MCQs / Anatomy / PESSI

A 53-year-old woman presents to the office complaining of extreme, non-radiating stabbing pain in the epigastric region that occurs approximately 30 minutes after finishing a meal, which resolves on its own after a while. She notes that the pain began a few months ago. Endoscopy shows benign mucosa of the stomach and proximal duodenum. A barium swallow study reveals an extremely narrowed duodenum. Which of the following structures is most likely involved in causing this woman’s condition?

A 3-year-old boy presents to the emergency department after he developed coughing, wheezing, and shortness of breath about 10 minutes prior to presentation. His mother had briefly left him alone lying on his back in the toy room before the onset of symptoms. Physical exam reveals wheezing and decreased breath sounds on the right side. A chest X-ray is ordered STAT. Which of the following is the most likely site where the aspirated foreign body is lodged?

A 50-year-old man presents to the emergency department complaining of chest pain and drooling that started immediately after eating a steak. There is normal speech and unlabored breathing, however, drooling is apparent, and he complains of vague and constant chest pain throughout the exam. Endoscopy confirms the presence of a retained bolus of meat 24 cm (9.4 in) beyond the incisors where a stricture is identified. The bolus is removed and the stricture is dilated. Which of the following anatomic spaces contains the stricture?

A 48-year-old woman presents to the doctor’s office complaining of frequent episodes of severe heartburn and chest pain. She reports feeling like food is stuck in her throat at times. Antacids and other over-the-counter remedies have failed to alleviate the discomfort. Several biopsies were obtained endoscopically, including those from the distal oesophagus, gastroesophageal junction, and the body of the stomach. Which histological finding is associated with the highest risk of developing oesophagal adenocarcinoma in the near future?

A 58-year-old department store manager presents to his doctor’s office with complaints of waking up frequently in the middle of the night with abdominal pain during the past month. The patient also complains of poor appetite as a result of the pain. His clothes hang on him loosely. Upper gastrointestinal endoscopy reveals heavy acid secretion and gastric peptic ulcer. What is the most likely location of the gastric ulcer in the stomach?

A 45-year-old bank manager is brought to the emergency department by ambulance after vomiting bright red blood while at work. He complains of severe abdominal pain that is stabbing in nature and relieved by nothing. He has had mild intermittent abdominal pain for the last two weeks, that improved with food or milk. Pulse is 115/min and blood pressure is 90/60 mm Hg. On physical exam, he appears pale and diaphoretic. An intravenous bolus of fluid is given while he is prepared for an urgent esophagogastroduodenoscopy (EGD), which shows a bleeding duodenal ulcer on the posteromedial wall of the descending duodenum. Which artery is bleeding?

A 59-year-old truck driver presents to the emergency department with excruciating pain around his anus after returning from his usual weeklong trucking trip. The patient admits to drinking beer when not working and notes that his meals usually consist of fast food. On examination, a tender lump is noted on the right side of the anus which is visible without the aid of an anoscope. The lump is 1 cm in diameter, bluish, and surrounded by oedema. It is soft and tender to palpation. Which vein drains the vessels responsible for the formation of this lump?

A 32-year-old man jumps off a 3-story building during a suicide attempt. Paramedics arrive quickly, and he is taken to the hospital, where several stable lumbar fractures and a shattered right calcaneus are found. He undergoes surgery and his calcaneus is repaired with eleven screws. Which of the following statements best describes the long term post-surgery outcome in this patient?

A 45-year-old man was administered the Mantoux tuberculin skin test (TST) in a follow-up visit. Today’s reading, 3 days after being administered the test, shows an induration of 10 mm. Given his recent immigration from a country with a high prevalence of tuberculosis, which of the following is true regarding the type of radiograph shown?

A 24-year-old man presents to the emergency department by ambulance after being involved in a motor vehicle accident. He is awake and having significant difficulty breathing. His vital signs include blood pressure 70/50 mm Hg, pulse 120/min, and respiratory rate 32/min. A primary trauma survey reveals multiple bruises and lacerations on the right anterior chest wall and a penetrating injury just below the right nipple. Breath sounds are absent on the right, and hyper resonant on percussion. Jugular venous distention (JVD) is present. A bedside chest x-ray reveals a collapsed right lung with depression of the right hemidiaphragm and mediastinal shift to the left. Which of the following is the most appropriate next step in the management of this patient?

A 50-year-old man who has difficulty breathing and speaking presents to the emergency department by ambulance. His wife reports that he might have swallowed a fishbone. While taking his history the patient develops a paroxysmal cough. Visualization of his oropharynx and larynx shows a fishbone lodged in the right piriform recess. After successfully removing the fishbone the patient feels comfortable, but he is not able to cough like before. Damage to which of the following nerves is responsible for the impaired cough reflex in this patient?

A 72-year-old woman presents to the emergency department complaining of left gluteal pain for the last 3 months. The onset of the pain was gradual, and she does not recall any trauma to the region. She describes the pain as sharp, progressive, and radiating down the posterior left thigh to the level of the knee. Physical examination of the left gluteal region reveals atrophy and muscle weakness. The computed tomography scan of the pelvis demonstrates a heterogeneously-enhancing blockage in the deep branch of the superior gluteal artery, suggestive of an embolic process. Complete occlusion of the artery in question may cause muscle ischemia and atrophy that would compromise the ability to perform which of the following actions?

A mother brings in her 12-year-old boy, who has a 4-day history of fever and generalized weakness. She says her son was involved in a fight at school four days ago and sustained minor injuries to the face. This morning, he started to complain of pain in his right eye. Physical examination reveals periorbital erythema, right eye oedema, ophthalmoplegia, and proptosis. Which of the following findings will most likely be present on the affected side of this patient as a sequela of his current condition?

