinal cord is crushed at the level of the
(D} Rhomboid major upper part of the first lumbar vertebra. Which
(E} Longissimus capitis structure is most likely damaged? B

25, A 25-year-old soldier suffers a gunshot

29. Which structure may herniate through the
wound on the lower part of his back and is un-
annulus fibrosus, thereby impinging on the
able to move his legs. A neurologic examination
roots of the spinal nerve? A
and magnetic resonance imaging (MRI) scan
reveal injury of the cauda equina. Which of the
following is most likely damaged? 30. Cerebrospinal fluid (CSF) is produced by
vascular choroid plexuses in the ventricles of
{A} Dorsal primary rami
the brain and accumulated in which space?p)
(B} Ventral primary rami
(C) Dorsal roots of the thoracic spinal nerves

(E) Lumbar spinal nerves

Questions 26 to 30: Choose the appropriate let-

tered structure in this magnetic resonance im-
aging (MRI) scan of the back (see Figure below).
 Review Test

Directions: Each of the numbered items or incomplete statements in this section is followed by
answers or by completions of the statement. Select the one-lettered answer or completion that is
best in each case.

1. A 32-year-old patient who weighs 275 Ib degeneration of nerve cell bodies in which of
comes to the doctor’s office. On the surface of the following structures?
the chest, the physician is able to locate the (A) Dorsal root ganglion and anterior horn of
apex of the heart: the spinal cord
(A) At the level of the sternal angle (B} Sympathetic chain ganglion and dorsal
(B) In the left fourth intercostal space root ganglion
(C) In the left fifth intercostal space (C) Sympathetic chain ganglion and posterior
(D} In the right fifth intercostal space horn of the spinal cord
(E) At the level of the xiphoid process of the
sternum
(E) Anterior and lateral horns of the spinal
2. A 43-year-old female patient has been cord
lying down on the hospital bed for more than
4 months. Her normal, quiet expiration is 5. A 27-year-old cardiac patient with an irregu-
achieved by contraction of which of the follow- lar heartbeat visits her doctor's office for exami-
ing structures? nation. Where should the physician place the
stethoscope to listen to the sound of the mitral
(B} Serratus posterior superior muscles
valve?
(C) Pectoralis minor muscles (A) Over the medial end of the second left
(D)} Serratus anterior muscles intercostal space
(E} Diaphragm (B) Over the medial end of the second right
intercostal space
3. A 23-year-old man received a gunshot (C) In the left fourth intercostal space at the
wound, and his greater splanchnic nerve was midclavicular line
destroyed. Which of the following nerve fibers
would be injured? clavicular line
(A) General somatic afferent (GSA) and pre- (E) Over the right half of the lower end of the
ganglionic sympathetic fibers body of the sternum
(B) General visceral afferent (GVA) and post-
ganglionic sympathetic fibers 6. A 19-year-old man came to the emergency
department, and his angiogram exhibited that he
(D) General somatic efferent (GSE) and post- was bleeding from the vein that is accompanied
ganglionic sympathetic fibers by the posterior interventricular artery. Which of
(E) GVA and GSE fibers the following veins is most likely to be ruptured?
(A) Great cardiac vein
4. A 17-year-old boy was involved in a gang (B) Middle cardiac vein
fight, and a stab wound severed the white (C} Anterior cardiac vein
rami communicantes at the level of his sixth (D} Small cardiac vein
thoracic vertebra. This injury would result in (E) Oblique veins of the left atrium

93
94 BRS Gross Anatomy

7. A 37-year-old patient with palpitation was (D) Right middle bronchus

examined by her physician, and one of the (E) Right inferior bronchus
diagnostic records included a posterior-ante-
rior chest radiograph. Which of the following 12. An 83-year-old man with a typical coro-
comprises the largest portion of the sternocos- nary circulation has been suffering from an
tal surface of the heart seen on the radiograph? embolism of the circumflex branch of the left
(A) Left atrium coronary artery. This condition would result in
(B} Right atrium ischemia of which of the following areas of the
(C) Left ventricle heart?
(A) Anterior part of the left ventricle
(E} Base of the heart (B) Anterior interventricular region
(C) Posterior interventricular region
8. A5-year-old girl is brought to the emer-
gency department because of difficulty breath- (E) Anterior part of the right ventricle
ing (dyspnea), palpitations, and shortness of
breath. Doppler study of the heart reveals an 13. A 44-year-old man with a stab wound was
atrial septal defect (ASD). This malformation brought to the emergency department, and a
usually results from incomplete closure of physician found that the patient was suffering
which of the following embryonic structures? from a laceration of his right phrenic nerve.
(A) Ductus arteriosus Which of the following conditions has likely
(B}) Ductus venosus occurred?
(C) Sinus venarum (A) Injury to only GSE fibers
(B) Difficulty in expiration
(E} Truncus arteriosus

9. A 54-year-old patient is implanted with (D) Normal function of the diaphragm

an artificial cardiac pacemaker. Which of (E) Loss of sensation in the costal part of the
the following conductive tissues of the heart diaphragm
had a defective function that required the
pacemaker? 14. An 8-year-old boy with ASD presents to
(A) Atrioventricular (AV) bundle a pediatrician. This congenital heart defect
(B}) AVnode shunts blood from the left atrium to the right
atrium and causes hypertrophy of the right
(C)
Sinoatrial
(SA) node
(D} Purkinje fiber atrium, right ventricle, and pulmonary trunk.
(E} Moderator band Which of the following veins opens into the
hypertrophied atrium?
10. A thoracic surgeon removed the right mid- (A) Middle cardiac vein
dle lobar (secondary) bronchus along with lung (B} Small cardiac vein
tissue from a 57-year-old heavy smoker with (C} Oblique cardiac vein
lung cancer. Which of the following broncho-
pulmonary segments must contain cancerous (E) Right pulmonary vein
tissues?
15. A 37-year-old patient with severe chest
(B) Anterior and posterior pain, shortness of breath, and congestive heart
(C) Anterior basal and medial basal failure was admitted to a local hospital. His
(D) Anterior basal and posterior basal coronary angiograms reveal a thrombosis in the
(E) Lateral basal and posterior basal circumflex branch of the left coronary artery.
Which of the following conditions could result
11. The bronchogram of a 45-year-old female from the blockage of blood flow in the circum-
smoker shows the presence of a tumor in the flex branch?
eparterial bronchus. Which airway is most (A) Tricuspid valve insufficiency
likely blocked?
(A) Left superior bronchus (C} Ischemia of AV node
(B) Left inferior bronchus (D) Paralysis of pectinate muscle
(E) Necrosis of septomarginal trabecula
 |Chapter3 Big 95

16. A 75-year-old patient has been suffer- 21. A 75-year-old woman was admitted to a
ing from lung cancer located near the cardiac local hospital, and bronchograms and radio-
notch, a deep indentation on the lung. Which of graphs revealed a lung carcinoma in her left
the following lobes is most likely to be excised? lung. Which of the following structures or char-
(A) Superior lobe of the right lung acteristics does the cancerous lung contain?
(B} Middle lobe of the right lung (A) Horizontal fissure
(C) Inferior lobe of the right lung (B) Groove for superior vena cava (SVC)
(C} Middle lobe
(E} Inferior lobe of the left lung
(E) Larger capacity than the right
17. A thoracentesis is performed to aspirate an
abnormal accumulation of fluid in a 37-year- 22. An 18-year-old girl is thrust into the steer-
old patient with pleural effusion. A needle ing wheel while driving and experiences dif-
should be inserted at the midaxillary line ficulty in expiration. Which of the following
between which of the following two ribs so as to muscles is most likely damaged?
avoid puncturing the lung? (A) Levator costarum
(A) Ribs 1 and 3 (B) Innermost intercostal muscle
(B) Ribs3and5 (C} External intercostal muscle
(C) Ribs5and7 (D) Diaphragm

(E} Ribs 9 and 11

23. A 78-year-old patient presents with an
18. A newborn baby is readmitted to the hos- advanced cancer in the posterior mediastinum.
pital with hypoxia and upon testing is found to The surgeons are in a dilemma as to how to
have pulmonary stenosis, dextraposition of the manage the condition. Which of the following
aorta, interventricular septal defect, and hyper- structures is most likely damaged?
trophy of the right ventricle. Which of the fol- (A) Brachiocephalic veins
lowing is best described by these symptoms? (B) Trachea
(A) ASD (C) Arch of the azygos vein
(B) Patent ductus arteriosus (D) Arch of the aorta

(D} Aortic stenosis

(E} Coarctation of the aorta 24. A 46-year-old patient comes to his doctor's
office and complains of chest pain and head-
19. A 33-year-old patient is suffering from a ache. His computed tomography (CT) scan
sudden occlusion at the origin of the descend- reveals a tumor located just superior to the root
ing (thoracic) aorta. This condition would most of the right lung. Blood flow in which of the
likely decrease blood flow in which of the fol- following veins is most likely blocked by this
lowing intercostal arteries? tumor?
(A) Upper six anterior (A) Hemiazygos vein
(B) All of the posterior
(C) Upper two posterior (C) Right subclavian vein
(D) Lower anterior (D) Right brachiocephalic vein
(E) Accessory hemiazygos vein

20. A 56-year-old patient recently suffered a 25. A 21-year-old patient with a stab wound
myocardial infarction in the area of the apex of reveals a laceration of the right vagus nerve
the heart. The occlusion by atherosclerosis is in proximal to the origin of the recurrent laryngeal
which of the following arteries? nerve. Which of the following conditions would
(A) Marginal artery most likely result from this lesion?
(B} Right coronary artery at its origin (A) Contraction of bronchial muscle
(B) Stimulation of bronchial gland secretion
(D} Posterior interventricular artery (C) Dilation of the bronchial lumen
(E} Circumflex branch of the left coronary (D} Decrease in cardiac rate
artery (E) Constriction of coronary artery
 96 BRS Gross Anatomy

26. A neonate appears severely cyanotic and

breathing rapidly. Cardiac echocardiogram (D) Ascending aorta
reveals that the aorta lies to the right of the pul- (E) Left ventricle
monary trunk. Which of the following is most
likely occurred during development? 31. A 37-year-old man is brought to the emer-
gency department complaining of severe chest
(A) AP septum failed to develop in a spiral
pain. His angiogram reveals thromboses of both
fashion
(B) Excessive resorption of septum primum brachiocephalic veins just before entering the
(C) Pulmonary valve atresia superior vena cava. This condition would most
(D) Persistent truncus arteriosus likely cause a dilation of which of the following
(E} Coarctation of the aorta veins?
(A) Azygos
27, A 12-year-old boy was admitted to a local (B) Hemiazygos
hospital with a known history of heart prob- (C) Right superior intercostal
lems. His left ventricular hypertrophy could
result from which of the following conditions? (E) Internal thoracic
(A) Aconstricted pulmonary trunk
(B} An abnormally small left AV opening 32. A cardiologist is on clinical rounds with
(C) Improper closing of the pulmonary valves her medical students. She asks them, “During
(D} An abnormally large right AV opening the cardiac cycle, which of the following events
occurs?”
(A) AV valves close during diastole
28. A 31-year-old man was involved in a severe (B) Aortic valve closes during systole
automobile accident and suffered laceration of (C) Pulmonary valve opens during diastole
the left primary bronchus. The damaged pri-
mary bronchus:
(A) Has a larger diameter than the right pri- (E) Aortic valve closes at the same time as AV
mary bronchus valve
(B} Often receives more foreign bodies than
the right primary bronchus 33. Coronary angiographs of a 44-year-old
(C) Gives rise to the eparterial bronchus male patient reveal an occlusion of the cir-
cumflex branch of the left coronary artery. This
(E} Runs under the arch of the azygos vein patient has been suffering from myocardial
infarction in which of the following areas?
29. A 62-year-old woman who is a heavy smoker (A) Right and left ventricles
has an advanced lung cancer that spread into (B) Right and left atria
her right third posterior intercostal space pos- (C)} Interventricular septum
terior to the midaxillary line. If cancer cells (D) Apex of the heart
are carried in the venous drainage, they would
travel first to which of the following veins?
(A) svc 34. A patient has a small but solid tumor in the
(B) Right superior intercostal vein mediastinum, which is confined at the level of
(C) Right brachiocephalic vein the sternal angle. Which of the following struc-
(D} Azygos vein tures would most likely be found at this level?
(E} Hemiazygos vein
(B) Beginning of the ascending aorta
30. A radiologist examines posterior-anterior (C} Middle of the aortic arch
chest radiographs of a 27-year-old victim of a (D) Articulation of the third rib with the
car accident. Which of the following structures sternum
forms the right border of the cardiovascular (E) Superior border of the superior
silhouette? mediastinum
(A) Arch of the aorta
(B} Pulmonary trunk
 |Chapter3 Big 97

35. A 37-year-old house painter fell from a 40. A 47-year-old man with a known atrial
ladder and fractured his left third rib and the fibrillation returns to see his cardiologist for
structures with which it articulated. Which of follow-up of his cardiac health. The right atrium
the following structures would most likely be is important in this case because it:
damaged? (A) Receives blood from the oblique cardiac vein
(A) Manubrium of the sternum (B) Is associated with the apex of the heart

(C) Spinous process of the third thoracic (D) Receives the right pulmonary vein
vertebra (E}) Ishypertrophied by pulmonary stenosis
(D} Body of the fourth thoracic vertebra
(E) Transverse process of the second thoracic 41. A 57-year-old patient has a heart murmur
vertebra resulting from the inability to maintain constant
tension on the cusps of the AV valve. Which of
36. A 45-year-old woman presents with a tumor the following structures is most likely damaged?
confined to the posterior mediastinum. This (A) Crista terminalis
could result in compression of which of the fol- (B) Septomarginal trabecula
lowing structures?
(A) Trachea (D) Pectinate muscle
(E) Anulus fibrosus
(C) Arch of the aorta
(D} Arch of the azygos vein 42. A mother with diabetes gives birth to a baby
(E} Phrenic nerve who is diagnosed as having dextroposition of
the aorta and the pulmonary trunk with cya-
37. A 62-year-old patient with pericardial effu- nosis and shortness of breath. Which of the fol-
sion comes to a local hospital for aspiration lowing structures is required to remain patent
of pericardial fluid by pericardiocentesis. The until surgical correction of the deformity?
needle is inserted into the pericardial cav- (A) Umbilical arteries
ity through which of the following intercostal (B}) Umbilical vein
spaces adjacent to the sternum?
(A) Right fourth intercostal space (D} Ductus venosus
(B) Left fourth intercostal space (E} Sinus venosus
(C) Right fifth intercostal space
43. During early development of the respira-
(E} Right sixth intercostal space tory system, the laryngotracheal tube maintains
communication with the primitive foregut.
38. The attending faculty in the coronary inten- Which of the following embryonic structures is
sive care unit demonstrates to his students most likely responsible for partitioning these
anormal heart examination. The first heart two embryonic structures?
sound is produced by near-simultaneous clo- (A) Tracheoesophageal folds
sure of which of the following valves? (B) Tracheoesophageal fistula
(A) Aortic and tricuspid
(B} Aortic and pulmonary (D) Laryngotracheal diverticulum
(C) Tricuspid
and mitral (E} Laryngotracheal septum
(D} Mitral and pulmonary
(E} Tricuspid and pulmonary 44. A 32-year-old patient has a tension pneu-
mothorax that can be treated with needle
39. A 27-year-old patient with Marfan syn- aspiration. To avoid an injury of the intercos-
drome has an aneurysm of the aortic arch. tal neurovascular bundle, the needle may be
This may compress which of the following inserted in which of the following locations?
structures?
(A) Right vagus nerve (B) Deep to the upper border of the ribs
(B) Left phrenic nerve (C} Beneath the lower border of the ribs
(C) Right sympathetic trunk (D} Between the external and internal
intercostals
(E} Left greater splanchnic nerve (E} Through the transversus thoracis muscle
98 BRS Gross Anatomy

45. A 9-month-old girl was admitted to the chil- 49. Which structure branches into the bron-
dren’s hospital with tachypnea (fast breathing) chial arteries?
and shortness of breath. Physical examination
further exhibits tachycardia (fast heart rate), 50. Into which structure does the azygos vein
a bounding peripheral pulse, and her angio- drain venous blood?
graphs reveal a patent ductus arteriosus. Which
A
of the following embryonic arterial structures is
51. The left coronary artery arises from which
most likely responsible for the origin of the pat-
structure? C
ent ductus arteriosus?
(A) Right fourth arch
52. Which structure is crossed superiorly by the
(B) Left fifth arch
aortic arch and left pulmonary artery?
(C) Right fifth arch

(E} Right sixth arch Questions 53 to 58: Choose the appropriate

lettered site or structure in this CT scan (see
46. A 7-day-old baby is diagnosed as having Figure below) of the thorax. Which structure in
congenital neonatal emphysema, which is this CT scan:
caused by collapsed bronchi because of failure

Sram.
of bronchial cartilage development. Bronchial
cartilages are derived from which of the follow-
ing derivations?
(A) Ectoderm
r |,
B— :
:
(C) Endoderm
(D) Proctodeum

>
(E} Neuroectoderm

Questions 47 to 52: Choose the appropriate

lettered site or structure in this CT scan (see 53. Can be removed in a surgical resection of
Figure below) of the thorax from a 42-year-old a lobe to remove lung cancer on the diaphrag-
man who complains of chest pain and matic surface? B
breathing problems. His electrocardiogram
shows left ventricular hypertrophy. 54. Becomes hypertrophied as result of the pul-
monary stenosis? C

“Oe
55. Receives oxygenated blood via pulmonary
veins? E

56. Lies on the right side of the aortic arch and

9 ascending aorta?
ne
57. Contains the septomarginal trabecula?

47. Stenosis of which structure may produce

58. Takes its origin from the left ventricle and
left ventricular hypertrophy? C
ends at the sternal angle?

48. Which structure is most likely to be

removed by a pulmonary surgeon in a surgical
resection of a lobe (lobectomy) to remove lung
cancer in the apex of the right lung? B
 Review Test

Directions: Each of the numbered items or incomplete statements in this section is followed by
answers or by completions of the statement. Select the one-lettered answer or completion that is
best in each case.

1. A 63-year-old man comes to the emergency

department with back pain, weakness, and short- (D} Sympathetic chain ganglion
ness of breath. On examination, he has an aneu- (E) Celiac ganglion
rysm of the abdominal aorta at the aortic hiatus
of the diaphragm. Which of the following pairs of 5. A 42-year-old obese woman with seven
structures would most likely be compressed? children is brought to a local hospital by her
(A} Vagus nerve and azygos vein daughter. Physical examination and her radio-
(B} Esophagus and vagus nerve graph reveal that large gallstones have ulcer-
ated through the posterior wall of the fundus of
(D} Thoracic duct and vagus nerve the gallbladder into the intestine. Which of the
(E) Inferior vena cava (IVC) and phrenic nerve following parts of the intestine is most likely to
initially contain gallstones?
2. A 36-year-old woman with yellow pigmen- (A) Cecum
tation of the skin and sclerae presents at the (B) Ascending colon
outpatient clinic. Which of the following condi- (C) Transverse colon
tions most likely is the cause of her obstructive (D) Descending colon
jaundice? (E) Sigmoid colon
{A} Aneurysm of the splenic artery
(B) Perforated ulcer of the stomach 6. A 35-year-old woman comes to a local hospi-
(C) Obstruction of the main pancreatic duct tal with abdominal tenderness and acute pain.
On examination, her physician observes that an
(E} Cancer in the body of the pancreas abdominal infection has spread retroperitone-
ally. Which of the following structures is most
3. A 2-year-old boy presents with pain in likely affected?
his groin that has been increasing in nature (A) Stomach
over the past few weeks. He is found to have a (B) Transverse colon
degenerative malformation of the transversalis (C) Jejunum
fascia during development. Which of the fol- (D) Descending colon
lowing structures on the anterior abdominal (E) Spleen
wall is likely defective?
(A) Superficial inguinal ring 7. During an annual health examination of a
46-year-old woman, a physician finds hyperse-
(C) Inguinal ligament cretion of norepinephrine from her suprarenal
(D} Sac of a direct inguinal hernia medulla. Which of the following types of nerve
(E} Anterior wall of the inguinal canal fibers are most likely overstimulated?

