19- Fawzia Orthopedics MSQs (1)

Question 1

1- A 50-year-old woman attends her Genera) Practitioner due to a change in appearance. She finds difficulty removing her rings, reports: an increase ‘in shoe size and photographs reveal a change in her facial appearance. Visual field tests are-performed to direct confrontation. Which of the following defects is most likely to be associated with her presentation?

Answer 1

Bitemporal hemianopia

Question 2

2- 60-year-old man presents with a short history of pain in the right cheek and right upper teeth Maxillary sinus infection is diagnosed. This sinus is particularly prone to infection because of?

Answer 2

Position of the sinus ostium high on the medial wall

Question 3

3- A 37-year-old man presents with severe headache, photophobia arid neck stiffness. Karnig’s sign is positive and a midline lumbar puncture is performed immediately to determine if a cerebrospinal fluid (CSF) pathogen is involved. In performing this procedure, which is ‘he first of the following structures to be pierced by the lumbar puncture needle?

Answer 3

Interspinous ligament

Question 4

4- A 70-year-old woman from a nursing home presents to the! Emergency Department with abdominal pain and vomiting. On examination, she is dehydrated and her abdomen is distended. There is a 3 cm 4 cm swelling in her right groin which is non-tender, and there is no cough impulse. At operation, a femoral Hernia found. Which of the following lies medial to the neck of the hernia?

Answer 4

Lacunar ligament

Question 5

8- An 80-year-old man dislocates his shoulder it is reduced in the Emergency Department. At review three weeks later, he is unable to actively initiate abduction of his arm. Which muscle most likely damaged?

Answer 5

Supraspinatus

Question 6

9- A 42-year-old multiparous woman is admitted to the Emergency Department due to pelvic discomfort. The duty gynecologist diagnoses uterine prolapse. Which anatomical structure gives significant direct support to the uterus?

Answer 6

Transverse perinea! Muscles

Question 6

5- A 26-year-old man presents to the Emergency Department with extensive bleeding from his arm after sustaining a glass injury. On examination there is a 7 cm transverse laceration across the anterior aspect of his elbow. On exploring the cubital fossa you would expect the brachial artery to be:

Answer 6

lateral to the median nerve

Question 7

6- A 45-year-old mart presents with backache and leg pain due to a prolapsed lumbar Intervertebral disc. The pain, which is aggravated by coughing and sneezing, radiates to the lateral aspect of the foot. On examination, there is weakness of the plantar flexors of the foot, which nerve root is most likely to be involved?

Answer 7

S1

Question 8

7- A 22-year-old man has been stabbed in the left fifth intercostal space at the edge of the sternum. Which structure is most likely to have been penetrated?

Answer 8

Right ventricle

Question 9

10- In describing the sino-atrial node, which one of the following statements is correct?

Answer 9

A it is part of the somatic nervous system
B It is usually supplied by the left coronary artery
C If lies in the wall of the left atrium
D It lies in the wall of the right ventricle
E It receives fibers derived from the vagus nerves(Right)

Question 10

11- A 45-year-old man presents with fever and pain in his right loin and groin. A soft swelling was noted in his femoral triangle. Diagnosis of a psoas abscess was made. Which of the following statements is most accurate regarding psoas major?

Answer 10

It arises from the lateral borders of the bodies of T12 to L5
……………………………………………………..
Origin:
Bodies, transverse processes and intervertebral discs of all lumbar vertebrae and T12
Insertion:
Top of femur (shares tendon with iliacus)
Joints crossed:
· Hip and intervertebral joints of lumbar vertebrae
Joint action:
Origin fixed: flexes hip
Insertion fixed: pulls on spine to increase the lumbar lordosis
Unilaterally: assists in lateral flexion of the trunk
Stabilises lumbar spine

Question 11

12- Which one of me following muscles is an extensor of the hip?

Answer 11

Semitendinosus

Question 12

13- A 65-year-old man presents with haematuria and left loin pain. Computerised tomography demonstrates a left renal tumour. He undergoes a left radical nephrectomy. Where does the left renal artery lie?

Answer 12

Posterior to the left renal vein

Question 13

14- Within the posterior triangle, which nerve is at particular risk of damage during surgery?

Answer 13

Spinal accessory

Spinal Acc nerve = Nerve supply to Trapezius and Sternocleidomastoid

POSTERIOR TRIANGLE OF NECK
· Boundaries: Posterior border of sternocleidomastoid, anterior border of trapezius, mid 1/3 clavicle
. Shape: Spiral
· Roof: Investing fascia, platysma, external jugular vein
· Floor: Prevertebral fascia covering muscles, subclavian artery, trunks of brachial plexus & cervical plexus
· Contents:
· Arteries: Occipital, superficial cervical, suprascpular
· Veins: Transverse cervical, suprascapular, external jugular
. Nerves: Branches of cervical plexus, spinal root of accessory
. Muscle: Omohyoid with its sling
. Lymph nodes: Occipital (rubella/scalp infections)
Supraclavicular (part of the deep chain)

Question 14

15- The right and left pulmonary arteries are derived from which of the following embryological aortic arches?

Answer 14

Sixth aortic arch

Question 15

16- During arch aortography, the vertebral artery would be seen to arise directly from which of the following?

Answer 15

Subclavian artery

Question 16

17- A 3-year-old boy is admitted to hospital with severe vomiting. Radiographic examination reveals that he is suffering from annular pancreas. Which of these structures is constricted?

Answer 16

Second part of duodenum
………………………………………………
Congenital Disorders:

. Pancreatic Divisum:
. Most common 3-10%
· Failure of fetal duct union.
· Congenital chronic pancreatitis.
. Cystic Fibrosis:
· CFTR gene mutation
- thick secretions.
. Annular Pancreas
· 2nd part duodenum obstruction.
· Ectopic Pancreas
· stomach and duodenum.

Question 17

18- A 36-year-old man presents with a two-month history of low back pain radiating to his left leg After clinical examination he is referred for an MRI scan. This shows a prolapsed intervertebral disc. The clinical signs are consistent with pressure on SI roots. Which combination of clinical signs is most likely?

Answer 17

Weak ankle plantarfiexion; altered sensation on the sole of the foot; loss of ankle jerk reflex.

Question 18

19- A surgeon makes a Pfannenstiel incision for access to the pelvic organs. He incises the abdominal wall down to and through the rectus sheath .- He retracts the rectus abdominis muscles laterally from the midline to expose the:

Answer 18

transversalis fascia
……………………………………….
In CS section the rectus muscle is not cut

Surgeons don’t cut muscle unless needed

Remember in thyroidectomy the strap muscles are not cut unless it’s needed

if required to be cut cut as high as possible to protect the innervation by the ansa cervicalis

this reminds us with the tracheostomy where the thyroid isthmus might require division unlike the cricothyrodotomy

Question 19

20- A year-old patient in the intensive care unit has a tracheostomy performed via the second, third and fourth tracheal rings. Which intervening structure is most likely to require transection?

Answer 19

Thyroid isthmus

Question 20

21- In an emergency situation what is the most appropriate surgical method of obtaining an airway?

Answer 20

Piercing the cricothyroid membrane

Question 21

22- A.20-year-old man presents to the Emergency Department with a stab injury to the thenar eminence. On examination he is found to have a 2 cm long laceration with loss of sensation in the thumb and index finger and weakness: of the thenar muscles. Which of the following structures is most likely to have been injured?

