124. Question 2 of 2 A 36-year-old male office worker comes to the clinic complaining of general weakness and shortness of breath.

e also relates a rapid! throbbing pulse after climbing a flight of stairs. "hich of the following correctly pertains to normal mitral #al#e function$ A. %he papillary muscles are rudimentary and ha#e no ma&or function B. 't pre#ents regurgitation of blood during #entricular rela(ation C. %he chordae tendineae and papillary muscles pre#ent e#ersion of the #al#e cusps D. %he papillary muscles contract to close the #al#e The answer is: C )uring the cardiac cycle! differential pressures between the atria and #entricles open and close the atrio#entricular #al#es. %he papillary muscles attach the chordae tendineae to the heart wall and pro#ide an important dynamic mechanism to ensure the competence of the #al#es. )uring the e&ection phase of #entricular systole! shortening of the papillary muscle compensates for the decrease in the #entricular chamber si*e and thereby! pre#ents e#ersion of the atrio#entricular #al#e leaflets! thereby pre#enting regurgitation during #entricular systole. 12+. Question 1 of + A 64-year-old man is brought into the emergency room after e(periencing more than 3 h of increasing chest pain that was unrelie#ed by rest! antacids! or nitroglycerin. e complains of nausea without #omiting. ,urther -uestioning re#eals a two-year history of e(ertional angina pectoris .pressing chest pain that often radiated along the inner aspect of the left arm when the patient climbed one flight of stairs/. 0ropranolol! which reduces the response of the heart to stress! and nitroglycerin! which dilates systemic #eins as well as coronary arteries! had been prescribed pre#iously. 1n physical e(amination he is found to be acyanotic .normal blood o(ygenation/! tachypneic .rapid breathing/! tachycardiac .rapid pulse rate/ with a regular rhythm! and diaphoretic .sweating/. %his patient2s tachycardia probably is mediated by refle( arcs associated with decreased cardiac output and possibly reduced blood pressure. %he #isceral efferent .motor/ pathway of this cardiac response is mediated by which of the following$ A. 3arotid branches of the glossopharyngeal ner#es B. 4reater splanchnic ner#es C. 0hrenic ner#es D. 5ympathetic cer#ical and thoracic cardiac fibers

E. 6agus and recurrent laryngeal ner#es The answer is: D %he afferent limb of the cardiac refle( is mediated by the carotid branch of the glossopharyngeal ner#e .37 '8/ from the aortic body and sinus as well as by the #agus ner#e .37 8/ from the aortic body. %he efferent limb! which is carried by the sympathetic di#ision of the autonomic ner#ous system! mediates increases in heart rate and strength of heart beat through release of norepinephrine at the postganglionic effector site. %he sympathetic cardiac accelerator fibers! affecting primarily the #entricles! are deri#ed from the superior! middle! and inferior cer#ical ganglia .cer#ical cardiac ner#es/ as well as from the upper four thoracic ganglia .thoracic cardiac ner#es/! whence they con#erge on the cardiac ple(us before reaching the heart. 0arasympathetic fibers deri#ed from 37 8 and its recurrent laryngeal branch decrease heart rate and stroke #olume through release of acetylcholine! principally in the #icinity of the sinuatrial node. 126. Question 2 of + A 64-year-old man is brought into the emergency room after e(periencing more than 3 h of increasing chest pain that was unrelie#ed by rest! antacids! or nitroglycerin. e complains of nausea without #omiting. ,urther -uestioning re#eals a two-year history of e(ertional angina pectoris .pressing chest pain that often radiated along the inner aspect of the left arm when the patient climbed one flight of stairs/. 0ropranolol! which reduces the response of the heart to stress! and nitroglycerin! which dilates systemic #eins as well as coronary arteries! had been prescribed pre#iously. 1n physical e(amination he is found to be acyanotic .normal blood o(ygenation/! tachypneic .rapid breathing/! tachycardiac .rapid pulse rate/ with a regular rhythm! and diaphoretic .sweating/. 'n angina pectoris! the pain radiating down the left arm is mediated by increased acti#ity in afferent .sensory/ fibers contained in which of the following$ A. 3arotid branch of the glossopharyngeal ner#es B. 4reater splanchnic ner#es C. 0hrenic ner#es D. %horacic splanchnic ner#es E. 6agus ner#e and recurrent laryngeal ner#es The answer is: D Afferent inner#ation from the heart and coronary arteries tra#els to the cardiac ple(us along the sympathetic pathways. 1nce the afferent fibers pass through the cardiac ple(us! they run along the cer#ical and thoracic cardiac ner#es to the cer#ical and upper four thoracic sympathetic ganglia. a#ing tra#ersed these ganglia! the fibers gain access .#ia

the white rami communicantes/ to the upper four thoracic spinal ner#es and the corresponding le#els of the spinal cord. %he #isceral afferent fibers associated with the #agus ner#e are associated with refle(es and do not carry nocicepti#e information. %he greater! lesser! and least splanchnic ner#es con#ey #isceral afferents from the abdominal region. 129. Question 3 of + A 64-year-old man is brought into the emergency room after e(periencing more than 3 h of increasing chest pain that was unrelie#ed by rest! antacids! or nitroglycerin. e complains of nausea without #omiting. ,urther -uestioning re#eals a two-year history of e(ertional angina pectoris .pressing chest pain that often radiated along the inner aspect of the left arm when the patient climbed one flight of stairs/. 0ropranolol! which reduces the response of the heart to stress! and nitroglycerin! which dilates systemic #eins as well as coronary arteries! had been prescribed pre#iously. 1n physical e(amination he is found to be acyanotic .normal blood o(ygenation/! tachypneic .rapid breathing/! tachycardiac .rapid pulse rate/ with a regular rhythm! and diaphoretic .sweating/. %he patient is admitted to a coronary care unit for tests and obser#ation. An electrocardiogram re#eals a pattern consistent with a small #entricular posteroseptal infarct from ischemic necrosis that resulted from inade-uate blood supply. 'n the diagram of a normal heart shown below! the coronary artery most likely to be in#ol#ed in a posteroseptal infarct .as in this patient/ is indicated by which letter$

A. A B. : C. 3 D. ) E. ; The answer is: D %he artery labeled ) in the diagram accompanying the -uestion represents the posterior