4. A 29-year-old man comes to a local hospital (B) Postganglionic sympathetic fibers

with duodenal peptic ulcer and complains of (C) Somatic motor fibers
cramping epigastric pain. Which of the follow- (D) Postganglionic parasympathetic fibers
ing structures harbors the cell bodies of abdom- (E} Preganglionic parasympathetic fibers
inal pain fibers?
(A) Lateral horn of the spinal cord
(B) Anterior horn of the spinal cord

151
 152 BRS Gross Anatomy

8. A 6-year-old girl comes to her pediatrician stomach. It is observed that the pain comes
with constipation, abdominal distention, and from peritoneal irritation by gastric contents
vomiting. After thorough examination, she in the lesser sac. Which of the following nerves
is diagnosed as having Hirschsprung disease contain sensory nerve fibers that convey this
(aganglionic megacolon), which is a congenital sharp, stabbing pain?
disease and leads to dilation of the colon. This (A) Vagus nerves
condition is caused by an absence of which of (B) Greater splanchnic nerves
the following kinds of neural cell bodies?
(A) Sympathetic preganglionic neuron cell (D}) White rami communicantes
bodies (E) Gray rami communicantes
(B) Sympathetic postganglionic neuron cell
bodies 13. A young boy is brought to the hospital after
(C) Parasympathetic preganglionic neuron cell a bicycle accident and possible pelvic fracture.
bodies While awaiting a computed tomography (CT)
(D) Parasympathetic postganglionic neuron scan of his pelvis, a physician proceeds with
cell bodies a focal neurologic examination. In testing the
(E} Sensory neuron cell bodies child’s reflexes, which of the following nerves
would carry afferent impulses of the cremas-
9. A pediatric surgeon is resecting a possible teric reflex?
malignant mass from the liver of a neonate with (A) Subcostal nerve
cerebral palsy. The surgeon divides the round (B) Lateral femoral cutaneous nerve
ligament of the liver during surgery. A fibrous
remnant of which of the following fetal vessels (D) Iliohypogastric nerve
is severed? (E) Femoral nerve
(A) Ductus venosus
(B) Ductus arteriosus 14. A 21-year-old man receives a penetrating
(C)
umbilical
Left vein knife wound in the abdomen and is injured in
(D} Right umbilical vein both the superior mesenteric artery and the
(E} Umbilical artery vagus nerve. Which portion of the colon would
most likely be impaired by this injury?
10. A 27-year-old woman has suffered a gun- (A) Ascending and descending colons
shot wound to her midabdomen. After examin- (B) Transverse and sigmoid colons
ing the patient's angiogram, a trauma surgeon (C) Descending and sigmoid colons
locates the source of bleeding from pairs of
veins that typically terminate in the same vein. (E) Transverse and descending colons
Which of the following veins are damaged?
(A) Left and right ovarian veins 15. A 42-year-old man with portal hypertension
(B} Left and right gastroepiploic veins secondary to cirrhosis of the liver and
(C) Left and right colic veins subsequent massive ascites presents to the
(D} Left and right suprarenal veins emergency department. He refuses to have a
transjugular intrahepatic portosystemic shunt
(TIPS) procedure and prefers surgery. Which of
11. A 43-year-old man complains of abdominal the following surgical connections is involved
pain just above his umbilicus. On examination, in the most practical method of shunting portal
a tumor is found anterior to the IVC. Which of blood around the liver?
the following structures would most likely be (A) Superior mesenteric vein to the inferior
compressed by this tumor? mesenteric vein
(A) Right sympathetic trunk (B) Portal vein to the superior vena cava
(B} Left third lumbar artery (C} Portal vein to the left renal vein

(D} Leftrenal artery (E) Superior rectal vein to the left colic vein
(E} Cisterna chyli
16. A 78-year-old man is suffering from
12. A 33-year-old man with a perforated gas- ischemia of the suprarenal glands. This
tric ulcer complains of excruciating pain in his
 (ENTITY Abdomen 153

condition results from rapid occlusion of direct and symptoms, the diagnosis of acute appen-
branches of which of the following arteries? dicitis was made. During an appendectomy
(A) Aorta, splenic, and inferior phrenic arteries performed at McBurney point, which of the fol-
(B) Renal, splenic, and inferior mesenteric lowing structures is most likely to be injured?
arteries (A) Deep circumflex femoral artery
(C) Aorta, inferior phrenic, and renal arteries (B) Inferior epigastric artery
(D) Superior mesenteric, inferior mesenteric,
and renal arteries (D) Genitofemoral nerve
(E) Aorta and hepatic and renal arteries (E) Spermatic cord

17. A radiograph of a 32-year-old woman 21, A 54-year-old man with a long history
reveals a perforation in the posterior wall of of alcohol abuse presents to the emergency
the stomach in which the gastric contents have department with rapidly increasing abdominal
spilled into the lesser sac. The general surgeon distention most likely resulting from an altera-
has opened the lienogastric (gastrosplenic) liga- tion in portal systemic blood flow. Which of the
ment to reach the lesser sac and notes erosion following characteristics is associated with the
of the ulcer into an artery. Which of the follow- portal vein or the portal venous system?
ing vessels is most likely involved? (A) Lower blood pressure than in the IVC
(A) Splenic artery (B) Least risk of venous varices because of por-
(B} Gastroduodenal artery tal hypertension
(C) Left gastric artery (C) Distention of the portal vein resulting from
(D} Right gastric artery its numerous valves

18. A 35-year-old woman with a history of (E} Less blood flow than in the hepatic artery
cholecystectomy arrives in the emergency
department with intractable hiccups most likely 22. While examining radiographs and angio-
caused by an abdominal abscess secondary grams of a 52-year-old patient, a physician
to surgical infection. Which of the following is trying to distinguish the jejunum from the
nerves carries pain sensation caused by irrita- ileum. He has observed that the jejunum has:
tion of the peritoneum on the central portion of (A) Fewer plicae circulares
the inferior surface of the diaphragm?
(B)
mesenteric
Fewer arterial arcades
{A} Vagus nerve (C) Less digestion and absorption of nutrients
(B) Lower intercostal nerve (D) Shorter vasa recta
(E) More fat in its mesentery
(D) Greater splanchnic nerve
(E) Subcostal nerve 23. A 67-year-old woman with a long history
of liver cirrhosis was seen in the emergency
19. A 16-year-old boy with a ruptured spleen department. In this patient with portal hyper-
comes to the emergency department for sple- tension, which of the following veins is most
nectomy. Soon after ligation of the splenic likely to be dilated?
artery just distal to its origin, a surgical resident
observes that the patient is healing normally. (B) Inferior epigastric vein
Normal blood flow would occur in which of the (C) Inferior phrenic vein
following arteries? (D) Suprarenal vein
(A) Short gastric arteries (E} Ovarian vein
(B} Dorsal pancreatic artery
24. A 26-year-old patient is admitted to a local
(D} Left gastroepiploic artery hospital with a retroperitoneal infection. Which
(E} Artery in the lienorenal ligament of the following arteries is most likely to be
infected?
20. A9-year-old boy was admitted to the emer- (A) Left gastric artery
gency department complaining of nausea, (B) Proper hepatic artery
vomiting, fever, and loss of appetite. On exami- (C) Middle colic artery
nation, he was found to have tenderness and (D) Sigmoid arteries
pain on the right lower quadrant. Based on signs
 154 BRS Gross Anatomy

25. A pediatric surgeon has resected a structure (C} Joins the main pancreatic duct, which car-
that is a fibrous remnant of an embryonic or ries hormones
fetal artery in a 5-year-old child. Which of the (D) Is formed by union of the right and left he-
following structures is most likely to be divided? patic duct
(A) Lateral umbilical fold (E} Lies posterior to the portal vein in the right
free edge of the lesser omentum
(B) Medial umbilical fold
(C) Median umbilical fold
(D} Ligamentum teres hepatis 30. A patient with diverticulosis of the colon
(E} Ligamentum venosum presents for follow-up to his primary care phy-
sician with ongoing complaints of left lower
26. A 57-year-old patient has a tumor in the quadrant pain and occasionally bloody stools.
body of the pancreas that obstructs the inferior His physician begins workup with appropriat-
mesenteric vein just before joining the splenic ing test by recalling that the sigmoid colon:
vein. Which of the following veins is most likely (A) Is drained by systemic veins
to be enlarged? (B) Isa retroperitoneal organ
(A) Middle colic vein (C) Receives parasympathetic fibers from the
(B} Left gastroepiploic vein vagus nerve
(C) Inferior pancreaticoduodenal vein (D) Receives its blood from the superior mes-
(D} Ileocolic vein enteric artery

27. Anelderly man with prostatic hypertrophy 31. A 19-year-old man with a ruptured appen-
returns to his urologist with another case of dix is sent to the emergency department
epididymitis. An acute infection involving the for surgery. To cut off the blood supply to
dartos muscle layer of the scrotum most likely the appendix (if collateral circulation is dis-
leads to an enlargement of which of the follow- counted), a surgeon should ligate which of the
ing lymph nodes? following arteries?

(A) Preaortic nodes (A) Middle colic artery

(B) Lumbar nodes (B) Right colic artery
(C) External iliac nodes
(D) Inferior mesenteric artery
(E} Common iliac nodes (E) Common iliac artery

28. A patient with cirrhosis is scheduled for 32. Because of an inflammatory bowel disease
liver transplant surgery. During the operation (Crohn disease) and a small bowel obstruction
rounds, the transplant physician explains to leading to bowel ischemia, an elderly woman
his residents that one of the reasons a surgeon requires bypass of her ileum and jejunum and
must pay close attention to the anatomic loca- is scheduled for a gastrocolostomy. The sur-
tion of the liver is that this organ: geon will ligate all arteries that send branches
to the stomach. Which of the following arteries
(A} Receives blood only from the hepatic
may be spared?
arteries
(B) Manufactures red blood cells in an adult (A) Splenic artery
(C) Drains bile from the quadrate lobe into the (B) Gastroduodenal artery
right hepatic duct (C) Inferior
pancreaticoduodenal
artery
(D) Left gastroepiploic artery
(E} Functions to concentrate and store bile (E) Proper hepatic artery

29. A 41-year-old woman is brought to the 33. A 38-year-old woman with peptic ulcer
emergency department by her family because disease of the stomach experiences severe
of acute onset of right upper quadrant pain, abdominal pain. Which of the following ner-
nausea, and vomiting. For this case, it is impor- vous structures is most likely involved?
tant to remember that the bile duct:
(B) Ventral roots of the spinal nerve
(A) Drains bile into the second part of the
(C} Lower intercostal nerve
duodenum
(B} Can be blocked by cancer in the body of (D) Vagus nerve
the pancreas (E) Gray ramus communicans
 (ENTITY Abdomen 155

34. A 3-year-old boy is diagnosed as having a pancreas. Which of the following structures is
persistent processus vaginalis in its middle por- most likely compressed by this tumor?
tion. Which of the following conditions is most (A) Main pancreatic duct
likely to be associated with this developmental (B) Splenic artery
anomaly? (C} Portal vein
(A) Direct inguinal hernia
(B} Gubernaculum testis (E) Superior pancreaticoduodenal artery
(C) Hematocele
39. A 6-year-old boy comes to his pediatrician
(E} Cryptorchidism with a lump in the groin near the thigh and pain
in the groin. On examination, the physician
35, Examination of a 54-year-old man reveals makes a diagnosis of a direct inguinal hernia
an isolated tumor located at the porta hepatis. because the herniated tissue:
This tumor most likely compresses which of the (A) Enters the deep inguinal ring
following structures? (B) Lies lateral to the inferior epigastric artery
(A) Cystic duct (C) Is covered by spermatic fasciae
(B) Hepatic veins (D} Descends into the scrotum
(C) Common hepatic artery
(D} Left gastric artery
40. A 21-year-old man developed a hernia after
lifting heavy boxes while moving into his new
36. A patient is rushed to the operating room house. During the repair of his resulting hernia,
for an emergent cholecystectomy (resection of the urologist recalls that the genitofemoral
a gallbladder) because of cholecystitis. While nerve:
locating landmarks before surgical resection (A) Runs in front of the quadratus lumborum
of an infected gallbladder, the surgeon recalls (B) Isa branch of the femoral nerve
a portal-caval anastomosis. Which of the (C} Supplies the testis
following pairs of veins form a portal-caval
anastomosis? (E} Gives rise to an anterior scrotal branch
(A) Hepatic veins and IVC
(B)
Superior
and middle rectal vein 41. An oncologist is reviewing a CT scan of a
(C) Left and right gastric vein 74-year-old man with newly diagnosed hepa-
(D} Inferior and superficial epigastric veins tocellular carcinoma. He locates the affected
(E) Suprarenal and renal veins quadrate lobe of the liver that:
(A) Lies between the IVC and ligamentum
37. Mrs. Jones is undergoing a routine colonos- venosum
copy for colon cancer prevention. The gastroen- (B) Receives blood from the right hepatic
terologist finds a Meckel diverticulum. Which artery
of the following statements is true about the (C) Drains bile into the left hepatic duct
diverticulum? (D) Isa medial superior segment
(A) Itis found 2 ft distal to the ileocecal (E)} Is functionally a part of the right lobe
junction
(B) Itis located on the mesenteric side of the 42, A 58-year-old man is presented with
ileum edema of the lower limb and enlarged
(C) It occurs in approximately 20% of the superficial veins of the abdominal wall.
population Examination of radiographs and angiograms
reveals obstruction of the IVC just proximal
to the entrance of the renal vein. This venous
(E} It may contain renal and suprarenal tissues blockage may result in dilation of which of the
following veins?
38. A 54-year-old man comes to a hospital with
abdominal pain, jaundice, loss of appetite, (B) Right inferior phrenic vein
and weight loss. On examination of his radio- (C) Right hepatic vein
grams and CT scans, a physician finds a slowly (D) Left gastric vein
growing tumor in the uncinate process of the (E) Portal vein
156 BRS Gross Anatomy

43. A physical fitness trainer for a young Hol- mesenteric artery. Which of the following
lywood movie star explains the reasons for structures is likely compressed by this tumor?
100 stomach crunches a day. The young star, (A) Fundus of the stomach
a medical student before ‘hitting it big; reaf-
firms to his trainer that the lateral margin of the (C} Transverse colon
rectus abdominis, the muscle responsible for a (D) Hepatopancreatic ampulla
washboard stomach, defines which of the fol- (E} Duodenojejunal junction
lowing structures?
(A) Linea alba 48. An emergent hernia repair is scheduled. As
the attending physician is driving to the hos-
(C) Linea semicircularis pital, the medical student assisting on the case
(D) Transversalis fascia quickly reviews his anatomy atlas and is trying
(E} Falxinguinalis to commit to memory that the internal oblique
abdominis muscle contributes to the formation
44. During surgical treatment of portal hyper- of which of the following structures?
tension in a 59-year-old man with liver cirrho- (A) Inguinal ligament
sis, a surgeon inadvertently lacerates the dilated (B) Deep inguinal ring
paraumbilical veins. The veins must be repaired
to allow collateral flow. Which of the following (D) Internal spermatic fascia
ligaments is most likely severed? (E) Reflected inguinal ligament
(A) Lienorenal ligament
(B} Lienogastric ligament 49. A 9-year-old girl has crashed into her
(C) Gastrophrenic ligament neighbor’s brick fence while riding her bike
and is brought to the emergency department
(E} Ligamentum venosum with a great deal of abdominal pain. Her
radiogram and angiogram show laceration
45. A 43-year-old woman is admitted to the hos- of the superior mesenteric artery immedi-
pital because of deep abdominal pain in her epi- ately distal to the origin of the middle colic
gastric region. On examination, it is observed that artery. If collateral circulation is discounted,
a retroperitoneal infection erodes an artery that which of the following organs may become
runs along the superior border of the pancreas. ischemic?
Which of the following arteries is likely injured? (A) Descending colon
(A) Right gastric artery (B}) Duodenum
(B} Left gastroepiploic artery (C} Pancreas

(D} Gastroduodenal artery (E) Transverse colon

(E} Dorsal pancreatic artery
50. A 53-year-old woman with known kidney
46. A 19-year-old young woman with a long disease presents to a hospital because her pain
history of irritable bowel syndrome presents has become increasingly more severe. A physi-
for the possibility of surgical resection of the cian performing kidney surgery must remem-
gastrointestinal (GI) tract where the vagal ber that:
parasympathetic innervation terminates. (A) The left kidney lies a bit lower than the
Which of the following sites is most appropriate right one
for surgical resection? (B) The perirenal fat lies external to the renal
(A) Duodenojejunal junction fascia
(B} Teocecal junction (C} The renal fascia does not surround the su-
(C) Right colic flexure prarenal gland

(E} Anorectal junction

(E} The right renal artery is shorter than the
47. A 58-year-old man is admitted to the left renal artery
hospital with severe abdominal pain, nausea,
and vomiting resulting in dehydration. 51. A neonatal baby was born with diabetes mel-
Emergency CT scan reveals a tumor located litus due to an inadequate production of insulin.
between the celiac trunk and the superior Cells in the endocrine portion of the pancreas
 (ENTITY Abdomen 157

that secrete insulin, glucagon, and somatostatin 55. Which structure is hematopoietic in early
are derived from which of the following? life and later destroys worn-out red blood cells?
(A) Ectoderm
(B}) Mesoderm 56. Which structure runs along the superior
(C)
Endoderm border of the pancreas and enters the lienore-
(D}) Proctodeum nal ligament?
(E} Neural crest cells
8 D
57. Which structure is divided into the proper
52. During development, the midgut artery hepatic and gastroduodenal arteries?
appears to be markedly narrowed at its origin.
A
Which of the following structures is derived
58. Which structure provides an attachment of
from the midgut and may receive inadequate
the suspensory muscle of the duodenum (liga-
blood supply?
ment of Treitz)? B
(A) Gallbladder
(B} Stomach
59. Which structure is retroperitoneal in posi-
(C) Descending colon
tion and receives blood from the splenic artery?
(E} Rectum Cc
Questions 60 to 64: Choose the appropriate let-
53. A 3-year-old boy is admitted to the tered structure in this CT scan of the abdomen
children’s hospital with complaints of rest- (see Figure below) at the level of the upper lum-
lessness, abdominal pain, and fever. An MRI bar vertebra.
examination reveals that he has a double ureter.
Which of the following embryonic structures is
most likely failed to develop normally?
(A) Mesonephric (Wolffian) duct
(B) Paramesonephric (Miillerian) duct

(D) Metanephros
(E) Pronephros

54. A neonate has a small reducible protrusion

through a defined ring at the umbilicus. His
pediatrician indicates to the parents that this
will likely close spontaneously. Which of the
following congenital malformations is present? 60. Which structure is a direct branch of the
aorta and supplies blood to the ascending and
transverse colons?
(B} Symptomatic patent urachus
D
(C) Patent omphalomesenteric duct
(D) Omphalocele 61. Which structure receives blood from the
(E) Gastroschisis liver and kidney and enters the thorax by pierc-
ing the central tendon of the diaphragm?
Questions 55 to 59: Choose the appropri- B
ate lettered structure in this CT scan of the 62. Which structure receives bile, concentrates
abdomen (see Figure below) at the level of the it by absorbing water and salt, and stores it?
12th thoracic vertebra. A
63. Which structure receives blood from the left
gonad and suprarenal gland?
E
64. Which structure receives blood from the
portal vein?
Cc
 Review Test

Directions: Each of the numbered items or incomplete statements in this section is followed by
answers or by completions of the statement. Select the one-lettered answer or completion that is
best in each case.

