9- Mixed Anatomy (2)MSQs Only

Question 1

100 of 610

A 38 year old lady is due to undergo a parathyroidectomy for hyperparathyroidism. At operation the inferior parathyroid gland is identified as being enlarged. A vessel is located adjacent to the gland laterally. This vessel is most likely to be the:

Answer 1

Common carotid artery

The common carotid artery is a lateral relation of the inferior parathyroid.

Question 2

103 of 610

A 60 year old female attends the preoperative hernia clinic. She reports some visual difficulty. On examination she is noted to have a homonymous hemianopia. Where is the lesion most likely to be?

Answer 2

Optic tract
………………………………….
Lesions before optic chiasm:
Monocular vision loss = Optic nerve lesion
Bitemporal hemianopia = Optic chiasm lesion

Lesions after the optic chiasm:
Homonymous hemianopia = Optic tract lesion
Upper quadranopia = Temporal lobe lesion
Lower quadranopia = Parietal lobe lesion

Unfortunately we thought as surgeons we could forget about visual field defects!
However the college seem to like them. Remember a homonymous hemianopia is indicative of an optic tract lesion. Parietal lobe lesions tend to cause inferior quadranopias and there is a bitemporal hemianopia with optic chiasm lesion or pituitary tumours.

Question 2

102 of 610

During an Ivor Lewis Oesophagectomy for carcinoma of the lower third of the oesophagus which structure is divided to allow mobilisation of the oesophagus?

Answer 2

Azygos vein

The azygos vein is routinely divided during an oesophagectomy to allow mobilisation. It arches anteriorly to insert into the SVC on the right hand side.

Question 3

101 of 610

What is the largest branch of the brachial artery?

Answer 3

Profunda brachii artery

The profunda brachii artery is the largest branch and then continues in the radial groove of the humerus.

Question 4

104 of 610

Which of the following structures separates the subclavian artery from the subclavian vein?

Answer 4

Scalenus anterior

The artery and vein are separated by scalenus anterior. This muscle runs from the transverse processes of C3,4,5 and 6 to insert onto the scalene tubercle of the first rib.

Question 5

105 of 610

A 67 year old man is undergoing an angiogram for gastro intestinal bleeding. The radiologist advances the catheter into the coeliac axis. At what spinal level does this vessel typically arise from the aorta?

Answer 5

T12

The coeliac axis lies at T12, it takes an almost horizontal angle off the aorta. It has three major branches.

Question 6

106 of 610

Which of the nerves below innervates the tensor tympani muscle?

Answer 6

Trigeminal

The tensor tympani muscle (in conjunction with stapedius) helps to mitigate the effects of loud sounds. The tensor tympani is innervated by the trigeminal nerve (the stapedius by the facial). In some people with hyperacousia, the tensor tympani muscle does not function normally.

Question 7

107 of 610

A 34 year old male is being examined in the pre-operative assessment clinic. A murmur is identified in the 4th intercostal space just next to the left side of the sternum. From where is it most likely to have originated?

Answer 7

Tricuspid valve

The tricuspid valve is generally referred to being best auscultated adjacent to the sternum. The plane of projected sound from the mitral area is best heard in the region of the cadiac apex.

Question 8

109 of 610

Which of the following structures lies posterior to the femoral nerve in the femoral triangle?

Answer 8

Iliacus

The iliacus lies posterior to the femoral nerve in the femoral triangle. The femoral sheath lies anterior to the iliacus and pectineus muscles.

Question 8

108 of 610

The vertebral artery traverses all of the following except?

Answer 8

Transverse process of C6

Transverse process of the axis

Vertebral canal

Foramen magnum

Intervertebral foramen (Right)
………………………………………….
The vertebral artery passes through the foramina which are located in the transverse processes of the cervical vertebra, it does not traverse the intervertebral foramen.

Question 9

110 of 610

A 24 year old lady is stabbed in the buttock. Following the injury the wound is sutured in the emergency department. Eight weeks later she attends the clinic, as she walks into the clinic room she has a waddling gait and difficulty with thigh abduction. On examination she has buttock muscle wasting. Which nerve has been injured?

Answer 9

Superior gluteal nerve

Damage to the superior gluteal nerve will result in a Trendelenburg gait.