inter#entricular .descending/ artery! which supplies blood to the posterior portions of the inter#entricular septum as well as to the posterior wall of the right #entricle. %his artery usually is a branch of the right coronary artery! and the diagnosis of this patient2s disorder is consistent with the results of the ;34! which indicates a posterior septal infarct. %he anterior inter#entricular artery .3/ arises from the left coronary artery .A/ and supplies the anterior portion of the inter#entricular septum and the anterior walls of both #entricles. %he posterior inter#entricular artery .)/ usually anastomoses with the anterior inter#entricular artery .3/ near the ape( of the heart. %he circumfle( artery .:/ circles toward the back of the heart in the coronary sulcus and may occasionally gi#e rise to the posterior inter#entricular artery .)/. %he right marginal artery .;/ is a branch of the right coronary artery. 12<. Question 4 of + A 64-year-old man is brought into the emergency room after e(periencing more than 3 h of increasing chest pain that was unrelie#ed by rest! antacids! or nitroglycerin. e complains of nausea without #omiting. ,urther -uestioning re#eals a two-year history of e(ertional angina pectoris .pressing chest pain that often radiated along the inner aspect of the left arm when the patient climbed one flight of stairs/. 0ropranolol! which reduces the response of the heart to stress! and nitroglycerin! which dilates systemic #eins as well as coronary arteries! had been prescribed pre#iously. 1n physical e(amination he is found to be acyanotic .normal blood o(ygenation/! tachypneic .rapid breathing/! tachycardiac .rapid pulse rate/ with a regular rhythm! and diaphoretic .sweating/. %o impro#e the blood flow to the inter#entricular septum! a coronary bypass procedure is elected. )uring surgery the anterior inter#entricular artery is located and prepared to recei#e a graft. "hich of the following is the #essel lying ad&acent to the anterior inter#entricular artery$ A. Anterior cardiac #ein B. 3oronary sinus C. 4reat cardiac #ein D. =iddle cardiac #ein E. 5mall cardiac #ein The answer is: C %he great cardiac #ein accompanies the anterior inter#entricular .descending/ artery. %he anterior cardiac #eins pass across the right coronary sulcus to drain directly into the right atrium. %he middle cardiac #ein lies in the posterior inter#entricular sulcus with the posterior descending artery. %he small cardiac #ein accompanies the right marginal #ein and the right coronary artery. %he coronary sinus! accompanying the circumfle( artery in the left coronary sulcus! recei#es the great! middle! and small cardiac #eins before draining into the right atrium.

12>. Question + of + A 64-year-old man is brought into the emergency room after e(periencing more than 3 h of increasing chest pain that was unrelie#ed by rest! antacids! or nitroglycerin. e complains of nausea without #omiting. ,urther -uestioning re#eals a two-year history of e(ertional angina pectoris .pressing chest pain that often radiated along the inner aspect of the left arm when the patient climbed one flight of stairs/. 0ropranolol! which reduces the response of the heart to stress! and nitroglycerin! which dilates systemic #eins as well as coronary arteries! had been prescribed pre#iously. 1n physical e(amination he is found to be acyanotic .normal blood o(ygenation/! tachypneic .rapid breathing/! tachycardiac .rapid pulse rate/ with a regular rhythm! and diaphoretic .sweating/. A section of superficial #ein remo#ed from the lower portion of the patient2s leg is grafted from the aorta to the coronary artery &ust distal to the site of occlusion. 'n coronary bypass surgery! which of the following statements is true$ A. %he pro(imal end of the #ein is anastomosed to the aorta B. %he distal end of the #ein is anastomosed to the aorta %he orientation is unimportant because aortic pressure is always higher than C. #enous pressure D. %he orientation is unimportant because the #ein is being used as an artery E. %he orientation would be important only if a coronary #ein were being bypassed The answer is: B 'n a coronary bypass procedure! the distal end of the #ein graft is anastomosed to the aorta so that the presence of a #al#e or #al#e leaflets in the graft will not obstruct the flow of coronary blood. 'n recent years! the re#ersed saphenous #ein graft from the calf has been the choice for this procedure. %his #ein is closer in si*e to the coronary arteries than one taken from the thigh. 13?. Question 1 of 9 A 46-year-old bakery worker is admitted to a hospital in acute distress. 5he has e(perienced se#ere abdominal pain! nausea! and #omiting for two days. %he pain! which is sharp and constant! began in the epigastric region and radiated bilaterally around the chest to &ust below the scapulas. 5ubse-uently! the pain became locali*ed in the right hypochondrium. %he patient! who has a history of similar attacks after hearty meals o#er the past fi#e years! is moderately o#erweight and the mother of four. 0alpation re#eals marked tenderness in the right hypochondriac region and some rigidity of the abdominal musculature. An (-ray without contrast medium shows numerous calcified stones in the region of the gallbladder. %he patient shows no sign of icterus .&aundice/.

)iffuse pain referred to the epigastric region and radiating circumferentially around the chest is the result of afferent fibers that tra#el #ia which of the following ner#es$ A. 4reater splanchnic B. 'ntercostal C. 0hrenic D. 6agus The answer is: A 6isceral afferent pain fibers from the gallbladder tra#el through the celiac ple(us! thence along the greater splanchnic ner#es to le#els %+@%> of the spinal cord. %hus! pain originating from the gallbladder will be referred to .appear as if coming from/ the dermatomes ser#ed by %+@%>! which include a band from the infrascapular region to the epigastrium. 131. Question 2 of 9 A 46-year-old bakery worker is admitted to a hospital in acute distress. 5he has e(perienced se#ere abdominal pain! nausea! and #omiting for two days. %he pain! which is sharp and constant! began in the epigastric region and radiated bilaterally around the chest to &ust below the scapulas. 5ubse-uently! the pain became locali*ed in the right hypochondrium. %he patient! who has a history of similar attacks after hearty meals o#er the past fi#e years! is moderately o#erweight and the mother of four. 0alpation re#eals marked tenderness in the right hypochondriac region and some rigidity of the abdominal musculature. An (-ray without contrast medium shows numerous calcified stones in the region of the gallbladder. %he patient shows no sign of icterus .&aundice/. %he patient recei#es a general anesthetic in preparation for a cholecystectomy. A right subcostal incision is made! which begins near the (iphoid process! runs along and immediately beneath the costal margin to the anterior a(illary line! and transects the rectus abdominis muscle and rectus sheath. At the le#el of the transpyloric plane! the anterior wall of the sheath of the rectus abdominis muscle recei#es contributions from which of the following$ A. Aponeuroses of the internal and e(ternal obli-ue muscles B. Aponeuroses of the trans#ersus abdominis and internal obli-ue muscles Aponeuroses of the trans#ersus abdominis and internal and e(ternal obli-ue C. muscles D. %rans#ersalis fascia E. %rans#ersalis fascia and aponeurosis of the trans#ersus abdominis muscle The answer is: A

%he rectus sheath is formed by the aponeuroses of the abdominal wall musculature. :etween the costal margin and the umbilicus! the aponeurosis of the internal obli-ue muscle splitsA one portion passes anterior and the other posterior to the rectus abdominis muscle. %he aponeurosis of the e(ternal obli-ue muscle fuses with the anterior leaflet of the aponeurosis of the internal obli-ue muscle to form the anterior wall of the rectus sheath. %he aponeurosis of the trans#ersus abdominis muscle fuses with the posterior leaflet of the aponeurosis of the internal obli-ue muscle to form the posterior wall of the rectus sheath. Appro(imately midway between the umbilicus and symphysis pubis! the aponeuroses of the internal obli-ue and trans#ersus abdominis muscles pass anterior to the rectus abdominis muscle to contribute to the anterior leaf of the rectus sheath. %his abrupt transition results in a free edge to the posterior rectus sheath! known as the arcuate line .of )ouglas/. :etween this line and the pubis! only the trans#ersalis fascia separates the rectus abdominis muscle from the peritoneum. 't is here! where the inferior epigastric artery gains access to the rectus sheath! that #entral lateral .spigelian/ herniation may occur. 132. Question 3 of 9 A 46-year-old bakery worker is admitted to a hospital in acute distress. 5he has e(perienced se#ere abdominal pain! nausea! and #omiting for two days. %he pain! which is sharp and constant! began in the epigastric region and radiated bilaterally around the chest to &ust below the scapulas. 5ubse-uently! the pain became locali*ed in the right hypochondrium. %he patient! who has a history of similar attacks after hearty meals o#er the past fi#e years! is moderately o#erweight and the mother of four. 0alpation re#eals marked tenderness in the right hypochondriac region and some rigidity of the abdominal musculature. An (-ray without contrast medium shows numerous calcified stones in the region of the gallbladder. %he patient shows no sign of icterus .&aundice/. ;(ploration of the peritoneal ca#ity disclosed a distended gallbladder. "here is the gallbladder located$ A. :etween the left and caudate lobes of the li#er B. :etween the right and -uadrate lobes of the li#er C. 'n the falciform ligament D. 'n the lesser omentum E. 'n the right anterior leaf of the coronary ligament The answer is: B %he gallbladder lies on the inferior surface of the li#er between the right and -uadrate lobes. %he caudate lobe lies posteriorly between the right and left lobes. %he falciform ligament! a portion of the lesser omentum! attaches to the li#er at the incisura between the -uadrate and left lobes as well as along the fissure for the round ligament. %oward the superior surface of the li#er! the falciform ligament splits to form the left and right