1. A 68-year-old woman with uterine carci- 5. A 29-year-old carpenter sustains severe

noma undergoes surgical resection. This can- injuries of the pelvic splanchnic nerve by a deep
cer can spread directly to the labia majora in puncture wound, which has become contami-
lymphatics that follow which of the following nated. The injured parasympathetic pregangli-
structures? onic fibers in the splanchnic nerve are most likely
(A) Pubic arcuate ligament to synapse in which of the following ganglia?
(B) Suspensory ligament of the ovary
(C) Cardinal (transverse cervical) ligament
(D} Suspensory ligament of the clitoris (B}) Sympathetic chain ganglia
(C) Collateral ganglia
(D) Dorsal root ganglia
2. A17-year-old boy suffers a traumatic groin (E} Ganglion impar
injury during a soccer match. The urologist
notices tenderness and swelling of the boy’s left 6. A 59-year-old woman comes to a local hos-
testicle that may be produced by thrombosis in pital for uterine cancer surgery. As the uterine
which of the following veins? artery passes from the internal iliac artery to the
(A) Left internal pudendal vein uterus, it crosses superior to which of the fol-
lowing structures that is sometimes mistakenly
(C) Inferior vena cava ligated during such surgery?
(D} Left inferior epigastric vein (A) Ovarian artery
(E) Left external pudendal vein (B) Ovarian ligament
(C) Uterine tube
3. On a busy Saturday night in Chicago, a
16-year-old boy presents to the emergency de- (E) Round ligament of the uterus
partment with a stab wound from a knife that
entered the pelvis above the piriformis muscle. 7. A 29-year-old woman is admitted to a hospi-
Which of the following structures is most likely tal because the birth of her child is several days
to be damaged? overdue. Tearing of the pelvic diaphragm dur-
(A) Sciatic nerve ing childbirth leads to paralysis of which of the
(B} Internal pudendal artery following muscles?
(A) Piriformis
(D} Inferior gluteal artery (B) Sphincter urethrae
(E} Posterior femoral cutaneous nerve (C) Obturator internus

4. A 22-year-old woman receives a deep cut (E) Sphincter ani externus

in the inguinal canal 1 in. lateral to the pubic
tubercle. Which of the following ligaments is 8. A 37-year-old small business manager re-
lacerated within the inguinal canal? ceives a gunshot wound in the pelvic cavity,
(A) Suspensory ligament of the ovary resulting in a lesion of the sacral splanchnic
(B} Ovarian ligament nerves. Which of the following nerve fibers
(C) Mesosalpinx would primarily be damaged?
(A) Postganglionic parasympathetic fibers
(E} Rectouterine ligament (B) Postganglionic sympathetic fibers

204
 [ERIE Perineum and Pelvis 205

13. A 59-year-old man is diagnosed with pros-

(D} Preganglionic parasympathetic fibers tate cancer following a digital rectal examina-
(E} Postganglionic sympathetic and parasym- tion. For the resection of prostate cancer, it is
pathetic fibers important to know that the prostatic ducts open
into or on which of the following structures:
9. A young couple is having difficulty (A) Membranous part of the urethra
conceiving a child. Their physician at a (B) Seminal colliculus
reproduction and fertility clinic explains to (C) Spongy urethra
them that
{A} The ovary lies within the broad ligament (E) Prostatic utricle
(B} The glans clitoris is formed from the cor-
pus spongiosum 14. A 29-year-old woman with a ruptured ec-
(C) Erection of the penis is a sympathetic topic pregnancy is admitted to a hospital for
response culdocentesis. A long needle on the syringe is
(D} Ejaculation follows parasympathetic most efficiently inserted through which of the
stimulation following structures?
(A) Anterior fornix of the vagina

(C} Anterior wall of the rectum

10. A 46-year-old woman has a history of (D) Posterior wall of the uterine body
infection in her perineal region. A comprehen- (E) Posterior wall of the bladder
sive examination reveals a tear of the superior
boundary of the superficial perineal space. 15. A 37-year-old man is suffering from carci-
Which of the following structures would most noma of the skin of the penis. Cancer cells are
likely be injured? likely to metastasize directly to which of the fol-
(A) Pelvic diaphragm lowing lymph nodes?
(B) Colles fascia (A) External iliac nodes
(C) Superficial perineal fascia (B) Internal iliac nodes
(D) Deep perineal fascia
(D) Aortic (lumbar) nodes
(E) Deep inguinal nodes
11. A58-year-old man is diagnosed as having
a slowly growing tumor in the deep perineal 16. A 42-year-old woman who has had six
space. Which of the following structures would children develops a weakness of the urogenital
most likely be injured? diaphragm. Paralysis of which of the following
muscles would cause such a symptom?
(B) Crus of penis
(C) Bulb of vestibule (B) Coccygeus
(D} Spongy urethra (C) Superficial transversus perinei
(E} Great vestibular gland (D) Levator ani
(E} Obturator internus
12. An elderly man with a benign enlarge-
ment of his prostate experiences difficulty in 17. A 43-year-old man has a benign tumor
urination, urinary frequency, and urgency. located near a gap between the arcuate pubic
Which of the following lobes of the prostate ligament and the transverse perineal ligament.
gland is commonly involved in benign hyper- Which of the following structures is most likely
trophy that obstructs the prostatic urethra? compressed by this tumor?
(A) Anterior lobe (A) Perineal nerve

(C) Right lateral lobe (C} Superficial dorsal vein

(D) Left lateral lobe (D) Posterior scrotal nerve
(E} Posterior lobe (E} Deep artery of the penis
206 BRS Gross Anatomy

18. An obstetrician performs a median episiot- (C) Lies lateral to the dorsal artery of the penis
omy on a woman before parturition to prevent (D) Is found in the corpus spongiosum
uncontrolled tearing. If the perineal body is (E) Is dilated during erection
damaged, the function of which of the following
muscles might be impaired? 23. A 62-year-old man is incapable of penile
(A) Ischiocavernosus and sphincter urethrae erection after rectal surgery with prostatectomy.
(B) Deep transverse perineal and obturator The patient most likely has a lesion of which of
internus the following nerves?
(A) Dorsal nerve of the penis
(B) Perineal nerve
(D) External anal sphincter and sphincter (C) Hypogastric nerve
urethrae (D) Sacral splanchnic nerve
(E} Bulbospongiosus and ischiocavernosus

19. A 22-year-old man has a gonorrheal infec- 24, A 23-year-old massage therapist who spe-
tion that has infiltrated the space between the cializes in women’s health attends a lecture at
inferior fascia of the urogenital diaphragm and an annual conference on techniques of mas-
the superficial perineal fascia. Which of the fol- sage. She asks, “What structure is drained by
lowing structures might be inflamed? the lumbar (aortic) lymph nodes?” Which of the
following structures is the correct answer to this
(B} Bulbourethral gland question?
(C) Membranous part of the male urethra (A) Perineum
(D) Deep transverse perineal muscle (B) Lower part of the vagina
(E) Sphincter urethrae (C) External genitalia

20. A 39-year-old man is unable to expel the (E) Lower part of the anterior abdominal wall
last drops of urine from the urethra at the end
of micturition because of paralysis of the ex- 25. A sexually active adolescent presents with
ternal urethral sphincter and bulbospongiosus an infection within the ischiorectal fossa.
muscles. This condition may occur as a result Which of the following structures is most likely
of injury to which of the following nervous injured?
structures? (A) Vestibular bulb
(A) Pelvic plexus (B) Seminal vesicle
(B) Prostatic plexus (C) Greater vestibular gland

(D) Pelvic splanchnic nerve (E) Internal pudendal artery

(E) Sacral splanchnic nerve
26. A first-year resident in the urology depart-
21, A 21-year-old marine biologist asks about ment reviews pelvic anatomy before seeing
her first bimanual examination, and it is ex- patients. Which of the following statements is
plained to her that the normal position of the correct?
uterus is
(A) The dorsal artery of the penis supplies the
glans penis.
(B) Retroflexed and anteverted (B) The seminal vesicles store spermatozoa.
(C) Anteflexed and retroverted (C) The duct of the bulbourethral gland opens
(D) Retroverted and retroflexed into the membranous urethra.
(E} Anteverted and retroverted (D) The duct of the greater vestibular gland
opens into the vagina.
22. After his bath but before getting dressed, (E) The anterior lobe of the prostate gland is
a 4-year-old boy was playing with his puppy. prone to carcinomatous transformation.
The boy’s penis was bitten by the puppy,
and the deep dorsal vein was injured. The 27. A 43-year-old woman presents with a pro-
damaged vein lapsed uterus. Repair of a prolapsed uterus re-
(A) Lies superficial to Buck fascia quires knowledge of the supporting structures
of the uterus. Which of the following structures
 [ERIE Perineum and Pelvis 207

plays the most important role in the support of the following nerves is most likely damaged
the uterus? during the surgery?
(A) Sacral splanchnic nerve
(B) Sphincter urethrae
(C) Uterosacral ligament (C} Pudendal nerve
(D} Ovarian ligament (D) Dorsal nerve of the penis
(E} Arcuate pubic ligament (E) Posterior scrotal nerve

28. A 16-year-old boy presents to the emer- 33. While performing a pelvic exenteration,
gency department with rupture of the penile the surgical oncologist notices a fractured or
urethra. Extravasated urine from this injury can ruptured boundary of the pelvic inlet. Which of
spread into which of the following structures? the following structures is most likely damaged?
(A) Scrotum
(B) Ischiorectal fossa (B) Anterior-inferior iliac spine
(C) Pelvic cavity (C) Inguinal ligament
(D) Testis (D) Iliac crest
(E} Thigh (E} Arcuate pubic ligament

29. A 23-year-old woman visits her obstetrician 34. A 32-year-old patient with multiple frac-
for an annual checkup. During vaginal exami- tures of the pelvis has no cutaneous sensation
nation, which of the following structures may in the urogenital triangle. The function of which
be palpated? of the following nerves is most likely to be
(A) Apex of the urinary bladder spared?
(B) Fundus of the uterus (A) Ilioinguinal nerve
(C) Terminal part of the round ligament of the
uterus (C) Posterior cutaneous nerve of the thigh
(D} Body of the clitoris (D} Pudendal nerve
(E} Genitofemoral nerve

30. A 53-year-old bank teller is admitted to a lo- 35, A 22-year-old victim of an automobile acci-
cal hospital for surgical removal of a benign pel- dent has received destructive damage to struc-
vic tumor confined within the broad ligament. tures that form the boundary of the perineum.
There is a risk of injuring which of the following Which of the following structures is spared?
structures that lies in this ligament? (A) Pubic arcuate ligament
(A) Ovary (B) Tip of the coccyx
(B) Proximal part of the pelvic ureter (C} Ischial tuberosities
(C) Terminal part of the round ligament of the
uterus (E} Sacrotuberous ligament

(E) Suspensory ligament of the ovary 36. A 32-year-old man undergoes vasectomy as
a means of permanent birth control. A physi-
31. A 72-year-old man comes to his physician cian performing the vasectomy by making an
for an annual checkup. Which of the following incision on each side of the scrotum should
structures is most readily palpated during rectal remember which of the following statements
examination? most applicable to the scrotum?

(B} Epididymis
(C) Ejaculatory duct (B) It receives blood primarily from the
(D} Ureter testicular artery.
(E} Testis (C) Its venous blood drains primarily into the
renal vein on the left.
32. A 48-year-old college football coach under- (D) Its lymphatic drainage is primarily into
goes a radical prostatectomy for a malignant upper lumbar nodes.
tumor in his prostate. Following surgery, he is (E) Its dartos tunic is continuous with the
incapable of achieving an erection. Which of perineal membrane.
 208 BRS Gross Anatomy

37. A 37-year-old woman complains ofa

bearing-down sensation in her womb and an (E) Bulbospongiosus
increased frequency of and burning sensation
on urination. On examination by her gynecolo- 42. A radiologist interprets a lymphangiogram
gist, she is diagnosed with a uterine prolapse. for a 29-year-old patient with metastatic carci-
Which of the following structures provides the noma. Upper lumbar nodes most likely receive
primary support for the cervix of the uterus? lymph from which of the following structures?
(A) External anal sphincter (A) Lower part of the anal canal
(B} Broad ligament of the uterus (B) Labium majus
(C} Clitoris
(D} Round ligament of the uterus (D) Testis
(E) Suspensory ligament of the ovary (E} Scrotum

38. A woman is delivering a breech baby. The 43. A 49-year-old woman has a large mass on
obstetrician decides that it is best to perform a the pelvic brim. Which of the following struc-
mediolateral episiotomy. Which of the follow- tures is most likely compressed by this mass
ing structures should the obstetrician avoid when crossing the pelvic brim?
incising? (A) Deep dorsal vein of the penis
(A) Vaginal wall (B) Uterine tube
(B) Superficial transverse perineal muscle (C) Ovarian ligament
(C) Bulbospongiosus (D) Uterine artery

(E} Perineal membrane

44. A 26-year-old man comes to a hospital with
39. During pelvic surgery, a surgeon notices fever, nausea, pain, and itching in the perineal
severe bleeding from the artery that remains region. On examination by a urologist, he is
within the true pelvis. Which of the following diagnosed as having infected bulbourethral
arteries is most likely to be injured? (Cowper) glands. Which of the following struc-
(A) Iliolumbar artery tures is/are affected by this infection?
(B} Obturator artery (A) Superficial perineal space
(C) Uterine artery
(D} Internal pudendal artery (C}) Production of sperm
(E} Inferior gluteal artery (D) Testis
(E} Seminal vesicles
40. A neurosurgeon performs a surgical resec-
tion of a rare meningeal tumor in the sacral 45. A 21-year-old man is involved in a high-
region. He tries to avoid an injury of the nerve speed motor vehicle accident. As a result, he
that arises from the lumbosacral plexus and has extensive damage to his sphincter urethra.
remains within the abdominal or pelvic cavity. Which of the following best describes the
To which of the following nerves should he pay injured sphincter urethra?
particular attention? (A) Smooth muscle
(A) Ilioinguinal nerve (B)
Innervated
by the perineal nerve
(B} Genitofemoral nerve (C) Lying between the perineal membrane and
(C) Lumbosacral trunk Colles fascia
(D}) Femoral nerve (D) Enclosed in the pelvic fascia
(E} Lateral femoral cutaneous nerve (E) Part of the pelvic diaphragm

41. After repair of a ruptured diverticulum, a 46. A 6-month-old male infant is admitted
31-year-old patient begins to spike with fever to the children’s hospital because he has no
and complains of abdominal pain. An infection testis in his scrotum. During physical examina-
in the deep perineal space would most likely tion, the pediatrician palpated the testis in the
damage which of the following structures? inguinal canal. What is the diagnosis of this
(A) Ischiocavernosus muscles condition?
(B) Superficial transverse perineal muscles (A) Male pseudchermaphroditism
(C) Levator ani (B) Hypospadias
 [ERIE Perineum and Pelvis 209

(C) Epispadias 51. A5-month-old boy is admitted to the chil-

dren’s hospital because of urine being expelled
(E} Chordee from the dorsal aspect of the penis. Which of
the following embryologic structures failed to
47. An obstetrician is about to perform a pu- fuse in this patient?
dendal block so a woman can experience less (A) Labioscrotal swellings or folds
pain when she delivers her child. He recalls (B) Urogenital sinus
what he learned in medical school about this
nerve. Which of the following statements is (D) Phallus
correct? (E} Urethral folds
(A) It passes superficial to the sacrotuberous
ligament 52. A 78-year-old man has carcinoma of the
(B} It innervates the testis and epididymis rectum. The cancer is likely to metastasize via
inamale the veins into which of the following structures?
(C) It provides motor fibers to the coccygeus (A) Spleen
(B) Kidney

(E) It arises from the lumbar plexus (D}) Duodenum

(E) Suprarenal gland
48. A trauma surgeon in the emergency depart-
ment at a local center examines a 14-year-old 53. During a partial hysterectomy leaving the
boy with extensive pelvic injuries after a hit and ovaries in tact, the surgeon detaches the ovary
run accident. The surgeon inspects the ischio- from the uterus by transecting the ovarian liga-
rectal fossa because it ment. This ligament developed from which
(A) Accumulates urine leaking from rupture of embryonic structure?
the bulb of the penis (A) Mesonephric duct
(B) Contains the inferior rectal vessels (B) Urogenital folds
(C) Has a pudendal canal along its medial wall
(D} Is bounded anteriorly by the sacrotuberous (D) Processus vaginalis
ligament (E) Paramesonephric ducts
(E) Contains a perineal branch of the fifth
lumbar nerve Questions 54 to 58: Choose the appropriate
lettered structure in this magnetic resonance
49. An elderly man with prostatitis is seen at image (see Figure below) of the female
an internal medicine clinic. The seminal col- perineum and pelvis.
liculus of his prostate gland is infected, and its
fine openings are closed. Which of the following
structures is/are most likely to be disturbed?
(A) Ducts of the prostate gland
(B) Prostatic utricle
(C) Ducts of the bulbourethral glands

(E} Duct of the seminal vesicles

50. A general surgeon is giving a lecture to a

team of surgery residents. She describes char-
acteristics of structures above the pectinate line 54. Which structure extends between the ves-
of the anal canal, which include tibule and the cervix of the uterus and serves
(A) Stratified squamous epithelium as the excretory channel for the products of
(B} Venous drainage into the caval system menstruation? D
(C) Lymphatic drainage into the superficial
inguinal nodes 55. Which structure in the female is much
shorter than the corresponding structure in the
(E} External hemorrhoids male?
A
210 BRS Gross Anatomy

56. Into which structure does hemorrhage 59. Which structure, when fractured, results in
occur after injury to the inferior rectal vessels? paralysis of the obturator internus muscles?
E
57. Which structure has a Houston valve or 60. Which structure secretes fluid containing
fold, with its venous blood drained by the portal fructose, which allows for forensic
venous system? CG determination of rape?

58. Which structure is innervated by the nerve 61. In which structure would ligation of the
passing through both the greater and lesser external iliac artery reduce blood pressure?
sciatic foramina? B A
62. A knife wound to the obturator foramen
Questions 59 to 63: Choose the appropriate might injure which structure?
lettered structure in this computed tomography
scan (see Figure below) of the male perineum 63. A stab wound immediately superior to
and pelvis. the pubic symphysis on the anterior pelvic
wall would most likely injure which visceral
organ first?
Cc
 Review Test

Directions: Each of the numbered items or incomplete statements in this section is followed by an-
swers or by completions of the statement. Select the one-lettered answer or completion that is best
in each case.