Question 10

111 of 610

A 44 year old man is undergoing a parotidectomy and the surgeon is carefully preserving the facial nerve. Unfortunately his trainee then proceeds to divide it. Which of the following will not be affected as a result?

Answer 10

Taste sensation from anterior two thirds of the tongue

The chorda tympani branches inside the facial canal and will therefore be unaffected by this most unfortunate event! The corneal reflex is mediated by the opthalmic branch of the trigeminal nerve sensing the stimulus on the cornea, lid or conjunctiva; the facial nerve initiates the motor response of the reflex.

Question 11

113 of 610

A 32 year old rugby player is hit hard on the shoulder during a rough tackle. Clinically, his arm is hanging loose on the side. It is pronated and medially rotated. What structure is most likely to have been compromised?

Answer 11

Brachial trunks C5-6

The patient has an Erb’s palsy involving brachial trunks C5-6.
INJURY OF THE BRACHIAL PLEXUS
(t) Complete avulsion of all roots of the plexus :leads to :
paralysis of all muscles of upper limb except trapezius
Supplied by supraclavicular and intercostobrachial respectively
(b) anaesthesia of all skin of u-L except skin of tip of shoulder &floor of axilla.
(2) Injury of the upper trunk (C5,6) :Erb’s paralysis : leads ta:
(a) paralysis of abductors &lat-rotators of arm+Flexors &supinators of forearm
(b) anaesthesia of skin of lat-aspect of forearm & lower/2 of arm.
(c) Deformity: porter’s or policeman tip position-
(3) Injury of the lower trunk (C8,TI) : Klumpke’s paralysis : leads to:
(a) paralysis of flexors of wrist & fingers +all intrinsic muscles of the hand.
b andesthesia of the skin along the ulnar border of forearm &hand.
(e) Deformity : claw hand deformity

Question 11

112 of 610

A 73 year old man undergoes an excision biopsy of a lymph node that is closely applied to sternocleidomastoid. This muscle is mobilized and a nerve that is present is damaged. Which muscle below is most likely to be affected?

Answer 11

Trapezius

The accessory nerve has a number of lymph nodes applied to it near the sternocleidomastoid muscle. It is particularly at risk if SCM is mobilized. If injured, the trapezius muscle and SCM will be paralysed.

Question 12

114 of 610

You are assisting in an open right adrenalectomy for a large adrenal adenoma. The consultant is distracted and you helpfully pull the adrenal into the wound to improve the view. Unfortunately this is followed by brisk bleeding. The vessel responsible for this is most likely to be:

Answer 12

Inferior vena cava

It drains directly via a very short vessel. If the sutures are not carefully tied then it may be avulsed off the IVC. An injury best managed using a Satinsky clamp and a 6/0 prolene suture.

Question 13

117 of 610

Which of the following does not pass through the superior orbital fissure?

Answer 13

Opthalmic artery
…………………………
Mnemonic for the nerves passing through the supraorbital fissure:

Live Frankly To See Absolutely No Insult

Lacrimal
Frontal
Trochlear
Superior Division of Oculomotor
Abducens
Nasociliary
Inferior Division of Oculomotor nerve

The opthalmic artery arises from the internal carotid immediately after it has pierced the dura and arachnoid. It runs through the optic canal below the optic nerve and within its dural and arachnoid sheaths. It terminates as the supratrochlear and dorsal nasal arteries.

Question 13

115 of 610

A 72 year old man has a fall. He is found to have a fractured neck of femur and goes on to have a left hip hemiarthroplasty. Two months post operatively he is found to have an odd gait. When standing on his left leg his pelvis dips on the right side. There is no foot drop. What is the cause?

Answer 13

Superior gluteal nerve damage

This patient has a trendelenburg gait caused by damage to the superior gluteal nerve causing weakness of the abductor muscles. Classically a patient is asked to stand on one leg and the pelvis dips on the opposite side. The absence of a foot drop excludes the possibility of polio or L5 radiculopathy.

Question 14

116 of 610

At which level is the hilum of the left kidney located?

Answer 14

L1

Remember L1 (‘left one’) is the level of the hilum of the left kidney

Question 15

118 of 610

Which of the muscles listed below is attached to the anterior aspect of the fibrous capsule that encases the elbow joint?