Answer 21

Sensory and motor branches of median nerve
………………………………………………..
The thenar eminence is the mound formed at the base of the thumb on the palm of the hand by the intrinsic group of muscles of the thumb. The skin overlying this region is the area stimulated when trying to elicit a We palmomental reflex.

Question 22

23- A 65-year-old man presents with vomiting and weight loss. On examination he had 3 palpable epigastric mass. The transpyloric plane lies at which; vertebral level?

Answer 22

L1

Structures Crossed By
Transpyloric Plane :
L1 vertebra
Pylorus
Pancreatic neck
Duodenojejunal flexure
Fundus of gall bladder
9th costal cartilage
Hila of kidneys
Origin of portal vein
Transverse mesocolon
2nd part of duodenum
Superior mesenteric artery origin
Hilum of spleen
Termination of spinal cord

Question 23

24- A 75-year-old man presents with hepatomegaly and ascites. Computerised tomography shows evidence of post hepatic portal hypertension. The inferior vena cava passes through the Diaphragm at which vertebral level ?

Answer 23

T8

Question 24

26- A 35-year-old man is admitted to hospital with vomiting, nausea and severe headaches. An MRI scan reveals a tumour of the cerebellopontine angle. Which one of the following pairs of cranial nerves is most likely to be compressed by this tumour?

Answer 24

Facial and vestibulocochlear

2244
cerebral 2 (1,2 )
midbrain 2 (3,4)
pons 4 ( 5,6,7,8 )
medulla 4 ( 9,10,11,12

Question 24

25- An 82-year-old man has complete occlusion of his inferior mesenteric artery on angiography but no symptoms or signs of colonic ischemia. Which of the following arteries is the most likely additional source of blood supply to the territory of the inferior mesenteric artery?

Answer 24

Middle colic

In human anatomy, the marginal artery of the colon, also known as the marginal artery of Drummond : connects the inferior mesenteric artery with the superior mesenteric artery. It is sometimes absent, as an anatomical variant.

Question 25

27- A 10-year-old child presents with progressive facial weakness and a squint. On examination there is a lower motor neuron facial weakness and failure of abduction of one eye. An MRI scan shows a small, intrinsic mass lesion within the central nervous system. Where is this most likely to be located?

Answer 25

The pons

Squint can occure due to 3rd 4th 6th cranial nerves
Here he is targeting the facialand trigeminal along with the abducense 6th cranial nerve
5678 at the pons
2244
Cerebrum 2
mid brain 2
pons 4
medulla 4

Question 26

28- A 45-year-old woman presents with pain, swelling and stiffness affecting all her metacarpophalangeal joints. She has noticed weakness in her grip and her handwriting has changed. She is unable to extend her fingers fully. The index, middle and ring fingers in both hands show an ulnar deviation. The most Can likely diagnosis is:

Answer 26

rheumatoid arthritis

Question 27

29- A 22-year-old man arrives to the Emergency Department with sudden breath less ness due to a large pneumothorax. A chest drain is inserted into the fifth left intercostal space in 5th mid-axillary line. There is haemorrhape into the drainage bottle. Which of the following structures is the most likely cause of this acute haemorrhage?

Answer 27

Intercostal artery

Question 28

30- In order to expose the right axillary artery, a transverse skin incision is typically made below the clavicle from a point just lateral to the sternal end of the clavicle to the deltopectoral groove. Which of the following structures would be encountered in the dissection down to the vessel ?

Answer 28

Thoraco-acromial artery

Question 29

31- A 4-year-old boy presents to the Emergency Department with a two-day history of headache vomiting and drowsiness. A CT scan reveals dilatation of both his lateral ventricles and his third cerebral ventricle. His fourth ventricle was of normal size. It is suspected that he has an obstruction to his cerebrospinal fluid flow. At which of the following sites is the obstruction most likely to be?

Answer 29

Cerebral aqueduct (of Sylvius)

Question 30

32- A 56-year-old man with chronic emphysema is on the high dependency unit (HDU), ten days after anterior resection. He has developed acute shortness of breath’ and hypotension): Which of the following landmarks would be the most appropriate to use to obtain a femoral arterial blood gas sample?

Answer 30

A point midway between the anterior superior iliac-spine and the’ pubic symphysis

Question 31

33- A 70-year-old man complains of persistent numbness since.an inguinal hernia repair one year previously. The numbness affects the top of the scrotum, root of penis, and a small area below the medial part of the inguinal ligament. Which nerve is likely to have been damaged?

Answer 31

llioinguinal nerve

Question 32

34- A 12-year-old girl has a diastolic murmur. It is maximally audible in the second left intercostal space. Pathology of which structure is the most likely cause ?

Answer 32

Pulmonary valve

Anatomical site of the valves are not the same as the auscaltatory sites

Question 33

35- A 60-year-old man undergoes cystectomy for a bladder carcinoma. During surgery, the ureters are identified. On which region of the bladder do the ureters pierce the bladder wall?

Answer 33

Posterior surface

A very famous Recall Anatomy Question yet does come with many answsers if you found Base in the options choose it if not go for posterior like here

Question 33

36- A 23-year old man is assaulted and sustains a stabbing injury to the left groin. The wound- is cleaned and a simple dressing applied; Six months later the patient returns with pulsatile swelling at the site of the injury. The most probable lesion present is:

Answer 33

False aneurysm of the femoral artery

Question 33

37- A 16-year-old boy is hit on the left side of the face by a ball. There are no broken bones but the boy complains of numbness of the face below the eye. Which nerve has most likely been compromised?

Answer 33

infra-orbital nerve

Question 33

38- The Cori cycle is important in lactate metabolism in the Septic surgical patient It is used to describe a pathway in which glucose is metabolised anaerobically to lactate in one tissue and the lactate is converted back to glucose in another; Which one of the following relies on this cycle to meet all of its energy needs?

Answer 33

Erythrocyte

Question 34

39- After receiving an intermascular Injection in the buttock, a 25 year-old man complains of inability to evert his foot Which nerve is most likely to have been injured ?

Answer 34

Common peroneal (fibular) component of sciatic
…………………………………………………….
The Common Peroneal Nerve
Superficial peroneal nerve
. Motor functions
. Foot eversion
. Deep peroneal nerve
. Motor functions
· Foot dorsiflexion, toe extension

Question 34

40- After resection of d rectal tumour a patient experiences erectile dysfunction. Which of the following nerves is most likely to have been damaged in surgery?

Answer 34

Pelvic splanchnic nerves

Question 35

41- A 73-year-old man with a history of irregular bowel movements presents with dysuria, pneumaturia and an Escherichia ccli urinary tract Infection. CT scans show a mass involving the sigmoid colon and the bladder. What is the commonest cause of this presentation?

Answer 35

Colonic diverticular disease

Question 36

42- A 69-year man with recta! cancer undergoes low anterior resection. The liver is disease free. The pathology of his tumour was reported as a large tumour invading from the rectum into the mesorectum. Two nodes of 24 lymph nodes, close to the tumour were carcinoma on histology. The tumour was completely excised. What is the correct pathological staging of his tumour?

Answer 36

Dukes’ C
……………………………
The Dukes’ Classification System

Astler and Coller (1954) adapted the original Dukes system as follows:

Stage A - Limited to mucosa.