coronary ligaments! which define the bare area of the li#er. %he coronary ligaments come together again to form the gastrohepatic ligament of the lesser omentum. 133. Question 4 of 9 A 46-year-old bakery worker is admitted to a hospital in acute distress. 5he has e(perienced se#ere abdominal pain! nausea! and #omiting for two days. %he pain! which is sharp and constant! began in the epigastric region and radiated bilaterally around the chest to &ust below the scapulas. 5ubse-uently! the pain became locali*ed in the right hypochondrium. %he patient! who has a history of similar attacks after hearty meals o#er the past fi#e years! is moderately o#erweight and the mother of four. 0alpation re#eals marked tenderness in the right hypochondriac region and some rigidity of the abdominal musculature. An (-ray without contrast medium shows numerous calcified stones in the region of the gallbladder. %he patient shows no sign of icterus .&aundice/. %he lesser omentum is incised close to its free edge! and the biliary tree is identified and freed by blunt dissection. %he li-uid contents of the gallbladder are aspirated with a syringe! the fundus incised! and the stones remo#ed. %he entire duct system is carefully probed for stones! one of which is found to be obstructing a duct. 'n #iew of the obser#ation that the patient is not &aundiced! which of the following is the most probable location of the obstruction$ A. %he bile duct B. %he common hepatic duct C. %he cystic duct D. "ithin the duodenal papilla pro(imal to the &uncture with the pancreatic duct E. "ithin the duodenal papilla distal to the &uncture with the pancreatic duct The answer is: C 1bstruction of any portion of the biliary tree will produce symptoms of gallbladder attack. 'f the common hepatic duct or bile duct is occluded by stone or tumor! biliary stasis with accompanying &aundice occurs. 'n addition! blockage of the duodenal papilla .of 6ater/! distal to the &uncture of the bile duct with the pancreatic duct! can lead to complicating pancreatitis. 'f only the cystic duct is obstructed! &aundice will not occur because bile may flow freely from the li#er to the duodenum. :ile duct obstruction also may arise as a result of pressure e(erted on the duct by an e(ternal mass! such as a tumor in the head of the pancreas. 134. Question + of 9 A 46-year-old bakery worker is admitted to a hospital in acute distress. 5he has e(perienced se#ere abdominal pain! nausea! and #omiting for two days. %he pain! which is sharp and constant! began in the epigastric region and radiated bilaterally around the

chest to &ust below the scapulas. 5ubse-uently! the pain became locali*ed in the right hypochondrium. %he patient! who has a history of similar attacks after hearty meals o#er the past fi#e years! is moderately o#erweight and the mother of four. 0alpation re#eals marked tenderness in the right hypochondriac region and some rigidity of the abdominal musculature. An (-ray without contrast medium shows numerous calcified stones in the region of the gallbladder. %he patient shows no sign of icterus .&aundice/. %he biliary duct system is carefully dissected. %he cystic artery and cystic duct both are identified! ligated! and di#ided! the duct at a point about an eighth of an inch from its &uncture with the common hepatic duct. %he gallbladder is then freed from the inferior surface of the li#er by blunt dissection and remo#ed. owe#er! the operati#e field suddenly fills with arterial blood. %o locate and ligate the bleeder! hemorrhage should be controlled by which of the following procedures$ A. Bigating the common hepatic artery Bigating the proper hepatic artery distal to the origin of the right gastric and gastroduodenal arteries Bigating the left hepatic artery! especially if there are additional .aberrant/ left C. hepatic arteries present B. D. Bigating the hepatic portal #ein E. %emporarily compressing the hepatic pedicle The answer is: E 3ompressing the hepatic pedicle and its contained #ascular structures between the forefinger placed in the omental foramen .of "inslow/ and the thumb placed anteriorly is a con#enient way to stem e(trahepatic hemorrhage until the source of bleeding can be located and ligated. %he blood supply to the li#er is #ariableA se#eral potential anastomotic loops e(ist between branches of the e(trahepatic arterial system. %hus! ligation of the common hepatic artery pro(imal to the gastroduodenal artery will enable arterial blood to reach the li#er from branches of the splenic artery .#ia anastomotic left and right gastroepiploic arteries/ and the superior mesenteric artery .#ia the anastomotic inferior and superior pancreaticoduodenal arteries/. Bigation of the proper hepatic artery pro(imal to the origin of the right gastric artery will enable arterial blood to reach the li#er from branches of the celiac artery .#ia anastomotic left and right gastric arteries/. owe#er! ligation distal to the &uncture of the right gastric artery will terminate most of! if not all! the blood supply to the li#er and incur a danger of ischemia! if not necrosis! of hepatic tissue. :ecause accessory or aberrant hepatic arteries usually are not sources of collateral blood supply to the li#er! they cannot be relied on to pro#ide intrahepatic anastomotic connections. 13+. Question 6 of 9 A 46-year-old bakery worker is admitted to a hospital in acute distress. 5he has e(perienced se#ere abdominal pain! nausea! and #omiting for two days. %he pain! which

is sharp and constant! began in the epigastric region and radiated bilaterally around the chest to &ust below the scapulas. 5ubse-uently! the pain became locali*ed in the right hypochondrium. %he patient! who has a history of similar attacks after hearty meals o#er the past fi#e years! is moderately o#erweight and the mother of four. 0alpation re#eals marked tenderness in the right hypochondriac region and some rigidity of the abdominal musculature. An (-ray without contrast medium shows numerous calcified stones in the region of the gallbladder. %he patient shows no sign of icterus .&aundice/. 't is ascertained that an accessory right hepatic artery inad#ertently had been torn. %here is no choice but to ligate the accessory artery. "hich of the following will be the most likely effect of this ligation$ A. 'schemic necrosis of the -uadrate lobe of the li#er B. 'schemic necrosis of a discrete portion of the right lobe of the li#er C. 7o necrosis in any lobe because of the integrity of the hepatic portal #ein D. 7o necrosis in any lobe because of e(trahepatic collateral blood supply E. 7o necrosis in any lobe because of intrahepatic collateral blood supply The answer is: B :ecause few intrahepatic arterial anastomoses e(ist! ligation of a left or right hepatic artery or of an aberrant .accessory/ hepatic artery will result in ischemic necrosis of the region of the li#er supplied by that #essel. %he left hepatic artery supplies the left lobe and the -uadrate lobe! as well as half the caudate lobe. %he right hepatic artery supplies the right lobe and the other half of the caudate lobeA it also usually supplies the gallbladder through the cystic artery. 7o ma&or e(trahepatic anastomotic connections distal to the right gastric artery e(ist! and the hepatic portal #ein has far too low a partial pressure of o(ygen to supply the metabolic re-uirements of li#er parenchyma. 136. Question 9 of 9 A 46-year-old bakery worker is admitted to a hospital in acute distress. 5he has e(perienced se#ere abdominal pain! nausea! and #omiting for two days. %he pain! which is sharp and constant! began in the epigastric region and radiated bilaterally around the chest to &ust below the scapulas. 5ubse-uently! the pain became locali*ed in the right hypochondrium. %he patient! who has a history of similar attacks after hearty meals o#er the past fi#e years! is moderately o#erweight and the mother of four. 0alpation re#eals marked tenderness in the right hypochondriac region and some rigidity of the abdominal musculature. An (-ray without contrast medium shows numerous calcified stones in the region of the gallbladder. %he patient shows no sign of icterus .&aundice/. %he subcostal incision! which parallels the costal margin anteriorly! is closed in layers. %he patient is allowed up on her first postoperati#e dayA on the third day the drain .which shows no bile leakage/ is withdrawn! and on the tenth day the patient is discharged. As a

