GROSS ANATOMY BOARD REVIEW 2006

1. A 54 year-old contractor has been coming to you for many years with intermittent bouts of low back pain. Recently, his pain has worsened and following an intense imaging study, you discover that the body of his L4 vertebra has shifted anteriorly on L5. The defect causing the displacement of L4 is most likely located in which of the following regions? A. B. C. D. E. Body Lamina Pedicle Spinous process Transverse process

2. A structural steel worker comes to you to be evaluated for disability. Seven months previous, he fell and severely sprained his neck. At work he is required to lift heavy objects above his head. Presently, he is having difficulty abducting his arm - he can only elevate his arm slightly above his shoulder. Physical exam yielded a well-nourished, muscular individual with normal body habitus. Strength testing in abduction through the available range of motion is normal. When asked to shrug his shoulders, the patients left side is much stronger than the right. Upper limb pulses were normal bilaterally. Which of the following would most likely be the cause of his inability to undergo complete abduction of the affected limb? A. B. C. D. E. Cervical disc injury between C5 and C6 Paralysis of the trapezius Thoracic outlet syndrome Torn rotator cuff Upper brachial plexus injury

3. A laborer who hangs high level billboards comes to your office complaining of back pain localized to the mid-thoracic region. Through palpatory physical diagnosis you discover T4 - 8 SL, RR. Which of the following muscles is responsible for this condition? A. B. C. D. E. Iliocostalis Latissimus dorsi Longissimus Rotatores Semispinalis

4. A 23 year-old gymnast comes to your office with a longstanding complaint of paresthesias affecting the lateral aspect of his arm and proximal forearm. Recently, he has noticed weakness during abduction and lateral rotation of the arm. Which of the following would most likely account for this pattern of motor deficit preceded by sensory loss? A. B. C. D. E. Compression of the median nerve Compression of the radial nerve Injury to the upper brachial plexus Injury to the lower brachial plexus Herniation of an intervertebral disk

5. A 16 year-old high school quarterback was speared in the ribs with the helmet of the opposing teams left tackle. No ribs were broken, but the area was bruised and sore for several weeks. After the injury healed, the quarterback was evaluated by the team physician for clearance to return to practice. During the examination, the physician noticed that the inferior angle of the patients right scapula protruded inordinately. Paralysis to which of the following muscles would most likely be the cause of this condition? A. B. C. D. E. Latissimus dorsi Pectoralis minor Rhomboid major and minor Serratus anterior Trapezius

6. A tightrope walker fell from his perch atop the high wire, first caught the wire under his axilla and then hung by the same arm for ten minutes. Luckily he was rescued when he fell 25 feet into a catch net that had been hurriedly constructed to save him. Following recuperation, the hand that saved him slowly began to curl and eventually all fingers, except his thumb, took on the appearance of a claw. Which of the following scenarios would be plausible to explain his resultant condition? A. B. C. D. E. Compromise to the ulnar nerve as it passes posterior to the medial epicondyle Compression of the median nerve in the hand while he dangled from the high wire Paralysis of the lumbricals and interossei Trauma to the radial nerve as the wirewalker caught himself by his axilla Stretching of the upper brachial plexus

7. Complete fracture of the medial epicondyle of the humerus would most likely lead to which of the following conditions? A. B. C. D. E. Inability to abduct the thumb Inability to extend the wrist Laceration of the radial nerve Loss of the pincher mechanism between the thumb and index finger Loss of the power grip

8. A 20 year-old ice skater suffered a fall while doing a competitive program. When you see her, her wrist is swollen and extremely tender. Palpation on the dorsum of the wrist between the tendons of the thumb as they cross the carpus yields exquisite pain. When reviewing the x-rays, you will not be surprised to see which of the following injuries? A. B. C. D. E. Fracture of the distal radial epiphysis Fracture of the hamulus of hamate Lunate dislocation Scaphoid fracture Torn triangular cartilage

9. Which of the following can be attributed to impingement of structures which course through the carpal tunnel? A. B. C. D. E. Atrophy of the hyopthenar eminence Diminished adduction of the thumb Loss of the grasp reflex Paresthesias of involving the 5th digit Tunneling of the interosseous spaces

10. A 39 year-old female patient comes to your office with multiple complaints. Physical examination reveals deviation of the tongue, drooping of the faucial pillars with deviation of the palate, diminished gag and cough reflexes and weakness upon shrugging of the shoulder; all other findings are normal. Without the aid of further diagnostic procedures, where would you tentatively place the site of the lesion? A. B. C. D. E. Carotid sheath at the base of the skull Infratemporal fossa Lateral to the tonsillar fossa Pterygopalatine fossa Submandibular region