Stage B1 - Extending into muscularis propria but not penetrating through it; nodes not involved.

Stage B2 - Penetrating through muscularis propria; nodes not involved

Stage C1 - Extending into muscularis propria but not penetrating through it. Nodes involved.

Stage C2 - Penetrating through muscularis propria. Nodes involved.

Stage D - Distant metastatic spread.

Question 36

43- A 76-year-old woman falls and sustains an inter-trochanteric fractured neck of femur Following operative fixation her recovery is prolonged and she is discharged to a rehabilitation unit Six weeks after her original operation she is readmitted. She is drowsy, hypotensive and bradycardic. An ECG shows low voltage complexes and a prolonged QT interval Under-activity of which of the following glands gives the best explanation of the clinical picture?

Answer 36

Thyroid

Low voltage ecg in hypothyroidism

Question 37

44- A 36-year-old man falls on his outstretched right hand. Examination reveals tenderness in the anatomical snuff box. Which one of the following tendons form a boundary of the anatomical snuff box?

Answer 37

Extensor pollicis longus

Question 38

45- A 55-year-old man presents with back ache. Neurological examination reveals lack of extension of the left great toe .; Which of the following spinal cord segments are likely to be involved?

Answer 38

L4, L5 & S1
……………………………….
L1 & L2 - hip flexion
L3 & L4 - knee extension
L5 to S2 - knee flexion
L4- ankle dorsiflexion
S1 & S2 - plantarflexion
L5 - great toe extension
S2 & S3 - adduction toes

Question 39

46- A 34-year-old man is seen in the Emergency Department with a fibular fracture following football match. On examination he is noted to have loss of foot eversion. Which area of skin should be examined to confirm. loss of the cutaneous distribution of the affected- nerve ?

Answer 39

Cross the dorsal surface of the foot
……………………………………………………………
The Dorsum is the one you see when you look at your foot :D

Question 40

47- A 50-year-old man complains of recent onset diplopia. On examination he is unable to lookinwards and downwards with his right eye; The most likely diagnosis is a lesion of the?

Answer 40

trochlear nerve
………………………………………………
CN IV: Trochlear Nerve
Function:
. Somatic motor to superior oblique muscle of the eye.
. Exiting foramen= superior orbital fissure
· Origin=midbrain
. Test: Check eye movements
. Symptoms of nerve damage:
. Outward rotation of the affected eye
· Vertical diplopia

Question 40

49- A 66-year-old woman with known tumour of her spine has started to retain urine and is experiencing decreased anal and rectal tone. The tumour is pressing directly on the conus medullaris. At which one of the following vertebral levels is the tumour most likely to be located?

Answer 40

L1/L2
…………………………….
The conus medullaris (Latin for “medullary cone”) or conus terminalis is the tapered, lower end of the spinal cord. It occurs near lumbar vertebral levels 1 (L1) and 2 (L2), occasionally lower. … After the spinal cord tapers out, the spinal nerves continue to branch out diagonally, forming the cauda equina

Question 41

48- A surgeon is carrying out an elective splenectomy for congenital spherocytosis. Which structure will be divided in order to mobilize the spleen from the posterior abdominal wall?

Answer 41

Lienorenal ligament
……………………………………….
The gastrosplenic ligament contains the short gastric & left gastro-epiploic vessels
The lienorenal ligament contains the tail of pancreas & splenic vessels)
The two ligments are the remnants of the the dorsal mesentery of the stomach. The ventral mesentery is the lesser omentum and the falciform ligament

Question 41

50- A 50-year-old woman presents with a history of faecal incontinence over the past few year She had a prolonged and difficult first stage of labor 20 years previously. Physical examination reveals a relatively lax anal sphincter. Which nerve is likely to have been damaged in labour?

Answer 41

Pudendal nerve

remember Pudendal nerve s234 keep the poo of the floor it’s responsible for incontence but not erection which was nervi ergintis splanchnic nerves

Question 42

51- A 4-year-old boy, is brought to the Emergency Department with a painful right elbow. His father stales that he was swinging his son by his arms when the pain came on suddenly An X- ray shows that the radial head is displaced from its usual position. What is the ligament (of the proximal radio-ulnar joint) that holds the radial head in place?

Answer 42

Annular ligament

Question 43

52- A 35-year-old man presents with a three-week history of low back pain and a threeday history of pain and weakness in his left leg. Physical examination demonstrates numbness over the posterior aspect of the left calf extending to the lateral aspect of the foot. Left ankle reflex is absent. A magnetic resonance scan shows compression of the left S1 nerve root. What is the most likely responsible structure?

Answer 43

Nucleus pulposus

Question 44

53- A 60-year-old woman with breast carcinoma complains of difficulty chewing her. . food and is found to have numbness of the lower lip on one side. CT scanning shows a small metastatic lesion affecting the bony skull base on. The same side as the lip numbness. Which foramen is the most likely to involve?

Answer 44

Foramen ovale

Mandibular branch of the Trigeminal nerve CN V

Question 44

54- A 60-year»old man presents to the-Emergency Department with epistaxis. The source Of the bleeding is identified as Little’s area and resolves with direct cautery. Which vessel is most likely responsible for the bleeding?

Answer 44

Sphenopalatine artery

Question 44

56- A 4-year-old boy presents to the Emergency Department with a two-day history of Headache, vomiting and drowsiness. A. CT scan reveals dilatation of both his lateral ventricles and his third cerebral ventricle: His fourth ventricle was of normal size. It is suspected that he has an obstruction to his cerebrospinal fluid flow At which of the following sites is the obstruction most likely to be?

Answer 44

Cerebral aqueduct of Sylvius

Question 45

57- A 30-year-old man is assaulted with a hammer and sustains a depressed fracture at the Vertex, of the skull Profuse venous bleeding is noted at the fracture site. Which vascular structure is most likely to have been perforated?

Answer 45

Superior sagittal sinus
………………………………………….
remember there is another important land mark in the skull called The Pterion it is the site for Middle menengeal artery mostly got injuried because it’s the weakest point in the skull

Question 46

55- A 26-year-old man is having a stereotactic frame fitted to his skull prior to radiosurgery on a cerebral arteriovenous malformation. Four pins secure the frame tightly through the scalp to the outer table of the skull, two anteriorly, two posteriorly. On insertion of one of the- posterior pins, arterial haemorrhage is encountered. Which artery is most likely to have been punctured?

Answer 46

The occipital artery

Question 47

58- A 19-year-old man was assaulted and sustained injuries to the right side of his head. After two weeks he notices dial his right eye is dry and it could not produce tears. from which ganglion is post synaptic fibers arise to supply lacrimal gland?

Answer 47

Pterygopalatine ganglion
……………………………………………….
Lacrimal Gland Peterggopalatine Ganglion
While the Parotid is Otic Ganglion

Question 48

59- A 35-year-old motorcyclist is involved in a road traffic accident and fractures his temporal bone, completely transecting the facial nerve just distal to the geniculate ganglion. Which function of this nerve remains?

Answer 48

Lacrimation

Question 49

60- A-56 year old man presents with headache and vomiting with deterioration over the last two weeks. On examination he has papilledema. A CT scan shows a space occupying lesion in the right parietal lobe. He develops a sudden homonymous hemianopia. Which past of the visual system to be affected?