An otherwise healthy 85-year-old woman presents with left-sided weakness. Her symptoms started 4 hours ago. Physical examination reveals decreased sensation on the left side, which is worse in the left side of the face and left upper extremity. The patient has significant weakness in her left upper extremity and weakness and drooping in the lower half of the left side of her face. Ophthalmic examination reveals conjugate eye deviation to the right. The patient is started on aspirin. A contrast CT of the head a few days later reveals an ischemic stroke involving the lateral convexity of the right cerebral hemisphere. Which of the following additional findings would most likely be seen in this patient?

A 56-year-old man with a history of diabetes mellitus, hypertension, and hypercholesterolemia is brought to the emergency department by his wife. She reports that symptoms started 1 hour ago with difficulty swallowing breakfast and a hoarse voice. He was recently admitted for a transient ischemic attack (TIA), but was not compliant with his discharge instructions and medication. Physical exam reveals left-sided partial ptosis and miosis, along with diplopia and nystagmus. The right side of the face and body has markedly more sweating than the left side. MRI of the brain reveals an ischemic infarct at the level of the left lateral medulla. Which of the following most likely accounts for this patient’s symptoms?

A 63-year-old man is brought to the emergency department by his wife. She is concerned that her husband may be having another stroke. The man says he woke up with right-sided facial weakness and drooping. Past medical history is significant for a recent case of shingles that was treated with acyclovir, as well as a stroke ten years ago from which he recovered with no residual functional deficits. On physical examination, there is weakness and drooping of the entire right side of his face, but the sensation is intact. The remainder of his physical examination is unremarkable. Which of the following findings would also be seen?

A 56-year-old woman presents to the emergency department with severe pain in her legs. She has had these pains in the past, but access to a doctor was not readily available in her remote village back home. She and her family recently moved to the United States. She is seen walking to her stretcher with a broad-based gait. Ophthalmic examination shows an absent pupillary light reflex and pupillary constriction with accommodation and convergence. What other sign or symptom is most likely present in this patient?

A professional musician visits his physician after a morning concert. He complains of painless swelling in his right cheek when he plays his tuba. Physical examination of the patient reveals slight facial asymmetry due to minor swelling on the right side of the face. The skin over the swelling is smooth without any secondary changes. Palpation reveals a soft and non-tender swelling. The oral opening is normal without any trismus. Further examination reveals swelling of the left buccal mucosa extending from the first to the third molar. Bedside ultrasound shows small areas of high echogenicity consistent with pneumoparotid. Which nerve is associated with motor function to prevent air from entering the affected duct in this patient?

A 75-year-old man presents to his physician with a 1-year history of dysphagia for solids. His more recent complaints include dysphagia for liquids as well. The patient states that he has no difficulty initiating swallowing but occasionally food is stuck in his throat. He does not complain of pain while swallowing but has noticed minor unintentional weight loss. The patient has no history of speech-related pain or nasal regurgitation. His family history is unremarkable. During the examination, the patient appears ill, malnourished, and slightly pale. He is not jaundiced nor cyanotic. Physical examination is unremarkable. A swallowing study reveals a small outpouching in the posterior neck. Which nerve is most likely involved in this patient’s symptoms?

A 78-year old woman presents to the emergency department with severe abdominal pain. Her past medical history is significant for congestive heart failure, hypertension, hyperlipidemia, and gout. Her medications include lisinopril, metoprolol, atorvastatin, and allopurinol. Blood pressure is 125/90 mm Hg, pulse is 95/min, and temperature is 37.3°C (99.2°F). Abdominal X-ray reveals a dilated bowel with bowel wall thickening and pneumatosis intestinalis isolated to the splenic flexure and descending colon. These findings are highly indicative of ischemic colitis with a differential diagnosis of pseudomembranous colitis. Which vessel contributes the most to the delivery of blood to the affected area?

The hepatocytes associated with acute clinical manifestations of alcoholic liver disease (ALD) are predominantly located in which area of the hepatic lobule?

A 38-year-old man presents to the emergency department after suffering a motor vehicle accident, as the passenger. He has no obvious injuries, but complains of excruciating right hip pain. His right leg is externally rotated, abducted, and extended at the hip. The femoral head can be palpated anterior to the pelvis. Plain radiographs of the pelvis reveal a right anterior hip dislocation and femoral head fracture. Which sensory and motor deficits are most likely in this patient’s right lower extremity?

A 75-year-old woman presents with sudden loss of vision. She says that she was reading when she suddenly was not able to see the print on half of the page. Her symptoms started 4 hours ago and are accompanied by a severe posterior headache. Vital signs reveal the following: blood pressure 119/76 mm Hg, pulse 89 beats per minute, and oxygen saturation 98% on room air. The patient is unable to recognize her niece when she arrives to see her. A non-contrast computed tomography of the head shows no evidence of hemorrhagic stroke. What is the most likely diagnosis in this patient?

A 25-year-old man is referred to a neurologist for right-hand weakness. He was involved in a motor vehicle accident 2 months ago in which his right hand was injured. Physical exam reveals a weak grip of the right hand, with an inability to adduct his fingers. Which of the following muscles is most likely affected?

A 32 year old man has complaints of pain on the medial side of his left forearm. There was also associated weakness of finger abduction and finger adduction, as well weakness upon adduction of his thumb. Finger flexion was normal. On inspection, atrophy of the muscles of his left hand was noted. What is the SINGLE most likely associated injury?