result of the location and direction of the incision! one might e(pect healing to result in which of the following$ A. Boss of blood supply and necrosis of a portion of the rectus abdominis muscle B. 5ignificant paralysis of a portion of the rectus abdominis muscle C. =inimal scarring D. 7egligible possibility of subse-uent abdominal herniation The answer is: B %he rectus abdominis muscle recei#es an abundant collateral blood supply. %he ner#e supply to the rectus abdominis muscle is deri#ed from abdominal e(tensions of the lower se#en intercostal ner#es and from the iliohypogastric ner#e. %hese ner#es run between the internal obli-ue and trans#ersus abdominis muscles to reach the lateral border of the rectus sheath! which they pierce to reach the rectus abdominis muscle. 3onse-uently! a subcostal incision from the (iphisternal angle to the anterior a(illary line is apt to se#er one or two of these ner#es and thus paraly*e a significant portion of the ipsilateral rectus abdominis muscle. An affected patient may be predisposed to subse-uent abdominal herniation. Although the direction of an incision along the costal margin is perforce perpendicular to the dermal clea#age lines .of Banger/ and thus may produce discomfort and healing with significant scarring! such an incision is &ustified by the re-uired operati#e e(posure that it pro#ides. 139. Question 1 of 3 A 39-year-old man with a history of alcohol abuse was seen in the emergency room complaining of stomach cramps in the region of the umbilicus. e reported se#eral recent incidents of #omiting that contained no noticeable blood! although he had in the past #omited bright red blood. e insisted that he had been on the wagon for the past se#eral months. 0hysical e(amination re#ealed a mass about the umbilicus with indications of periumbilical peritoneal inflammation. is white blood cell count was high and he had a temperature of 3>.4C3 .1?3C,/. e was admitted to the surgical ser#ice for emergency reduction of an umbilical hernia with suspected strangulation. %he crampy abdominal pain referred to the umbilical region and knowledge of peritoneal structure would lead the e(amining physician to suspect that which of the following wass most likely the strangulated section of gut$ A. Ascending colon B. )escending colon C. 5mall intestine D. 5igmoid colon E. 5tomach

The answer is: C %he umbilical region is inner#ated by the tenth intercostal ner#e. %he afferent ner#e fibers from the &e&unum and ileum as well as from the ascending colon and trans#erse colon tra#el through the superior mesenteric ple(us and along the lesser splanchnic ner#e to spinal ner#es %1? and %11. %hus! pain originating from these portions of the gastrointestinal tract will refer pain to the umbilical region. %he ascending colon and descending colon! which are secondarily retroperitoneal! are unlikely to be in#ol#ed in the umbilical herniation. %he mobile trans#erse colon could be in#ol#ed! but the referred pain would tend to be subumbilical! not periumbilical. 13<. Question 2 of 3 A 39-year-old man with a history of alcohol abuse was seen in the emergency room complaining of stomach cramps in the region of the umbilicus. e reported se#eral recent incidents of #omiting that contained no noticeable blood! although he had in the past #omited bright red blood. e insisted that he had been on the wagon for the past se#eral months. 0hysical e(amination re#ealed a mass about the umbilicus with indications of periumbilical peritoneal inflammation. is white blood cell count was high and he had a temperature of 3>.4C3 .1?3C,/. e was admitted to the surgical ser#ice for emergency reduction of an umbilical hernia with suspected strangulation. After the herniated segment of gut was placed into the abdominal ca#ity! its color changed from purple to pink! which indicated that the #asculature was functional. %he small intestine normally recei#es significant collateral circulation from which of the following arteries$ A. )escending branch of the left colic artery B. Denal arteries C. 5plenic artery D. 5uperior pancreaticoduodenal artery The answer is: D %he &e&unum and ileum recei#e their principal blood supply from the superior mesenteric artery. A strong collateral circulation is deri#ed from the superior pancreatic artery! a branch of the pancreaticoduodenal artery that arises from the hepatic branch of the celiac artery. %he superior pancreatic artery anastomoses with the inferior pancreatic artery! the first branch of the superior mesenteric artery. %he collateral circulation is weak between the right colic artery and the ileal branches. %here are no possibilities for superior mesenteric anastomoses from the splenic! the descending branch of the left colic! or renal arteries. 13>.

Question 3 of 3 A 39-year-old man with a history of alcohol abuse was seen in the emergency room complaining of stomach cramps in the region of the umbilicus. e reported se#eral recent incidents of #omiting that contained no noticeable blood! although he had in the past #omited bright red blood. e insisted that he had been on the wagon for the past se#eral months. 0hysical e(amination re#ealed a mass about the umbilicus with indications of periumbilical peritoneal inflammation. is white blood cell count was high and he had a temperature of 3>.4C3 .1?3C,/. e was admitted to the surgical ser#ice for emergency reduction of an umbilical hernia with suspected strangulation. 1n manual e(ploration of the abdominal ca#ity! the li#er was felt to be hard and nodular. %his! in addition to the history of hematemesis! indicated that control of the portal hypertension was necessary. 'n a patient with cirrhosis of the li#er! #enous hypertension would be e(pected in which of the following #eins$ A. epatic #ein B. Denal #ein C. 5hort gastric #eins D. 5uprarenal #ein The answer is: C %he short gastric #eins are branches of the splenic #ein and! therefore! would e(perience the portal pressure. %he short gastric #eins also anastomose with the esophageal #eins and produce esophageal #arices. %he hepatic #ein! between the li#er and inferior #ena ca#a! drains the li#er and is not part of the portal system. %here are no communications between the portal system and the renal or suprarenal #eins. 14?. Question 1 of 2 A middle-aged woman describes flushing! se#ere headaches! and a feeling that her heart is Egoing to e(plodeE when she gets e(cited. At the beginning of a physical e(amination her blood pressure .13?F<+/ is not significantly abo#e normal. owe#er! on palpation of her upper left -uadrant! the e(amining physician notices the onset of sympathetic signs. er blood pressure .2??F13+/ is abnormally high. A subse-uent 3% scan confirms the suspected tumor of the left adrenal gland. %he patient is scheduled for surgery. %he symptoms that the patient correlated with the onset of e(citement were due to ner#ous stimulation of the adrenal glands. %he adrenal medulla recei#es its inner#ation from which of the following ner#es$ A. 0reganglionic sympathetic ner#es B. 0ostsynaptic sympathetic ner#es C. 0reganglionic parasympathetic ner#es

