7- Fawzia Sheet MSQs (2)

Question 1

1- 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 1

A. Foramen caecum
B Foramen magnum
C Foramen ovale
D. Foramen rotundum
E. Foramen spinosum

Ans C

Mandibular branch of the Trigeminal nerve CN V

Question 2

2- 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 2

A. Anterior ethmoidal artery oget
B. Infraorbital artery
C. Middle meningeal artery
D Sphenopalatine artery
E. Supratrochlear artery

Ans D

Question 3

3- 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 3

A The ascending pharyngeal artery
B The middle meningeal artery
C The occipital artery
D The posterior cerebral artery
E The posterior communicating artery

Ans C

Question 4

4- A 4-year-old boy presents to the Emergency Department with a two-day history of ether We Headache, vomiting and drowsiness. A. CT scan reveals dilatation of both his lateralo We 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 4

A. Cerebral aqueduct of Sylvius
B. Infundibular recess
C. Interventricular foramen (of Monro)
D. Lateral foramen of fourth ventricle (foramen of Luschka)
E. Median foramen of fourth ventricle (foramen of Magedie)

Ans A

Question 5

5- 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 5

A. Cavernous sinus
B. Inferior sagittal sinus
C. Sigmoid sinus
D. Superior petrosal sinus
E. Superior sagittal sinus

Ans E

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 6

6- 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 6

A. Geniculate ganglion
B. Inferior ganglion of the vagus nerve Can
C. Otic ganglion
D. Pterygopalatine ganglion
E. Superior cervical ganglion

Ans D

Lacrimal Gland Peterggopalatine Ganglion While the Parotid is Otic Ganglion

Question 7

7- 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 7

A. Lacrimation
B. Salivation from the submandibular gland
C. Sensation to the anterior tongue
D. Smile
E. Taste

Ans A

Question 8

8- 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 8

A. Lens
B. Optic Chiasm
C. Optic radiation
D. Retina
E. Second cranial nerve

Ans C
Bitemporatl Hemianopia = Optic CHiasma
Homonymous hemianopia = optic radiation

Question 9

9- 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 9

A. Left-sided acute subdural haematoma
B. Left-sided extradural haematoma
C. Left-sided midbrain haematoma
D. Right-sided acute subdural haematoma
E. Right-sided extradural haematoma

Ans B

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 9

10- 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 9

A. Left anterior cerebral
B. Left middle cerebral
C. right anterior cerebral
D. Right middle cerebral
E. Right posterior cerebral

Ans A

ACA stroke.
· Paralysis of contralateral foot and leg
· 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 10

11- 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 10

A. Anterior cerebral
B. Middle cerebral
C. Middle meningeal
D Posterior cerebral
H. Superficial temporal

Ans C

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 uMR
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 11

12- 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 11

A. Compression of oculomotor nerve parasympathetic fibres
B. Compression of sympathetic fibres to the left iris
C. Compression of the afferent fibres in the left optic nerve
D. Compression of the Edinger Westphal nucleus
E. Compression of the optic chiasmae

Ans A

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 12

13- 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 12

A. Ansa cervicalis
B. Cervical plexus branch
C. Cranial accessory nerve
D. Spinal accessory nerve
E. Vagus nerve

Ans D

Question 13

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

Answer 13

A. Arch of the aorta
B. Brachiocephalic artery
C. Common carotid artery
D. Internal carotid-artery
E. Subclavian artery

Ans E

Question 14

14- 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 14

A. Axonotmesis of the C5 nerve root
B. Axonotmesis of the T1 nerve root
C. Neuropraxia of the C5 nerve root
D. Neuropraxia of the T1 nerve root
E. Neurotmesis of the C5 nerve foot

Ans C

Question 15

17- 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 15

A Brachiocephalic trunk
B Left axillary artery
C Left common carotid artery
D Left subclavian artery
E Left vertebral artery

Ans D

Question 15

16- 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 15

A. .Micro-emboli from the left common carotid artery
B. Micro-emboli from the le\t internal carotid artery
C. Stenosis.of the subclavian artery at the level of the costo-cervical trunk
D. Stenosis of the subclavian artery distal to the insertion of scalenus anterior
E. Stenosis of the subclavian artery proximal to the first branch

Ans E

Question 16

18- 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 16

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
D. Is accompanied within the skull by preganglionic sympathetic nerves
E. Passes through the foramen ovale

Ans C

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 16

19- 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 16

A. Annulus fibrosus
B Anterior longitudinal ligament
C. Nucleus pulposus
D. posterior longitudinal ligament
E Vertebral end plate

Ans C

Question 17

20- 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 17

A .. Anterior spinal artery
B. Epidural artery
C. Subarachnoid vein
D. Veins within the erector spinae muscles
E. Vertebral venous plexus

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

Question 18

21- A 29 year old pregnant woman is having uncontrolled labor pains. She has an epidural for pain relief. Which of the following is true?