A 55 year old man with rheumatoid arthritis struck his hand against a door. On examination, he could extend the interphalangeal joint of his right thumb but the metacarpophalangeal joint of the thumb remained flex. What is the SINGLE most likely tendon to have been damaged?

A 55 year old man with a history of a stroke a year ago has severe difficulty remembering events in his life. This includes important events like the year he married his wife. Along with the long term memory impairment, he has altered sexual behaviour which has been seen after the stroke. He is also noted to have a visual defect after the stroke. What is the SINGLE most likely visual defect?

A 45 year old man was hit on his back by a chair during a fight. He presents with back pain and bruising. The back pain is specifically at the midpoint of the spine at the level of the iliac crest. Which vertebrae is likely to be affected?

What important landmark is found above the 5th intercostal space and anterior to the mid axillary line?

A 63 year old lady with a BMI of 32 has pigmentation on her legs. Dilated veins could be seen on the lateral aspect of her ankles. Which SINGLE structure would be involved?

A 37-year-old woman with obesity presents to the neurology clinic complaining of severe pain in her left wrist and a tingling sensation in her left thumb and index finger. The pain started as an occasional throb that subsided with ibuprofen, but it has progressively worsened and now wakes her up at night. She works as a typist and her pain increases after typing all day. There are no symptoms in the right hand. Nerve conduction studies reveal delayed conduction velocity of the median nerve across the wrist. Which of the following additional findings would most likely be present in this patient?

A 32 year man presents to A&E with a fracture dislocation of his right elbow. He complains of loss of sensation in his little finger and ring finger. Which is the SINGLE most likely nerve to be involved?

A 58 year old man underwent surgery for varicose veins of the leg. He is now complaining of numbness on the medial side of his foot. What is the SINGLE most likely nerve involved?

A 24 year old man is hit by a baton just above the knee on his right leg. This is followed by loss of motor control of the leg. His foot drops and is unable to dorsiflex his foot. There is loss of sensation over the front and outer half of the leg and dorsum of the foot. What is the SINGLE most anatomical structure to be affected?

A population study was conducted to evaluate coronary artery disease in the general population. A cohort of 700 patients underwent coronary angiography to evaluate the geographic distribution of coronary arteries throughout the heart. Which of the following was likely the most common finding in this cohort?

A 62 year old male comes to the GP complaining of double vision when climbing down the stairs. Which is the SINGLE most likely nerve to be affected?

A 32 year old patient presents to Accident & Emergency with a deep cut on the surface of her palm and the surface of the back of her wrist. She has an inability to extend the distal phalanx of her ring finger. What is the SINGLE most likely structure affected?

A 49-year-old man is brought to the emergency department by ambulance for sudden-onset chest pain that radiates into his neck and down his left arm. It began two hours ago while he was having dinner. His past medical history is remarkable for hypercholesterolemia and coronary artery disease. His temperature is 37.0°C (98.6°F), blood pressure is 155/90 mm Hg, the pulse is 112/min, and respiratory rate is 25/min. Troponin I levels are elevated. A 12-lead electrocardiogram (ECG) was performed and the ECG shows ST elevations in leads II, III, and aVF. What is the most likely aetiology of this man’s condition?

A 45 year old man presents to the clinic with herpes zoster over the dermatome of the maxillary branch of the trigeminal nerve. Which SINGLE type of mucosa will be affected along with the dermatome?

A 39-year-old man presents with painless swelling of the right testes and a sensation of heaviness. The physical examination revealed an intra-testicular solid mass that could not be felt separately from the testis. After a thorough evaluation, he was diagnosed with testicular seminoma. What location will involved lymph nodes be found?

A 46 year old man is being treated for a pleural effusion. A chest drain has been sited just below the 4th rib, anterior to the mid-axillary line on his right side. What SINGLE structure is at particular risk of injury?

A 45-year-old man presents to the physician with complaints of increased urinary frequency and smaller amounts of urine for the past two months. He does not complain of any pain during urination. He is frustrated that he wakes up two or three times per night to urinate. He has tried reducing the amount of water he consumes before bed and made some other dietary changes without any improvement. He has no family history of prostate disease. Physical examination is negative for any suprapubic mass or tenderness, and there is no tenderness near the costovertebral angle. Which of the following is the best next step in managing this patient?

A 64 year old woman has difficulty in moving her right shoulder on recovering from surgery of the posterior triangle of her neck. What is the SINGLE most likely anatomical structure to be affected?

A 72 year old woman has had a stroke a month ago. Since then she has had left upper and left lower limbs which are paralyzed and she has difficulty in speaking. Which is the SINGLE most likely anatomical site to be affected?

A 35 year old man is due for a surgery to attempt to removal of a glioma. What is the SINGLE most likely anatomical structure to be opened during the surgery?

A 69 year old woman has been diagnosed with left ovary carcinoma. What lymph nodes are likely to be removed?

A 68 year old woman is unable to extend the interphalangeal joint of her right thumb six weeks following a fracture of the right radius. The other fingers and thumb movements are unaffected. What is the SINGLE most likely tendon to be damaged?

A 12 year old boy presents with a painful swollen knee after a sudden fall on his right knee. The pain is localized below the knee cap. Which SINGLE anatomical structure is most likely to be affected?

A 34 year old man has a white patch on the margin of the mid-third of his tongue. Which is the SINGLE most likely lymph node involved?

A 45 year old man has a cancer of the posterior oropharynx. What is the SINGLE most likely lymph node to be involved?

A 36 year old male involved in a street fight presents to Accidents and Emergency with bruises and deformity of his lower right knee. He was given pain relief and an X-ray was ordered. The X-ray shows a fracture of the neckof the fibula. What is the SINGLE most associated nerve injury?