D. 0ostganglionic parasympathetic ner#es E. 5omatic ner#es The answer is: A %he adrenal medulla is inner#ated from thoracic le#els of the spinal cord mediated by preganglionic sympathetic ner#e fibers tra#eling in the lesser and least splanchnic ner#es! with some contribution from the greater splanchnic and lumbar splanchnic ner#es. :ecause both the adrenal medulla and postganglionic sympathetic neurons are adrenergic and deri#ed from neural crest tissue! the homology of the chromaffin cells and postganglionic sympathetic neurons is apparent. %here appears to be no parasympathetic inner#ation to the adrenal medulla and no inner#ation whate#er to the adrenal corte(. 141. Question 2 of 2 A middle-aged woman describes flushing! se#ere headaches! and a feeling that her heart is Egoing to e(plodeE when she gets e(cited. At the beginning of a physical e(amination her blood pressure .13?F<+/ is not significantly abo#e normal. owe#er! on palpation of her upper left -uadrant! the e(amining physician notices the onset of sympathetic signs. er blood pressure .2??F13+/ is abnormally high. A subse-uent 3% scan confirms the suspected tumor of the left adrenal gland. %he patient is scheduled for surgery. %he adrenal gland is located! and the #enous drainage is ligated to pre#ent lifethreatening -uantities of adrenalin from entering the bloodstream on manipulation of the gland. 7ormally! the left adrenal #enous drainage is into which of the following #eins$ A. 'nferior #ena ca#a B. Beft a*ygos #ein C. Beft inferior phrenic #ein D. Beft renal #ein E. 5uperior mesenteric #ein The answer is: D %he #enous drainage from each adrenal gland tends to be through a single #ein. %he left adrenal gland usually drains into the left renal #ein superior to the point where the gonadal #ein enters the left renal #ein. %he left adrenal #ein usually anastomoses with the hemia*ygos #ein and may pro#ide an important route of collateral #enous return. %he right adrenal gland usually drains directly into the inferior #ena ca#a. 142. Question 1 of 4 "hile mo#ing furniture! an 1<-year-old man e(periences e(cruciating pain in his right

groin. A few hours later he also de#elops pain in the umbilical region with accompanying nausea. At this point he seeks medical attention. ;(amination re#eals a bulge midway between the midline and the anterior superior iliac spine! but superior to the inguinal ligament. 1n coughing or straining! the bulge increases and the inguinal pain intensifies. %he bulge courses medially and inferiorly into the upper portion of the scrotum and cannot be reduced with the finger pressure of the e(aminer. 't is decided that a medical emergency e(ists! and the patient is scheduled for immediate surgery. 7ausea and diffuse pain referred to the umbilical region in this patient most probably are due to which of the following$ A. 3ompression of the genitofemoral ner#e B. 3ompression of the ilioinguinal ner#e C. )ilation of the inguinal canal D. 'ncarceration of a loop of small bowel E. 'schemic necrosis of the cremaster muscle The answer is: D %he diffuse central abdominal pain in the patient presented is probably referred pain from the loop of small bowel incarcerated within the herniated peritoneal sac. 3ompression of the bowel results in compromise of the blood supply and subse-uent ischemic necrosis. %he #isceral afferent fibers from the distal small bowel tra#el along the blood #essels to reach the superior mesenteric ple(us and lesser splanchnic ner#es! which they follow to the %1?@%11 le#els of the spinal cord. %he pain! therefore! is referred to .appears as if originating from/ the %1?@%11 dermatomes! which supply the umbilical region. :ecause the gut de#elops as a midline structure! #isceral pain tends to be centrally located regardless of the adult location of any particular region of the gut. As a result of dilation of the inguinal canal by the hernial sac! howe#er! the patient also e(periences locali*ed somatic pain mediated by the iliohypogastric! ilioinguinal! and genitofemoral ner#es. 143. Question 2 of 4 "hile mo#ing furniture! an 1<-year-old man e(periences e(cruciating pain in his right groin. A few hours later he also de#elops pain in the umbilical region with accompanying nausea. At this point he seeks medical attention. ;(amination re#eals a bulge midway between the midline and the anterior superior iliac spine! but superior to the inguinal ligament. 1n coughing or straining! the bulge increases and the inguinal pain intensifies. %he bulge courses medially and inferiorly into the upper portion of the scrotum and cannot be reduced with the finger pressure of the e(aminer. 't is decided that a medical emergency e(ists! and the patient is scheduled for immediate surgery. )uring surgery! one would e(pect to find which of the following arteries in the inguinal region$

A. Aberrant obturator .if present/ B. )eep circumfle( iliac C. ;(ternal iliac D. ;(ternal pudendal E. 'nferior epigastric The answer is: B %he deep circumfle( iliac artery! which arises from the internal iliac artery opposite the inferior epigastric artery! parallels the inguinal ligament as it courses toward the anterosuperior iliac spine. %he e(ternal pudendal and superficial epigastric arteries are branches of the femoral artery that supply! respecti#ely! the superficial pubic .hypogastric/ region! the inguinal regions! and the anterior surfaces of the scrotum or labia ma&ora. %he inferior epigastric artery! a branch of the e(ternal iliac artery! courses superomedially beneath the aponeuroses of the abdominal wall to gain access to the rectus sheath by passing anterior to the arcuate line .of )ouglas/. An aberrant obturator artery .present in about 3?G of the population/ usually arises from the inferior epigastric artery and courses inferiorly deep to the pubic ramus to the obturator foramen. 144. Question 3 of 4 "hile mo#ing furniture! an 1<-year-old man e(periences e(cruciating pain in his right groin. A few hours later he also de#elops pain in the umbilical region with accompanying nausea. At this point he seeks medical attention. ;(amination re#eals a bulge midway between the midline and the anterior superior iliac spine! but superior to the inguinal ligament. 1n coughing or straining! the bulge increases and the inguinal pain intensifies. %he bulge courses medially and inferiorly into the upper portion of the scrotum and cannot be reduced with the finger pressure of the e(aminer. 't is decided that a medical emergency e(ists! and the patient is scheduled for immediate surgery. %he e(ternal obli-ue aponeurosis is incised and the superficial ring is opened. %he inguinal canal is then opened by blunt dissection. Abdominal wall structures that usually contribute directly to the spermatic cord include which of the following$ A. ;(ternal obli-ue muscle B. ,al( inguinalis C. 'nternal obli-ue muscle D. Dectus sheath E. %rans#ersus abdominis muscle