Answer 49

Optic radiation

Bitemporatl Hemianopia = Optic CHiasma
Homonymous hemianopia = optic radiation

Question 50

61- A 19- year-old man fell down a flight of stairs. On presentation to the Emergency Department his Glasgow Coma Score (GCS) was 14/15 with no local neurological signs. An hour later he Vomited and his GCS deteriorated to 10. He developed a fixed and dilated left pupil. Which of the following is likely to seen on the scan?

Answer 50

Left-sided extradural haematoma

1st key in this stem is the lucid interval exclusive for the extradural hemorrhage
The 2nd key eye affected on the same side of the brain insult

Question 51

62- A 65 years old man with known ischemic heart disease and atrial fibrillation presents with a paralysis of his right lower limb. Which arterial territory is most likely to be involved?

Answer 51

Left anterior cerebral
………………………………………
ACA stroke:
· Paralysis of contralateral foot ralateral toot
. Sensory loss over toes, foot and leg
. Impairment of gait and stance Abulia (slowness and prolonged delays to perform acts)
. Flat affect, lack of spontaneity, slowness, distractibility
· Cognitive impairment, such as perseveration and amnesia
· Urinary incontinence

Question 52

66- A 32-year-oid mountain biker presents to the outpatient clinic. He fell awkwardly, with excessive lateral flexion of his neck to the left side. He describes some paresthesia over his right shoulder and lateral arm. Which appears to have been improving over the past hour. What is the most likely injury suggested by this history?

Answer 52

Neuropraxia of the C5 nerve root

Question 52

64- A 19-year-old man fell down a flight of stairs. On presentation to the Emergency Department his Glasgow coma scale (GCS) was 14/15 with no focal neurological signs. An hour later he vomited and his GCS deteriorated to 10. He developed a fixed and dilated left pupil -. Which of the following accounts for the pupillary signs?

Answer 52

Compression of oculomotor nerve parasympathetic fibres
…………………………………………………..
ParaSympathetic Nerve = 1973
Occulomotor (3)
Sympathetic dilate
Parasympathetic constricts
When one is damaged the other dominates
When Parasympathetic damaged no constriction
Sympathetic dilatation dominate

Question 52

63- A 34-year-oid man is admitted to-the Emergency Department with a head injury. On examination his Glasgow coma scale is 9. A CT scan of the brain demonstrates an extra dural haemorrhage. Which of the following arteries is the most likely source of this?

Answer 52

Middle meningeal
………………………………………..
MMA commonly injured at pterion Branch from Maxillary artery which is divided by the lateral ptergoid which function to open the mandible
The maxillary is branching from the erxternal carotid

The internal carotid doesn’t has any extracranial branches

The 1st branch of the internal carotid is the ophthalmic artery which is within the optic canal with the optic nerve

While the ophthalmic nerve within the cavernous sinus

Question 53

65- A 32-years old man presents with a painful torticollis there is no past medical history and his only complaint is that he has been feeling rather tired over the last 4 nights. On examination, he has large rubbery mass in the lateral aspect of his neck as well as a few smaller masses along his internal jugular vein. You correctly assume that the muscular neck spasm and the large mass are connected. The most likely cause of his torticollis is due to pressure on?

Answer 53

Spinal accessory nerve

Question 54

67- During arch aortography, the vertebral artery would be seen to; a rise directly from which of the following?

Answer 54

Subclavian artery

Question 55

68- A 75-year-old man, who smokes heavily, underwent coronary artery bypass grafting six months ago. A left internal-mammary artery graft was used. He now complains of angina on pegging his laundry on the washing line to dry. Which of the following lesions best explains his symptoms?

Answer 55

Stenosis of the subclavian artery proximal to the first branch
……………………………………………………..
SUBCLAVIAN ARTERY
(branches from parts 3-2-0)

1st part:
Medial to scalenus anterior
Arches over suprapleural membrane
Branches (3)
Vertebral
Internal thoracic
Thyrocervical trunk
2nd part:
Posterior to scalenus anterior
Branches (2)
Costocervical
Deep cervical
Superior intercostal
Dorsal scapular
3rd part:
Lateral to scalenous anterior
End outer border first rib Branches (0)

Question 56

69- A 19-year-old woman presents to the Emergency .Department profoundly hypovolemic having fallen from a horse. A postero-anterior (PA) chest radiograph shows a fracture to the medial third of the left clavicle. Which of the following vessels was-most likely damaged?

Answer 56

Left subclavian artery
…………………………………………
Subclavian artery branches
m- VITamin C & D

Vertebral artery
Internal thoracic artery
Thyrocervical trunk
Costocervical trunk
Dorsoscapular artery

Question 57

70- A 65-year-old man has a history of transient ischemic attacks. He is due to undergo carotid endarterectomy. Which one of the following is true of the internal carotid artery?

Answer 57

A. Begins at the level of the sixth cervical vertebra ter
B. Divides into the anterior, middle and posterior cerebral arteries
C. Gives off the ophthalmic artery(Right)
D. Is accompanied within the skull by preganglionic sympathetic nerves
E. Passes through the foramen
………………………………………………………………..
C4 is the Common carotid Bifurcation

the preganglionic cells of the sympathetic nervous system are located between the first thoracic segment and third lumbar segments of the spinal cord
The carotid canal is a passage within the petrous temporal bone and transmits the internal carotid artery and sympathetic plexus. Its inferior opening is called the carotid foramen and is situated anteriorly to the jugular fossa and medially to the carotid plate.

The two nerves that pass from the foramen lacerum are the greater petrosal nerve, which represents the pre-ganglionic parasympathetic fibers, and the deep petrosal nerve which, representing the post-ganglionic sympathetic fibers So simply The internal carotid artery doesn’t pass through the foramen lacerum and not related to the preganglionic sympathetic nerves which already found in the foramen lacerum

A useful mnemonic to remember the branches of the internal carotid artery is:

. A VIP’S COMMA

Mnemonic

· A: anterior choroidal artery (C7)
. V: Vidian artery (C2)
· I: inferolateral trunk (C4)
· P: posterior communicating artery (C7)
· S: superior hypophyseal artery (C6)
· C: caroticotympanic artery (C2)
· O: ophthalmic artery (C6)
· M: meningohypophyseal trunk (C4)
· M: middle cerebral artery (C7)
· A: anterior cerebral artery (C7)

Question 57

72- A 21-year-old map comes into the Emergency Department with a severe headache and neck stiffness of recent onset. You suspect acute meningitis and decide immediately to treat with antibiotics and perform a lumbar puncture. After your third attempt to obtain for cerebrospinal fluid (CSF) you notice that the fluid obtained is stained red. However during the collection of CSF into three containers it is noted that the final bottle is now cleared of any blood. Which anatomical structure is the most likely to be responsible for this bleeding?

Answer 57

Vertebral venous plexus

Also Study the layers the needle will pass throough during the Spinal Anethesia and lumbar puncture

Question 58

71- A 35-year-old man presents with a three-week history of low back pain and a three day history of pain and weakness in his left leg. Physical examination demonstrates numbness over the posterior aspect of the left calf extending to the lateral aspect, of the foot. Left ankle reflex is absent. A magnetic resonance scan shows compression of the left S1. nerve root. What is the most likely structure compressing the nerve?