A 63 year old woman presents to the Emergency Department with an inability to flex the proximal interphalangeal joint of her fingers of the left hand. Upon further questioning, she reveals that she has broken a wine glass and caused a cut on the surface of her left hand. She also had no previous procedure done to her hand. On examination, there was 2×2 cm clean cut on the left hand. Extension at wrist joint was normal with no problem in adduction and abduction of the hand. However, she was unable to flex her first metacarpophalangeal joint. An X-ray of the left hand was done which was normal. What structure is most likely to be injured in her case?

You are observing a medical student perform a neurological examination on a patient. They forget to perform the reflexes so you decide to quiz them on their neuroanatomy. Which of the following reflexes and innervating spinal nerves are correctly paired?

What SINGLE anatomical landmark correlates to the tip of the 9th costal cartilage?

A 23 year old man is having difficulty in speaking following a stab wound to the right of his neck. On the tongue protrusion test, the tip of tongue is deviated to the right. Which of the following nerve is the SINGLE most likely to be affected in
this patient?

A 53-year-old businessman is rushed to the emergency department with sudden onset of severe crushing chest pain radiating to his left arm and jaw. He has a history of episodic chest pain on exertion for which he uses nitroglycerin sublingually, but his medication did not relieve the pain today. Blood pressure is 141/97 mm Hg, pulse is 110/min, respiratory rate is 18/min, and temperature is 37°C (98.6°F). Physical examination reveals an uncomfortable and diaphoretic man with mildly labored breathing. Cardiac auscultation reveals tachycardia with a regular rhythm. His electrocardiogram (ECG) shows ST-segment elevation in leads II, III, and aVF. Laboratory testing shows elevated cardiac troponin. The patient undergoes percutaneous coronary intervention (PCI). Which coronary artery needs the stent?

A 31-year-old woman presents to the emergency department with a two-day history of high-grade fever, right-sided flank pain, malaise, and multiple episodes of vomiting. There is no significant past medical history. Temperature is 40.0°C (104.0°F), pulse is 120/min, respiratory rate is 28/min, and blood pressure is 100/70 mm Hg. Physical examination reveals severe tenderness of the right costovertebral angle. Laboratory testing reveals leukocytosis with predominant neutrophilia, elevated C-reactive protein, and elevated ferritin levels. A retroperitoneal organ infection is suspected. Which of the following best describes the organ involved?

A 31-year-old man presents to the emergency department with sudden shortness of breath and chest pain. Physical exam reveals stony dullness on percussion and absent breath sounds on one side. Chest X-ray shows the opacification of one of his lungs. Thoracentesis reveals chylothorax that probably resulted from the rupture of the thoracic duct. Which of the following areas will have normal lymphatic drainage?

A 24-day-old neonate is brought to the emergency department because of high-grade fever, inability to feed, and lethargy. He was previously active and energetic, feeding every 2–3 hours and making 6–8 wet diapers every day. A lumbar puncture is ordered and empiric antibiotics are started. Which of the following structures will be traversed with the needle during the lumbar puncture?

A 13-year-old girl presents to a medical office for the evaluation of a lump on the front of her neck. The patient denies pain, but states that the mass bothers her because “it moves when I swallow.” The physical examination reveals a midline neck mass that is above the hyoid bone but below the level of the mandible. The mass is minimally mobile and feels fluctuant without erythema. The patient is afebrile and all vital signs are stable. A complete blood count and thyroid function tests are within normal limits. What is the most likely cause of this patient’s presentation?

A newborn is rushed to the neonatal ICU after becoming cyanotic shortly after birth. An ultrasound is performed, which shows the aorta coming off the right ventricle and lying anterior to the pulmonary artery. The newborn is given prostaglandin E1, and surgery is planned to correct the anatomical defect. Which of the following developmental processes failed to occur in the newborn?

A 1-month-old infant is brought to the emergency department after he had a coughing spell while feeding and turned blue. His mother says that the blue color went away when she picked him up and brought his knees to his chest. Chest X-ray reveals a boot-shaped heart. The mother is told that he has a condition caused by an anterosuperior displacement of the infundibular septum. What are the 4 features of the baby’s cardiac condition?

A 26-year-old gravida 2 para 1 at 24 weeks gestation is admitted to the labor and delivery suite with mild abdominal cramps, uterine contractions, and a watery vaginal discharge. She has a history of preterm birth. The vital signs are as follows: blood pressure 125/80 mm Hg, heart rate 100/min, respiratory rate 13/min, and temperature 36.6℃ (97.9℉). The pelvic examination reveals cervical softening and shortening. Transvaginal ultrasound shows a cervical length of 12 mm, which is consistent with preterm labor. A tocolytic and a single dose of betamethasone are administered. Betamethasone stimulates which fetal cells?

A 17-year-old teenager presents to the emergency department with severe bleeding from his right hand. He was involved in a fight about 30 minutes ago and received a penetrating stab wound by a sharp knife in the region of the ‘anatomical snuffbox’. A vascular surgeon is called in for consultation. Damage to which artery is most likely responsible for his excessive bleeding?

A 42-year-old overweight man who works as a waiter develops excruciating pain in the heel of his right foot. Symptoms are most intense after getting out of bed and improve after walking. On physical exam, both feet have flat medial arches. There is tenderness to palpation along the inner aspect of the right calcaneus, minimal active dorsiflexion, and pain with passive dorsiflexion. X-ray reveals a calcaneal bone spur at the attachment of the right plantar fascia, which is also present in the left foot. He is diagnosed with plantar fasciitis and encouraged to lose weight, rest, apply ice to the foot, and take anti-inflammatory medications. Which of the following statements is most accurate?