Answer 15

Brachialis

The brachialis inserts some of its fibres into the fibrous joint of the elbow capsule and when it contracts, it helps to flex the joint.

Question 16

119 of 610

Parasympathetic fibres innervating the parotid gland originate from which of the following?

Answer 16

Otic ganglion

Secretion of saliva by the parotid gland is controlled by nerve fibres originating in the inferior salivatory nucleus; these leave the brain via the tympanic nerve (branch of glossopharyngeal nerve (CN IX), travel through the tympanic plexus (located in the middle ear), and then form the lesser petrosal nerve until reaching the otic ganglion. After synapsing in the Otic ganglion, the postganglionic (postsynaptic) fibres travel as part of the auriculotemporal nerve (a branch of the mandibular nerve (V3) to reach the parotid gland.

Inferior salivary nucleus - tympanic n of IX - tympanic
plexus in middle ear - lesser petrosal n ->- otic
ganglion ->- auriculotemporal ot V - parotid gland

Question 16

121 of 610

At which of the following levels does the inferior thyroid artery enter the thyroid gland?

Answer 16

C6

It enters the gland at C6.

Question 16

120 of 610

An occlusion of the anterior cerebral artery may compromise the blood supply to the following structures except:

Answer 16

Medial inferior surface of the frontal lobe

Corpus callosum

Medial surface of the frontal lobe

Olfactory bulb

Brocas area ( Right)
…………………………………
Brocas area is usually supplied by branches from the middle cerebral artery.

Question 17

122 of 610

Which of the cranial nerves listed below is least likely to carry parasympathetic fibres?

Answer 17

II

Cranial nerves carrying parasympathetic fibres
X IX VII III (1973)

The optic nerve carries no parasympathetic fibres.

The cranial preganglionic parasympathetic nerves arise from specific nuclei in the CNS. These synapse at one of four parasympathetic ganglia; otic, pterygopalatine, ciliary and submandibular. From these ganglia the parasympathetic nerves complete their journey to their target tissues via CN V (trigeminal) branches (ophthalmic nerve CNV branch 1, Maxillary nerve CN V branch2, mandibular nerve CN V branch 3)

Question 18

123 of 610

An elderly man develops a squamous cell carcinoma affecting the lobule of his ear. To which lymph node is the lesion most likely to metastasize?

Answer 18

Superficial cervical nodes

The lobule drains to the superficial cervical nodes.

Question 19

124 of 610

A 10 year old child has a grommet inserted for a glue ear. What type of epithelium is present on the external aspect of the tympanic membrane?

Answer 19

Stratified squamous

The external aspect of the tympanic membrane is lined by stratified squamous epithelium. This is significant clinically in the development of middle ear infections when this type of epithelium may migrate inside the middle ear.

Question 20

125 of 610

A 5 year old boy presents with recurrent headaches. As part of his assessment he undergoes an MRI scan of his brain. This demonstrates enlargement of the lateral and third ventricles. Where is the most likely site of obstruction?

Answer 20

Aqueduct of Sylvius

The CSF flows from the 3rd to the 4th ventricle via the Aqueduct of Sylvius.

Question 21

126 of 610

A 28 year old rugby player injures his right humerus and on examination is noted to have a minor sensory deficit overlying the point of deltoid insertion into the humerus. Which of the nerves listed below is most likely to have been affected?

Answer 21

Axillary

This patch of skin is supplied by the axillary nerve

Question 22

127 of 610

The following statements relating to the musculocutaneous nerve are true except?

Answer 22

It arises from the lateral cord of the brachial plexus

It provides cutaneous innervation to the lateral side of the forearm

If damaged, then extension of the elbow joint will be impaired( Right)

It supplies the biceps muscle

It runs beneath biceps
……………………………………………
It supplies biceps, brachialis and coracobrachialis. If damaged then elbow flexion will be impaired.

Question 23

129 of 610

A 34 year old man undergoes excision of a sarcoma from the right buttock. During the procedure the sciatic nerve is sacrificed. Which of the following will not occur as a result of this process?

Answer 23

Loss of extension at the knee joint(Right)

Foot drop

Inability to extend extensor hallucis longus

Diminished sensation of the posterior aspect of the thigh

Loss of sensation to the posterior aspect of the lower leg
………………………………………..
Extension of the knee joint is caused by the obturator and femoral nerves.
Sensation to the posterior aspect of the thigh is via the posterior cutaneous nerve of the thigh and this is a direct branch from the plexus itself.