1. A 27-year-old patient exhibits a loss of skin 5. A 47-year-old woman is unable to invert

sensation and paralysis of muscles on the plan- her foot after she stumbled on her driveway.
tar aspect of the medial side of the foot. Which Which of the following nerves are most likely
of the following nerves is most likely damaged? injured?
(A) Common peroneal (A) Superficial and deep peroneal

(C) Superficial peroneal (C) Superficial peroneal and tibial

(D) Deep peroneal (D) Medial and lateral plantar
(E) Sural (E} Obturator and tibial

2. A patient with a deep knife wound in the 6. A 22-year-old patient is unable to “unlock”
buttock walks with a waddling gait that is char- the knee joint to permit flexion of the leg.
acterized by the pelvis falling toward one side Which of the following muscles is most likely
at each step. Which of the following nerves is damaged?
damaged? (A) Rectus femoris
(A) Obturator nerve (B} Semimembranosus
(B) Nerve to obturator internus (C) Popliteus
(D) Gastrocnemius
(D} Inferior gluteal nerve (E) Biceps femoris
(E} Femoral nerve
7. A patient presents with sensory loss on ad-
3. A patient is unable to prevent anterior dis- jacent sides of the great and second toes and
placement of the femur on the tibia when the impaired dorsiflexion of the foot. These signs
knee is flexed. Which of the following ligaments probably indicate damage to which of the
is most likely damaged? following nerves?
(A) Anterior cruciate (A) Superficial peroneal
(B) Fibular collateral (B) Lateral plantar
(C) Patellar (C) Deep peroneal
(D) Sural
(E} Tibial collateral (E} Tibial

4. A 41-year-old man was involved ina fight and 8. A motorcyclist falls from his bike in an acci-
felt weakness in extending the knee joint. On ex- dent and gets a deep gash that severs the super-
amination, he was diagnosed with a lesion of the ficial peroneal nerve near its origin. Which of
femoral nerve. Which of the following symptoms the following muscles is paralyzed?
would be a result of this nerve damage?
(A) Paralysis of the psoas major muscle (B) Extensor hallucis longus
(B) Loss of skin sensation on the lateral side of (C) Extensor digitorum longus
the foot (D} Peroneus tertius
(C) Loss of skin sensation over the greater (E} Extensor digitorum brevis
trochanter

(E} Paralysis of the tensor fasciae latae

258
 (Ge Lower Limb 259

9. A 67-year-old patient has been given a 13. A thoracic surgeon is going to collect a por-
course of antibiotics by gluteal intramuscular tion of the greater saphenous vein for coronary
injections after a major abdominal surgery. bypass surgery. He has observed that this vein
To avoid damaging the sciatic nerve during an runs
injection, the needle should be inserted into (A) Posterior to the medial malleolus
which of the following areas? (B) Into the popliteal vein
(A) Over the sacrospinous ligament (C) Anterior to the medial condyles of the tibia
(B} Midway between the ischial tuberosity and and femur
the lesser trochanter
(C) Midpoint of the gemelli muscles (E} Along with the femoral artery

14. A 52-year-old woman slipped and fell

(E} Lower medial quadrant of the gluteal and now complains of being unable to extend
region her leg at the knee joint. Which of the follow-
ing muscles was paralyzed as a result of this
10. A 20-year-old patient cannot flex and medi- accident?
ally rotate the thigh while running and climb- (A) Semitendinosus
ing. Which of the following muscles is most (B) Sartorius
likely damaged? (C) Gracilis
(A) Semimembranosus
(B) Sartorius (E) Biceps femoris
(C) Rectus femoris
(D) Vastus intermedius 15. A patient experiences weakness in dorsi-
flexing and inverting the foot. Which of the fol-
lowing muscles is damaged?
11. A 21-year-old man was involved in a mo- (A) Peroneus longus
torcycle accident, resulting in destruction of the (B) Peroneus brevis
groove in the lower surface of the cuboid bone.
(C) Tibialis anterior
Which of the following muscle tendons is most (D) Extensor digitorum longus
likely damaged? (E) Peroneus tertius
(A) Flexor hallucis longus
(B}) Peroneus brevis Questions 16 to 20: A 62-year-old woman slips
and falls on the bathroom floor. As a result, she
(D) Tibialis anterior has a posterior dislocation of the hip joint and a
(E) Tibialis posterior fracture of the neck of the femur.

12. A construction worker falls feet first from a 16. Rupture of the ligamentum teres capitis
roof. He sustains a fracture of the groove on the femoris may lead to damage to a branch of
undersurface of the sustentaculum tali of the which of the following arteries?
calcaneus bone. Which of the following muscle
(A) Medial circumflex femoral
tendons is most likely torn?
(B) Lateral circumflex femoral
(A) Flexor digitorum brevis
(B} Flexor digitorum longus (D) Superior gluteal
(C) Flexor hallucis brevis (E) Inferior gluteal

(E) Tibialis posterior

 260 BRS Gross Anatomy

17. Fracture of the neck of the femur results in 22. A patient experiences paralysis of the
avascular necrosis of the femoral head, prob- muscle that originates from the femur and con-
ably resulting from lack of blood supply from tributes directly to the stability of the knee joint.
which of the following arteries? Which of the following muscles is involved?
(A) Obturator
(B} Superior gluteal (B} Semimembranosus
(C) Inferior gluteal (C) Sartorius
(D) Biceps femoris (long head)
(E} Lateral femoral circumflex (E) Rectus femoris

18. Ifthe acetabulum is fractured at its pos- 23. A patient is involved in a motorcycle wreck
terosuperior margin by dislocation of the hip that results in avulsion of the skin over the an-
joint, which of the following bones could be terolateral leg and ankle. Which of the following
involved? structures is most likely destroyed with this type
(A) Pubis of injury?
(B) Ischium (A) Deep peroneal nerve
(C) Tium (B) Extensor digitorum longus muscle tendon
(D}) Sacrum (C) Dorsalis pedis artery
(E} Head of the femur (D) Great saphenous vein

19. The woman experiences weakness when

abducting and medially rotating the thigh after 24. A knife wound penetrates the superficial
this accident. Which of the following muscles is vein that terminates in the popliteal vein.
most likely damaged? Bleeding occurs from which of the following
(A) Piriformis vessels?
(B} Obturator internus (A) Posterior tibial vein
(C} Quadratus femoris (B) Anterior tibial vein
(D} Gluteus maximus (C} Peroneal vein
(D) Great saphenous vein

20. The woman undergoes hip surgery. If all of

the arteries that are part of the cruciate anasto- 25. A 10-year-old boy falls from a tree house.
mosis of the upper thigh are ligated, which of The resultant heavy compression of the sole of
the following arteries maintains blood flow? his foot against the ground caused a fracture
(A) Medial femoral circumflex of the head of the talus. Which of the following
(B) Lateral femoral circumflex structures is unable to function normally?
(C) Superior gluteal (A) Transverse arch
(D} Inferior gluteal
(E} First perforating (C) Lateral longitudinal arch
(D) Tendon of the peroneus longus
21, A 34-year-old woman sustains a deep cut (E) Long plantar ligament
on the dorsum of the foot just distal to her ankle
joint by a falling kitchen knife. A physician in 26. A 24-year-old woman complains of weak-
the emergency department has ligated the dor- ness when she extends her thigh and rotates
salis pedis artery proximal to the injured area. it laterally. Which of the following muscles is
Which of the following conditions most likely paralyzed?
occurs as a result of the injury? (A) Obturator externus
(A) Ischemia in the peroneus longus muscle (B) Sartorius
(B} Aneurysm in the plantar arterial arch (C} Tensor fasciae latae

(E} Semitendinosus
(D) Low blood pressure in the anterior tibial
artery
(E} High blood pressure in the arcuate artery
 (Ge Lower Limb 261

27. A patient with hereditary blood clotting Questions 31 to 35: A 20-year-old college stu-
problems presents with pain in the back of her dent receives a severe blow on the inferolateral
knee. An arteriograph reveals a blood clot in the side of the left knee joint while playing football.
popliteal artery at its proximal end. Which of Radiographic examination reveals a fracture of
the following arteries will allow blood to reach the head and neck of the fibula.
the foot?
(A) Anterior tibial 31. Which of the following nerves is damaged?
(B) Posterior tibial (A) Sciatic
(C) Peroneal (B) Tibial
(C) Common peroneal
(E} Superior medial genicular (D) Deep peroneal
(E) Superficial peroneal
28. A 72-year-old woman complains ofa
cramplike pain in her thigh and leg. She was 32. After injury to this nerve, which of the fol-
diagnosed as having a severe intermittent clau- lowing muscles could be paralyzed?
dication. Following surgery, an infection was
(A) Gastrocnemius
found in the adductor canal, damaging the en-
(B) Popliteus
closed structures. Which of the following struc-
tures remains intact?
(D) Flexor digitorum longus
{A} Femoral artery (E) Tibialis posterior
(B) Femoral vein
(C) Saphenous nerve 33. Ifthe lateral (fibular) collateral ligament
is torn by this fracture, which of the following
(E} Nerve to the vastus medialis conditions may occur?
(A) Abnormal passive abduction of the
29. A basketball player was hit in the thigh by
extended leg
an opponent’s knee. Which of the following ar-
teries is likely to compress and cause ischemia
because of the bruise and damage to the exten-
(C} Anterior displacement of the femur on the
sor muscles of the leg?
tibia
(A) Popliteal (D) Posterior displacement of the femur on the
(B) Deep femoral tibia
(E) Maximal flexion of the leg
(D} Posterior tibial
(E} Peroneal 34. Which of the following arteries could also
be damaged by this fracture?
30. An elderly woman fell at home and frac-
(A) Popliteal
tured the greater trochanter of her femut.
(B) Posterior tibial
Which of the following muscles would continue
to function normally? (C) Anterior tibial
(D) Peroneal
(A) Piriformis (E} Lateral inferior genicular
(B} Obturator internus
(C) Gluteus medius 35. Which of the following conditions would
occur from this fracture?
(E) Gluteus minimus
(A) Ischemia in the gastrocnemius
(B) Loss of plantar flexion
(C) Trendelenburg sign

(E) Flat foot

 262 BRS Gross Anatomy

36. A construction worker is hit on the leg with 41. While playing football, a 19-year-old col-
a concrete block and is subsequently unable lege student receives a twisting injury to his
to plantar flex and invert his foot. Which of the knee when being tackled from the lateral side.
following muscles is most likely damaged? Which of the following conditions most likely
(A) Extensor digitorum longus has occurred?
(B) Tibialis anterior
(B) Ruptured fibular collateral ligament
(D} Peroneus longus (C) Tenderness on pressure along the fibular
(E} Peroneus brevis collateral ligament
(D) Injury of the posterior cruciate ligament
37. The obturator nerve and the sciatic (tibial (E) Swelling on the back of the knee joint
portion) nerve of a 15-year-old boy are tran-
sected as a result of a motorcycle accident. This 42. A patient has weakness when flexing both
injury would result in complete paralysis of her thigh and leg. Which of the following mus-
which of the following muscles? cles is most likely injured?
(A) Rectus femoris (A) Rectus femoris
(B) Biceps femoris, short head (B) Semitendinosus
(C) Pectineus (C} Biceps femoris

(E) Sartorius (E) Adductor longus

38. A 24-year-old woman presents to her physi- 43. A 35-year-old man has difficulty in dorsi-
cian with weakness in flexing the hip joint and flexing the foot. Which of the following muscles
extending the knee joint. Which muscle is most is most likely damaged?
likely involved in this scenario? (A) Tibialis posterior
(A) Sartorius (B) Flexor digitorum longus
(B) Gracilis
(C) Rectus femoris (D) Peroneus longus
(D) Vastus medialis (E) Peroneus brevis
(E) Semimembranosus
44. An injury to the leg of a golfer results in loss
39. A 17-year-old boy was stabbed during of the ability to invert the foot. Which of the fol-
a gang fight, resulting in the transection of lowing muscles is most likely paralyzed?
the obturator nerve. Which of the following
muscles is completely paralyzed? (B) Peroneus longus
(A) Pectineus (C} Peroneus brevis
(B} Adductor magnus (D} Peroneus tertius
(E) Extensor digitorum longus
(D) Biceps femoris
(E) Semimembranosus 45. An orthopedic surgeon ligates the posterior
tibial artery at its origin. Which of the following
40. A 32-year-old carpenter fell from the roof. arteries has no blood flow immediately after the
The lateral longitudinal arch of his foot was ligation?
flattened from fracture and displacement of the
keystone for the arch. Which of the following
(A) Peroneal
(B) Dorsalis pedis
bones is damaged? (C) Superior medial genicular
(A) Calcaneus (D) Anterior tibial
(E} Descending genicular
(C) Head of the talus
(D) Medial cuneiform
(E} Navicular bone
 (Ge Lower Limb 263

46. Before knee surgery, a surgeon ligates arter- 50. A 14-year-old gymnastic silver medalist falls
ies participating in the anastomosis around the from the parallel bar and complains of pains
knee joint. Which of the following arteries is from the knee and ankle joints. On physical ex-
most likely spared? amination, her physician found that the muscle
(A) Lateral superior genicular responsible for flexing the leg at the knee joint
(B} Medial inferior genicular and plantar flexing the foot is severely weak-
(C) Descending branch of the lateral femoral ened. Which of the following muscles involved
circumflex in both movements was most likely damaged in
this accident?
(A) Tibialis posterior
(E} Anterior tibial recurrent
(C) Soleus
47. A 25-year-old gladiator sustains a penetrat- (D) Peroneus longus
ing injury that severs the superficial peroneal (E) Flexor digitorum longus
nerve. This will most likely cause paralysis of
which of the following muscles? 51. A 28-year-old basketball player falls while
(A) Peroneus tertius rebounding and is unable to run and jump. On
physical examination, he has pain and weak-
(C) Flexor hallucis longus ness when extending his thigh and flexing his
(D) Tibialis anterior leg. Which muscle involved in both movements
(E) Tibialis posterior is most likely injured?
(A) Short head of biceps femoris
48. A patient presents with a thrombosis in (B) Adductor magnus
the popliteal vein. This thrombosis most likely
causes reduction of blood flow in which of the (D) Sartorius
following veins? (E}) Gracilis
(A) Greater saphenous
(B) Lesser saphenous 52. A 52-year-old woman comes to an orthope-
dic surgeon complaining of an uncomfortable
(D} Posterior tibial feeling in her knee and ankle joints. After a
(E} Anterior tibial thorough examination, she is diagnosed as hav-
ing arthritis with mild discomfort with passive
49. A 21-year-old tennis player comes to an movements. The muscles acting at the ankle
emergency room and complains of pain in the joint appear normal with good strength. Which
knee joint. On examination, he has an infection muscle can both dorsiflex and invert her foot?
inside the knee joint capsule but outside the sy- (A) Peroneus longus
novial cavity. Which of the following structures (B) Peroneus brevis
is preserved from this infection? (C} Peroneus tertius
(A) Anterior cruciate ligament (D) Extensor hallucis longus
(B} Posterior cruciate ligament (E) Extensor digitorum longus
(C) Lateral meniscus

(E} Medial meniscus

264 BRS Gross Anatomy

Questions 53 to 56: Choose the appropriate

lettered site or structure in the following
radiographs of the knee joint (see Figure below)
to match the following descriptions.

53. Rupture of the tendon superior to this 55. A knife penetrating through this point
structure would most likely cause an inability would most likely cause muscle ischemia in the
to extend the knee joint. anterior compartment of the leg.
Cc B
54. Fracture of this structure would most likely 56. Fracture of this structure would most likely
cause weakness in adduction, flexion, and cause a lesion of the common peroneal nerve,
extension of the thigh. A resulting in paralysis of the muscles in the ante-
rior and lateral compartments of the leg.
E
 (Ge Lower Limb 265

Questions 57 to 60: Choose the appropriate let-

tered site or structure in the radiograph of the
hip and pelvis (see Figure below) to match the
following descriptions.

57. Which structure in this radiograph may be 59. Which fractured structure is likely to cause
fractured, resulting in loss of the chief flexor of paralysis of the adductor magnus?
the thigh? D Cc
60. Which structure becomes necrotic after the
58. Fracture of which structure may destroy the medial femoral circumflex artery is severed?
site of insertion of the muscle that can rotate
the thigh laterally and its tendon that passes A
through the lesser sciatic foramen?

B
266 BRS Gross Anatomy

Questions 61 to 64: Choose the appropriate

lettered site or structure in the following radio-
graph of the ankle and foot (see Figure below)
to match the following descriptions.
D E

61. The flexor hallucis longus tendon is dam- 63. The medial longitudinal arch of the foot is
aged in a groove on the posterior surface of a flattened because the spring ligament is torn.
tarsal bone. Which bone in the radiograph is Which bone in the radiograph is most likely
likely fractured? A fractured? D

62. The tibialis anterior and peroneus longus 64. The peroneus longus muscle tendon is
muscles are weakened. Which bone in the ra- damaged in a groove ofa tarsal bone by frac-
diograph is most likely fractured? ture. Which bone in the radiograph is most
E likely fractured? B
 Review Test

Directions: Each of the numbered items or incomplete statements in this section is followed by an-
swers or by completions of the statement. Select the one-lettered answer or completion that is best
in each case.

1. A 21-year-old patient has a lesion of the up- (D} Dorsal interosseous

per trunk of the brachial plexus (Erb-Duchenne
paralysis). Which of the following is the most
likely diagnosis? 5. A 27-year-old patient presents with an in-
(A) Paralysis of the rhomboid major ability to draw the scapula forward and down-
(B} Inability to elevate the arm above the ward because of paralysis of the pectoralis
horizontal minor. Which of the following would most likely
be a cause of his condition?
(D) Loss of sensation on the medial side of the (A) Fracture of the clavicle
arm (B) Injury to the posterior cord of the brachial
(E} Inability to adduct the thumb plexus
(C) Fracture
of the coracoid process
2. A patient comes in with a gunshot wound (D) Axillary nerve injury
and requires surgery in which his thoracoac- (E) Defects in the posterior wall of the axilla
romial trunk needs to be ligated. Which of the
following arterial branches would maintain 6. A 22-year-old patient received a stab wound
normal blood flow? in the chest that injured the intercostobrachial
(A) Acromial nerve. Which of the following conditions results
(B) Pectoral from the described lesion of the nerve?
(C) Clavicular (A) Inability to move the ribs
(D) Deltoid (B) Loss of tactile sensation on the lateral
aspect of the arm
(C) Absence of sweating on the posterior
3. A 29-year-old man comes in with a stab aspect of the arm
wound, cannot raise his arm above horizontal, (D) Loss of sensory fibers from the second
and exhibits a condition known as “winged intercostal nerve
scapula.” Which of the following structures of the (E} Damage to the sympathetic preganglionic
brachial plexus would most likely be damaged? fibers
(A) Medial cord
(B) Posterior cord 7. A 16-year-old boy fell from a motorcycle, and
(C) Lower trunk his radial nerve was severely damaged because
of a fracture of the midshaft of the humerus.
(E) Upper trunk Which of the following conditions would most
likely result from this accident?
4. A 16-year-old patient has weakness flex-
ing the metacarpophalangeal joint of the ring
finger and is unable to adduct the same finger. (B) Weakness in pronating the forearm
Which of the following muscles is most likely (C) Sensory loss over the ventral aspect of the
paralyzed? base of the thumb
(A) Flexor digitorum profundus (D) Inability to oppose the thumb
(B} Extensor digitorum (E} Inability to abduct the fingers
(C) Lumbrical

319
320 BRS Gross Anatomy

8. A patient comes in complaining that she 13. A 14-year-old boy falls on his outstretched
cannot flex her proximal interphalangeal joints. hand and has a fracture of the scaphoid bone.
Which of the following muscles appear(s) to be The fracture is most likely accompanied by a
paralyzed on further examination of her finger? rupture of which of the following arteries?
(A) Palmar interossei (A) Brachial artery
(B) Dorsal interossei (B) Ulnar artery
(C) Flexor digitorum profundus (C} Deep palmar arterial arch

(E} Lumbricals (E) Princeps pollicis artery

9. A 21-year-old woman walks in with a shoul- 14. A 12-year-old boy walks in; he fell out of
der and arm injury after falling during horse- a tree and fractured the upper portion of his
back riding. Examination indicates that she humerus. Which of the following nerves are
cannot adduct her arm because of paralysis of intimately related to the humerus and are most
which of the following muscles? likely to be injured by such a fracture?
(A) Teres minor (A) Axillary and musculocutaneous
(B) Supraspinatus (B) Radial and ulnar

(D) Infraspinatus (D} Median and musculocutaneous

(E) Serratus anterior (E) Median and ulnar

10. A 35-year-old man walks in with a stab 15. A man injures his wrist on broken glass.
wound to the most medial side of the proxi- Which of the following structures entering the
mal portion of the cubital fossa. Which of palm superficial to the flexor retinaculum may
the following structures would most likely be be damaged?
damaged? (A) Ulnar nerve and median nerve
(A) Biceps brachii tendon (B) Median nerve and flexor digitorum
(B) Radial nerve profundus
(C) Brachial artery (C) Median nerve and flexor pollicis longus
(D} Radial recurrent artery
(E) Ulnar nerve and flexor digitorum
superficialis
11. The police bring in a murder suspect who
has been in a gunfight with a police officer. The 16. A patient with Bennett fracture (a fracture
suspect was struck by a bullet in the arm; his of the base of the first metacarpal bone) experi-
median nerve has been damaged. Which of the ences an impaired thumb movement. Which of
following symptoms is likely produced by this the following intrinsic muscles of the thumb is
nerve damage? most likely injured?
(A) Waiter’s tip hand (A) Abductor pollicis brevis
(B) Claw hand (B) Flexor pollicis brevis (superficial head)
(C) Wrist drop
(D) Adductor pollicis
(E} Flattening of the hypothenar eminence (E) Flexor pollicis brevis (deep head)