A newborn is two hours old. She was born at 33 weeks’ gestation to a primigravid 23-year-old mother who has no significant past medical history. The newborn shows severe tachypnea, grunting, and nasal flaring on physical examination. A chest radiograph shows hypoinflation, diffuse bilateral granular opacities, and air bronchograms. Intubation is currently being planned. Based on the most likely diagnosis, which of the following cells are responsible for the present situation?

A 55-year-old man visits the clinic with his wife. He has had difficulty swallowing solid foods for the past 2 months. His wife adds that his voice is getting hoarse, but they thought it was part of his recovery from a recently diagnosed influenza infection. His medical history is significant for type 2 diabetes mellitus, for which he is on metformin. He suffered from many childhood diseases due to lack of medical care and poverty. His blood pressure is 125/87 mm Hg, pulse is 95/min, respiratory rate is 14/min, and temperature is 37.1°C (98.7°F). On examination, an opening snap is heard over the cardiac apex. An echocardiogram shows an enlarged cardiac chamber pressing into his esophagus. Changes in which of the following structures is most likely responsible for this patient’s symptoms?

A 62-year-old man presents to the emergency department with concerns about having had two episodes of bright red blood in his stool this week. He denies fever, weight loss, pain, pruritus, or urinary symptoms. His past medical history is significant for gastroesophageal reflux disease (GERD). He was hospitalized earlier this year for pneumonia, and his stay was complicated by delirium tremens. He admits to the daily consumption of 6-8 beers for the past ten years. His temperature is 37.0°C (98.6°F), blood pressure is 130/80 mm Hg, pulse is 78/min, and respiratory rate is 12/min. Physical examination reveals a distended abdomen with shifting dullness on percussion. Multiple purple spider web-like lesions are found on the skin of his chest and arms, which blanch when pressure is applied. A fecal occult blood test is negative. On anoscopy, a non-tender, dilated vascular protrusion is noted superior to the pectinate line. Which of the following is most likely true about this man’s current condition?

A 24-year-old woman is brought to the emergency department after a motor vehicle collision. She was a restrained passenger at the time of impact. A preliminary examination reveals pallor and moderate distress. The patient complains of sharp pain in the posterior aspect of the left shoulder. Vital signs include temperature 37.0°C (98.6°F); right arm blood pressure 94/63 mm Hg; left arm blood pressure 90/61 mm Hg; pulse 122/min; and respirations 24/min. Cardiopulmonary auscultation reveals normal heart sounds and clear lungs. Neck veins are not distended. Several large ecchymoses are visible over the chest and abdomen in a seatbelt pattern. The patient’s abdomen is tender on superficial palpation with mild rebound tenderness and rigidity. Her range of motion is normal with 5/5 motor strength in all extremities, with no wrist drop. A FAST scan is pending. Based on the patient’s current presentation, which organ is most likely affected?

A 50-year-old man presents to his primary care provider complaining of double vision and trouble seeing out of his right eye. His vision started worsening about 2 months ago and has slowly gotten worse. It is now severely affecting his quality of life. His past medical history is significant for poorly controlled hypertension and hyperlipidemia. He takes amlodipine, atorvastatin, and a baby aspirin every day. He smokes 2–3 cigarettes a day and drinks a glass of wine with dinner every night. Today, his blood pressure is 145/85 mm Hg, the heart rate is 90/min, the respiratory rate is 14/min, and the temperature is 37.0°C (98.6°F). On physical exam, he appears pleasant and talkative. His heart has a regular rate and rhythm and his lungs are clear to auscultation bilaterally. Examination of the eyes reveals a dilated left pupil that is positioned inferolateral, with ptosis. An angiogram of the head and neck is performed, and he is referred to a neurologist. The angiogram reveals a 1-cm berry aneurysm at the junction of the posterior communicating artery and the posterior cerebral artery, that is impinging on and compressing the ocular nerve. Which of the following statements best describes the mechanism behind the oculomotor findings seen in this patient?

A 21-year-old man suffers a traumatic injury and dies after a motor vehicle accident. At autopsy, the patient demonstrates abnormally increased mobility at the neck. A section of the cervical spinal cord at C6 is removed and processed into slides. Which of the following gross anatomic features is most likely true of this spinal cord level?

A 31-year-old woman presents to the clinic with shortness of breath, palpitations, and fatigue. She has had these symptoms over the last several weeks. Last night she could not fall asleep due to palpitations. She has a past medical history of infective endocarditis six months ago that was successfully treated with antibiotics. She does not smoke or drink alcohol. Her blood pressure is 138/89 mm Hg and her pulse is 76/min and regular. The cardiac exam reveals a soft S1, an S3 gallop, a hyperdynamic apex beat, and a pansystolic murmur that radiates to the axilla. Echocardiography reveals incompetence of one of the valves. Which of the following sites is the best location to auscultate this defect?

A 27-year-old man is brought to the emergency department by ambulance thirty minutes after being involved in a motorcycle accident. Blood pressure is 80/50 mm Hg, pulse is 130/min, and respiratory rate is 40/min. Physical exam reveals a metallic foreign body protruding from his chest at the right parasternal border, fourth intercostal space. The man is immediately taken to the operating room, where a penetrating injury to the heart is identified. Which of the following coronary arteries supply the region of the heart that is most likely injured in this patient?