11. Two months after thyroidectomy a 32 year-old female patient reports hoarseness. The surgical wound is well healed and no abnormalities were noted during the surgical procedure. Parathyroid function is normal, CBC with differential unremarkable, BUN normal, creatinine normal, and upon laryngoscopy, the muscles of the larynx demonstrate paresis or paralysis. Based on this scenario, which laryngeal muscle is still intact? A. B. C. D. E. Cricothyroid Lateral cricoarytenoid Oblique arytenoid Posterior cricoarytenoid Thyroarytenoid

12. You see a 7 year-old male patient in the emergency department. His chief complaint is sore throat with pain radiating into his ears. His parents report that he has had several sore throats in the past year, each treated with antibiotics. Physical examination reveals high fever, red throat, swollen glands along his mandible, and productive sputum of green-white color tinged with blood. A diagnosis of tonsillitis with spread to the tubal lymphoid tissue is made. Surgical resection is determined to be the necessary treatment. During surgery, excessive bleeding from the tonsilar bed may be caused by lesioning direct branches arising from which of the following arteries? A. B. C. D. E. Buccal External carotid Facial Internal carotid Maxillary

13. Anne, a 47 year-old accountant, reports that she is troubled by repeated sinus headaches. She states that her current headache has been bothering her intermittently for 4 days. Routine physical examination reveals sinusitis of both the frontal and maxillary sinuses. The maxillary sinus on the left is infected to such an extent that its resonance is dulled. Additionally, Anne complains that she is unable to feel her incisor teeth on the left. Impingement of which of the following nerves can cause this finding? A. B. C. D. E. Anterior superior alveolar Buccal of CN V3 Greater palatine Nasopalatine Posterior superior alveolar

14. After several months of dealing with visual difficulties, James, a 55 year-old construction worker, makes an appointment with you. You immediately notice a ptosis of the right eyelid with pupillary constriction in the same eye. Besides a flushed cheek, the skin is very dry over the right face. Without further testing, your immediate impression is that he has some how injured which of the following structures? A. B. C. D. E. Ciliary ganglion Pterygopalatine ganglion Seventh cranial nerve Superior cervical ganglion Sympathetic plexus on the internal carotid artery

15. You see a 16 year-old female patient in the emergency department. She was playing the catchers position in a softball game when she was hit in the pterion with a bat; she immediately lost consciousness. She regained consciousness while en route to the hospital, but is disoriented and complains of a severe headache of a pounding nature. You order an MRI suspecting damage to which of the following? A. B. C. D. E. Anterior cerebral artery Deep auricular artery Middle cerebral artery Middle meningeal artery Superficial temporal artery

16. A 17 year-old football player who has been chewing tobacco almost constantly since he was thirteen is seen by an oncologist for removal of an unhealed lesion inferiorly near the tip of the tongue. The oncologist plans to remove the lesion and the first set of lymph nodes to which the lesion will drain. Which lymph node(s) will be removed? A. B. C. D. E. All superior deep cervical nodes Inferior deep cervical nodes Jugulodigastric Submental Submandibular

17. During a routine physical, a 35 year-old female complains of pain in the temporal region. The pain is well localized to the temporomandibular joint and is exacerbated by chewing. She reports no prior history of joint disease in this region, however, she recalls biting down hard on a fireball about a day before the pain started. Palpation reveals that the articular disc is moved anteriorly as compared to the rest of the joint. Which muscle could be the cause of this abnormal joint positioning and therefore the pain? A. B. C. D. E. Buccinator Lateral pterygoid Masseter Medial pterygoid Temporalis

18. An adventurous 4 year-old boy has fallen through a glass door at home and was brought to the emergency department by his father. The only injury is a deep laceration to the scalp (easily hidden by the hair), running from about the superior temporal line to the sagittal suture; the bleeding is copious. Which of the following contributes to the excessive bleeding? A. B. C. D. E. Emissary veins communicating with the subaponeurotic layer Sharpey fibers of the pericranium holding the wound open The abundant arterial supply to the loose areolar tissue The abundant arterial supply within the dense connective tissue layer The muscles of the galea aponeurotica pulling the wound open

19. You have been providing care to a patient with vascular disease for approximately 15 years. During the past few years you have specifically followed a berry aneurysm, which developed, on the internal carotid artery within the cavernous sinus. Today the patient presents with a complaint of a neurological origin. Which of the following symptoms could be caused by the aneurysm you have been following? A. B. C. D. E. Anesthesia of the skin overlying the mandible on the same side as the aneurysm Blindness on the affected side due to blockage of the ophthalmic artery Disturbances to the bilateral temporal visual fields Paresis of lateral eye movements ipsilateral to the aneurysm Paresis of superior, inferior and medial eye movements contraleral to the aneurysm