12. An automobile body shop worker has his 17. A 27-year-old pianist with a known carpal
middle finger crushed while working ona tunnel syndrome experiences difficulty in finger
transmission. Which of the following muscles is movements. Which of the following intrinsic
most likely to retain function? muscles of her hand is paralyzed?
(A) Extensor digitorum (A) Palmar interossei and adductor pollicis
(B} Flexor digitorum profundus (B) Dorsal interossei and lateral two
lumbricals
(D} Dorsal interosseous
(E} Lumbrical
 Upper Limb 321

(D) Abductor pollicis brevis and palmar the following groups of muscles have lost their
interossei functions?
(E} Medial two and lateral two lumbricals (A) Brachioradialis and supinator

18. A 31-year-old roofer walks in with tenosy- (C} Pronator teres and supinator
novitis resulting from a deep penetrated wound (D) Supinator and pronator quadratus
in the palm by a big nail. Examination indicates (E) Brachialis and pronator teres
that he has an infection in the ulnar bursa. This
infection most likely resulted in necrosis of 23. A 23-year-old man complains of numb-
which of the following tendons? ness on the medial side of the arm following a
(A) Tendon of the flexor carpi ulnaris stab wound in the axilla. On examination, he is
(B} Tendon of the flexor pollicis longus diagnosed with an injury of his medial brachial
cutaneous nerve. In which of the following
(D) Tendon of the flexor carpi radialis structures are the cell bodies of the damaged
(E} Tendon of the palmaris longus nerve involved in numbness located?
(A) Sympathetic chain ganglion
19. An 18-year-old boy involved in an automo-
bile accident presents with an arm that cannot (C} Anterior horn of the spinal cord
abduct. His paralysis is caused by damage to (D) Lateral horn of the spinal cord
which of the following nerves? (E) Posterior horn of the spinal cord

(B) Thoracodorsal and upper subscapular 24. A 38-year-old homebuilder was involved in
(C) Axillary and musculocutaneous an accident and is unable to supinate his fore-
(D) Radial and lower subscapular arm. Which of the following nerves are most
(E} Suprascapular and dorsal scapular likely damaged?
(A) Suprascapular and axillary
20. A 17-year-old boy with a stab wound re- (B}) Musculocutaneous and median
ceived multiple injuries on the upper part of the (C) Axillary and radial
arm and required surgery. If the brachial artery
were ligated at its origin, which of the following (E) Median and ulnar
arteries would supply blood to the profunda
brachii artery? 25. A 31-year-old patient complains of sensory
(A) Lateral thoracic loss over the anterior and posterior surfaces
(B) Subscapular of the medial third of the hand and the medial
(C)
Posterior
humeral circumflex one and one-half fingers. He is diagnosed bya
(D) Superior ulnar collateral physician as having “funny bone” symptoms.
(E} Radial recurrent Which of the following nerves is injured?
(A) Axillary
21, A 23-year-old woman who receives a deep (B) Radial
cut to her ring finger by a kitchen knife is un- (C} Median
able to move the metacarpophalangeal joint. (D) Ulnar
Which of the following pairs of nerves was (E) Musculocutaneous
damaged?
(A) Median and ulnar 26. A patient with a deep stab wound in the
(B) Radial and median middle of the forearm has impaired movement
(C) Musculocutaneous and ulnar of the thumb. Examination indicates a lesion of
the anterior interosseous nerve. Which of the
(E} Radial and axillary following muscles is paralyzed?
(A) Flexor pollicis longus and brevis
22, A 27-year-old baseball player is hit on his (B) Flexor pollicis longus and opponens
forearm by a high-speed ball during the World pollicis
Series, and the muscles that form the floor of
the cubital fossa appear to be torn. Which of
quadratus
322 BRS Gross Anatomy

(D} Flexor digitorum profundus and 31. The victim of an automobile accident has a
superficialis destructive injury of the proximal row of carpal
(E) Flexor pollicis brevis and pronator bones. Which of the following bones is most
quadratus likely damaged?
(A) Capitate
27. A 29-year-old patient comes in; he cannot (B}) Hamate
flex the distal interphalangeal (DIP) joint of the (C} Trapezium
index finger. His physician determines that he
(D) Triquetrum
has nerve damage from a supracondylar frac- (E) Trapezoid
ture. Which of the following conditions is also a
symptom of this nerve damage? 32. A patient has a torn rotator cuff of the
(A) Inability to flex the DIP joint of the ring shoulder joint as the result of an automobile
finger accident. Which of the following muscle
(B} Atrophy of the hypothenar eminence tendons is intact and has normal function?
(A) Supraspinatus
(B) Subscapularis
(D} Paralysis of all the thumb muscles (
(E) Loss of supination (D} Teres minor
(E) Infraspinatus
28. A 27-year-old man with cubital tunnel syn-
drome complains of numbness and tingling in 33. A patient complains of having pain with re-
the ring and little finger and back and sides of peated movements of his thumb (claudication).
his hand because of damage to a nerve in the His physician performs the Allen test and finds
tunnel at the elbow. Which of the following an insufficiency of the radial artery. Which of
muscles is most likely to be paralyzed? the following conditions would be a result of
{A} Flexor digitorum superficialis the radial artery stenosis?
(B} Opponens pollicis (A) A marked decrease in the blood flow in the
superficial palmar arterial arch
(D) Pronator teres (B) Decreased pulsation in the artery passing
(E) Supinator superficial to the flexor retinaculum
(C} Ischemia of the entire extensor muscles of
29. A secretary comes in to your office com- the forearm
plaining of pain in her wrists from typing all
day. You determine that she likely has carpal
tunnel syndrome. Which of the following condi- (E) A low blood pressure in the anterior inter-
tions would help you determine the diagnosis? osseous artery
(A) Inability to adduct the little finger
(B} Inability to flex the DIP joint of the ring 34. A patient bleeding from the shoulder sec-
finger ondary to a knife wound is in fair condition
because there is vascular anastomosis around
(D) Loss of skin sensation of the medial one the shoulder. Which of the following arteries
and one-half fingers is most likely a direct branch of the subclavian
(E) Atrophied adductor pollicis muscle artery that is involved in the anastomosis?

30. A man is unable to hold typing paper be- (B) Thoracoacromial artery
tween his index and middle fingers. Which of (C) Circumflex scapular artery
the following nerves was likely injured? (D) Transverse cervical artery
(A) Radial nerve (E} Suprascapular artery
(B) Median nerve
35. During a breast examination of a 56-year-
(D} Musculocutaneous nerve old woman, the physician found a palpable
(E} Axillary nerve mass in her breast. Which of the following
 Upper Limb 323

characteristics of breast cancer and its diagnosis (C) Knife wound on the teres major muscle
is correct?
(A) Elevated nipple
(B} Polymastia (E} A tumor in the triangular space in the
(C) Shortening of the clavipectoral fascia shoulder region

(E} Enlargement of the breast 40. A 49-year-old woman is diagnosed as hav-

ing a large lump in her right breast. Lymph
36. A patient with a stab wound receives a lac- from the cancerous breast drains primarily into
eration of the musculocutaneous nerve. Which which of the following nodes?
of the following conditions is most likely to have (A) Apical nodes
occurred?
(C) Parasternal (internal thoracic) nodes
forearm (D) Supraclavicular nodes
(B} Inability to extend the forearm (E) Nodes of the anterior abdominal wall
(C) Paralysis of brachioradialis muscle
(D) Loss of tactile sensation on the arm 41. A 17-year-old boy fell from his motorcycle
(E} Constriction of blood vessels on the hand and complains of numbness of the lateral part
of the arm. Examination reveals that the axillary
37. A 20-year-old man fell from the parallel nerve is severed. Which of the following types
bar during the Olympic trial. A neurologic of axons is most likely spared?
examination reveals that he has a lesion of the (A) Postganglionic sympathetic axons
lateral cord of the brachial plexus. Which of the (B) Somatic afferent axons
following muscles is most likely weakened by
this injury? (D) General somatic efferent axons
(A) Subscapularis (E} General visceral afferent axons
(B} Teres major
(C) Latissimus dorsi 42. A construction worker suffers a destructive
(D) Teres minor injury of the structures related to the anatomic
snuffbox. Which of the following structures
would most likely be damaged?
38. A 24-year-old carpenter suffers a crush (A) Triquetral bone
injury of his entire little finger. Which of the (B) Trapezoid bone
following muscles is most likely to be spared? (C} Extensor indicis tendon
(A) Flexor digitorum profundus (D) Abductor pollicis brevis tendon
(B} Extensor digitorum
(C) Palmar interossei
43. Arock climber falls on his shoulder, result-
(E} Lumbricals ing in a chipping off of the lesser tubercle of
the humerus. Which of the following structures
39. A 7-year-old boy falls from a tree house and would most likely have structural and
is brought to the emergency department of a functional damage?
local hospital. On examination, he has weak- (A) Supraspinatus muscle
ness in rotating his arm laterally because of an (B) Infraspinatus muscle
injury of a nerve. Which of the following condi-
tions is most likely to cause a loss of this nerve (D} Teres minor muscle
function? (E) Coracohumeral ligament
(A) Injury to the lateral cord of the brachial
plexus 44. A 22-year-old female Macarena dancer fell
(B) Fracture of the anatomic neck of the from the stage and complains of elbow pain
humerus and inability to supinate her forearm. Which
324 BRS Gross Anatomy

of the following nerves are most likely injured 48. Which of the following nerves is most likely
from this accident? injured as a result of this accident?
(A) Median and ulnar nerves (A) Axillary
(B} Axillary and radial nerves (B} Musculocutaneous
(C)
musculocutaneous
Radial and nerves (C} Radial
(D} Ulnar and axillary nerves (D} Median
(E} Musculocutaneous and median nerves

Questions 45 to 47: A 37-year-old female patient 49. Which of the following muscles is most
has a fracture of the clavicle. The junction of the likely paralyzed as a result of this accident?
middle and lateral thirds of the bone exhibits (A) Extensor pollicis brevis
overriding of the medial and lateral fragments. (B) Abductor pollicis longus
The arm is rotated medially, but it is not rotated (C} Abductor pollicis brevis
laterally.
(E) Opponens pollicis
45. The lateral portion of the fractured clavicle is
displaced downward by which of the following? 50. After this injury, the patient is unable to do
(A) Deltoid and trapezius muscles which of the following?
(B} Pectoralis major and deltoid muscles (A) Flex the proximal interphalangeal joint of
(C) Pectoralis minor muscle and gravity his ring finger
(D) Trapezius and pectoralis minor muscles (B) Flex the DIP joint of his index finger
(C) Feel sensation on his middle finger
(D) Abduct his thumb
46. Which of the following muscles causes up-
ward displacement of the medial fragment?
(A) Pectoralis major Questions 51 to 55: A 10-year-old boy falls off
(B) Deltoid his bike, has difficulty in moving his shoulder,
(C) Trapezius and is brought to the emergency department.
His radiograph and angiograph reveal fracture
(E) Scalenus anterior of the surgical neck of his humerus and bleed-
ing from the point of the fracture.
47. Which of the following conditions is most
likely to occur secondary to the fractured 51. Which of the following nerves is most likely
clavicle? injured as a result of this accident?
(A) A fatal hemorrhage from the brachioce- (A) Musculocutaneous
phalic vein
(C} Radial
(D} Median
(C) Thrombosis of the subclavian artery, caus- (E} Ulnar
ing an embolism in the ascending aorta
(D} Damage to the upper trunk of the brachial 52. Following this accident, the damaged nerve
plexus causes difficulty in abduction, extension, and
(E} Damage to the long thoracic nerve, caus- lateral rotation of his arm. Cell bodies of the
ing the winged scapula injured nerve involved in movement of his arm
are located in which of the following structures?
Questions 48 to 50: A 21-year-old man injures (A) Dorsal root ganglion
his right arm in an automobile accident. Radio- (B} Sympathetic chain ganglion
graphic examination reveals a fracture of the
medial epicondyle of the humerus. (D) Lateral horn of the spinal cord
(E) Posterior horn of the spinal cord
 Upper Limb 325

53. The damaged nerve causes numbness of Questions 58 to 62: A 17-year-old boy is injured
the lateral side of the arm. Cell bodies of the in an automobile accident. He has a fracture of
injured nerve fibers involved in sensory loss are the shaft of the humerus.
located in which of the following structures?
(A) Anterior horn of the spinal cord 58. Which of the following nerves is most likely
(B) Posterior horn of the spinal cord damaged?
(C) Lateral horn of the spinal cord (A) Axillary nerve

(E) Sympathetic chain ganglia (C} Musculocutaneous nerve

(D} Median nerve
54. This accident most likely leads to the (E} Ulnar nerve
damage of which of the following arteries?
(A) Axillary 59. Asa result of this fracture, the patient shows
(B) Deep brachial lack of sweating on the back of the arm and
(C)
Posterior
humeral circumflex forearm. Cell bodies of the damaged nerve fi-
(D) Superior ulnar collateral bers involved in sweating are located in which
(E) Scapular circumflex of the following structures?
(A) Anterior horn of the spinal cord
55. Following this accident, the boy has weak- (B) Posterior horn of the spinal cord
ness in rotating his arm laterally. Which of the (C} Lateral horn of the spinal cord
following muscles are paralyzed?
(A) Teres major and teres minor (E} Dorsal root ganglion

(C) Infraspinatus and deltoid 60. Following this accident, the patient has no
(D} Supraspinatus and subscapularis cutaneous sensation in which of the following
(E) Teres minor and infraspinatus areas?
(A) Medial aspect of the arm
Questions 56 to 57: A 64-year-old man with a (B) Lateral aspect of the forearm
history of liver cirrhosis has been examined (C) Palmar aspect of the second and third
for hepatitis A, B, and C viruses. In an attempt digits
to obtain a blood sample from the patient’s (D) Area of the anatomic snuffbox
median cubital vein, a registered nurse inadver- (E) Medial one and one-half fingers
tently procures arterial blood.
61. Which of the following arteries may be
56. The blood most likely comes from which of damaged?
the following arteries? (A) Brachial artery
(A) Brachial (B) Posterior humeral circumflex artery
(B) Radial
(C) Ulnar (D) Radial artery
(D} Common interosseous (E) Radial recurrent artery
(E) Superior ulnar collateral
62. After this accident, supination is still pos-
57. During the procedure, the needle hits a sible through contraction of which of the fol-
nerve medial to the artery. Which of the follow- lowing muscles?
ing nerves is most likely damaged? (A) Supinator
(A) Radial (B) Pronator teres
(C} Brachioradialis
(C) Ulnar
(D) Lateral antebrachial (E) Supraspinatus
(E} Medial antebrachial
326 BRS Gross Anatomy

63. A cyclist is thrown over his handle bars 64. A patient presents with pain in the neck,
and breaks his clavicle as he hits the ground on numbness and tingling in the fingers, and a
his shoulder. Which of the following is correct week grip. This presentation suggests thoracic
regarding the development of the clavicle? outlet syndrome. Which of the following causes
has an embryological etiology?
(A) It develops through intramembranous
ossification (A) Traumatic injury
(B} Itis the last upper limb bone to begin (B) Cardiovascular disease
ossification
(C) The clavicle forms from somitic mesoderm (D) Pancoast tumor
(D) Itis the first limb bone to complete (E} Scalene muscle inflammation
ossification
(E} Associated muscles form from somatic lat-
eral plate mesoderm

Questions 65 to 66: A 11-year-old boy falls down

the stairs. A physician examines the radiograph
of the boy’s shoulder region (see Figure below).

65. Ifthe structure indicated by the letter A 66. If the structure indicated by the letter B is
is calcified, which of the following muscles is fractured, which of the following structures is
most likely paralyzed? most likely injured?
(A) Deltoid (A) Musculocutaneous nerve
(B} Teres major (B) Radial nerve
(C) Teres minor (C) Deep brachial artery

(E) Subscapularis (E} Scapular circumflex artery

 Upper Limb 327

Questions 67 to 69: Choose the appropriate

lettered site or structure in the radiograph
of the elbow joint (see Figure below) and its
associated structures to match the following
descriptions.

E D

A F

B Cc

67. Destruction of this area would most likely 69. A lesion of the radial nerve would most
cause weakness of supination and flexion of the likely cause paralysis of muscles that are
forearm. B attached to this area.

68. Destruction of this area would most likely

cause weakness of pronation of the forearm and
flexion of the wrist joints. E
328 BRS Gross Anatomy

Questions 70 to 71: Choose the appropriate

lettered site or structure in the following radio-
graph of the wrist and hand (see Figure below).

70. Destruction of the structure indicated by 71. If the floor of the anatomic snuffbox and
the letter E most likely causes weakness of origin of the abductor pollicis brevis are dam-
which of the following muscles? aged, which of the following bones is most
(A) Flexor carpi radialis likely to be involved?
(B} Palmaris longus (A) A
(B)B
(D) Brachioradialis (C) Cc
(E} Flexor digitorum superficialis (D) D
(E} E
 Upper Limb 329

Questions 72 to 75: Choose the appropriate let-

tered site or structure in this transverse magnetic
resonance imaging through the middle of the
palm of a woman’s right hand (see Figure below)
that matches the following descriptions.

F E D Cc

72. The patient is unable to abduct her middle 74. The patient is unable to adduct her little fin-
finger because of paralysis of this structure. ger because of paralysis of this structure.
D
73. A lesion of the median nerve causes paraly- 75, Atrophy of this structure impairs extension
sis of this structure. A of both the metacarpophalangeal and interpha-
langeal joints. E
 Review Test

Directions: Each of the numbered items or incomplete statements in this section is followed by
answers or by completions of the statement. Select the one-lettered answer or completion that is
best in each case.