Question 24

134 of 610

A 40 year old lady trips and falls through a glass door and sustains a severe laceration to her left arm. Amongst her injuries it is noticed that she has lost the ability to adduct the fingers of her left hand. Injury to which of the following nerves is most likely to account for her examination findings?

Answer 24

Ulnar

The interossei are supplied by the ulnar nerve.

Question 24

133 of 610

A 53 year old man is undergoing a radical gastrectomy for carcinoma of the stomach. Which of these structures will need to be divided to gain access to the coeliac axis?

Answer 24

Lesser omentum

The lesser omentum will need to be divided. During a radical gastrectomy this forms one of the nodal stations that will need to be taken.

Question 24

131 of 610

A cervical rib is due to which of the following?

Answer 24

Elongation of the transverse processes of the 7th cervical vertebra

Cervical ribs occur as a result of the elongation of the transverse process of the 7th cervical vertebra. It is usually a fibrous band that attaches to the first thoracic rib.

Question 24

130 of 610

A 23 year old lady with troublesome axillary hyperhidrosis is undergoing a thorascopic sympathectomy to treat the condition. Which of the following structures will need to be divided to access the sympathetic trunk?

Answer 24

Parietal pleura

The sympathetic chain lies posterior to the parietal pleura. During a thorascopic sympathectomy this structure will need to be divided. The intercostal vessels lie posteriorly. They may be damaged with troublesome bleeding but otherwise are best left alone as deliberate division will not improve surgical access.

Question 25

132 of 610

A 67 year old man is due to undergo a revisional total hip replacement using a posterior approach. After dividing gluteus maximus in the line of its fibres there is brisk arterial bleeding. Which of the following vessels is likely to be responsible?

Answer 25

Inferior gluteal artery

The inferior gluteal artery runs on the deep surface of the gluteus maximus muscle. It is a branch of the internal iliac artery. It is commonly divided during the posterior approach to the hip joint.

Question 25

135 of 610

A 33 year old man is stabbed in the right chest and undergoes a thoracotomy. The right lung is mobilised and the pleural reflection at the lung hilum is opened. Which of the structures listed below does not lie within this region?

Answer 25

Pulmonary artery

Azygos vein(Right)

Pulmonary vein

Bronchus

None of the above
………………………………………….
The pleural reflections encase the hilum of the lung and continue inferiorly as the pulmonary ligament. It encases the pulmonary vessels and bronchus. The azygos vein is not contained within it.

Question 26

137 of 610

Which of the nerves listed below is responsible for the innervation of gluteus maximus?

Answer 26

Inferior gluteal nerve

Question 26

136 of 610

The pudendal canal is a fascial canal located on the lateral wall of the ischioanal fossa. In this location, it lies on the inferior border of which of the following muscles?

Answer 26

Obturator internus

The coccygeus, pubococcygeus and iliococcygeus form part of the pelvic diaphragm and are not related to it. The piriformis exits the pelvis via the greater sciatic foramen and is not associated with the canal in the ischiorectal fossa.

Question 27

138 of 610

What is the origin of the superior gluteal artery?

Answer 27

Internal iliac artery

The inferior gluteal artery arises from the anterior trunk of the internal iliac artery
The superior gluteal artery arises from the posterior trunk of the internal iliac artery

Question 28

139 of 610

A 67 year old man has an abdominal aortic aneurysm which displaces the left renal vein. Which branch of the aorta is most likely to be affected

Answer 28

Superior mesenteric artery

The left renal vein lies behind of the SMA as it branches off the aorta. Whilst juxtarenal AAA may sometimes require the division of the left renal vein, direct involvement of the SMA may require a hybrid surgical bypass and subsequent endovascular occlusion.

Question 28

141 of 610

A patient presents with superior vena caval obstruction. How many collateral circulations exist as alternative pathways of venous return?

Answer 28

Four

There are 4 collateral venous systems:
· Azygos venous system
· Internal mammary venous pathway
. Long thoracic venous system with connections to the femoral and vertebral
veins (2 pathways)

Despite this, venous hypertension still occurs.