20. You see a patient in the emergency department who has attempted suicide by placing a rifle in his mouth. When he reached for the trigger he turned his head slightly. The bullet entered his head lateral to the midline near the posterior extent of the hard palate, traveled superiorly through the skull (without deflection) and exited inferior to the lateral canthus of the eye (without damaging the eyeball). The bullet traveling this path could have injured which of the following? A. B. C. D. E. Chorda tympani Hypoglossal nerve Infraorbital nerve Lingual nerve Sigmoid sinus

21. You suspect that an infant is suffering from a large patent ductus arteriosus. Which of the following conditions would support your hypothesis? A. B. C. D. E. Decreased flow through the pulmonary valve Increased flow through the aortic valve Increased left ventricular filling Hypertrophy of the left atrium Right ventricular hypertrophy

22. A 49-year old male smoker presents with the main complaint of coughing and difficulty breathing. Imaging studies reveal enlarged paratracheal (tracheal) nodes are discovered on the left side. This finding indicates metastasis arising from which of the following structures? A. B. C. D. E. Inferior lobe of left lung Inferior lobe of right lung Middle lobe of right lung Superior lobe of left lung Superior lobe of right lung

23. A 14-year-old girl experiences dyspnea due to environmentally induced asthma. After being chased by a rabid, 6-year-old pit bull terrier, her mother notices that her breathing, although rapid, is not as labored. This less labored response by the lungs was mediated by neurons with their soma in which of the following locations? A. B. C. D. E. Brainstem Dorsal root ganglia Pulmonary plexus Superior ganglion of the vagus Sympathetic chain ganglia (T2-T5)

24. A forty-two-year-old male presents with intermittent numbness of the left arm and edema of the ankles. His overall health appears to be good, he is normotensive, all pulses symmetrical with the exception of a diminished left radial pulse, and he is on no medications. Displacement of which of the following osseous structures may be responsible for his condition? A. B. C. D. E. Clavicle First rib Manubrium Scapula Second thoracic vertebra

25. Traumatic injury damages nerves as they pass inferiorly from a plexus associated with the hilum of the lung. This would most likely result in which of the following? A. B. C. D. E. Bronchodilation Decreased heart rate Decreased upper GI motility Increased heart rate Loss of contractility in the aorta

26. A hepatic tumor within the liver parenchyma obstructs outflow to the inferior vena cava. Which of the following veins would carry a resultant increase in blood flow? A. B. C. D. E. Ascending lumbar Common iliac Left renal Portal Right renal

27. A 63 year-old chronic alcoholic is rushed to the ER with severe abdominal pain. Ultrasound reveals a large cyst in the caudate lobe of the liver that subsequently ruptures. A significant quantity of fluid becomes localized in the hepatorenal recess. It has most likely gained access to this area by passing through which of the following? A. B. C. D. E. Epiploic foramen Left infracolic gutter Left paracolic gutter Retroperitoneal space Right infracolic gutter

28. A man presents with an aneurysm of the superior mesenteric artery close to its origin. Which of the following organs may become enlarged due to impaired venous return? A. B. C. D. E. Bladder Gallbladder Left Kidney Right Kidney Spleen

29. During a rugby match, a 42 year-old male player was gang tackled and kneed in the groin. He felt a dull, constant, achy pain in his lower abdomen accompanied by nausea. The latter is the result of nerve cell bodies located where? A. B. C. D. E. Brainstem Dorsal root ganglia T5 -T9 Inferior ganglion of the vagus Pelvic plexus Sympathetic chain ganglia L1 - L2

30. A one hundred and four pound 96-year old male, presents in your office for a routine checkup. While you are conducting your examination, he aspirates a piece of hard candy he is sucking on and begins to turn blue. You prepare to administer the Heimlich maneuver because you surmise that the candy has most likely become lodged in the: A. B. C. D. E. Choanae Epiglottic vallecula Left main stem bronchus Piriform recess Right primary bronchus

31. Ann, a 56-year-old retired medical secretary, has continually gained weight over the past year despite dieting. During her annual checkup her family doctor observed an obvious size increase in the patients abdomen and palpated the presence of a large abdominal mass. Without any further testing, the physician ordered a laporotomy for this patient. After the abdominopelvic cavity was opened, the surgeon saw a mass about the size of a large softball. The mass was biopsied and the pathologist determined that the patient had a mucinous cystadenocarcinoma, a malignant type of ovarian tumor. Which of the following groups of lymph nodes would have been infected first by this tumor? A. B. C. D. E. Common iliac Deep inguinal Internal iliac Lumbar Sacral