1. A 38-year-old man has had thyroid surgery 5. A 17-year-old boy receives an injury to the
to remove his papillary carcinoma. The external phrenic nerve by a knife wound in the neck.
laryngeal nerve that accompanies the superior The damaged nerve passes by which of the fol-
thyroid artery is damaged during the surgery. lowing structures in the neck?
This injury could result in a severe impairment (A) Anterior to the subclavian vein
of function of which of the following? (B) Posterior to the subclavian artery
(A) Relaxing the vocal cords (C) Deep to the brachial plexus
(B} Rotating the arytenoid cartilages (D) Medial to the common carotid artery

(D} Widening the rima glottidis

(E} Abducting the vocal cords 6. A 45-year-old woman is suffering from
numbness over the tip of her nose. Which of the
2. A 27-year-old woman with a goiter comes to following nerves is most likely to be damaged?
the hospital for surgical treatment. The surgeon
must ligate the superior laryngeal artery before
nerve
surgically resecting the goiter, so care must be (B) Maxillary division of the trigeminal nerve
taken to avoid injury to which of the following (C) Mandibular division of the trigeminal
nerves? nerve
{A} External laryngeal nerve (D) Facial nerve
(E) Auriculotemporal nerve
(C) Superior laryngeal nerve
(D} Hypoglossal nerve 7. A 26-year-old singer visits her physician—an
(E} Vagus nerve ear, nose, and throat (ENT) surgeon—and com-
plains of changes in her voice. A laryngoscopic
3. A 19-year-old woman complains of numb- examination demonstrates a lesion of the supe-
ness of the nasopharynx after surgical removal rior laryngeal nerve, causing weakness of which
of the adenoid. A lesion of which of the follow- of the following muscles?
ing nerves would be expected?
(A) Maxillary nerve (B) Middle pharyngeal constrictor
(B} Superior cervical ganglion (C) Superior pharyngeal constrictor
(C) External laryngeal nerve (D) Thyroarytenoid
(E} Thyrohyoid
(E} Vagus nerve
8. A 44-year-old man with “crocodile tears syn-
4. During surgery on a 56-year-old man for a drome” has spontaneous lacrimation during
squamous cell carcinoma of the neck, the sur- eating because of misdirection of regenerating
geon notices profuse bleeding from the deep autonomic nerve fibers. Which of the following
cervical artery. Which of the following arteries nerves has been injured?
must be ligated immediately to stop bleeding?
(A) Inferior thyroid artery
(B} Transverse cervical artery (B) Auriculotemporal nerve
(C) Thyrocervical trunk (C) Chorda tympani in the infratemporal fossa
(D) Facial nerve at the stylomastoid foramen
(E} Ascending cervical artery (E) Lacrimal nerve
435
436 BRS Gross Anatomy

9. A young girl complains of dryness of the 13. A 25-year-old man is involved in an auto-
nose and the palate. This would indicate a le- mobile accident and slams his head into a con-
sion of which of the following ganglia? crete wall of a bridge. His CT scan reveals that
(A) Nodose ganglion the middle meningeal artery has ruptured but
(B} Otic ganglion the meninges remain intact. Blood leaking from
this artery enters which of the following spaces?
(C) Pterygopalatine ganglion
(D} Submandibular ganglion (A) Subarachnoid space
(E} Ciliary ganglion (B) Subdural space

10. A 33-year-old woman develops Bell palsy. (D) Subpial space

She must be cautious because this can result in (E) Cranial dural sinuses
corneal inflammation and subsequent ulcer-
ation. This symptom results from which of the 14. A 27-year-old paratrooper lands on a pine
following conditions? tree. Consequently, preganglionic parasym-
{A} Sensory loss of the cornea and conjunctiva pathetic nerves leaving the central nervous
(B} Lack of secretion of the parotid gland system are lacerated. Which of the following
structures contain cell bodies of the damaged
(D} Absence of sweating on the face nerve fibers?
(E} Inability to constrict the pupil (A) Cervical and sacral spinal cord
(B) Cervical and thoracic spinal cord
11. A 39-year-old woman presents to your (C} Brain stem and cervical spinal cord
clinic with complaints of headache and diz- (D) Thoracic and lumbar spinal cord
ziness. She has an infection of a cranial dural
sinus. The sinus that lies in the margin of the
tentorium cerebelli and runs from the posterior 15. A 67-year-old woman comes to her physi-
end of the cavernous sinus to the transverse cian complaining of visual loss. Her MRI scan
sinus is infected. Which of the following sinuses shows an enlarged pituitary gland that lies in
is affected by inflammation? the sella turcica, immediately posterior and su-
(A) Straight sinus perior to which of the following structures?
(B} Inferior sagittal sinus (A) Frontal sinus
(C) Sphenoparietal sinus (B) Maxillary sinus
(C} Ethmoid air cells
(E} Cavernous sinus (D}) Mastoid air cells

12. A 24-year-old man falls from his motorcycle

and lands in a creek. Death may result from 16. After having a tonsillectomy, a 57-year-old
bilateral severance of which of the following man with a long history of chewing tobacco
nerves? use is unable to detect taste on the posterior
(A) Trigeminal nerve one-third of his tongue. Which of the following
(B) Facial nerve nerves has most likely been injured?
(A) Internal laryngeal nerve
(D} Spinal accessory nerve (B) Lingual nerve
(E} Hypoglossal nerve
(D) Greater palatine nerve
(E) Chorda tympani
 Head and Neck 437

17. A 14-year-old boy hits his head on the as- 21. A 71-year-old woman often visits an emer-
phalt road after falling off his skateboard. His gency department with swallowing difficulties
radiograph reveals damage to the sella turcica. and subsequent choking while eating food.
This is probably due to fracture of which of the Which of the following pairs of muscles is most
following bones? instrumental in preventing food from entering
(A) Frontal bone the larynx and trachea during swallowing?
(B) Ethmoid bone (A) Sternohyoid and sternothyroid muscles
(C) Temporal bone
(D) Basioccipital bone muscles
(C) Inferior pharyngeal constrictor and thyro-
hyoid muscles
18. The nerve accompanying the superior (D) Levator veli palatini and tensor veli pala-
thyroid artery may be damaged during an op- tini muscles
eration on the thyroid gland. Which of the fol- (E) Musculus uvulae and geniohyoid muscles
lowing functional defects may result from this
injury? 22. A 31-year-old woman complains of head-
(A) Loss of sensation above the vocal cord ache and dizziness after hitting a kitchen
(B} Loss of lateral rotation of the arytenoid cabinet door with her head. Her MRI scan and
cartilages venogram showa large blood clot in the great
(C) Paralysis of the vocalis muscle cerebral vein of Galen. The obstructed vein of
(D} Lack of abduction of the vocal cord the brain is a direct tributary of which of the fol-
lowing venous structures?
(A) Emissary veins
19. A 37-year-old patient has an infectious in- (B) Pterygoid venous plexus
flammation of the dural venous sinus closest to (C} Diploic veins
the pituitary gland and a secondary thrombus
formation. Which of the following is the most (E) Internal jugular vein
likely site of infection?
(A) Straight sinus 23. A 41-year-old woman overdoses on some
prescription medications that have a common
(C) Superior petrosal sinus side effect of autonomic nerve stimulation.
(D} Sigmoid sinus Which of the following conditions or actions
(E} Confluence of sinuses results from stimulation of the parasympathetic
fibers to the eyeball?
20. A young singer at the local music theater (A) Enhanced vision for distant objects
visits her physician and complains of vocal (B) Dilation of the pupil
difficulties. On examination, she is unable to (C} Contraction of capillaries in the iris
abduct the vocal cords during quiet breathing.
Which of the following muscles is most likely (E} Flattening of the lens
paralyzed?
(A) Vocalis muscle 24. A 53-year-old woman with a severe middle
(B} Cricothyroid muscle ear infection comes to the hospital. On exami-
(C) Oblique arytenoid muscle nation, the physician finds that the infection
has injured the tympanic nerve. The damaged
(E} Thyroarytenoid muscle nerve:
(A) Isa branch of the facial nerve
(B) Contains postganglionic parasympathetic
fibers
(C) Synapses with fibers in the lesser petrosal
nerve

(E) Forms the tympanic plexus in the external

auditory meatus
438 BRS Gross Anatomy

25, A 13-year-old boy competing in a mo- 29. A 43-year-old man has new onset of dif-
tocross competition falls from his bike and ficulty with speaking. Examination by the ENT
sustains massive head injuries. Which of the resident reveals problems in elevating the hy-
following cavities are separated from the mid- oid bone and floor of the mouth, secondary to
dle cranial fossa by a thin layer of bone? paralysis of the posterior belly of the digastric
(A) Auditory tube and bony orbit muscle. Which of the following nerves is most
likely involved?
(C) Sigmoid sinus and frontal sinus (A) Accessory nerve
(D) Sphenoid sinus and ethmoid sinus (B) Trigeminal nerve
(E} Maxillary sinus and middle ear cavity (C} Ansa cervicalis

26. A 32-year-old house painter suffers from (E) Glossopharyngeal nerve

ahead injury after falling off a ladder and has
bleeding in his head. During intraoperative 30. The drummer of a local band presents to
testing, the neurosurgeon notes loss of general your clinic with hearing loss. Otoscopic exami-
sensation in the dura of the middle cranial nation reveals loss of contraction of the tensor
fossa. Which of the following nerves has been tympani and the stapedius, which prevents
affected? damage to the eardrum and middle ear os-
{A} Vagus nerve sicles. These muscles are most likely controlled
(B) Facial nerve by which of the following nerves?
(C) Hypoglossal nerve (A) Chorda tympani and tympanic nerve

(E} Glossopharyngeal nerve (C) Auditory and vagus nerves

(D) Facial and auditory nerves
27. During a carotid endarterectomy ofa (E} Trigeminal and accessory nerves
57-year-old man who suffered a stroke, the
carotid sinus is damaged. A third-year medical 31. The pupil in the eye of a 43-year-old pa-
student in surgical rotation notices that the in- tient remains small even when room lighting
jured structure: is dim. Which of the following nerves would be
(A) Is located at the origin of the external ca- injured?
rotid artery (A) Trochlear nerve
(B) Is innervated by the facial nerve
(C) Functions as a chemoreceptor (C) Oculomotor nerve
(D) Ophthalmic nerve
(E} Communicates freely with the cavernous (E) Abducens nerve
sinus
32. A pharyngeal (gag) reflex is the contrac-
28. During a game, a 26-year-old baseball tion of the pharyngeal constrictor muscles that
player is hit in the head by a baseball, which is elicited by touching the back of a patient's
fractures the optic canal. Which of the following pharynx (e.g., with a tongue depressor). Affer-
pairs of structures is most likely to be damaged? ent nerve fibers that innervated the pharyngeal
(A) Optic nerve and ophthalmic vein mucosa are branches of which of the following
(B) Ophthalmic vein and ophthalmic nerve nerves?
(A) Trigeminal nerve
(D) Ophthalmic nerve and optic nerve (B) Facial nerve
(E} Ophthalmic artery and ophthalmic vein (C)
Glossopharyngeal
nerve
(D) Vagus nerve
(E) Hypoglossal nerve
 Head and Neck 439

33. A benign tumor in the orbit of a 49-year-old 37. A 53-year-old man has difficulty with
man compresses a structure that runs through breathing through his nose. On examination,
both the superior orbital fissure and the com- his physician finds that he has swelling of the
mon tendinous ring. Which of the following mucous membranes of the superior nasal me-
structures is most likely damaged? atus. Which opening of the paranasal sinuses is
(A) Frontal nerve most likely plugged?
(B) Lacrimal nerve (A) Middle ethmoidal sinus
(C) Trochlear nerve (B) Maxillary sinus
(
(E) Ophthalmic vein (D) Anterior ethmoidal sinus
(E) Frontal sinus
34. A 37-year-old man feels a little discomfort
when moving his tongue, pharynx, and larynx. 38. A 61-year-old woman is found to have ocu-
Physical examination indicates that the muscles lar lymphoma invading her optic canal. Which
attached to the styloid process are paralyzed. of the following structures would most likely be
Which of the following groups of cranial nerves damaged?
are damaged? (A) Ophthalmic vein
(A)
glossopharyngeal,
Facial, and hypoglossal (B) Ophthalmic nerve
nerves (C) Oculomotor nerve
(B} Hypoglossal, vagus, and facial nerves (D) Trochlear nerve
(C) Glossopharyngeal, trigeminal, and vagus {
nerves
(D} Vagus, spinal accessory, and hypoglossal 39. A 76-year-old man with swallowing difficul-
nerves ties undergoes imaging for a possible mass. The
(E} Facial, glossopharyngeal, and vagus nerves CT scan image at the level of the cricothyroid
ligament in his neck should show which of the
35. A high school basketball player experiences following structures?
a sudden difficulty in breathing and is brought
to an emergency department. When a low tra- (B) External carotid arteries
cheotomy is performed below the isthmus of (C) Inferior thyroid veins
the thyroid, which of the following vessels may (D) Thyrocervical trunks
be encountered? (E} Internal laryngeal nerves
(A) Inferior thyroid artery
40. The muscles that are of branchiomeric
(C) Costocervical trunk origin are paralyzed in a 26-year-old patient. A
(D} Superior thyroid artery lesion of which of the following nerves would
(E} Right brachiocephalic vein cause muscle dysfunction?
(A) Oculomotor nerve
36. A 59-year-old man complains of numb- (B) Trochlear nerve
ness in the anterior cervical triangle. Therefore,
damage has occurred to which of the following (D} Abducens nerve
nerves? (E) Hypoglossal nerve
(A) Phrenic nerve
(B) Greater auricular nerve 41. During surgery for a malignant parotid
tumor in a 69-year-old woman, the main trunk
(D) Supraclavicular nerve of the facial nerve is lacerated. Which of the fol-
(E) Lesser occipital nerve lowing muscles is paralyzed?
(A) Masseter muscle
(B} Stylopharyngeus muscle
(C) Anterior belly of the digastric muscle

(E) Tensor tympani

 440 BRS Gross Anatomy

42. During a gang fight, a 17-year-old boy is 46. A57-year-old man comes to the local hos-
punched, and his nasal septum is broken. pital with fever, headache, nausea, and vomit-
Which of the following structures would be ing. Laboratory tests reveal an infection, and
damaged? radiologic examination localizes the infection
(A) Septal cartilage and nasal bone to the cavernous sinus. Which of the following
(B) Inferior concha and vomer nerves would be unaffected by this condition?
(A) Oculomotor nerves
(D} Septal cartilage and middle concha (B}) Abducens nerves
(E) Cribriform plate and frontal bone (C} Trochlear nerves

43. A 58-year-old woman comes to the hospi- (E) Ophthalmic nerves

tal and complains of progressive loss of voice,
numbness, loss of taste on the back part of her 47. A7-year-old girl has difficulty breathing
tongue, and difficulty in shrugging her shoul- through her nose and is brought to her pediatri-
ders. Her MRI scan reveals a dural meningioma cian. On examination, she is diagnosed with ade-
that compresses the nerves leaving the skull. noids. Which of the following tonsils is enlarged?
These nerves leave the skull through which of (A) Palatine tonsil
the following openings?
(A) Foramen spinosum (C} Tubal tonsil
(B) Foramen rotundum (D) Lingual tonsil
(C) Internal auditory meatus (E) Eustachian tonsil

(E} Foramen lacerum 48. A 59-year-old woman with pain at the side
of her skull comes to the emergency depart-
44, A 21-year-old woman presents to her physi- ment. An emergent head CT scan shows a large
cian with a swelling on her neck. On examina- lesion in the internal auditory meatus. This
tion, she is diagnosed with an infection within condition may progress and damage which of
the carotid sheath. Which of the following the following pairs of structures?
structures would be damaged? (A) Vagus and glossopharyngeal nerves
{A} Vagus nerve and middle cervical ganglion (B) Internal carotid and vertebral arteries
(B) Internal carotid artery and recurrent laryn- (C) Internal jugular vein and trigeminal nerve
geal nerve
(C) Internal jugular vein and vagus nerve (E) Hypoglossal and accessory nerves
(D} Sympathetic trunk and common carotid
artery 49. After ingesting a toxic substance found in
(E} External carotid artery and ansa cervicalis her friend’s home, a 12-year-old girl is unable to
close her lips. Which of the following muscles
45. An angiogram of a 45-year-old man shows may be paralyzed?
an occlusion of the costocervical trunk. This (A) Levator labii superioris
obstruction could produce a marked decrease (B) Zygomaticus minor
in the blood flow in which of the following
arteries? (D) Lateral pterygoid
(A) Superior thoracic artery (E) Depressor labii inferioris
(B} Transverse cervical artery
(C) Ascending cervical artery 50. A 37-year-old man receives a direct blow to
his head and is brought to an emergency depart-
(E)} Inferior thyroid artery ment. His radiograph shows a fracture of the floor
of the middle cranial cavity, causing severance of
the greater petrosal nerve. Which of the following
conditions could be produced by this injury?
(A) Increased lacrimal gland secretion
(B) Loss of taste sensation in the epiglottis

(D) Decreased parotid gland secretion

(E) Loss of sensation in the pharynx
 Head and Neck 441

51. A 65-year-old man with multiple vision 56. A 60-year-old man is unable to open his
problems comes to the local eye clinic. The pu- eye because of a rare neuromuscular disease.
pillary light reflex can be eliminated by cutting Which of the following muscles would most
which of the following nerves? likely be paralyzed?
(A) Short ciliary, ophthalmic, and oculomotor (A) Orbicularis oculi
nerves (B} Orbicularis oris
(B} Long ciliary, optic, and short ciliary nerves (C} Frontalis

(D) Optic and long ciliary nerves and ciliary (E) Superior rectus
ganglion
(E} Ophthalmic and optic nerves and ciliary 57. A 46-year-old man visits the speech thera-
ganglion pist complaining of dryness of the mouth. The
therapist performs a swallowing study and,
52. A 12-year-old boy has difficulty in breath- on examination, finds that the man has a lack
ing because he is choking on food. A school of salivary secretion from the submandibular
nurse performs the Valsalva maneuver to expel gland. This indicates a lesion of which of the
air from his lungs and thus dislodge the food. following nervous structures?
When that fails, she performs a needle crico- (A) Lingual nerve at its origin
thyrotomy, which would open into which of the
following regions? (C) Superior cervical ganglion
{A} Rima glottidis (D) Lesser petrosal nerve
(B} Laryngeal vestibule (E) Auriculotemporal nerve
(C) Laryngeal ventricle
58. A51-year-old woman traveling through Brit-
(E} Piriform recess ish Columbia can see the beautiful blue sky with
white clouds butis unable to focus on her face in
53. A 59-year-old stroke patient is unable to the mirror. Her lack of accommodation results
swallow because of a nerve injury. Which of the from paralysis of which of the following muscles?
following nerves is unaffected? (A) Tarsal muscle
(A) Hypoglossal nerve (B) Sphincter pupillae
(C} Dilator pupillae
(C) Vagus nerve
(D) Facial nerve (E} Orbitalis muscles
(E} Trigeminal nerve
59. A 3-year-old girl is admitted to the hospital
54. A 2-year-boy presents with midfacial and with pain and hearing defect. An MRI examina-
mandibular hypoplasia, cleft palate, deformed tion reveals that she has developmental defects
external ear, and defect in hearing. Which of the in the auditory tube and middle ear cavity.
following embryonic structures is most likely Which of the following pharyngeal pouches is
developed abnormally? most likely developed abnormally?

(B} Second pharyngeal arch (B) Second pouch

(C) Third pharyngeal arch (C) Third pouch
(D} Fourth pharyngeal arch (D) Fourth pouch
(E} Sixth pharyngeal arch (E) Second and fourth pouches

55. A 64-year-old woman is unable to open her 60. A 42-year-old patient has an aneurysm
mouth or jaw because of tetanus resulting from at the junction of the posterior cerebral and
a penetrating wound from a rusty nail. Which posterior communicating arteries that has
of the following muscles would most likely be compressed a nerve. On the affected side, the
paralyzed? patient is most likely to exhibit:
(A) Masseter muscle (A) Bitemporal hemianopsia
(B} Medial pterygoid muscle
(C) A medially deviated eye
(D) Buccinator muscle (D) A constricted pupil
(E) Temporalis muscle (E) Anosmia
442 BRS Gross Anatomy

Questions 61 to 65: Choose the appropriate let- Questions 65 to 70: Choose the appropriate
tered structure in this radiograph of the lateral lettered structure in this MRI scan (see Figure
view of the head (below). below) showing a sagittal section through the
head and neck.

66. When the nerve on the right side is dam-

aged, which structure is deviated to the left
side?

67. A lesion of the first cervical spinal nerve

61. Which structure lies lateral to the lateral would cause functional impairment of which
wall of the nasal cavity and inferior to the floor structure?
of the orbit? Cc
Cc
68. Tears drain through the nasolacrimal duct
62. A middle ear infection may spread into into the space below which structure?
which structure?
B
B
69. Which structure runs along the line of at-
63. Which structure has numerous small cavi- tachment of the falx cerebri to the tentorium
ties and lies between the orbit and the nasal cerebelli?
cavity? D

70. A tumor of which structure can be removed

64. Which structure would spread infection through the transsphenoidal approach follow-
into the anterior part of the middle nasal me- ing the septum of the nose through the body of
atus through the frontonasal duct? the sphenoid?
E
65. CSF is formed by vascular choroid plexus in A
which structure?
A
 Head and Neck 443

Questions 71 to 75: Choose the appropriate let- Questions 76 to 80: Choose the appropriate let-
tered structure in this MRI scan showing a tered structure in this angiogram of the cerebral
transaxial section through the head (see Figure vasculature (see Figure below). Collateral circu-
below). lations are discounted for the next five
questions.

76. Aneurysm of which artery causes a perichi-

71, Which structure mediates the afferent limb asmal lesion that may cause nasal hemianopia?
of the pupillary light reflex? D
B 77. A large tumor in the foramen magnum may
72, Which structure is formed by the perpen- decrease blood flow in which artery?
dicular plate of the ethmoid bone, vomer, and B
septal cartilage? 78. A blockage of which artery may cause isch-
A emia of the midbrain and the temporal and oc-
73. Which structure may be paralyzed as a re- cipital lobes of the cerebrum?
sult of infection of the cavernous sinus? A
D 79. Ischemia of the posterior inferior surface
74, Which structure pierces the dural roof of of the cerebellum is caused by obstruction of
the cavernous sinus between the anterior and which artery?
middle clinoid processes? E
E 80. A lesion of which artery may cause oxygen
75, Which structure may be obliterated by a deficiency to the medial surface of the frontal
pituitary tumor? and parietal lobes of the brain?

Cc Cc
 Review Test

Directions: Each of the numbered items or incomplete statements in this section is followed by
answers or by completions of the statement. Select the one-lettered answer or completion that is
best in each case.