Question 28

140 of 610

An 18 year old man is cutting some plants when a small piece of vegetable matter enters his eye. His eye becomes watery. Which of the following is responsible for relaying parasympathetic neuronal signals to the lacrimal apparatus?

Answer 28

Pterygopalatine ganglion

The parasympathetic fibres to the lacrimal apparatus transit via the pterygopalatine ganglion.

Question 29

141 of 610

A patient presents with superior vena caval obstruction. How many collateral circulations exist as alternative pathways of venous return?

Answer 29

Four

There are 4 collateral venous systems:
· Azygos venous system
· Internal mammary venous pathway
. Long thoracic venous system with connections to the femoral and vertebral veins (2 pathways)

Despite this, venous hypertension still occurs.

Question 30

142 of 610

A 5 year old boy is playing with some small ball bearings. Unfortunately, he inhales one. To which of the following lung regions is the ball most likely to settle?

Answer 30

Right lower lobe

As the most dependent part of the right lung a small object is most likely to lodge here. Most objects will preferentially enter the right lung owing to the angle the right main bronchus takes from the trachea.

Question 31

143 of 610

Which of the following laryngeal tumours will not typically metastasise to the cervical lymph nodes?

Answer 31

Glottic(Right)

Supraglottic

Subglottic

Transglottic

Aryepiglottic fold
………………………………………………
The vocal cords have no lymphatic drainage and therefore this region serves as a lymphatic watershed. The supraglottic part drains to the upper deep cervical nodes through vessels piercing the thyrohyoid membrane. The sub glottic part drains to the pre laryngeal, pre tracheal and inferior deep cervical nodes. The aryepiglottic and vestibular folds have a rich lymphatic drainage and will metastasise early.

Question 32

144 of 610

A 24 year old man falls and sustains a fracture through his scaphoid bone. From which of the following areas does the scaphoid derive the majority of its blood supply?

Answer 32

From the distal end

The blood supply to the scaphoid enters from a small non articular surface near its distal end. Transverse fractures through the scaphoid therefore carry a risk of non union.

Question 33

145 of 610

A 35 year old man falls and sustains a fracture to the medial third of his clavicle. Which vessel is at greatest risk of injury?

Answer 33

Subclavian vein

The subclavian vein lies behind subclavius and the medial part of the clavicle. It rests on the first rib, below and in front of the third part of the subclavian artery, and then on scalenus anterior which separates it from the second part of the artery (posteriorly).

Question 34

146 of 610

What is the anatomical level of the transpyloric plane?

Answer 34

L1

Question 35

147 of 610

An 21 year old man undergoes an uncomplicated tonsillectomy for recurrent attacks of tonsillitis. Post operatively he complains of otalgia. Which nerve is responsible?

Answer 35

Glossopharyngeal

The glossopharyngeal nerve supplies this area and the ear and otalgia may be the result of referred pain.

Question 36

148 of 610

Which of the following nerves is most commonly damaged during a superficial parotidectomy?

Answer 36

Greater auricular

If you are confused by this, make sure you are clear on what the question is asking- its about nerve injury. Its very rare for the facial nerve to be injured during parotid surgery.

The greater auricular nerve and in particular its lobular branch is commonly injured in parotid surgery and consent usually makes particular reference to this. In a superficial parotidectomy, the facial nerve should not be injured and this is less common than a greater auricular nerve injury.

Question 36

149 of 610

Which muscle initiates abduction of the shoulder?

Answer 36

Supraspinatus

The intermediate portion of the deltoid muscle is the chief abductor of the humerus. However, it can only do this after the movement has been initiated by supraspinatus. Damage to the tendon of supraspinatus is a common form of rotator cuff disease.

Question 37

150 of 610

Where are the reticulo-endothelial cells concentrated within the spleen?

Answer 37

Within the white pulp

The reticuloendothelial cells are concerned with the immune functions of the spleen and these are therefore concentrated in the white pulp.

Question 38

152 of 610

During a block dissection of the groin, the sartorius muscle is identified. What is the nerve supply to this muscle?

Answer 38

Anterior division of the femoral nerve

Sartorius is supplied by the anterior (superficial) branch of the femoral nerve.
Most of the branches of the superficial femoral nerve are cutaneous. However, it does also supply sartorius.