Answer 58

Nucleus pulposus

Question 59

73- A 24 years old man is brought to the Emergency Department following a road traffic accident. He has obvious airway compromise due to mouth/ facial haemorrhage which requires a surgical airway. The surface landmarks used to localise, the optimal site for a tracheostomy incision are midway between the suprasternal notch and which of the following?

Answer 59

Cricoid
……………………………………………
Remember Cricoid Cartilage at C 6 ( Common Recall)
And in Tracheostomy you cut the thyroid Isthmus

VERTEBRAL LEVELS OF STRUCTURES

C1 Open mouth, dens, spinal root of XI crosses transverse process of atlas, Superior cervical ganglion
C2 Superior cervical ganglion
C3 Body of hyoid bone
C4 Upper thyroid cartilage, bifurcation of common carotid artery
C6 Cricoid cartilage, larynx becomes trachea, pharynx becomes oesophagus, vertebral artery enters foramen transversum, middle cervical ganglion, carotid tubercle of Chassaignac; inferior thyroid artery crosses to thyroid
C7 First easily palpable spinous process, stellate ganglion

Question 60

74- A 40 -. year-Qld woman presents with a parotid tumour. A biopsy reveals perineural invasion. Which is the most likely pathology?

Answer 60

Adenoid cystic carcinoma

Perineural invasion ,distant metastasis, survival rate 5 years less than acinic it is only 35 %
The key is the perineural invasion

Adenoid Cystic Carcinoma
3 basic growth patterns :
· Tubular - grade 1
· Cribriform - grade 2
· Solid - grade 3

Question 61

75- In order to expose the right axillary artery, a transverse skin incision is typically made below the clavicle from a point just lateral- to the sternal end of the clavicle to the deltopectoral groove. Which of the following structures would be encountered in the dissection down to the vessel?

Answer 61

Thoraco-acromial artery

Question 62

76- The right and left pulmonary arteries are derived from which of the following embryological aortic arches?

Answer 62

Sixth aortic arch

Question 63

77- In the fetal circulation, the majority of blood passing from the inferior vena cava into tire right atrium subsequently passes next into which; one of the following?

Answer 63

Left atrium
…………………………………
1. Oxygenated blood comes from the placenta traveling to the fetus in the umbilical Vein
2. The umbilical vein dumps 50% of blood into the inferior Vena Cava - through the Ductus Venosus and the other 50% Of the blood enters the inferior Margin of the liver
3. The blood from the inferior Vena Cava enters into the right Atrium
4. Since the placenta is supplying Oxygen to the fetus - much blood is Shunted away from the lungs through The Foramen Ovale and the Ductus Arteriosus.
5. Blood travels from the left ventricle to the Aorta - which gives blood to perfuse the organs.
6. Blood then enters the very low resistance umbilical arteries on its way back to the placenta.

Question 64

78- A 2 day old baby presents with increasing respiratory distress. He was born at term By normal vaginal delivery. On examination he has cyanosis of the lower limbs and marked respiratory in drawing of the chest His femoral pulses ate absent bilaterally and he has been anuric for the last 2 hours. Pulse rate is 140 beats/minute, regular, and his blood pressure is 60/30 mmhg in both upper limbs. What is the most likely diagnosis?

Answer 64

Interrupted aortic arch
…………………………………………….
Tetralogy of Fallot (TOF) is a congenital heart defect with four components:

1) large ventricular septal defect (VSD), which is a hole between the two ventricles or tepumping chambers in the heart
2) pulmonary stenosis, which is narrowing beneath or in the blood vessel leading to the lungs
3) overriding of the aorta, in which the aorta lies directly above the ventricular septal defect
4) as a result of these events, the right ventricle becomes thickened or hypertrophied.

Question 65

79- A 22-year-old men arrives in the Emergency Department with sudden breathlessness due to a large pneumothorax. An immediate chest drain is inserted into the fifth left intercostal space in the mid-axillary line, There is hemorrhage into the drainage bottle. Which of the following structures is the most likely cause of this acute hemorrhage ?

Answer 65

Intercostal artery m
………………………………………..
Thoracic Trauma

Life Threatening Injuries:
· Flail chest out
· Tracheobronchial injury now in
· Tension pneumothorax:
· Needle thoracocentesis
- 5th ICS MAL for adult
- UNCHANGED 2nd ICS for child
. 28-32 Fr chest drain for hemothorax (not 36-40 Fr)
. Algorithm for circulatory arrest approach
. Aortic rupture management with Beta Blocker
. Trauma team

Question 66

80- A 12-year-old child was admitted to the Emergency Department having inhaled a peanut.
Where will the peanut most likely to have lodged?

Answer 66

Right lower lobe bronchus

Question 67

81- A 23-year-old man presents to the Emergency Department-with non-specific: chest pains. A postero-anterior (PA) chest radiograph is performed and is normal. Immediately inferior cauidal to the outline of the aortic knuckle was a farther structure with a convex border.
What is this structure?

Answer 67

The pulmonary trunk

Question 67

83- A 58-year-old man, admitted for inguinal hernia surgery, is found to have an enlarged heart shadow on his chest radiograph. Which one of the/following statements is true of the right ventricle?

Answer 67

Is directly related to the diaphragm
……………………………………………………………….
Right Ventricle:
Features :
It has two parts:
1) the inflowing part It is rough due to presence of muscular ridges called trabeculae carneae.

2) the outflowing part /infundibulum It is smooth and forms the upper conical part of the right ventricle which gives rise to pulmonary trunk

Question 67

A 67-year-oid man is admitted to hospital for investigation of at irregular heart beat. The ‘conducting system’ of the heart includes which one of the following anatomical structures?

Answer 67

Atrioventricular node

Question 68

82- 12 years old girl has a diastolic murmur it is maximally audible in the 2nd left intercostal space. Pathology of which structure is the most likely cause ?

Answer 68

Pulmonary valve

Take care the Auscaltatory sites ( the site where you hear the valve ) is different site than the anatomical site of the valve where it’s found

Question 69

85- A 25-year-old woman undergoes.an elective right thoracoscopic procedure for treatment of right palmar hyperhidrosis. Diathermy is applied to a neural structure lying anterior to-the neck of tire right first rib. What is the most likely complication to occur as a result of this procedure?

Answer 69

Horner’s syndrome

Sympathetic is running near the neck of the first rib so similar to the concept of pancoast tumor

Question 70

86- A man suffers a brachial plexus injury. On examination, he has a Horner’s syndrome in association with upper limb paralysis. Which nerve roots does the Homer’s syndrome suggest involvement of?

Answer 70

C8 & T1 roots

Question 71

87- A 26-year-oJd man presents to the Emergency Department after sustaining a glass cut to his arm. On examination there is a 10 cm longitudinal laceration on the anterior aspect of his upper arm. He has symptoms suggestive of ulnar nerve injury. On exploring the upper part of the arm we would expect the ulnar nerve to be:

Answer 71

medial to the brachial artery
…………………………………………………..
Very Common Recall Question either about the median nerve or ulnar nerve relation
The median is lateral anterior then medial to the brachial artery
Ulnar nerve is ulnar to the brachial artery and behind the medial epicondyle, so the nerve is the guardian for the food
The radial is radial to the brachial artery and anterior to the lateral epicondyle
Ulnar nerve is ulnar to the ulnar artery
By the way remember the ring finger has sensory supply from the radial nerve it’s the finger that’s supplied by the whole 3 nerves may be this what made it the ring united name, if you got engaged looka t your ring and remember it

Question 72

88- A 36-year-pld man falls on his outstretched right hand .- Examination reveals . tenderness in the anatomical snuffbox. Which one of the following tendons form a boundary of the anatomical snuff box?