1. A 27-year-old man came to his physician (A) Cranial nerve V2

with drooping of the upper eyelid (ptosis), a (B) Cranial nerve VI
dilated pupil, and a difficulty in focusing on (C} Cranial nerves VII and VII
close objects. Furthermore, he has an internal
strabismus (medial deviation of the eye) and (E) Cranial nerve XII
inability to look inferiorly when the eye is ad-
ducted. Which of the following is the most likely 5. A 17-year-old boy is involved in a gang fight
cause? and receives a penetrating injury to the neck.
(A) Lesion in the medulla Which of the following conditions is most likely
(B) Tumor in the optic canal exhibited by this misadventure?
(A) Internal strabismus
(D} Lesion of the olfactory nerve (B) Trouble going down the stairs
(E) Fracture of the foramen spinosum
(D) Inability close the eye
2. A 16-year-old boy presents with double vi- (E) Deviation of tongue toward lesion side
sion. Further examination reveals that he has
difficulty in turning his eye inferolaterally and 6. A 28-year-old woman comes to her family
trouble going downstairs. Which of the follow- physician and complains of difficulty in swal-
ing nerves is most likely damaged? lowing. Further examination reveals that she
(A) Oculomotor nerve has no taste sensation of the posterior one-third
(B) Optic nerve of her tongue and a lack of secretion of the
(C) Ophthalmic nerve parotid gland. Which of the following would
most likely cause this condition?
(E} Abducens nerve (A) Fracture of the mandibular canal
(B) Section of the zygomatic nerve
3. A 31-year-old man with a penetrating injury
to the posterior triangle of the neck is unable (D) Tumor in the pituitary gland
to shrug his shoulder and turn the head to the (E} Lesion of the hypoglossal nerve
opposite side. Which of the following nerves is
most likely damaged? 7. A 34-year-old man in a bar fight suffers a
(A) Trigeminal nerve knife wound that severs the abducens nerve
(B) Facial nerve proximal to its entrance into the orbit. Which
(C) Glossopharyngeal nerve of the following conditions results from this
injury?
(E} Hypoglossal nerve (A) Ptosis of the upper eyelid
(B) Loss of the ability to dilate the pupil
4. A 23-year-old woman suffers from a fracture (C) External strabismus (lateral deviation)
of the jugular foramen by car accident. Which of (D) Loss of visual accommodation
the following nerves is/are most likely damaged?

471
 472 BRS Gross Anatomy

8. Following radical resection of a primary 13. A 47-year-old man cannot move his eyeball
tongue tumor, a 72-year-old patient has lost laterally. Which of the following conditions
general sensation on the anterior two-thirds would cause such a clinical sign?
of the tongue. This is probably due to injury to (A) Tumor of the pituitary gland
branches of which of the following nerves? (B) Occlusion of the posterior cerebral
artery
(B) Facial nerve (C) Infection in the maxillary sinus
(C) Glossopharyngeal nerve
(D} Vagus nerve (E) Tumor in the anterior cranial fossa
(E} Hypoglossal nerve
14. A young boy with a tooth abscess from a
9. A 53-year-old woman is diagnosed as having longstanding infection suffers damage of the
a pituitary tumor. If the tumor is large enough, lingual nerve as it enters the oral cavity. Which
she could exhibit which of the following of the following structures contain cell bodies of
disorders? injured nerve fibers?
(A) Blindness (A) Geniculate and otic ganglia
(B) Bitemporal (heteronymous) hemianopia (B) Trigeminal and submandibular ganglia
(C) Right nasal hemianopia (C) Trigeminal and dorsal root ganglia
(D} Left homonymous hemianopia
(E) Binasal hemianopia (E} Geniculate and pterygopalatine ganglia

10. A patient can move his eyeballs normally 15. A knife wound has severed the oculomo-
and see distant objects clearly but cannot focus tor nerve in a 45-year-old man. Which of the
on near objects. This condition may indicate following conditions will occur because of this
damage to which of the following structures? injury?
(A) Ciliary ganglion and oculomotor nerve (A) Constricted pupil
(B} Oculomotor nerve and long ciliary nerve (B) Abduction of the eyeball
(C} Complete ptosis
(D) Superior cervical ganglion and long ciliary (D) Impaired lacrimal secretion
nerve
(E) Oculomotor, trochlear, and abducens nerves
16. A 20-year-old guard at the gate of the Royal
11. A 32-year-old woman has hoarseness in King’s palace blinks his eyes when a strong
her voice, and her uvula is deviated to the left wind hits the cornea of his eye. The afferent
on phonation. Which of the following nerve is fibers of the corneal reflex arc are carried by
most likely damaged? which of the following nerves?
(A) Right trigeminal nerve (A) Optic nerve
(B} Left trigeminal nerve (B) Lacrimal nerve

(D} Left vagus nerve (D) Zygomatic nerve

(E} Left glosopharyngeal nerve (E} Oculomotor nerve

12. Following a penetrated injury in the sub- 17. A 71-year-old man suffers from a known
mandibular triangle, the tongue of a 45-year- benign tumor in the pterygoid canal. Which of
old patient deviates to the left on protrusion. the following nerve fibers could be injured by
Which of the following nerves is injured? this condition?
(A) Right lingual nerve (A) Postganglionic parasympathetic fibers
(B} Left lingual nerve (B) Taste fibers from the epiglottis
(C) Right hypoglossal nerve (C) General somatic afferent (GSA) fibers
(D) Preganglionic sympathetic fibers
(E} Left glossopharyngeal nerve
 (ETE Cranial and Autonomic Nerves 473

18. A 22-year-old patient has dryness of the (A) Ophthalmic nerve

corneal surface of his eye because of a lack of (B) Mandibular nerve
tears. Which of the following nerves may be (C) Maxillary nerve
damaged? (D) Opticnerve
(A) Proximal portion of the lacrimal nerve (E) Trochlear nerve
(B} Zygomatic branch of the facial nerve
(C) Lesser petrosal nerve 20. Muscles derived from the second (hyoid)
pharyngeal arch are innervated by which of the
(E) Deep petrosal nerve following cranial nerves?
(A) Trigeminal nerve
19. A 31-year-old hockey player is hit in the
head by a puck. His radiogram shows a fracture (C) Glossopharyngeal nerve
of the foramen rotundum. Which of the follow- (D) Vagus nerve
ing nerves would be damaged by this event? (E) Accessory nerve
 Comprehensive Examination

Directions: Each of the numbered items or incomplete statements in this section is followed by
answers or by completions of the statement. Select the one-lettered answer or completion that is
best in each case.

1. A young man is brought to the emergency (A) Numbness over the medial side of the
department after being mugged. He was forearm
stabbed in the shoulder after refusing to give (B) Inability to oppose the thumb
his wallet to his assailant. If the stab wound lac- (C) Weakness in pronating the forearm
erates the posterior humeral circumflex artery (D) Weakness in abducting the arm
passing through the quadrangular space on the (E)
Inability to extend the hand
shoulder region, which of the following nerves
might be injured? 5. An indoor soccer player runs into another
(A) Radial nerve player while running after the ball. She falls
to the ground and fractures the medial
(C) Thoracodorsal nerve epicondyle of the humerus. Which of the
(D} Suprascapular nerve following symptoms might she present with
(E) Accessory nerve when seeing the physician in the emergency
department?
2. A victim of an automobile accident is unable (A) Impaired abduction of the hand
to abduct her left arm. This indicates damage (B) Carpal tunnel syndrome
to which of the following parts of the brachial (C) Wrist drop
plexus? (D) Thenar atrophy
(A) Middle trunk and posterior cord
(B) Middle trunk and lateral cord
(C) Lower trunk and lateral cord
6. After winning a boxing match, a 24-year-old
(E) Lower trunk and medial cord man is unable to abduct his fingers. Which of
the following nerves is injured?
3. A biomedical engineer would like to recon- {A) Ulnar nerve
struct the arm of a boy who underwent ampu- (B) Median nerve
tation to treat a life-threatening infection. In (C) Radial nerve
designing the prosthetic arm, the engineer will {(D) Musculocutaneous nerve
need to know that which of the following mus- (E) Axillary nerve
cles flexes the elbow and is innervated by the
radial nerve? 7. A 42-year-old woman presents to an outpa-
(A) Flexor digitorum longus tient clinic with a 6-month history of numbness
(B)»-Brachioradiali and tingling on the palmar aspect of her lateral
(C) Brachialis three and one-half fingers, loss of pronation,
(D) Extensor digitorum longus and flattening of the thenar eminence. Injury te
(E) Biceps brachii which of the following nerves could cause such
a condition?
4. Young Johnny was playing on the play- (A) Axillary nerve
ground at school when he fell and struck his (B) Musculocutaneous nerve
arm against the swing set. He ran to the school
nurse, complaining of which of the following (D) Radial nerve
conditions as a result of injuring the radial (E) Ulnar nerve
nerve in the spiral groove of the humerus?

489
490 Comprehensive Examination

8. A ballet dancer falls to the floor and hurts severs the roots of C5 and C6 of the brachial
herself during a practice session before opening plexus. Which of the following muscles is likely
night. She sustains an injury to the thoraco- to be paralyzed?
dorsal nerve that would probably affect the
strength of which of the following movements? (B) Flexor carpi ulnaris
(A) Adduction of the scapula (C) Palmar interossei
(B) Elevation of the scapula (D) Adductor pollicis
(C) Abduction of the arm (E) Palmaris brevis
(D) Extension
of the arm
(E) Lateral rotation of the arm 13. The secretary of a rather verbose academic
physician in internal medicine complains
9. A 23-year-old man falls from a ladder and of numbness and tingling in her hands and
injures his arm. On examination, he feels fingers. She is constantly typing long patient
numbness and has no sweating on the lateral visit dictations and now has carpal tunnel syn-
side of his forearm, suggesting damage to the drome, which is due to compression of which of
lateral antebrachial cutaneous nerve. The the following structures?
cell bodies of injured nerve fibers involved in (A) Ulnar artery
sweating are located in which of the following (B) Ulnar nerve
structures? (C) Median nerve
(A) Collateral ganglia (D) Flexor carpi radialis tendon
(B) Dorsal root ganglia (E) Palmaris longus tendon
( : ;
(D) Lateral horn of spinal cord 14. While playing in a Super Bowl game, a
(E) Anterior horn of spinal cord 26-year-old professional football player is tack-
led, and his anterior cruciate ligament is torn.
10. There are only 30 minutes left before the Although not injured, the anterior cruciate
concert starts. The pianist accidentally cuts ligament of the knee joint:
herself over the palmar surface of her wrist and (A) Becomes taut during flexion of the leg
notices that she is unable to pick up a piece of (B) Resists
displacement
posterior of the fe-
music between her index and middle fingers. mur on the tibia
Which of the following nerves is most likely (C) Inserts into the medial femoral condyle
damaged? (D) Helps prevent hyperflexion of the knee
(A) Radial nerve joint
(B) Axillary nerve (E) Is lax when the knee is extended

(D) Median nerve 15. Aman interviewing for a new administra-

(E) Anterior interosseous nerve tive position as hospital chief executive officer
notices difficulty walking after sitting with his
11. A 29-year-old carpenter receives a crush leg crossed for 2 hours. He was nervous during
injury to his metacarpophalangeal joint of the the interview but even more so now that he is
fourth digit (ring finger) while remodeling his attempting to stand to follow two board mem-
neighbor's porch. Which of the following pairs bers for a tour of the hospital. Which of the
of nerves innervates the muscle that moves the following actions is most seriously affected by
injured joint? compression and temporary paralysis of the
(A) Median and ulnar nerves deep peroneal nerve?
(B) Radial and median nerves (A) Plantar flexion of the foot
(C) Musculocutaneous and ulnar nerves (B) Dorsiflexion of the foot
(D) Ulnar and radial nerves (C) Abduction of the toes
(E) Radial and axillary nerves (D) Adduction of the toes
(E) Inversion of the foot
12. A 21-year-old man celebrating his birthday
gets a little carried away with his friends and 16. Deep venous thrombosis is a common
starts a bar fight. He is stabbed with a knife that complication from sitting in one position for
 Comprehensive Examination 491

a prolonged duration, such as during a long Which of the following arteries might remain
car trip or a long plane flight. The first vascular intact?
channels likely to be obstructed or occluded by (A) Lateral femoral circumflex artery
an embolus from the deep veins of a lower limb (B) Medial femoral circumflex artery
are the: (C) Obturator artery
(A) Tributaries of the renal veins (D) Inferior gluteal artery
(B) Branches of the coronary arteries (E) Middle sacral artery
(C) Sinusoids of the liver
(D) Tributaries of the pulmonary veins 21. A 78-year-old woman undergoes knee
surgery because her lateral meniscus is torn.
Before injury, the normal lateral meniscus of
17. During recruitment by the local represen- the knee joint:
tative for the Marines, a young college student (A) Is C-shaped or forms a semicircle
presents with the condition known as flat foot. {B) Is attached to the fibular collateral
His foot is displaced laterally and everted, and ligament
the head of the talus is no longer supported. (C) Is larger than the medial meniscus
Which of the following ligaments probably is
stretched? (E) Is more frequently torn in injuries than the
medial meniscus
(B) Calcaneofibular
(C) Anterior talofibular 22. A 17-year-old boy is involved in a group
(D) Plantar calcaneocuboid (short plantar) fight, and a stab wound lacerates a ventral root
(E) Anterior tibiotalar of his thoracic spinal nerve. Cell bodies of the
injured nerve fibers are located in which of the
18. During a sports medicine physical by a lo- following nervous structures?
cal family physician, a young woman is tested (A) Dorsal root ganglia and sympathetic trunk
for stability of her joints before tryouts for the (B) Lateral horn of spinal cord and dorsal root
high school team. Which of the following liga- ganglia
ments is important in preventing forward dis- (CheAnteriort il ll Espinal
placement of the femur on the tibia when the cord
weight-bearing knee is flexed? (D) Sympathetic trunk and lateral horn of spi-
(A) Medial meniscus nal cord
(B) Tibial collateral ligament (E) Anterior horn of spinal cord and sympa-
(C) Fibular collateral ligament thetic trunk

(E) Anterior cruciate ligament 23. A race car driver is brought to the city
trauma center after a high-speed crash in which
19. A 21-year-old man falls from the attic and is his car spun out of control and struck a concrete
brought to the emergency department. Exam- embankment. He has blunt trauma to his chest
ination and x-rays reveal that the lateral longi- and undergoes extensive vascular studies to de-
tudinal arch of his foot is flattened. Which of the termine which blood vessels are still intact. The
following bones is displaced? interventional radiologist recalls that one of the
(A) Talus following veins drains directly into the superior
(B) Medial three metatarsals vena cava. Which vein would this be?
(C) Navicular (A) Internal thoracic vein
(D) Cuneiform (B) Azygos vein
(E) Cuboid (C) Hemiazygos vein
(D) Right superior intercostal vein
20. A 72-year-old woman with Parkinson dis- (E) Left superior intercostal vein
ease fell down in the bathtub at her home and
suffered a dislocation of the hip joint that may 24. A 58-year-old stockbroker is brought to the
result in vascular necrosis of the femoral head cardiac catheterization laboratory emergently
and neck because of injuries to the arteries. after evaluation in the emergency department
 492 Comprehensive Examination
(D) Third xit
has determined that he is suffering from an
acute myocardial infarction. During the cathe- (E) Clavicle
terization, he is found to have inadequate blood
flow in the artery that runs along the great car- 28. A stab wound penetrates the posterior tho-
diac vein in the anterior interventricular sulcus racic wall near vertebra of a 24-year-old man.
of the heart. This is most likely an acute occlu- Examination at the emergency department
sion of the: indicates a lesion of gray rami communicantes.
(A) Circumflex branch of the left coronary Which of the following nerve fibers would most
artery likely be damaged?
(B) Marginal branch of the right coronary (A) General somatic afferent (GSA) fibers
artery (B) Postganglionic parasympathetic fibers
(C) Left coronary artery (C) Preganglionic sympathetic fibers
(D) a .
(D) Right coronary artery
(E) Posterior interventricular artery (E) General visceral afferent (GVA) fibers

25. A retired teacher suffers from a massive 29. A31-year-old NHL hockey player com-
heart attack while playing golf and dies in the plains of numbness in the area of his umbilicus
intensive care unit. Autopsy reveals the cause after the national championship game. Which
of death as severely diminished blood flow in of the following structures that carries GSA fi-
the coronary arteries. This most likely resulted bers was injured during the hockey game?
from embolization of an atherosclerotic plaque (A) Sympathetic trunk
at the origin of which of the following vascular (B) Dorsal root
structures? (C) Greater splanchnic nerve
(A) Pulmonary trunk (D) Gray rami communicantes
(E) White rami communicantes
(C) Coronary sinus
(D) Descending aorta 30. A 75-year-old veteran suffers a heart attack
(E) Aortic arch and is found in his home unconscious. He is
in ventricular tachycardia and is shocked into
26. A 21-year-old woman comes to the emer- normal sinus rhythm. He undergoes emergent
gency department with acute chest pain and catheterization and is found to have thrombosis
shortness of breath. Her chest x-ray shows in the coronary sinus. Which of the following
opacification of one of her lungs. She under- cardiac veins might remain normal in diameter
goes thoracentesis, which reveals that she has by catheterization study by the cardiologist?
a chylothorax resulting from rupture of the tho- (A) Great cardiac vein
racic duct. Lymphatic drainage remains normal (B) Middle cardiac vein
in which of the following areas? (€) Anterior cardiac vein
(A) Left thorax (D) Small cardiac vein
(B) Right thorax (E) Oblique cardiac vein
(C) Left abdomen
(D) Right pelvis 31. A 35-year-old man is suffering from an in-
(E) Left lower limb fected mediastinum (mediastinitis) after neck
and chest injuries resulting from a head-on au-
27. An elderly man is choking on his food at tomobile collision. He has been intubated since
a restaurant, and attempts by other patrons to the accident and on broad-spectrum intrave-
dislodge the food bolus using the Heimlich pro- nous antibiotics since admission; however, the
cedure have failed. A retired anesthesiologist infection continues to progress throughout the
tushes to his table and prepares for emergent mediastinum. Which of the following structures
tracheotomy. She locates the manubrium of the is free from infection?
sternum and recalls that it is free from articula- (A) Thymus gland
tion with which of the following structures? (B) Esophagus
(A) Body of the sternum (C) Trachea
(B) First rib (D) Lungs
(C) Second rib (E) Heart
 Comprehensive Examination 493