A 24-year-old professional soccer player presents to the clinic with right knee instability during ambulation. He sustained a non-contact injury in yesterday’s match after pivoting on his right foot. He adds that he heard a popping sound at the time of injury. Physical exam reveals swelling of the knee joint with a positive anterior drawer test. Which of the following structures is most likely damaged in this patient?

A 60-year-old man presents to the clinic complaining of a persistent cough for the last few months, associated with progressive shortness of breath. During the past year, he has also noticed some weight loss and a decrease in his appetite. He has a 40-pack-year smoking history, but denies any alcohol use. Physical examination is unremarkable. Chest X-ray shows a mass in the right lung. Chest CT demonstrates a 5 cm mass with irregular borders near the hilum. A CT guided biopsy is planned. During the procedure, just after insertion of the needle, the patient starts to feel pain in his right shoulder. Which of the following nerves is responsible for his shoulder pain?

A 50-year-old man presents with a 1-week history of severe chest pain. His pain increases with breathing and is localized to the right side. He has tried over-the-counter medications at home, without any clinical benefit. The patient has a 20-pack-year smoking history and currently smokes 2 packs of cigarettes daily. He also drinks 3–4 cans of beer daily before dinner. His vital signs include temperature, 39.1°C (102.3°F); blood pressure, 127/85 mm Hg; pulse, 109/min; and respirations, 20/min. Respiratory examination shows dullness to percussion from the 7th rib inferiorly at the right midaxillary line, decreased vocal or tactile fremitus, and diminished breath sounds in the same area. A chest radiograph is shown in the image. The patient is prepared for thoracocentesis. Which of the following locations is the most appropriate for chest tube insertion?

A 38-year-old woman undergoes partial thyroidectomy for an enlarged thyroid gland compressing the trachea. During surgery, a young surgeon ligates the inferior thyroid arteries as close to the poles as possible to prevent intraoperative haemorrhage. After discharge, the patient presents to the outpatient clinic with hoarseness. What could be the most likely cause of her hoarseness?

A 26-year-old man from India visits the clinic with complaints of feeling tired all the time and experiencing a lack of energy for the past couple of weeks. He also complains of weakness and numbness in his lower limbs. He has been strictly vegan since age 18, including not consuming eggs and milk. He does not take any vitamin or dietary supplements. Physical examination reveals a smooth, red beefy tongue along with lower extremity sensory and motor deficits. What other finding is most likely to accompany this patient’s condition?

A 40-year-old businessman is brought to the emergency department by his assistant with a complaint of left-sided weakness after a chiropractic neck manipulation. Past medical history is unremarkable. His blood pressure is 125/75 mm Hg, heart rate is 86/min, respiratory rate is 13/min, and temperature is 36.8°C (98.2°F). A T2-weighted MRI reveals a left C5 hemicord lesion. The patient is treated with cervical immobilization, a course of steroids, and physical therapy. Which other finding will most likely be seen in this patient?

A 52-year-old diabetic man presents with fever, headache, and excruciating pain in his right eye. He has been experiencing symptoms for the past two days. He says he has been taking sitagliptin and metformin regularly. He reports a recent sore throat. On examination, vesicles are present in groups, with an erythematous base on the upper eyelid, forehead, and nose, all on the right half of his face. The patient is prescribed an antiviral agent and sent home. Which of the following nerves is most likely involved?

A 2-day-old boy is evaluated in the nursery for minimal movement of his left upper limb. He was born at 41 weeks gestation by an assisted forceps-vaginal delivery to a 42-year-old obese woman. Birth weight was 4.4 kg (9.7 lb). The mother had 4 previous vaginal deliveries, all requiring forceps. Examination of the left upper limb shows that the arm hangs by his side and is rotated medially. His forearm is extended and pronated, and his wrist and fingers are flexed. Moro reflex is present only on the right side. Which of the following muscles was spared from the injury sustained during delivery?

A 33-year-old woman presents to the emergency department with pain in her right wrist. She says that she was walking on the sidewalk a few hours ago when she slipped and landed forcefully on her outstretched right hand with her palm facing down. Vital signs are within normal limits. Physical exam reveals mild swelling of the right wrist and tenderness on the lateral aspect of the right hand with a decreased range of motion. The sensation is intact. The patient is able to make a fist with her right hand. A plain radiograph of her right wrist is shown in the image. Which of the following bones is most likely fractured in this patient?

A 58-year-old woman presents with difficulty moving her right shoulder. She underwent a right radical mastectomy with lymph node dissection 3 weeks ago. Her surgery went well with no complications. She has undergone some physical therapy which has not been effective. A few days ago, she started to notice brief periods of painful shoulder instability, especially while opening or closing doors. On physical examination, there is normally active and passive range of motion in the right shoulder. Strength is 5 out of 5 in all muscles of the right shoulder and upper extremity. The sensation is intact. When the patient is asked to push against the wall, her right shoulder blade moves backward (see image). Which of the following nerves is most likely injured in this patient?

A 67-year-old man presents to the office with complaints of abdominal pain. A trial of proton pump inhibitors that was started 5 weeks ago failed to alleviate the pain, which is described as dull, cramping, and worse during meals. The patient’s medical history is unremarkable. Physical examination is normal, except for tenderness in the epigastric region. Endoscopy reveals an eroding gastric ulcer in the proximal part of the greater curvature of the stomach, overlying a large pulsating artery. Which of the following arteries is most likely visible?

A 69-year-old man presents for surgery due to chronic pain associated with diverticulosis involving the sigmoid colon. The patient is a Jehovah’s witness and refuses blood transfusion even in an emergency. Which artery should be clamped briefly to prevent bleeding during a partial sigmoidectomy?