Answer 72

Extensor poliicis longus

Question 73

89- A 36-year-oid butcher injures his left index finger with a knife, suffering a deep laceration on the palmar aspect of the middle phalanx. On examination he is unable to flex DIP, which tendon is likely to have been injured?

Answer 73

Flexor digitorum profundus

Question 74

90- A 20-years man presents to the Emergency Department after accidentally tripping over and lacerating his hand on a glass bottle. On examination there is a 2 cm laceration on the hypothenar eminence with loss of flexion in the distal interphalangeal joint of the little finger. What is the most likely tendon to be injured?

Answer 74

Flexor digitorum profundus
…………………………………………………….
it’s funny to have the Flexor profundus cut without the superficialis but the trick is that the litlle finger can have only the profundus in about 15 % of the population :D and there is no flexor digiti minimi muscle but there is extensor digiti minimi has it’s own compartment in the 5th extensor compartment

and remember there is a palmaris brevis which is in the hypothenar eminence supplied by the ulnar nerve
while the palmaris longus supplied by the median nerve and can be abscent in 10 % of population and very commonly to be used as a tendon graft like the plantaris tendon muscle

Question 75

91- A 50-year-old alcoholic man presents-to the Emergency Department and is found to be unable to extend his wrist, thumb and fingers of his right hand. He is also found to have weak extension of the right elbow joint and loss of sensation on the dorsum of the first web space . Which nerve is most likely to have been injured?

Answer 75

Radial nerve

The PIN mainly motor the sensory supply makes the radial nerve more likely And remember The AIN is branching from the Median Nerve

POSTERIOR INTEROSSEOUS NERVE INNVERVATION:
PIN innvervates all muscles in the extensor compartment, except those highlighted in yellow:
- Brachioradialis
- ERCL
- ERCB

Origin from the median nerve as it emerges between the 2 heads of the pronator teres.
It descends on the interosseus membrane (with the anterior interosseus artery) between the flexor pollicis longus and flexor digitorum profundus. Terminates the nerve ends on the anterior surface of the carpal bones.
Branches

1- Muscular branches to flexor pollicis longus, pronator quadratus and the lateral half of flexor digitorum profundus.
2- Articular branches to wrist, inferior radio-ulnar and intercarpal joints.

Question 76

92- A.58 year-old man is due to have surgery for Dupuytrens contracture to release the ring finger of the light hand. ‘Which one of the following regarding the anatomy of the ring finger is correct?

Answer 76

A. Has a cutaneous innervation from the radial nerve (Raght)
B. Has no cutaneous innervation from the median nerve
C. Has no cutaneous innervation from the ulnar nerve
D. Has the flexor digitorum profundus inserting into the middle phalanx
E. Is abducted by a palmar interosseous muscle
…………………………………………………………………..
yes radial nerve innervation of the hand is masked by the ulnar and median nerve

Question 77

93- A 56-year-old man with chronic emphysema is on the high dependency unit (HDU), ten days after anterior resection. He has developed acute shortness of breath’ and hypotension): Which of the following landmarks would be the most appropriate to use to obtain a femoral arterial blood gas sample?

Answer 77

A point midway between the anterior superior iliac-spine and the’ pubic symphysis
………………………………………………………
MID-INGUINAL POINT
Halfway between the pubic symphysis and the anterior superior iliac spine.
The femoral artery crosses into the lower limb at this anatomical landmark.

INGUINAL LIGAMENT
A fibrous band extending from the anterior superior iliac spine to the pubic tubercle.
Formed by the lower border of external oblique aponeurosis, which is thickened and folded on itself.

Femoral Artery:
. It is the contiuation of the external iliac artery at the mid inguinal point
. It descends in the femoral triangle
. Then, it continues in the adductor canal
. It reaches the adductor hiatus where it becomes the popliteal artery
. It supplies all structures in the thigh

Question 78

94- A 64-year-old woman is-reviewed in the Emergency Department with an acute right groin swelling, below and lateral to the pubic tubercle. Which of the following forms the medial boundary of the ring through which this hernia is protruding?

Answer 78

Lacunar ligament

Question 79

95- A 70-year-old woman from a nursing home is brought to’ the Emergency Department with abdominal pain and vomiting. On examination, she is dehydrated and her abdomen is distended. There is a 3 cm x 4 cm swelling in the right groin which is nontender, and there is no cough impulse. At operation, a femoral hernia is found. Which one of the following lies immediately lateral to the hernial neck?

Answer 79

Femoral vein

From Medial to Lateral = OVAL

Question 80

96- 65 years old man presented with an inguino-scrotal swelling in the right groin which is non tender. A cough impulses is elicited, At operation, an indirect inguinal hernia is repaired. The cremasteric muscle is derived from which of the following

Answer 80

Internal oblique muscle
…………………………………………………….
the continuity of the abdominal layers with the inguinal canal and scrotal layers are a must trick

if you remembered the order of external internal and transversalis you can figure out the the layers

external fascia from ? external oblique

Internal Fascia from ? fascia transversalis

So where the middle cremastric be from ? of course from the internal oblique

Take them and continue to the scrotum

so they are always the same they are just expanding teratories

believe you know it and you will recall it

Coverings of the Spermatic Cord
They are three layers of fascia derived from the layers of the anterior abdominal wall. Each covering is acquired as the processus vaginalis descends into the scrotum through the layers of the abdominal wall.
1- External spermatic fascia derived from external oblique aponeurosis and attached to the margins of the superficial inguinal ring
2- Cremasteric fascia derived from the internal oblique muscle
3- Internal spermatic fascia derived from fascia transversalis and attached to the margins of the deep inguinal ring

Inguinal Hernia-Special Types:
Dual/Pantaloon/Saddle Hernia: Both direct and indirect sacs +
Sliding Hernia: (Hernia-en-glissade):Retroperitoneal organ is part of hernial sac
Richter’s Hernia: only part of circumference of the small gut is obstructed
Maydl’s Hernia: “W” shaped hernia
Littre’s Hernia: Meckel’s diverticulum
Amyand’s Hernia: Appendix

Question 81

97- 65-year-old man presents with a non-tender swelling in the right hemi-scrotum. At operation, the hydrocele sac is opened and 400 ml of fluid is drained. Which anatomical structure surrounds the fluid?

Answer 81

Patent processus vaginalis

Processus vaginalis in conginital hernia / hydrocele as a continuity of the peritonium but an old man definitly in tunica vaginalis the hydrocele will accumulate

Question 82

99- A 55-year-old man presents with acute back pain following a severe road traffic accident. Neurological examination reveals lack of sensation of the umbilicus and below. What is the spinal level of the neurological deficit likely to be?

Answer 82

T10
…………………..
Important Sensory Dermatomes
Umbilicus T10
Groin T12
Nipples T4
Shoulder C5

Face Sensation and mastication = Trigeminal and facial expressions = facial nerve( take care c = cervical not cranial, trigeminal nerve = cranial nerve V, while Cervical Nerve 5 is not the same thing of the cranial nerves don’t get tricked )

Question 83

101- A .surgeon is carrying out an elective splenectomy for congenital spherocytosis. Which structure will be divided in order to mobilise the spleen from the posterior Abdominal wall?