Answer 18

A. An epidural puncture should only be performed below the L1 level to avoid damage to the spinal cord
B. An epidural puncture should only be performed below the L4 level to avoid the spinal cord
C.The epidural space (also known as the extradural space) contains numerous nerve roots and a venous plexus
D. The liganientum flavum is rarely pierced during a low epidural procedure
E. The supraspinous and interspinous ligaments are rarely pierced during the procedure

Ans C

Question 19

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

Answer 19

A. Acinic cell .carcinoma
B . Adenocarcinoma
C. Adenoid cystic carcinoma
D. Lymphoma
E. Pleomorphic salivary adenoma

Ans C

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 20

22- 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 20

A Cricoid
B Hyoid
C Mastoid
D Laryngeal prominence
E Thyroid

Ans A

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 21

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

Answer 21

A. Second aortic arch
B. Third.aortic arch
C. Fourth aortic arch
D. Fifth aortic arch
E. Sixth aortic arch

Ans E

Question 21

24- 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 21

A. Lateral thoracic artery
B. Phrenic nerve
C. Suprascapular artery
D. Thoracic duct
E. Thoraco-acromial artery

Ans E

Question 22

26- 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 22

A. Aorta
B. Left atriumDrBishog
C. left ventricle B
D. pulmonary artery
E. Right ventricle

Ans B

Question 23

27- 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 23

A. Hypoplastic left heart syndrome
B. Interrupted aortic arch
C. Pulmonary atresia and ventricular septal defect
D. Transposition of the great arteries
E. Tricuspid atresia

Ans B

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 /pumping 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 24

28- 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 ?e

Answer 24

A. Intercostal artery m
B. Left pericardiophrenic artery
C. Linguia of the lung
D. Right ventricle of the heart
E. Spleen

Ans A

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 25

29- 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 25

A. Left lower lobe bronchus
B. left upper lobe bronchus
C. Right lower lobe bronchus
D. Right middle lobe bronchus
E. Right upper lobe bronchus

Ans C

Question 26

30- 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 26

A. The left atrium
B. The pulmonary trunk
C. The oesophagus
D. The right atrium
E. The superior vena cava

Ans B

Question 27

31- 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 27

A. Aortic valve
B. Ductus arteriosus
C Mitral valve
D. Pulmonary valve
E. Tricuspid valve

Ans D

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 28

32- 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 28

A. Has a muscular wall that is normally thicker than that of the Left ventricle
B. Forms the apex of the heart
C. Forms the right border of the heart
D. Is directly related to the diaphragm
E. Gives rise to the aorta

Ans D

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 29

33- 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 29

A. Atrioventricular node
B. Chordae tendineae
C. Fibrous skeleton of the heart
D. Interatrial septum
E. Phrenic nerve

Ans A

Question 30

34- 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 30

A. Bradycardia
B. Hoarseness
C. Horner’s syndrome
D. Raised right hemi diaphragm
E. Reduced right biceps tendon reflex

Ans C

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

Question 31

35- 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 31

A. C2 & C3 roots
B. C4 & C5 roots
C. C6 & C7 roots
D C8 & T1 roots
E. T2 & T3 roots

Ans D

Question 32

36- 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 32

A. anterior then medial to the brachial artery
B. medial then anterior to the brachial artery
C medial to the brachial artery
D. posterior then medial to the brachial artery
E. posterior to the brachial artery

Ans C

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 33

37- 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 33

A. Abductor pollicus brevis
B Extensor carpi radialis brevis
C. Extensor cairpi radialis longus
D. Extensor indicis
E. Extensor poliicis longus

Ans E

Question 34

38- 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 34

A. flexor carpi facialis
B. flexor carpi ulnaris
C. Flexor digitorum profundus
D. Flexor digitorum superficialis
E. Flexor indicis

Ans C

Question 35

39- 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 35

A Flexor digiti minimi brevis
B Flexor digitorum profundus
C Flexor digitorum superficialis
D Fourth palmar interosseous
E Lumbirical