A 61-year-old woman was unable to walk normally after undergoing a right total hip arthroplasty. She has a lurching gait, with the trunk swaying toward the right side during weight-bearing on the right leg. When she stands on her right foot, the pelvis drops toward the left side. She has no other medical or surgical problems. Which of the following nerves was most likely injured in this patient?

A 23-year-old woman presents to the emergency department for an exacerbation of low back and right leg pain. She had similar symptoms after a lifting injury 2 months ago, but the pain has become more severe. She describes the pain as shock-like and radiating from her low back to the posterior right thigh and calf, stopping at the ankle. Her pain is worse in the morning and occasionally awakens her at night. It is alleviated somewhat by walking. She denies any smoking, alcohol, or drug use. She has been working as a waitress and bending to take food is difficult. Vital signs are within normal limits. Physical exam reveals a positive right straight leg raise test with pain worsened by ankle dorsiflexion. Sensation is intact in the lower limbs. Her L4 and L5 reflexes are normal, but her S1 reflex is absent on the right side. CT of the lumbar spine shows an L5–S1 disc protrusion with right S1 nerve root compression. Which of the following muscle-nerve complexes is involved in producing an S1 reflex?

A 47-year-old man presents with gradual loss of voice and difficulty swallowing both solids and liquids. He reports that he has been dealing with these issues for the past couple of months. His medical history is insignificant, except for occasional mild headaches. Physical examination reveals loss of taste sensation on the posterior third of his tongue and palate, weakness in shrugging his shoulders, an absent gag reflex, and deviation of the uvula away from the midline. Magnetic resonance imaging reveals a meningioma, which is compressing some cranial nerves leaving the skull. Which of the following openings in the skull transmits the affected cranial nerves?

An ambulance brings a 28-year-old man to the emergency department for loss of consciousness after a closed head injury sustained by a kick to the head during a mixed martial arts competition. The family states that he initially lost consciousness, then woke up but lost consciousness again a few minutes later. Temperature is 37.0°C (98.6°F), blood pressure is 145/89 mm Hg, pulse is 66/min, and respiratory rate is 14/min. He remains unresponsive. An emergent non-contrast computed tomography (CT) scan is performed (see image). Injury to which of the following structures has occurred?

A 28-year-old man presents with visual disturbances. He says he has been having double vision since he woke up this morning. His medical history is insignificant except for occasional mild headaches. The patient is afebrile, and his vital signs are within normal limits. Physical examination of his eyes reveals paralysis of left lateral gaze. Also, at rest, he has esotropia of the left eye. A non-contrast computed tomography scan of the head reveals a tumor impinging on one of his cranial nerves. Which of the following nerves is most likely affected?

A 41-year-old woman presents with back pain for the past 2 days. She says the pain radiates down along the posterior right thigh and leg. She says the pain started suddenly after lifting a heavy box 2 days ago. Past medical history is irrelevant. Physical examination reveals a straight leg raise (SLR) test restricted to 30°, inability to walk on her toes, decreased sensation along the lateral border of her right foot, and diminished ankle jerk on the same side. Which of the following nerve roots is most likely compressed?

A 55-year-old construction worker falls off a 2-story scaffolding and injures his back. His coworkers bring him to the urgent care clinic within 30 minutes of the fall. He complains of right lower-limb weakness and loss of sensation in the left lower limb. He does not have any past medical history. His vital signs are stable. A neurologic examination reveals a total loss of motor function when testing right knee extension, along with right-sided loss of light touch sensation from the mid-thigh and below. There is a left-sided loss of pin-prick sensation of the lateral leg and entire foot. At the time of acute injury, what other finding is most likely to be found in this patient?

A 31 year old female with known gallstones undergoes a cholecystectomy. Unfortunately, she continues to have pain, and her liver function tests suggest an obstructive jaundice. An ERCP is performed which demonstrates a calculus lodged in the second part of the duodenum. What is the SINGLE most likely place that the stone was lodged?

Which of the following is located at the level of the first lumbar vertebra (L1)?

What anatomical structure or landmark lies just above the midpoint of the inguinal ligament?

Which landmark or anatomical structure is located at the midpoint between the suprasternal notch and pubic symphysis?

What is the SINGLE most likely anatomical structure to be pierced when inserting a drain in the mid-axillary line?

A 24 year old patient was lying down on the operating table in a position with his arms hanging down for 3 hours. Soon after he woke up, he complains of numbness and weakness on his left hand and has a wrist drop. There is a loss of sensation over a small area between the dorsal aspect of 1st and 2nd metacarpals. What is the SINGLE most likely structure to be damaged?

A 33 year old man presents with outward gaze and ptosis of his right eye. He also complains of seeing double. Which is the SINGLE most likely nerve to be affected?

A 35 year old man sat cross-legged for 30 minutes after which he found himself unable to dorsiflex his left foot and had loss of sensation in the web space between the big toe and the second toe. What is the SINGLE most likely anatomical structure to be affected?

A 37 year old man has a nonhealing ulcer on the skin of the right medial malleolus. Which SINGLE lymph node is likely to be involved?

A 48 year old main with a known posterior gastric ulcer presents with excruciating pain which subsides after analgesia. 8 days later, he becomes unwell and has a temperature of 38.5 C. A collection in the peritoneum is suspected. Where is the SINGLE most likely location of the collection?

A 60 year old man was screwing his cupboard to the wall when he suddenly felt a rupture at the cubital fossa resulting in a swollen elbow with weakness on flexion and supination. A lump in the distal arm is seen. What is the SINGLE most likely diagnosis?

What is the lymphatic drainage of the testes?