Answer 83

Lienoreaal ligament

Question 83

98- A 58-year-old woman, a known patient with thoracic right-sided meningioma, presents with features suggestive of a Brown-Sequard syndrome. The clinical, findings will include which of the following?

Answer 83

Right sided weakness, right sided proprioception and vibration loss, left sided loss of prick Sensation

Question 84

103- A 65-year-old man is undergoing an abdominal aortogram, A stenosis is demonstrated in a lateral aortic branch, arising at the level of the body of the second lumbar vertebra. The stenosed vessel is most likely to be the:

Answer 84

second left lumbar artery
………………………………………………….
T12 = Celiac +inf phrenic + 1st lumbar Car
L1 = Superior mesenteric + Renals L1/L2
there is a controsversry around this Q
L2 = 2nd Lumbar + gonadal arteries
L3 = IMA
L4= bifurcates

Question 84

100- A 75-year-old man presents with esophageal reflux. Endoscopy confirms the Presence of a hiatus hernia. The esophagus passes through the diaphragm at which level?

Answer 84

T10
……………………………………….
DIAPHRAGM - OPENINGS & RELATIONS
OPENINGS
Caval (T8):
· Inferior vena cava & right phrenic nerve
Left muscular dome (T8):
· Left phrenic nerve
Anterior hiatus (T9):
· Superior epigastric artery & vein
Oesophageal (T10):
· Oesophagus
· Left & right vagus nerves
· Oesophageal branches of left gastric artery/vein
· Lymphatics
Aortic (T12) (Strictly behind diaphragm):
· Aorta
· Azygos vein & hemiazygos vein (may pass via left crus
· Thoracic duct
Crura (T12):
· Greater, lesser & least splanchnic nerves
Behind medial arcuate ligament:
· Sympathetic chain
Behind lateral arcuate ligament:
· Subcostal nerve (T12), artery & vein
RELATIONS
Right dome reaches 4th costal space (nipple) in expiration
Left dome reaches 5th rib in expiration
Superior - pericardium, basal lung segments
Inferior - Right - liver, suprarenal, kidney
Left - stomach, suprarenal, kidney & spleen
Posterior - Aorta, azygos veins, oesophagus, vagi, pleural folds

Question 85

102- A 75-year-old woman, who has a carcinoma of the upper rectum, undergoes anterior resection. The arterial blood supply of the upper rectum arises from which of the following?

Answer 85

Inferior mesenteric artery

The rectum receives arterial supply through three main arteries: Superior rectal artery - terminal continuation of the inferior mesenteric artery. Middle rectal artery - branch of the internal iliac artery. Inferior rectal artery - branch of the internal pudendal artery.

Question 86

104- A 75-year-old man presents with deep vein thrombosis. Computerized Tomography confirms the presence of a thrombus’ in His common iliac vein extending into the inferior vena cava The common iliac veins join to form the inferior vena cava at which vertebral level?

Answer 86

L5

Question 87

105- A 28-year-old man presents with pain in his left scrotum. A diagnosis of varicocele is made. Which vessel is involved?

Answer 87

Testicular vein

any young patient with varicocele do US to exclude RCC occluding the renal vein Fingers Like Projections

Question 87

106- A 33-year-old man presents to the orthopedic outpatient clinic with a six-month history of low back pain radiating to the lateral aspect of the left upper thigh. Micturition and defecation are normal and there is no history of previous Injury. On examination, left lateral flexion of the spine is limited but a full range of hip movements are observed, although it is painful. Sensation is altered over the front of the knee. Left knee reflex is reduced. Which spinal nerve-is most likely to have been compressed?

Answer 87

L3

Question 88

107- A 45-year-old man presented with backache and leg pain due to -prolapsed lumbar . intervertebral’ disc. The pain, which is aggravated by coughing and sneezing; radiates to the dorsum of the foot On examination there is weakness, of the dorsiflexion of the foot. Which nerve root is most likely to be involved?

Answer 88

L5
…………………………………
Important Nerve Roots of Leg
L4
· Leg extension at knee
. Patellar tendon reflex
L5
Dorsiflexion at ankle
S1
. Plantar flexion at ankle
. Achilles tendon reflex

Nerve root(s)
C1 Upper cervical flexion
C2 Upper cervical extension
C3 Cervical lateral flexion
C4 Shoulder girdle elevation
C5 Shoulder abduction
C6 Elbow flexion
C7 Elbow extension
C8 Thumb extension
T1 Finger adduction
L1 / L2 Hip flexion
L3 Knee extension
L4 / L5 Ankle dorsiflexion
L5 Great toe extension
S1 Ankle plantar flexion
S4 Bladder and rectum motor supply

Question 89

108- A 55 year-old man presents with acute back pain following a severe road traffic accident. Neurological examination reveals lack of dorsi-flexion of the left ankle joint. Which of the following spinal cord, segments are most likely to be injured?

Answer 89

L4, L5 & S1

Question 90

109- After resection of a rectal tumour a patient experiences erectile dysfunction. Which of the following nerves is most likely to have been damaged in surgery?

Answer 90

Pelvic splanchnic nerves

nervi erjentis is in close proximity to rectum = Pelvic splanchnic nerves

Question 90

110- A 40-year-old. woman presents with faecal incontinence and; anatomically intact internal and external anal- sphincters. Which structure is most likely to have been damaged ?

Answer 90

Pudendal nerve

Question 91

111- A 50-year-old woman presents with a history of faecal incontinence over the past, few years. She had a prolonged and difficult first stage of labour 20 years previously. Physical examination reveals a relatively lax anal sphincter. Which nerve is likely to have been damaged in labour?

Answer 91

Pudendal nerve

Question 92

112- A 78-year-old woman presents with urinary urgency and incontinence. The external urethral sphincter is innervated by which of the following nerve roots?

Answer 92

S2.3& 4
………………………..
Femoral & Obturator : L2,3,4
Pudendal : S2,3,4 keep the poo of the floo
Sciatic & Tibial : L4,5,S1,2,3
Common Peroneal: L4,5,S1,2
Superficial fibular : L4,5,S1
Deep Fibular : L4,L5

Question 93

113- A 60-year-old man undergoes cystectomy a bladder carcinoma. During surgery, the ureters are identified. On which region of the bladder do the ureters pierce the bladder wall?

Answer 93

Posterior surface

Question 94

115- A 70-year-old man undergoes transurethral resection of bladder uimonr (TURBT). The tumour lies over the lateral side wall of the bladder just above the opening of the right ureteric orifice. Use of the diathermy suddenly causes the patient to ‘kick’ because of contraction of the hip adductors muscles. Which nerve has been stimulated?

Answer 94

Obturator nerve

Question 94

116- On-an ultrasound scan of the popliteal fossa when investigating-a swelling, which of the following structures is closest to the capsule of the knee joint?