Ans B

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 the population and very commonly to be used as a tendon graft like the plantaris tendon muscle

Question 36

40- 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 36

A Median nerve
B Musculocutaneous nerve
C Posterior interosseous nerve
D Radial nerve
B. Ulnar nerve

Ans D

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

Question 37

41- 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 37

A. Has a cutaneous innervation from the radial nerve
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

Ans A

yes radial nerve innervation of the hand is masked by the ulnar and median nerve

Question 38

42- 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 38

A. A point midway between the anterior superior iliac spine and the pubic tubercle
B. A point midway between the anterior superior iliac-spine and the’ pubic symphysis
C. A point midway between the greater trochanter and the pubic symphysis
D. a point 1 cm inferior and 4 cm lateral to the pubic tubercle
E. A point 2 cm lateral to the midway point between the anterior superior iliac spine and pubic symphysis

Ans B

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 39

43- 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 39

A. Conjoint tendon
B. Inferior epigastric artery
C. Inguinal ligament
D. Lacunar ligament
E. Pectineal ligament

Ans D

Ligaments:-

Inguinal ligament:
inferior edge of external abdominal oblique aponeurosis
ASIS to pubic tubercle

Pectineal ligament:
on pectineal line of superior pubic ramus

Lacunar ligament:
. connects inguinal and pectineal ligaments

Question 39

44- 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 39

A. Femoral artery
B. Femoral nerve
C. Femoral vein
D. Inguinal ligament
E. Pectineal ligament

Ans C

From Medial to Lateral = OVAL

Question 40

45- 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 40

A. External oblique aponeurosise
B Internal oblique muscle
C. Rectus abdaminis muscle
D. Rectus sheath
E. Trsusversalis fascia

Ans B

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

Question 41

47- 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 41

A Left sided weakness, left sided proprioception and vibration loss, right sided loss of pin prick Sensation

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

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

D. Right sided weakness, left sided proprioception and vibration loss, right sided loss of pin prick sensation

E. left sided weakness, right sided proprioception and vibration loss, left sided loss of pin prick sensation.

Ans B

Question 41

46- 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 41

A. Dartos muscle
B. Patent processus vaginalis
C. Testicular capsule
D. Tunica albuginea
E. Tunica vaginalis

Ans B

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

Question 42

48- 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 42

A T8
B T9
C T10
D T11
E T12

Ans C

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 43

49- 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 43

A T8
B T9
CT10
D T11
E T12

Ans C

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)
Caster
· 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 44

51- 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 44

A. Coeliac artery
B. Iliocolic artery
C. Inferior mesenteric artery
D. Internal iliac artery
E. Superior mesenteric artery

Ans C

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

Question 44

50- 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 44

A. Gastrosplenic ligament
B. Lesser omentum
C. Lienoreaal ligament
D. phrenicocolic ligament
E. Short gastric vessels

Ans C

Question 45

52- 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 45

A. coeliac artery
B. inferior mesenteric artery
C. left renal artery
D. second left lumbar artery
E. superior mesenteric artery

Ans : D

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 46

53- 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 46

A. L3
B. L4
C. L5
D. S1
E. S2

Ans C

Question 47

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

Answer 47

A Femoral vein
E. Inferior epigastric vein
C. Long saphenous vein
D Internal pudendal vein
E Testicular vein

Ans E

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

Question 48

55- 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 48

A. L1
B. L2
C. L3
D. L4
E. L5

Ans C

Question 49

56- 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 49

A. T12
8- L3
C. L5
D. S1
E. S2

Ans C

Question 50

57- 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 50

A. L1, L2 & L3
B. L2, L3 & L4
C L4, L5 & S1
D. S1, S2& S3
E. S3, S4 & S5

Ans C

Question 51

58- 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 51

A. Genitofemoral nerve
B, Lumbosacral, plexus
C. Pelvic splanchnic nerves
D. Perinea! branch of S4
E. Pudendal nerve

Ans C

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

Question 52

59- 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 52

A. First sacral nerve-root
B. Obturator nerve:
C. Pelvic splanchnic nerves
D. perineal nerve
E. Pudendal nerve

Ans E

Question 53

61- 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 53

A. L3, 4 & 5
B. L4, 5 & SI
C. L 5, S1 & 2
D. S1, 2 & 3
E. S2.3& 4

Ans E

Femoral & Obturator : L2,3,4
Pudendal : S2,3,4 keep the poo of the floor
Sciatic & Tibial : L4,5,S1,2,3
Common Peroneal: L4,5,S1,2 ther We Car*
Superficial fibular : L4,5,S1
Deep Fibular : L4,L5