Question 38

153 of 610

A 56 year old man undergoes a low anterior resection with legs in the Lloyd-Davies position. Post operatively he complains of foot drop. Which nerve has been injured?

Answer 38

Common peroneal nerve

Positioning legs in Lloyd- Davies stirrups can carry the risk of peroneal nerve neuropraxia if not done carefully.

Question 38

151 of 610

A 28 year old man requires a urethral catheter to be inserted prior to undergoing a splenectomy. Where is the first site of resistance to be encountered on inserting the catheter?

Answer 38

Membranous urethra

The membranous urethra is the least distensible portion of the urethra. This is due to the fact that it is surrounded by the external sphincter.

Question 38

154 of 610

A 23 year old man falls and slips at a nightclub. A shard of glass penetrates the skin at the level of the medial epicondyle, which of the following sequelae is least likely to occur?

Answer 38

Atrophy of the first dorsal interosseous muscle

Difficulty in abduction of the the 2nd, 3rd, 4th and 5th fingers

Claw like appearance of the hand(Right)

Loss of sensation on the anterior aspect of the 5th finger

Partial denervation of flexor digitorum profundus
……………………………………………………
Injury to the ulnar nerve in the mid to distal forearm will typically produce a claw hand. This consists of flexion of the 4th and 5th interphalangeal joints and extension of the metacarpophalangeal joints. The effects are potentiated when flexor digitorum profundus is not affected, and the clawing is more pronounced.More proximally sited ulnar nerve lesions produce a milder clinical picture owing to the simultaneous paralysis of flexor digitorum profundus (ulnar half).

This is the ‘ulnar paradox’, due to the more proximal level of transection the hand will typically not have a claw like appearance that may be seen following a more distal injury. The first dorsal interosseous muscle will be affected as it is supplied by the ulnar nerve.

Question 39

155 of 610

What is the most important structure involved in supporting the uterus?

Answer 39

Central perineal tendon

The central perineal tendon provides the main structural support to the uterus. Damage to this structure is commonly associated with the development of pelvic organ prolapse, even when other structures are intact.

Question 40

157 of 610

An injured axillary artery is ligated between the thyrocervical trunk of the subclavian and subscapular artery. Subsequent collateral circulation is likely to result in reversal of blood flow in which of the vessels listed below?

Answer 40

Circumflex scapular artery

It’s an easy question really, we just made the wording difficult (on purpose). It is asking about the branches of the axillary artery and knowledge of the fact that there is an extensive collateral network around the shoulder joint. As a result, the occlusion of the proximal aspect of the circumflex humeral inflow (from the axillary artery) ceases and there is then retrograde flow through it from collaterals.

It is all about anastomosis around shoulder jt, distal components of anastomosis dorsal scapular from subclavian anastomosis with circumflex scapular of subscapular if 3rd part axillary art.

The circumflex scapular artery is a branch of the subscapular artery and normally supplies the muscle on the dorsal aspect of the scapula. In this instance, flow is reversed in the circumflex scapular and subscapular arteries forming a collateral circulation around the scapula.

Question 41

156 of 610

A 53 year old man presents with unilateral hyperacousia. Which of the following nerves is least likely to be functioning normally?

Answer 41

Vestibulocochlear

Glossopharyngeal

Facial(Right)

Trochlear

Vagus
…………………………………………………..
Damage to the nerve in the bony canal may result in impaired innervation to stapedius and therefore sounds are no longer dampened. Another cause of hyperacusis is increased activity in the tensor tympani muscle, this is innervated by the trigeminal nerve.

Question 42

158 of 610

A 44 year old lady is undergoing an abdominal hysterectomy and the ureter is identified during the ligation of the uterine artery. At which site does it insert into the bladder?

Answer 42

Base

The ureters enter the bladder at the upper lateral aspect of the base of the bladder.
They are about 5cm apart from each other in the empty bladder. Internally this aspect is contained within the bladder trigone.

Question 42

160 of 610

A 63 year old lady is undergoing an axillary sentinel lymph node biopsy as part of her breast cancer treatment. Which of the structures listed below is most likely to be encountered?