32. A 42-year-old man who has a rare neurologic (E) Between the linea alba and linea
disorder comes to the emergency department. On semilunaris
examination, he is unable to protrude his tongue.
Which of the following muscles is paralyzed? 37. A32-year-old man is involved in a car acci-
(A) Hyoglossus dent and suffers from a crushed internal injury
( : in his abdomen. Examination reveals a lesion
(C) Styloglossus of parasympathetic fibers in the vagus nerve,
(D) Palatoglossus which interferes with glandular secretory or
(E) Geniohyoid smooth muscle functions in which of the fol-
lowing organs?
33. A new biotech company is interested in de- {A) Bladder
veloping a new mechanical heart with a super- {
ficial implantable and rechargeable battery for (C) Sigmoid colon
easy access. During the design phase, the phy- (D) Prostate gland
sician hired from the local academic hospital is (E) Rectum
asked about which structure carries or comes
in contact with oxygenated blood. Which of the 38. Pancreatic cancer has one of the highest
following answers is correct? mortality rates of all cancers because of the lack
(A) Pectinate muscle of symptoms until an advanced stage of disease.
(B) Crista terminalis The one exception is the cancer that is slow grow-
(€) Septomarginal trabecula ing and located in the head of the pancreas. This
may present in an early stage by causing com-
(E) Pulmonary artery pression of which of the following structures?
(A) Duodenojejunal junction
34. A 62-year-old man is diagnosed with a (B) Gastroduodenal artery
Pancoast tumor that invades the inferior trunk
(C) Bile duct
of the brachial plexus. Which of the following (D) Inferior mesenteric artery
muscle actions most likely resulted from injury (E) Common hepatic duct
to the brachial plexus?
(A) Lateral rotation of the arm 39. An elderly man with a known large abdom-
(B) Extension of the ring finger inal aortic aneurysm presents to the emergency
department with acute severe and diffuse pain
(D) Flexion of the forearm in his abdomen. The physician performing the
(E) Pronation of the forearm evaluation considers mesenteric ischemia, a
life-threatening disease, as a possible etiology.
35. A 67-year-old woman complains of Which of the following organs may be spared
increasing urinary frequency and a heaviness from ischemia in the presence of an occlusive
in her pelvic area. On examination, her uterine lesion in the celiac trunk?
cervix is visible at the vaginal opening. Which of
(A) Liver
the following conditions causes this symptom?
(B) Spleen
(A) Tear of the transversalis fascia (C)
Pancreas
(B) Weakness of the ovarian ligament (D) Gallbladder
(C) Relaxation
of the cardinal ligament (E) Stomach
(D) Weakness of the arcuate pubic ligament
(E) Paralysis of the piriformis muscle 40. A young woman with cryptogenic cirrho-
sis presents to the university hospital for an
36. Weight lifters in competition are often con- evaluation as a possible candidate for liver
cerned about muscle tone and complications
transplant. She has late-stage cirrhosis, and
with hernias. In particular, the most common
her liver-spleen scan shows a high degree of
hernia in this case is an indirect inguinal her-
portal hypertension. The portal venous system
nia, which appears:
includes which of the following veins?
(A) (A) Left suprarenal vein
(B) Between the inferior epigastric and obliter-
(B) Inferior epigastric vein
ated umbilical arteries
(C) Medial to the obliterated umbilical artery (D) Azygos vein
(D)} Between the median and medial umbilical
(E) Hepatic vein
folds
494 Comprehensive Examination

41. A2-month-old boy is admitted to the hos- (A) Lumbar splanchnic nerves
pital with diarrhea, vomiting, and difficulty in (B) Pelvic splanchnic nerves
bowel movements. A computed tomography (C) Sacral sympathetic chain ganglia
(CT) scan of his abdomen reveals a distinctly (D) Vagus nerve
dilated lower colon and is diagnosed as having (E) Sacral splanchnic nerves
Hirschsprung disease. Which of the following
is the most likely embryonic mechanism re- 45. Because of a lesion, the parasympathetic
sponsible for development of this congenital nerve fibers are unable to induce a contraction
megacolon? of the detrusor muscle and relaxation of the
(A) Malrotation of the hindgut internal sphincter. The injured parasympathetic
(B) Abnormal formation of the urorectal fibers that supply the urinary bladder are de-
septum tived from which of following nerves?
(C) Bail f i Jlmigration: (A) Vagus nerve
the hindgut (B) Pelvic splanchnic nerve
(D) Absence of visceral afferent cells in the my- (C) Sacral splanchnic nerve
enteric plexus (D) Lesser splanchnic nerve
(E) Failure of partitioning of the cloaca (E) Greater splanchnic nerve

42. A 29-year-old farmer falls on tractor 46. Ata local hospital tumor board, a gyneco-
blades and injures his groin. Several days logic oncologist discusses the next case for the
later, he comes to the emergency department multidisciplinary team. He explains the ratio-
and examination by the physician reveals that nale for using chemotherapy and radiation after
the urogenital diaphragm and bulbourethral surgical resection because carcinoma of the
glands are infected. The infected deep peri- uterus can spread directly to the labium majus
neal space: through lymphatics that follow the:
(A) Is formed superiorly by the perineal (A) Ovarian ligament
membrane (B) Suspensory ligament of the ovary
(B) Is formed inferiorly by Colles’ fascia (C)
ligament
Round of the uterus
(C) Contains a segment of the dorsal nerve of (D) Uterosacral ligaments
the penis (E) Pubocervical ligaments
(D) Contains superficial transverse perineal
muscles 47. A young couple is seeing a sex therapist for
(E) Contains the greater vestibular glands the first time to determine the cause of some of
their recent difficulties. The husband tells the
43. A 2-day-old baby is admitted to the hos- therapist that he no longer has sensation in his
pital with vomiting, fever, and rectal bleeding. scrotum after a race car accident. Which of the
Physical and CT scan examinations reveal small following nerves carries undamaged sensory
bowel obstruction and are diagnosed as having nerve fibers?
Meckel diverticulum. Which portion of the gas- (A) Dioinguinal nerve
trointestinal tract is most likely involved in the (B) Genitofemoral nerve
development of the diverticulum that may be
connected to the inner surface of the umbilicus (D) Perineal branch of the pudendal nerve
by a fibrous cord? (E) Perineal branch of the posterior femoral
(A) Stomach cutaneous nerve
(B) Jejunum
(C) eum 48. A patient has a damaged pelvic outlet as the
(D) Appendix result of an automobile accident. Following this
(E) Sigmoid colon accident, which of the following structures is
still intact?
44, A 59-year-old woman has a large pelvic (A) Sacrotuberous ligament
tumor that compresses the inferior hypogastric (B) Inferior pubic ramus
(pelvic) plexus. Parasympathetic nerve fibers
in this plexus come from which of the following (D) Ischial tuberosity
nerves? (E) Coccyx
 Comprehensive Examination 495

49. A forensic pathologist is examining the pel- vertebrae were crushed against the dashboard
vic bone of a murder victim to identify the sex of the van. Which of the following muscles
of the victim. Which of the following character- might be paralyzed?
istics is that of a female pelvis? (A) Trapezius
(A) Oval-shaped pelvic inlet {B) Latissimus dorsi
(B} Smaller pelvic outlet (C) Rhomboid major
(€) Lesser pubic angle
(D) Narrower and longer sacrum (E) Serratus posterior superior
(E) Narrower and deeper pelvic cavity
54. A middle-aged woman is receiving a shi-
50. A 26-year-old woman experiences severe atsu massage when her therapist notices that
back pain from an automobile accident. A CT the client has numbness in her neck. A lack of
scan reveals that the L5 vertebral foramen is sensation of the skin over the anterior triangle
completely obliterated by a collapsed L5 lam- of the neck may be due to injury to which of the
inae and pedicles. In this injury, which of the following nerves?
following structures is crushed? (A) Great auricular nerve
(A) Vertebral artery (B) Transverse cervical nerve
(B) Spinal cord (C) Superior ramus of the ansa cervicalis
(C) Filum terminale externus (filum of the (D) Inferior ramus of the ansa cervicalis
dura) (E) Superior laryngeal nerve
(D) Denticulate ligament
(E) Cauda equina 55. A young man presents to your clinic with
a 3-month history of an enlarging mass in his
51. A performer at the traveling circus for the right neck. He undergoes a CT scan that reveals
state fair has injured her shoulder during a rou- a fluid-filled mass where the common carotid
tine. When she fell off the trapeze, she struck the artery bifurcates. Which of the following is
ground on her back, and most of the blunt force another structure that would be located at this
was directed toward her shoulders. A crush level?
injury of the suboccipital nerve would result in (A) Thyroid isthmus
paralysis of which of the following muscles? (B) Cricoid cartilage
(A) Splenius capitis (C) Sternal angle
(B) Trapezius {
(c it (E) Jugular notch
(D) Levator scapulae
(E) Iliocostalis 56. An ultimate fighter is brought into the
locker room after being knocked out by his op-
52. A neonate is brought to the pediatrician ponent. He has suffered severe trauma to the
with headaches, fevers, and change in mental articular disk and capsule of the temporoman-
status, mostly manifesting as lethargy and lack dibular joint. This could result in paralysis of
of appetite. The baby is admitted emergently which of the following muscles?
to rule out meningitis and is to undergo a di- (A) Masseter
agnostic lumbar puncture. When withdrawing (B) Temporalis
cerebrospinal fluid (CSF), the needle may pen- {C) Medial pterygoid
etrate which of the following pairs of structures? ( :

(A) Dura mater and denticulate ligament (E) Buccinator

(B) Arachnoid mater and pia mater
(C) Dura mater and arachnoid mater 57. A 25-year-old woman is suffering from fa-
(D} Annulus fibrosus and pia mater cial paralysis and exhibits ptosis (drooping of
(E) Arachnoid mater and nucleus pulposus the upper eyelid). Injury to which of the follow-
ing nerves would result in ptosis?
53. Mrs. Jones was riding in the front seat of her (A) Trochlear nerve
son’s van when the vehicle abruptly stopped. (B) Abducens nerve
Unfortunately, she was not wearing her seatbelt (€) Oculomotor nerve
and was thrown forward. As a result of the ac- (D) Ophthalmic nerve
cident, the transverse processes of her cervical (E) Facial nerve
496 Comprehensive Examination
(c)-s ior pl i . it
58. A 67-year-old man is known to have an
infection in the superior petrosal sinus. The cinator muscles
infected sinus lies in the margin of which of the (D) Medial and lateral pterygoid muscles
following structures? (E) Tensor veli palatini and levator veli palatini
(A) Tentorium cerebelli
(B) Falx cerebri 63. A 31-year-old football player with a head
(C) Falx cerebelli injury is brought to a local emergency de-
(D) Diaphragma sellae partment. Physical examination, radiogram,
(E) Straight sinus and a magnetic resonance imaging scan
indicate a lesion of the trigeminal nerve.
59. A 59-year-old man has pus in the loose Which of the following muscles is most likely
connective tissue layer of the scalp, and conse- paralyzed?
quently, his superior sagittal sinus is infected. (A) Geniohyoid
The arachnoid granulations in the infected (B) Palatoglossus
sinus: (C) Cricothyroid
(A) Absorb CSF into the dural venous sinuses
(B) Are storage areas for CSF (E) Levator veli palatini
(C) Produce CSF
(D) Allow CSF to return to the ventricles of the 64. The muscle that indents the submandibular
brain gland and divides it into superficial and deep
(E) Filter venous blood into CSF parts is paralyzed because of compression by
a large salivary glandular tumor. Which of the
60. While speaking at a charity program, an el- following muscles is involved?
derly woman suddenly collapses to the ground. (A) Hyoglossus
She is diagnosed as having a massive stroke, but (B) Digastric posterior belly
it is unclear where the vascular lesion is located. (C) Styloglossus
She undergoes a cerebral arteriogram. Nor- (D) Stylohyoid
mally, the great cerebral vein of Galen drains (E)
Mylohyoid
directly into which of the following sinuses?
(A) Superior sagittal sinus 65. A young homeless child presents to the
(B) Inferior sagittal sinus emergency department with high fever and
(C) Cavernous sinus low blood pressure. He had strep throat 2
(D) Transverse sinus weeks ago when seen in the free clinic; how-
{E) Straight sinus ever, his parents did not give him his antibiotic
medication. He now has an abscess in the
61. While resecting a tumor in the palate, the auditory tube that is blocking communication
surgical intern removes the mass but finds between the nasopharynx and which of the
that it is deeply invasive into the tendon that following structures?
loops around the pterygoid hamulus. Which (A) Vestibule of the inner ear
of the following muscles would most likely be (B)
Middle
ear
paralyzed? (C) Semicircular canals
(A) Tensor tympani (D) External ear
(B) Tensor
veli palatini (E) Inner ear
(C) Levator veli palatini
(D) Superior pharyngeal constrictor 66. A man with a neuromuscular autoimmune
(E) Stylohyoid disease has another attack at home. His wife
calls the doctor’s office because he is unable to
62. During a domestic incident, a 28-year-old speak. Once at the office, he is unable to open
woman receives a vertical stab wound that lacerates his jaw because of paralysis of which of the
the pterygomandibular raphe. As a result, which of following muscles?
the following muscles would be paralyzed? (A) Medial pterygoid
(A) Superior and middle pharyngeal (B) Masseter
constrictors (C) Temporalis
(B) Middle and inferior pharyngeal
constrictors (E) Buccinator
 Comprehensive Examination 497

67. A 29-year-old baseball player whose head leading to progressive neurologic defects in the
is hit by a ball is brought to an emergency de- legs and feet.
partment. Physical examination and radiogram
71. Which of the following defects is commonly
reveal fracture of the temporal bone and dam-
age to the lesser petrosal nerve. Which of the associated with the tethered cord syndrome?
following conditions could occur as a result of (A) Spina bifida occulta
injury to the lesser petrosal nerve? (B) Kyphosis
(A) Lack of lacrimal secretion (C) Meningomyelocele
(B) Lack of submandibular gland secretion (D) Herniated disk
{E) Scoliosis
(C) Lack of parotid gland secretion
(D) Constriction of the pupil
(E) Ptosis of the upper eyelid 72. This girl has strong muscle function of the
flexors of the thigh, but she has weakness of the
68. A 26-year-old woman with the flu comes extensors (hamstrings). A lesion has occurred.
to an outpatient clinic. On examination, a
at which of the following spinal cord levels?
physician diagnoses her with sinus and palate (A) T12
infection, and her uvula deviates to the left side (B) Li
on phonation. Which of the following nerves is (C) L3
injured? (D) Ls
(A) Left hypoglossal nerve (E) s5
(B) Right hypoglossal nerve
(C) Left vagus nerve 73. A 36-year-old plumber slips and breaks a
( : porcelain sink, cutting an anterior aspect of
(E) Left trigeminal nerve his wrist deeply on a sharp edge. On arrival to
the emergency department, he can adduct his
69. During a palatine tonsillectomy, a surgeon thumb but not oppose it. Which of the following
must ligate arteries to avoid bleeding within the structures has been severed?
surgical field. Which of the following arteries (A) Radial nerve
can be spared? {B) Median nerve
(A) Lesser palatine artery (C) Ulnar nerve
(B) Facial artery {D) Anterior interosseous nerve
(C) Lingual artery ({E) Posterior interosseous nerve
(D) Superior thyroid artery
(E) Ascending pharyngeal artery 74. A 21-year-old soccer player is tackled via
a high-impact sweeping injury about the right
70. A young child is evaluated by his pediatri- knee, causing a posterior knee dislocation.
cian for chronic nosebleeds. He is referred to Soon after, he is unable to plantar flex his right
an allergist when it is determined that his nasal ankle or flex his toes. He also experiences loss
cavity is chronically dry because of a lack of of sensation on the sole of his right foot. Which
glandular secretions. A possible etiology may of the following nerves is most likely injured?
be a lesion of which of the following structures? (A) Saphenous nerve
(A) Superior cervical ganglion (B) Tibial nerve
(B) Lesser petrosal nerve (C) Deep peroneal nerve
(C) Facial nerve in the facial canal (D) Superficial peroneal nerve
(D) Greater petrosal nerve (E) Common peroneal nerve
(E) Deep petrosal nerve
75. A 56-year-old man with a one pack/day
Questions 71 and 72 are based on the following case: history of cigarette smoking is found to have a
A 12-year-old girl suffers from a type of neural tube malignant squamous cell carcinoma located
defect called tethered cord syndrome, a congenital in the superior sulcus of Pancoast (superior
anomaly that results from defective closure of the apex of the lung). Shortly after the diagnosis
neural tube. This syndrome is characterized by is known, the patient develops symptoms that
an abnormally low conus medullaris, which is consist of shoulder pain along with ptosis, mi-
tethered by a short, thickened filum terminale, osis, enophthalmos, and anhidrosis. Which of
498 Comprehensive Examination

the following nerves is most likely compressed (A) Axillary artery

by the tumor mass? (B) Superior epigastric artery
(A) Phrenic nerve (€) Costocervical trunk
(B) Vagus nerve
(E) Ascending aorta
(D) Ansa cervicalis
(E) Recurrent laryngeal nerve 80. A 34-year-old singer has been diagnosed
with thyroid cancer and consequently has a
76. A 57-year-old woman presents with in- thyroidectomy. He has been hoarse ever since
creasing numbness of the fourth and fifth digits the surgery 8 weeks ago. It has been suspected
on her right hand. On examination, it is noticed that a nerve was injured during the operation.
that she has a wasted hypothenar eminence, in- Which of the following nerves is most likely
ability to abduct the thumb, and a characteristic damaged?
claw hand. Which of the following nerves has (A) External laryngeal nerve
most likely been injured? (B) Internal laryngeal nerve
(A) Axillary nerve (
(B) Anterior interosseous nerve (D) Hypoglossal nerve
(C) Radial nerve (E) Glossopharyngeal nerve
(D) Ulnar nerve
(E) Median nerve 81. A 24-year-old woman presents with an
asymptomatic fluid-filled cyst on the midline
71. A 47-year-old woman has had a lumpec- of the neck. She is diagnosed with a thyroglos-
tomy and axillary dissection to check for sal duct cyst. Which organ migrates through
metastasis. She has come in for her follow-up the thyroglossal duct during embryologic
appointment, and her physician notices on her development?
physical examination that the medial part of (A) Inferior parathyroid glands
her scapula protrudes from her back and that (B) Submandibular glands
she is not able to raise her arm above the hori- (C) Thyroid gland
zontal level. Which of the following nerves has (D) Thymus
been damaged during her surgery? (E) Tongue
(A) Median nerve
(B) Ulnar nerve 82. Otitis media is an infection in the middle
(€) Thoracodorsal nerve ear cavity. From which embryologic structure
(D does the middle ear cavity form?
(E) Radial nerve (A) Pharyngeal groove 1
(B) Pharyngeal pouch 1
78. A 31-year-old carpenter cuts his left arm (€) Auricular hillocks
with a utility knife and is brought to a local (D) Pharyngeal membrane1
emergency department. He complains of (E) Pharyngeal pouch 2
numbness on the medial side of his arm. Which
of the following nerves is most likely injured? Questions 83 to 87: Choose the appropriate lettered
(A) Axillary nerve structure in the radiograph of the bones of the
(B) Musculocutaneous nerve hand (see Figure below).
(C) Medial brachial cutaneous nerve
(D) Medial antebrachial cutaneous nerve
(E) Radial nerve

79. A 54-year-old high school teacher has been

diagnosed with coronary artery disease and is
to undergo coronary bypass surgery. During the
surgery, the thoracic surgeon decides to use the
internal thoracic artery for one of the bypasses.
Which of the following arteries gives rise to the
internal thoracic artery?
 Comprehensive Examination 499

83. Which bone articulates with the radius and Questions 93 to $7: Choose the appropriate lettered
triquetrum? structure in the CT scan of the female pelvis (see
OY W
Figure below).
84. Fracture of which bone may cause paralysis
OM

of the flexor digiti minimi and opponens digiti

minimi muscles?

85. Which is the site of attachment of the mus-

cles that form the thenar eminence?

86. Which is the site of tendinous attachment

of the flexor digitorum superficialis?
93. Which structure is a common site of uterine D
cancer?
87. Fracture of which bone may cause a deep
tenderness in the anatomic snuffbox?
>

94. Which structure descends retroperitoneally on

the psoas muscle and runs under the uterine artery?
Questions 88 to 92: Choose the appropriate let-
tered structure in the CT scan of the abdomen
95. Which structure has venous blood that re-
(see Figure below).
turns to the portal and caval (systemic) venous
systems?
C
A
96. Stimulation of parasympathetic nerve
causes a contraction of the detrusor muscle in
which structure?

97. When the lesser trochanter is fractured, E

which structure is paralyzed?

Questions 98 to 100: Choose the appropriate let-

88. Thrombosis in which vessel causes a dila- tered structure in the CT scan of the male pelvis
(see Figure below).
rr OU

tion of the left testicular vein?

Dom

89. Which structure concentrates and stores

bile?

90. Laceration of which structure decreases

blood flow in the middle colic artery?

91. Which structure produces and excretes urine?

92. Thrombosis in which vessel causes a dila- 98. Which structure forms a medial boundary E
tion of the right suprarenal vein? of the inguinal triangle?
500 Comprehensive Examination

99. Rupture of which structure impairs secre- 101. Which sinus opens into the hiatus semilu-
tion of a fluid that produces the characteristic naris of the middle nasal meatus by way of the A
odor of semen? frontonasal duct or infundibulum?

100. Which structure receives the ejaculatory duct? 102. Meningioma in which structure com-
presses the ophthalmic vein and trochlear
Questions 101 and 102: Choose the appropriate =‘ "erve?
lettered structure in the radiograph of the head
(see Figure below).