Question 53

60- 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 53

A. Autonomic! nerves to the rectum .
B. Genitofemoral nerve
C. Lumbosacral trunk
D. Obturator nerve
E. Pudendal nerve

Ans E

Question 54

62- 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 54

A. Anterior surface
B. Apex
C. Lateral surfaces
D. Neck
E. Posterior surface

Ans E or Base if found

Question 55

63- 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 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 55

A. femoral nerve
7B. genitofemoral nerve
C. lumbosacral trunk
D. L3 ventral ramus
E. Obturator nerve

Ans E

Question 56

64- 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 56

A Femoral nerve
B Genitofemoral nerve
C Lateral femoral cutaneous nerve
D Obturator nerve
E Sciatic nerve

Ans D

Question 57

65- 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 57

A Great (long) saphenous vein
B Popliteal artery
C Popliteal vein
D. Small (short) saphenous vein
E. Tibial nerve

Ans B

Question 58

66- 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 58

A Popliteal artery
B Popliteus muscle
C Popliteal vein
D Tibial nerve
E Soleus muscle

Ans D

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

Question 59

67- 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 59

A Anterior cruciate ligament
B. Lateral collateral ligamentge
C. Medial collateral ligament -
D. Oblique popliteal ligament
E. Posterior cruciate ligament

Ans A

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 60

68- 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 60

A. Femoral nerve
B. Genitofemoral nerve
C Ilioinguinal nerve
D Lateral cutaneous nerve
E Sciatic nerve

Ans A

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 61

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

Answer 61

A. Adductor longus
B. Gracilis
C. Iliopsoas
D. Pectineus
E. Semitendinosus

Ans E

Question 62

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 62

A Biceps femoris tear
B. Gracilis tear
C. Gastrocnemius tear
D. Semimembranosus tear
E Semiteodinosus tear

Ans A

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

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 63

71- 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 63

A. Deep peroneal (fibular) nerve
B. Saphenous nerve
C. Superficial peroneal, (fibular)
D Sural nerve
E. Tibial nerve

Ans D

Question 64

72- 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 64

A. Peroneus brevis
B. Peroneus longus
C. Saphenous nerve
D. Superficial peroneal nerve
E. Sural nerve

Ans D

Question 65

73- 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 65

A. Common peroneal nerve
B. Deep peroneal nerve
C. Saphenous nerve
D. Superficial peroneal nerve
E. Sural nerve

Ans A

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

Question 66

74- 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 66

A. Apoptosis
B Atrophy
C. Hyperplasia
D. Hypertrophy
E. Hypoplasia

Ans E

Question 67

75- 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 67

A. Autonomic neuropathy
B. Femro popliteal stenosis
C. Neuropathic joint disease
D. Polyneuropathy
E. Radiculopathy

Ans B

Question 68

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

Answer 68

A. Above the levator ani
B. Between external and internal anal sphincter
C. Lateral to the obturator internus
D Medial to the internal anal-sphincter
E Medial to the pudendal canal

Ans E

Question 69

77- 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 69

A Hepatorenal pouch
B. Left subphrenic space
C. Lesser sac
D. Right paracolic gutter
E. Right subphrenic space

Ans A

Question 70

78- 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 her We constricted ?

Answer 70

A. First part of duodenum
B Second part of duodenum
C. Third part of duodenum
D. Proximal jejunum
E. Pylorus of stomach

Ans B

LIGAMENT OF TREITZ
2 parts, probably neither attached to crurae
1. Slip of striated muscle from diaphragm at oesophageal opening, ending in connective tissue at coeliac artery
2. Fibromuscular (non striated) band from region of coeliac artery to duodenojejunal junction and 3th & 4th parts of duodenum

Referred pain via general visceral afferents in sympathetics to T8-10 (epigastrium & para-umbilical)

Question 71

79- 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 71

A. External oblique aponeurosis
B. External oblique muscle
C. Internal oblique muscle
D Transversus abdominis muscle
E Transversalis fascia

Ans A

Question 72

80- 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 72

A Left colic artery
B Left gastroepiploic
C. Middle colic
D. Splenic
E. Superior rectal

Ans C

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 73

81- 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 73

A. Adenocarcinoma of the sigmoid colon
B Colonic diverticular disease
C Crohn’s disease
D Transitional cell carcinoma of the bladder
E Ulcerative colitis

Ans B