The answer is: C 5e#eral abdominal structures are in#ol#ed in the formation of the spermatic cord. %he deep fascia contributes the e(ternal spermatic fascia. Although some references include the e(ternal obli-ue muscle or aponeurosis! no contribution is deri#ed from that layer owing to a hiatus in the aponeurosis. %he cremaster muscle! a contribution of the internal obli-ue muscle! &oins the spermatic cord as the inguinal canal passes through that layer. %he trans#ersus abdominis muscle! which usually terminates as the fal( inguinalis &ust superior to the deep ring! contributes to the cremaster muscle in less than +G of all males. %he trans#ersalis fascia contributes the internal spermatic fascia. 14+. Question 4 of 4 "hile mo#ing furniture! an 1<-year-old man e(periences e(cruciating pain in his right groin. A few hours later he also de#elops pain in the umbilical region with accompanying nausea. At this point he seeks medical attention. ;(amination re#eals a bulge midway between the midline and the anterior superior iliac spine! but superior to the inguinal ligament. 1n coughing or straining! the bulge increases and the inguinal pain intensifies. %he bulge courses medially and inferiorly into the upper portion of the scrotum and cannot be reduced with the finger pressure of the e(aminer. 't is decided that a medical emergency e(ists! and the patient is scheduled for immediate surgery. At this point in the surgical procedure! it is noticed that a ner#e has been inad#ertently sectioned. %his ner#e e(ited through the superficial inguinal ring and was applied to the anterior aspect of the spermatic cord. "hich of the following is the most likely result of this operati#e error$ A. 'nability to produce spermato*oa in the right testis B. 'mpotence C. Boss of the cremasteric refle( on the right side D. Boss of the dartos response to cold E. Boss of sensation o#er portions of the base of the penis and anterior scrotum The answer is: E %he ilioinguinal ner#e e(its the abdominal wall through the superficial inguinal ring! where it is applied to the anterior surface of the spermatic cord. 5ection of this ner#e will result in paresthesia o#er the base of the penis and scrotum. %he femoral branch of the genitofemoral ner#e inner#ates the upper medial surface of the thigh! where it mediates the afferent limb of the cremasteric refle(. %he efferent limb of this refle( is carried by the genital branch of the genitofemoral ner#e! which lies within the cremaster layer. %he dartos response! which is sympathetic! arises from the sacral sympathetic chain and reaches the pudendal ner#e #ia gray rami communicantes.

146. Question 1 of 4 A 24-year-old woman seeking assistance for apparent infertility has been unable to concei#e despite repeated attempts in fi#e years of marriage. 5he re#ealed that her husband had fathered a child in a prior marriage. Although her menstrual periods are fairly regular! they are accompanied by e(treme lower back pain. %he lower back pain during menstruation e(perienced by this woman probably is referred from the pel#ic region. %he pathways that con#ey this pain sensation to the central ner#ous system in#ol#e which of the following$ A. ypogastric ner#e to B1@B2 B. Bumbosacral trunk to B4@B+ C. 0el#ic splanchnic ner#es to 52@54 D. 0udendal ner#e to 52@54 The answer is: A %he #isceral afferent fibers that mediate sensation from the fundus and body of the uterus! as well as from the o#iducts! tend to tra#el along the sympathetic ner#e pathways .#ia the hypogastric ner#e and lumbar splanchnics/ to reach the upper lumbar le#els .B1@ B2/ of the spinal cord. %hus! uterine pain will be referred to .appear as if originating from/ the upper lumbar dermatomes and produce apparent backache. %he #isceral afferent fibers that mediate sensation from the cer#ical neck of the uterus tra#el along the parasympathetic pathways .#ia the pel#ic splanchnic ner#es Hner#i erigentesI/ to the midsacral le#els .52@54/ of the spinal cord. 'n this instance! pain originating from the cer#i( will be referred to the midsacral dermatomes and produce pain that appears to arise from the perineum! gluteal region! and legs. 149. Question 2 of 4 A 24-year-old woman seeking assistance for apparent infertility has been unable to concei#e despite repeated attempts in fi#e years of marriage. 5he re#ealed that her husband had fathered a child in a prior marriage. Although her menstrual periods are fairly regular! they are accompanied by e(treme lower back pain. "hich of the following would be found immediately inferior to the left cardinal .lateral cer#ical/ ligament$ A. 1#arian neuro#ascular bundle B. Jterine tube C. Dound ligament of the uterus D. Jreter

E. Jterine artery and #ein The answer is: D %he ureter! lying &ust medial to the internal iliac artery in the deep pel#is! passes from posterior to anterior immediately inferior to the lateral cer#ical ligament. %his ligament contains the uterine artery and #ein to which the ureters pass inferior appro(imately midway along their course between internal iliac artery and uterus. %he ureter continues inferior to the anterior portion of the lateral cer#ical ligament .where it can sometimes be palpated through the walls of the #agina at the lateral fornices/ to gain access to the base of the urinary bladder. %he close association between uterine #essels and ureter is of ma&or importance during surgical procedures in the female pel#is. 14<. Question 3 of 4 A 24-year-old woman seeking assistance for apparent infertility has been unable to concei#e despite repeated attempts in fi#e years of marriage. 5he re#ealed that her husband had fathered a child in a prior marriage. Although her menstrual periods are fairly regular! they are accompanied by e(treme lower back pain. %he patient is scheduled for a hysterosalpingogram! in which radi-opa-ue material is in&ected into the uterus and uterine tubes. ;(amination of subse-uent radiographs discloses bilateral spillage of the contrast medium into the peritoneal ca#ity! an indication of which of the following$ A. %he uterine tubes are normal B. %he mesonephric ducts failed to form properly C. %he paramesonephric ducts failed to form properly D. %here is a rectouterine fistula E. %here is a #esico#aginal fistula The answer is: A %he uterus is formed by fusion of the paired paramesonephric ducts. %he uterine tubes are the unfused portions of these ducts. 0atency of the uterine tubes may be ascertained by hysterosalpingography! wherein radiopa-ue material is in&ected into the uterine ca#ity and uterine tubes through a catheter inserted into the e(ternal cer#ical os. Dadiographs delineate the ca#ity of the body of the uterus and the uterine tubes. 5pillage of the contrast material through the abdominal ostia into the peritoneal ca#ity demonstrates normal patency of the uterine tubes. %he abdominal ostia of the uterine tubes permit passage of infection! air! and spermato*oa into the female peritoneal ca#ity. %he rare rectouterine fistula would result in the appearance of contrast media in the rectum. A #esico#aginal fistula between the #agina and urethra or bladder would not be e#ident on a hysterosalpingogram.

14>. Question 4 of 4 A 24-year-old woman seeking assistance for apparent infertility has been unable to concei#e despite repeated attempts in fi#e years of marriage. 5he re#ealed that her husband had fathered a child in a prior marriage. Although her menstrual periods are fairly regular! they are accompanied by e(treme lower back pain. %he most important measurement of the pel#ic outlet! indicating the least dimension! is the trans#erse midplane diameter. 't is measured between which of the following$ A. 'schial spines B. 'schial tuberosities C. Bower margin of the pubic symphysis to the sacroiliac &oint D. 5acral promontory to the inferior margin of the pubic symphysis The answer is: A %he trans#erse midplane diameter is measured between the ischial spines. 't can be appro(imated by the somewhat greater trans#erse diameter measured between the ischial tuberosities. %he distance from the lower margin of the pubic symphysis to the sacroiliac &oint defines the sagittal diameter! which is usually the greatest dimension and! therefore! unimportant. 1+?. Question 1 of 2 A 4+-year-old plumber presented in the clinic complaining of long-standing pain in the elbow. 5ubse-uent e(amination re#ealed normal fle(ionFe(tension at both the elbow and the wrist but weakened abduction of the thumb and e(tension at the metacarpophalangeal &oints of the fingers. %hese symptoms were found to be caused by entrapment of the posterior interosseus ner#e. "hich of the following muscles could be e(pected to demonstrate normal contraction$ A. ;(tensor indices B. ;(tensor digitorum C. ;(tensor carpi radialis longus D. Abductor pollicis longus E. ;(tensor digit minimi The answer is: C