32. Your 51-year-old patient has a history of recurring kidney stones that he generally passes without too much difficulty or pain. Recently, one of the stones became lodged in the ureter where it courses through the urinary bladder and he has been experiencing excruciating pain. While some of the pain is dull, most of the time it is acute. Which of the following represent level(s) of nerve fibers that conduct the pain from the area of the lodged stone to the spinal cord? A. B. C. D. E. T9 T10 T12 L4 S1

33. Where are the cell bodies of the pain fibers that are registering pain in the above patient located? A. B. C. D. E. Brainstem Dorsal root ganglia Hypogastric plexus Pelvic plexus Sympathetic chain, sacral ganglia

34. A thrombus becomes lodged at the origin of the internal iliac artery and completely blocks arterial flow through its branches. Which of the following pairs of arterial anastomoses would effectively help restore blood to deprived pelvic structures? A. B. C. D. E. Inferior gluteal - superior gluteal Middle rectal inferior rectal Ovarian uterine Superior epigastric inferior epigastric Superior vesical inferior vesical

35. Your 49-year-old patient, who has a history of chronic anal fistulae, comes to your office complaining of a painful swelling in the anal area. Physical examination revealed a hot, red, tender swelling lateral to the right anal margin, and you correctly diagnose an ischioanal abscess. You elect to drain this abscess by a surgical incision. Which of the following structures could potentially be injured during this minor surgery? A. B. C. D. E. Dorsal nerve of the penis Inferior rectal vessels and nerve Internal pudendal vessels Perineal vessels and nerve Pudendal nerve

36. A 15-year-old male was running across a recently plowed field when he stumbled and over-inverted his right foot. While examining this patient in the ER you observe that his right ankle is tender and swollen. Movement of the ankle was restricted, especially when the foot was inverted. Gentle palpation demonstrated a small tender area inferior and anterior to the lateral malleolus. An X-ray of the ankle joint was negative. Which of the following structures is most likely injured? A. B. C. D. E. Anterior talofibular ligament Calcaneofibular ligament Deltoid ligament Posterior tibiotalar ligament Tibionavicular ligament

37. You see a 38-year-old male in the ER who was in a car accident. The man was crossing a busy street and he stepped in front of an oncoming car. The car bumper hit the lateral side of his left knee and fractured the neck of the fibula, injuring related structures. Which of the following actions of the foot would be totally abolished if there were injury to the nerve which courses superficial to the fibula? A. B. C. D. E. Abduction of toes Adduction of toes Dorsiflexion Inversion Plantar flexion

38. A 72-year-old female suffered a fall while shoveling snow on her sidewalk, which resulted in a
fracture of the neck of the left femur. Several weeks later, avascular necrosis of the head of the femur occurred. Disruption of which of the following arteries would be responsible for this condition? A. B. C. D. E. Acetabular branch of obturator First perforating Medial femoral circumflex Lateral femoral circumflex Superior gluteal

39. You see a 37-year-old male in the ER who is walking with the help of crutches. He tells you that he
was playing football with some of his friends and that he was clipped(hit from behind and the from the side simultaneously) as he was running down field on a kickoff. You examine the knee and find it to be markedly swollen and red. Which of the following structures would most likely be injured? A. B. C. D. E. Anterior cruciate and posterior cruciate Anterior cruciate, medial collateral, and medial meniscus Anterior cruciate and lateral collateral Posterior cruciate, lateral collateral, and lateral meniscus Posterior cruciate, medial collateral, and medial meniscus

40. As a third-year medical student, your first day at a new clinical rotation is at the local VA hospital. You
observe that an elderly male has an abnormal gait. As the man walks, his pelvis tips abnormally toward the unsupported side. You identify yourself to this man and inquire how long he has walked in the described manner. He tells you that he has walked this way for more than 40 years, after he recovered from poliomyelitis as a young boy. Based on your medical knowledge, which of the following nerves was affected by the polio? A. B. C. D. E. Femoral Inferior gluteal Obturator Sciatic Superior gluteal

ANSWER KEY: 1 B 11 A 2 B 12 C 3 E 13 A 4 E 14 D 5 D 15 D 6 C 16 D 7 E 17 B 8 D 18 B 9 C 19 D 10 A 20 C

21 E 22 D 23 E 24 B 25 C 26 D 27 A 28 C 29 C 30 E

31 D 32 D 33 B 34 C 35 B 36 A 37 C 38 C 39 B 40 E