Answer 94

Popliteal artery

Question 94

114- A 39-year-old woman with large, expanding ovarian mass that is removed surgically, requiring a lateral pelvic wall clearance, of lymph nodes. Four days postoperatively she We Ca complains of painful spasms in the groin area and remarks that she has an area of numbness on the medial side of her thigh. The most likely explanation for these, problems is that during surgery an injury was inflicted on the:

Answer 94

Obturator nerve

Question 95

117- A 21-year-old man has been stabbed in the back of the knee, dividing the popliteal artery, and is undergoing repair via a posterior approach. Which of the following structures is most likely to be encountered first, when dissecting deep from the skin „, incision?

Answer 95

Tibial nerve
………………………………
Popletal fossa in order from superficial to deep
Tibial Neve
Popliteal vein
Popliteal artery

Question 96

119- A 35-year-old man undergoes a right inguinal hernia repair under genera! anaesthetic as a day patient. He has a nerve block after the procedure. On recovery he has weakness of the right leg. Which nerve has been affected ?

Answer 96

Femoral nerve
……………………………………….
Injury to the nerves after inguinal hernia surgery is uncommon. The femoral nerve may be damaged by suture or staples, tissue scar entrapment, local anesthesia blockade or direct compression. We present a case of a transient lesion of the femoral nerve after mesh hernioplasty for a re-recurrent inguinal hernia, confirmed by radiological studies, electrophysiology and clinical recovery. The diagnosis, mechanism of injury and surgical approach are reviewed. Surgery to a recurrent hernia may be underestimated. The role of electromyography nerve conducting studies is emphasized insisting on the importance of clinical evolution for the successful management of these infrequent injuries.

TAP Nerve Block technique for hernioplasty

Question 96

118- A 25 years old man sustains a twisting injury while playing football. He develops immediate swelling of the knee and he can not continue the game. Six months later, he Is still not able to play football. His knee feels unsteady and tends to give way. On examination, he has a full range of knee motion. There is a positive anterior draw test and a small effusion. What is the most likely structure damaged?

Answer 96

Anterior cruciate ligament

ACL function is to limit anterior subluxation of tibia over femur .. a lax or deficient ACL allows the tibia to subluxate over the femur anteriorly .. test is done with knee in 90 degree flex ion and 45 degree hip flex ion .. thumb at the patellar tendon and fingers at the back of the knee .. anterior pull is given and and no bony end point is felt .. anterior translation of the tibia is seen as compared to contra lateral side

Question 97

120- Which one of the following muscles is an extensor of the hip?

Answer 97

Semitendinosus

Question 98

212- A 25-year-oid man is playing football when he complains of posterior thigh pain whilst sprinting with the ball. On examination he has tenderness in the lower lateral posterior thigh. He is unable to fully extend the knee due to pain. What is the most likely injury?

Answer 98

Biceps femoris tear

Remember Regarding the Innervation of Biceps Femoris It is a composite muscle as the short head of the biceps femoris develops in the flexor compartment of the thigh and is thus innervated by common fibular branch of the sciatic nerve (L5, S1), while the long head is innervated by the tibial branch of the sciatic nerve (L5, S1).

Hip Extension
Range of motion: 0 to 20 degree
Muscles:
Gluteus Maximus
· Semitendinosus
· Semimembranosus
· Biceps Femoris (long head)
Accessory muscles:
· Adductor Magnus (inferior)
· Gluteus Medius (posterior)

Question 99

122- In the posterolateral approach to a posterior malleolar fracture, an incision is made between the calcaneal (Achilles) tendon and the distal -. fibula. Which of the following structures is at risk?

Answer 99

Tibial nerve

Question 100

123- A 24-year-old man is assaulted and sustains a deep 2 cm long laceration to the lateral aspect of his lower leg. Physical examination show’s that the laceration is anterior to the lateral malleolus. Which of the following structures is most at risk of being divided?

Answer 100

Superficial peroneal nerve

Question 101

125- A 45-year-old woman suffers from spina bifida and is confined to a wheelchair. Her legs are not fully developed. What is the pathological process which has occurred in the legs?

Answer 101

Hypoplasia

Question 101

124- During recovery from varicose veins surgery 35 years old woman complains of weakness of dorsiflexion of the ankle Physical examination reveals absent sensation over the dorsum of the foot. Which of the following nerves is most likely injured?

Answer 101

Common peroneal nerve

Loss of Motor action of Deep peroneal Nerve & Sensory Supply of Superficial Nerve = Common Peroneal Nerve

Muscles:
Superficial peroneal nerve
supplies lateral compartment of leg (everters)

Deep peroneal
nerve supplies anterior muscles of leg
(dorsiflexors of ankle, extensors of toes).

Question 102

126- A 56-year-old man with documented Type 1 diabetes mellitus presents to the Surgical outpatient clinic with 3 months history of right leg pain brought on by walking 50 meters. He has no history of back pain. He has been a smoker for 10 years (10 cigarettes a day) ;- He stales his alcohol consumption to be 30 units per week. On clinical examination, significant findings include weak right foot pulses with altered sensation on dorsum of the right toot. What is the most likely diagnosis D from the following list?

Answer 102

Femro popliteal stenosis
……………………………………………….
TASC A lesions
· Single stenosis ≤10 cm in length
. Single occlusion ≤5 cm in length

TASC B lesions
· Multiple lesions (stenoses or occlusions), each ≤5 cm
· Single stenosis or occlusion ≤15 cm not involving the infrageniculate popliteal artery
. Heavily calcified occlusion s5 cm in length
· Single popliteal stenosis

TASC C lesions
. Multiple stenoses or occlusions totaling >15 cm with or without heavy calcification
· Recurrent stenoses or occlusions after failing

TASC D lesions
. Chronic total occlusions of CFA or SFA (>20 cm, involving the popliteal artery)
. Chronic total occlusion of popliteal artery and proximal trifurcation vessels

Question 102

128- Abdominal free fluid will collect in the lowest part of the peritoneal cavity. At operation with the patient supine, in which of the following will the fluid collect first?

Answer 102

Hepatorenal pouch

Heptaorenal Pouch = Morison’s pouch is an area between your liver and your right kidney.

Question 102

127- A 28-year-old man presents with an ischiorectal abscess. Where is ths abscess cavity likely to be sited?

Answer 102

Medial to the pudendal canal

Question 103

129- A 3-year-old boy is admitted to hospital with severe vomiting. Radiographic examination and history reveals that he is suffering from annular pancreas. Which of these structures is constricted ?

Answer 103

Second part of duodenum

Question 103

130- A 45 year-old man presents with a 3 cm * 4 cm swelling in the right groin which is non- tender. A cough impulse is elicited. At operation, an indirect inguinal hernia is found. The external inguinal ring is a defect in which of the following abdominal

Answer 103

External oblique aponeurosis

Question 104

131- An 82-year-old man has complete occlusion of his inferior mesenteric artery on angiography but no symptoms or .signs of colonic ischaemia. Which of the following arteries is the .most likely additional source of blood supply to the territory of the inferior mesenteric artery?

Answer 104

Middle colic

Why some areas of the colon are prone to ischemia
The colon is protected from ischemia by a collateral blood supply via the marginal artery of Drummond, a system of arcades connecting the major arteries. The anatomy is highly variable, however, and certain areas are more vulnerable in some people.

Question 104

132- A 73-year-old man with a history of irregular bowel movements presents with dysuria, pneumaturia and an Escherichia ccli urinary tract Infection. CT scans show a mass involving the sigmoid colon and the bladder. What is the commonest cause of this presentation?

Answer 104

Colonic diverticular disease