All of the muscles listed abo#e are inner#ated by the posterior interosseus branch of the radial ner#e .the terminal part of the deep radial ner#e/. ;(tensor carpi radialis longus! howe#er! is inner#ated by a muscular branch of the radial ner#e pro(imal to the origin of the deep branch. 'ts function would! therefore! be preser#ed in entrapment of the posterior interosseus ner#e. 1+1. Question 2 of 2 A 4+-year-old plumber presented in the clinic complaining of long-standing pain in the elbow. 5ubse-uent e(amination re#ealed normal fle(ionFe(tension at both the elbow and the wrist but weakened abduction of the thumb and e(tension at the metacarpophalangeal &oints of the fingers. %hese symptoms were found to be caused by entrapment of the posterior interosseus ner#e. "hich of the following muscles could itself cause entrapment of the posterior interosseus ner#e$ A. ;(tensor carpi ulnaris B. ;(tensor indices C. Anconeus D. ;(tensor digitorum E. 5upinator The answer is: E ;ach of the muscles listed abo#e is inner#ated by the deep branch of the radial ner#e or its terminal portion! the posterior interosseus ner#e. %he deep radial ner#e passes between the deep and superficial layers of the supinator muscle and lies on a bare area of the radius where it may be compressed by action of the supinator or damaged by a fracture of the radius. 1+2. Question 1 of + A 69-year-old woman slipped on a scatter rug and fell with her right arm e(tended in an attempt to ease the impact of the fall. 5he e(perienced immediate se#ere pain in the region of the right collar bone and in the right wrist. 0ainful mo#ement of the right arm was minimi*ed by holding the arm close to the body and by supporting the elbow with the left hand. %here is marked tenderness and some swelling in the region of the cla#icle about onethird of the distance from the sternum. %he e(aminer can feel the pro&ecting edges of the cla#icular fragments. %he radiograph confirms the fracture and shows ele#ation of the pro(imal fragment with depression and sublu(ation .underriding/ of the distal fragment.

%raction by which of the following muscles causes sublu(ation .the distal fragment underrides the pro(imal fragment/$ A. )eltoid muscle B. 0ectoralis ma&or muscle C. 0ectoralis minor muscle D. 5ternomastoid muscle E. %rape*ius muscle The answer is: B %he hori*ontal direction of the fibers of the cla#icular head of the pectoralis ma&or muscle draws the humerus medially and causes the distal fragment of the bone to sublu(. %he sternal head of this muscle also has the effect of pulling the arm medially! an effect that is normally offset by the strutlike action of the cla#icle. 1+3. Question 2 of + A 69-year-old woman slipped on a scatter rug and fell with her right arm e(tended in an attempt to ease the impact of the fall. 5he e(perienced immediate se#ere pain in the region of the right collar bone and in the right wrist. 0ainful mo#ement of the right arm was minimi*ed by holding the arm close to the body and by supporting the elbow with the left hand. 'nternal bleeding can be a complication if the sublu(ed bone fragment tears a #essel and punctures the pleura. "hich of the following #ascular structures is particularly #ulnerable in a cla#icular fracture$ A. A(illary artery B. :rachiocephalic artery C. Bateral thoracic artery D. 5ubcla#ian artery E. %horacoacromial trunk The answer is: D :ecause large and important neuro#ascular structures pass between the cla#icle and first rib! including the subcla#ian artery! cla#icular fracture may produce life-threatening bleeding into the pleural ca#ity. %he a(illary artery is the continuation of the subcla#ian after it has cleared the first rib! so neither this #essel nor its thoracoacromial branch is likely to be threatened by cla#icular fracture. %here is no brachiocephalic artery on the

left side! and on the right its terminal point is marked by its bifurcation into common carotid and subcla#ian arteries pro(imal to the fracture site. 1+4. Question 3 of + A 69-year-old woman slipped on a scatter rug and fell with her right arm e(tended in an attempt to ease the impact of the fall. 5he e(perienced immediate se#ere pain in the region of the right collar bone and in the right wrist. 0ainful mo#ement of the right arm was minimi*ed by holding the arm close to the body and by supporting the elbow with the left hand. =arked swelling is noted about the palmar aspect of the wrist. 0ersistent fle(ion of the fingers and apparent shortening of the middle finger is seen. %here is paresthesia .sensory dullness/ o#er the palmar aspect of the thumb! inde( finger! middle finger! and a -uestionable portion of the ring finger! yet when the wrist is gently fle(ed! intense pain spreads o#er this area. 5ensation o#er the palm seems normal. %he partial fle(ion of the fingers in this case is best e(plained by which of the following$ A. 3ompression of the radial artery B. 3ompression of the recurrent branch of the median ner#e C. 'mpingement of the fle(or tendons by a dislocated carpal bone D. 0aralysis of the dorsal interossei muscles E. 0aralysis of the fle(or digitorum superficialis muscle The answer is: C A fall on the e(tended hand will fre-uently dislocate the lunate bone anteriorly. %his dislocated bone may then impinge on the tendons of the e(trinsic digital fle(or muscles and thereby pre#ent fle(ion of the fingers. 3ompression of the median ner#e in the carpal tunnel cannot e(plain this obser#ation because the prime fle(ors of the digits are the e(trinsic fle(ors .fle(ors digitorum superficialis and profundus/! which recei#e their inner#ation in the forearm! well pro(imal to the in&ury. %he dorsal interossei! inner#ated by the ulnar ner#e! are digital e(tensors. %he recurrent branch of the median ner#e inner#ates the thenar muscles. 1++. Question 4 of + A 69-year-old woman slipped on a scatter rug and fell with her right arm e(tended in an attempt to ease the impact of the fall. 5he e(perienced immediate se#ere pain in the region of the right collar bone and in the right wrist. 0ainful mo#ement of the right arm was minimi*ed by holding the arm close to the body and by supporting the elbow with the left hand.

"hich of the following is the carpal bone most likely to dislocate anteriorly and cause a form of carpal tunnel syndrome$ A. 3apitate B. amate C. Bunate D. 7a#icular E. 5caphoid The answer is: C %he lunate bone tends to dislocate anteriorly into the trans#erse carpal arch! thereby entrapping the tendons of the e(trinsic digital fle(ors and compressing the median ner#e. %he capitate is fre-uently fractured but does not tend to dislocate into the carpal arch. %he hamate pro#ides an anchor for the trans#erse carpal ligament and is! therefore! located lateral to the carpal tunnel. %he na#icular .scaphoid/ bone has a tendency to fracture but does not dislocate into the carpal tunnel. 1+6. Question + of + A 69-year-old woman slipped on a scatter rug and fell with her right arm e(tended in an attempt to ease the impact of the fall. 5he e(perienced immediate se#ere pain in the region of the right collar bone and in the right wrist. 0ainful mo#ement of the right arm was minimi*ed by holding the arm close to the body and by supporting the elbow with the left hand. %he fractured cla#icle was reduced and the shoulder bandaged. %he lunate bone was surgically reduced. After eight weeks the bone had healed! but the patient was found to ha#e persistent loss of hand function. 'n addition to the region of original paresthesia .palmar aspects of the thumb! inde(! and middle fingers as well as a portion of the ring finger/! which of the following areas should also e(hibit paresthesia A. )orsal aspect of the distal phalanges of the inde( and middle fingers B. )orsal web space between the thumb and inde( finger C. =edial aspect of the fifth digit D. 5kin o#er the central palm The answer is: A 'n addition to supplying sensation to the palmar aspects of the thumb! inde(! and middle fingers as well as the radial portion of the ring finger! the median ner#e also supplies the dorsal aspect of the terminal phalan( of those fingers. %he dorsal web space between the thumb and inde( finger is supplied e(clusi#ely by the radial ner#e. %he fifth finger is

supplied completely by the ulnar ner#e. %he central region of the palm is supplied by the superficial branch of the median ner#e that arises pro(imal to the carpal tunnel and is not compromised by carpal tunnel syndrome because it passes superficial to the fle(or retinaculum. 1+9. Question 1 of 2 A workman accidentally lacerated his wrist as shown in the accompanying diagram. 1n e(ploration of the wound! a #essel and ner#e are found to ha#e been se#ered! but no muscle tendons were damaged.