A 15 year old boy complains of double vision when climbing down the stairs. This has occurred since he was hit in the face. The images that he sees appear one above the other. He also notices double vision when he looks to the right. What is the SINGLE most likely nerve to be affected?

A camel rider sustained an injury to the lateral side of his right leg just below the knee caused by the camel stick. The site is slightly bruised and tender to touch. He is unable to either dorsiflex or evert the foot. There is loss of sensation over the front and outer half of the leg and dorsum of the foot. What is the SINGLE most likely anatomical structure to be affected?

A 75 year old woman was referred by her general practitioner to the same day ophthalmology clinic because of a 4 hour history of sudden painless loss of vision affecting her right eye. Her medical history includes hypertension and heavy smoking. Ophthalmic assessment showed visual acuity of light perception only in the right eye and 6/9 in the left eye. Apart from early questioning, the patient admitted that she had previously experienced episodes of vision loss in the same eye, which lasted for a few seconds to a few minutes. What is the most likely artery involved in this scenario?

A 45 year old man has been informed by his doctors that he has a carcinoma of the head of the pancreas. Which SINGLE structure is in close proximity with the head of pancreas?

A 33 year old man suffered a mandibular fracture and now has loss of sensation over the chin and mucosal surface of the lower lip. Which SINGLE nerve is most likely to be involved?

A 32 year old woman has weakness of both her hands and neck pain immediately after a fall down a flight of stairs. She was brought in by a scoop stretcher by the paramedics with a hard cervical collar, adhesive tape and sandbags to immobilize the neck. An X-ray was ordered. Which is the SINGLE lowest vertebrae that need to be seen in a lateral cervical X-ray to help diagnose the injury?

A 33 year old man complains of double vision when he looks to the right. Which is the SINGLE most likely nerve to be involved?

Which artery descends into the anterior interventricular groove?

A 73 year old woman with rheumatoid arthritis is unable to extend the fingers of her right hand at the metacarpophalangeal joint and interphalangeal joints following a fall. What is the SINGLE most likely tendon to have been damaged?

A 53 year old man has reduced sensation on the medial and posterior aspect of his lower left forearm and tingling described as “pins and needles” in his left hand. He also has weakness of thumb extension and wrist ulnar deviation. There is wasting of the muscles of the left hand. What is the SINGLE most likely structure affected?

A 55 year old man presents with an ulcer of the scrotum. Which is the SINGLE most likely lymph node involved in it’s lymphatic drainage?

A 45-year-old bank manager is brought to the emergency department by ambulance after vomiting bright red blood while at work. He complains of severe abdominal pain that is stabbing in nature and relieved by nothing. He has had mild intermittent abdominal pain for the last two weeks, that improved with food or milk. Pulse is 115/min and blood pressure is 90/60 mm Hg. On physical exam, he appears pale and diaphoretic. An intravenous bolus of fluid is given while he is prepared for an urgent esophagogastroduodenoscopy (EGD), which shows a bleeding duodenal ulcer on the posteromedial wall of the descending duodenum. Which artery is bleeding?

A 32-year-old woman presents to her doctor’s office with abdominal distension, diffuse abdominal pain, and a history of 10–12 bowel movements a day for the last week. The patient was diagnosed with Crohn’s disease 3 years ago. Today, the vital signs are normal. Her abdomen is mildly distended and diffusely tender to palpation. A CT scan shows evidence of a fistula and strictures located in the last 30 cm (11.8 in) of her ileum. A resection of the affected portion of the bowel is scheduled. What changes in bile metabolism are expected in this patient post-procedure?

A 73-year-old woman with a past medical history of diabetes, hypertension, and hyperlipidemia presents to the emergency department with swelling in her left neck that started 4 months ago. The patient lost 6.8 kg (15.0 lb) during the same period. She denies any fever, night sweats, or itching. Physical examination reveals a painless swelling in front of her left ear and painless lymphadenopathy below the ear. A biopsy of the lymph nodes reveals mucoepidermoid carcinoma of the parotid gland. The tumour is surgically resected, but it is later discovered that a nerve was damaged during the procedure. Which of the following findings is most likely to be seen in this patient?

Which of the following sites of the portocaval anastomosis is most likely to rupture and bleed first in patients of portal hypertension?

A female patient is referred to a gastroenterology clinic for endoscopic retrograde cholangiopancreatography (ERCP) to stent her common bile duct. During the procedure, the sphincter at the entrance of the duct is constricted. Which statement correctly describes how the sphincter size is regulated?

A 12-year-old boy is brought to the emergency department late at night by his mother. She says that he has not been feeling well since this morning after breakfast. He skipped both lunch and dinner. He complains of abdominal pain as he points towards his lower abdomen, but says that the pain initially started at the center of his belly. His mother adds that he vomited once on the way to the hospital. His past medical history is noncontributory and his vaccinations are up-to-date. Vital signs include: temperature 38.1°C (100.6°F), pulse 98/min, respirations 20/min, and blood pressure 110/75 mm Hg. Physical exam reveals right lower quadrant tenderness. The patient undergoes laparoscopic abdominal surgery. During surgery, which of the following structures is most likely to facilitate identification of the inflamed organ?

A 25-year-old man presents to the emergency department with right knee pain. He was playing football yesterday when an opposing player tackled him from the side, and they both fell. His right foot was trapped under the other player, and his knee twisted during the fall. He immediately heard a popping sound and felt severe pain in his right knee. Since then, his knee has become swollen, On physical examination, his right knee is tender along the medial joint line, and a mild degree of swelling is noted. External rotation of the right knee elicits a significant sharp pain with a locking sensation. Which of the following structures is most likely injured?