,rom the indicated location of the laceration! which of the following is the in#ol#ed ner#e$ A. =edian ner#e B. Decurrent branch of the median ner#e C. 5uperficial branch of the radial ner#e D. Jlnar ner#e The answer is: D %he ulnar ner#e descends along the posta(ial .ulnar/ side of the forearm. 't passes lateral to the pisiform bone and under the carpal #olar ligament! but superficial to the trans#erse carpal ligament. 'n the hand it di#ides into superficial and deep branches. %he median ner#e lies deep to the trans#erse carpal ligament where it is protected from superficial lacerations. ;merging from the carpal tunnel! it gi#es off the #ulnerable recurrent branch to the thenar eminence. %he superficial branch of the radial ner#e supplies the dorsolateral aspects of the wrist and hand. 1+<. Question 2 of 2 A workman accidentally lacerated his wrist as shown in the accompanying diagram. 1n e(ploration of the wound! a #essel and ner#e are found to ha#e been se#ered! but no muscle tendons were damaged.

"hich of the following thumb mo#ements would be abolished$ A. Abduction B. Adduction C. ;(tension D. 1pposition The answer is: B %he ulnar ner#e inner#ates two of the intrinsic thenar musclesK the adductor pollicis and fre-uently the deep head of the fle(or pollicis bre#is. :ecause of the actions of the fle(or pollicis longus and the superficial head of the fle(or pollicis bre#is! there would probably be no noticeable deficit in fle(ion. owe#er! the ability to adduct the thumb would be lost with ulnar ner#e in&ury. 1+>. Question 1 of 2 1n the ad#ice of a lawyer! a 29-year-old casino employee #isited her personal physician because she found she could no longer fle( her thumb and was unable to deal cards. ;(amination re#ealed weakness at the interphalangeal &oint of the thumb as well as difficulty in bending the tips of the inde( and middle fingers. 5he could make a fist but had some difficulty in pinching with the thumb and inde( finger. %here was some forearm pain but no tingling or numbness. %hese symptoms indicate damage to which of the following ner#es$ A. 0osterior interosseus branch of the radial ner#e B. 0almar branch of the ulnar ner#e C. Decurrent branch of the median ner#e D. Anterior interosseus branch of the median ner#e E. )igital branches of the ulnar ner#e The answer is: D

%he anterior interosseus branch arises from the posterior portion of the median ner#e in the cubital fossa and inner#ates the fle(or pollicis longus! pronator -uadratus! and portion of the fle(or digitorum profundus inserting in the inde( and middle fingers. %hus! it mediates fle(ion of both the thumb and distal interphalangeal &oints of the inde( and middle fingers. 'n addition! the anterior interosseus branch has no sensory distribution. %he posterior interosseus branch of the radial ner#e supplies abductors of the thumb and e(tensors of the thumb and fingers. %he palmar branch of the ulnar ner#e is purely sensory. %he recurrent branch of the median ner#e inner#ates muscles of the thenar compartment .e.g.! fle(or pollicis bre#is/! and damage may result in some difficulty in fle(ion of the thumb! but not of the inde( and middle fingers. %he digital branches of the ulnar ner#e supply the ring and little fingers and are sensory. 16?. Question 2 of 2 1n the ad#ice of a lawyer! a 29-year-old casino employee #isited her personal physician because she found she could no longer fle( her thumb and was unable to deal cards. ;(amination re#ealed weakness at the interphalangeal &oint of the thumb as well as difficulty in bending the tips of the inde( and middle fingers. 5he could make a fist but had some difficulty in pinching with the thumb and inde( finger. %here was some forearm pain but no tingling or numbness. "hat type of &oint is the interphalangeal &oint$ A. :all and socket B. 4inglymus C. 4omphosis D. 5addle E. ;llipsoidal The answer is: B A &oint between phalanges is termed a ginglymus or EhingeE &oint. 't allows mo#ement in only one plane .fle(ion and e(tension are opposite mo#ements in the same plane/. %he hip &oint is typical of a ball and socket &oint. %his type of &oint permits mo#ement in all three a(es and in a combination termed circumduction. A gomphosis is the type of &oint made by a tooth with bone. %he carpometacarpal &oint of the thumb typifies a saddle &oint. 't permits mo#ement in two a(es. %he radiocarpal &oint at the wrist is an e(ample of an ellipsoidal &oint. 't is bia(ial! but the e(cursion of mo#ement is longer in one a(is. 161. Question 1 of 2 A patient e(perienced a prolonged stay in one position during a recent surgery and postoperati#e reco#ery that resulted in compression of the common peroneal ner#e

against the fibular head. "hich of the following motor deficits would be most likely to occur$ A. Boss of e(tension at the knee B. Boss of plantar fle(ion C. Boss of fle(ion at the knee D. Boss of e#ersion E. Boss of medial rotation of the tibia The answer is: D 3ompression of the common peroneal ner#e would affect all muscles inner#ated by this ner#e! including tibialis anterior! peroneus longus! and e(tensor digitorum longus. Boss of dorsifle(ion and e#ersion is usually complete. %he e(tensors of the knee &oint .-uadriceps femoris/ are supplied by the femoral ner#e! whereas the fle(ors of the knee &oint .the hamstrings and gracilis/ are supplied by the tibial ner#e and obturator ner#e! respecti#ely. %he gastrocnemius and soleus muscles are the principal plantar fle(ors of the foot and are inner#ated by the tibial ner#e. %he popliteus is the prime medial rotator of the tibia and is also inner#ated by the tibial ner#e. 162. Question 2 of 2 A patient e(perienced a prolonged stay in one position during a recent surgery and postoperati#e reco#ery that resulted in compression of the common peroneal ner#e against the fibular head. 'n the abo#e scenario! in#ersion of the foot is still intact although weakened. "hich of the following muscles supplies this action$ A. %ibialis posterior B. 0lantaris C. 0eroneus longus D. ;(tensor digitorum longus E. Quadratus plantae The answer is: A ,ollowing compression in&ury of the common peroneal ner#e! e#ersion is usually

completely impaired! whereas loss of in#ersion is only partial. %ibialis posterior is a powerful in#erter of the foot and is inner#ated by the tibial ner#eA therefore! its action would remain. %he peroneus longus is an e#erter of the foot! and its action is lost by compression of the common peroneal ner#e. %he e(tensor digitorum longus is inner#ated by the common peroneal ner#e but is an e#erter of the foot. %he -uadratus plantae is a fle(or of the toes and is inner#ated by the lateral plantar branch of the tibial ner#e.