Answer 42

Subclavian artery

Intercostobrachial nerve(Right)

Upper cord of the brachial plexus

Lower cord of the brachial plexus

Axillary nerve
…………………………………………………
This can be a challenging question. A particularly careless surgeon could encounter all of these. However, during a routine level 1 axillary exploration which is where the majority of sentinel nodes will be located, the nerves most commonly encountered are the intercostobrachial nerves.

Question 43

159 of 610

The superior aspect of the vagina drains to which of the following lymph node groups?

Answer 43

Internal iliac nodes

Superior Vagina - int & ext iliac L.N
Inferior Vagina - Superfacial ing L.N

Question 44

161 of 610

During a Patey mastectomy, the pectoralis minor muscle is divided to gain access to the level IlI axillary nodes. What is the nerve supply to this structure?

Answer 44

Medial pectoral nerve

Pectoralis minor is supplied by the medial pectoral nerve

Question 45

162 of 610

Which of the following statements relating to sternocleidomastoid is untrue?

Answer 45

The external jugular vein lies posteromedially.(Right)

It is supplied by the accessory nerve.

It has two heads of origin

It inserts into the lateral aspect of the mastoid process.

It marks the anterior border of the posterior triangle.
………………………………………………
The external jugular vein lies lateral (i.e. superficial) to the sternocleidomastoid.

Question 45

The following statements regarding the rectus abdominis muscle are true except:

Answer 45

It runs from the symphysis pubis to the xiphoid process

Its nerve supply is from the ventral rami of the lower 6 thoracic nerves

It has collateral supply from both superior and inferior epigastric vessels

It lies in a muscular aponeurosis throughout its length(Right)

It has a number of tendinous intersections that penetrate through the anterior layer of the muscle
……………………………………………..
Rectus abdominis
· Arises from the pubis.
. Inserts into 5th, 6th, 7th costal cartilages.
. The muscle lies in the rectal sheath, which also contains the superior and inferior epigastric artery and vein.
· Action: flexion of thoracic and lumbar spine.
· Nerve supply: anterior primary rami of T7-12.

The aponeurosis is deficient below the arcuate line.

Question 46

165 of 610
Which of the following options in relation to the liver is true?

Answer 46

Ligamentum venosum is an anterior relation of the liver

The portal triad comprises the hepatic artery, hepatic vein and tributary of the bile duct

The liver is completely covered by peritoneum

There are no nerves within the porta hepatis

The caudate lobe is superior to the porta hepatis(Right)
……………………………………………..
‘VC goes with VC’

The ligamentun Venosum and Caudate is on same side as Vena Cava [posterior].

Ligamentum venosum is posterior to the liver. The portal triad contains the portal vein rather than the hepatic vein. There is the ‘bare area of the liver’ created by a void due to the coronary ligament layers being widely separated. There are sympathetic and parasympathetic nerves in the porta hepatis.

Question 46

164 of 610

Which of the following structures does not pass anterior to the lateral malleolus?

Answer 46

Anterior tibial artery

Extensor digitorum longus

Lateral branch of the superficial peroneal nerve

Peroneus brevis(Right)

Peroneus tertius
……………………………………….
Peroneus brevis passes posterior to the lateral malleolus. Peroneus tertius is closely related to extensor digitorum and like that muscle, its tendon passes anterior to the lateral malleolus

Question 47

166 of 610

How many valves lie between the superior vena cava and the right atrium?

Answer 47

None(Right)

One

Two

Three

Four
…………………………………
There are no valves which is why it is relatively easy to insert a CVP line from the internal jugular vein into the right atrium.

Question 48

168 of 610

Which of the following muscles is penetrated by the parotid duct?

Answer 48

Buccinator

The duct crosses the masseter muscle and buccal fat pad and then penetrates the buccinator muscle to enter the oral cavity opposite the second upper molar tooth.

Question 48

167 of 610

The following are true of the ulnar nerve except:

Answer 48

It innervates the palmar interossei

Derived from the medial cord of the brachial plexus

Supplies the muscles of the thenar eminence(Right)

Supplies the medial half of flexor digitorum profundus

Passes superficial to the flexor retinaculum
……………………………………………………….
The muscles of the thenar eminence are supplied by the median nerve and atrophy of these is a feature of carpal tunnel syndrome.

Question 49

169 of 610

A 6 year old sustains a supracondylar fracture of the distal humerus. There are concerns that the radial nerve may have been injured. What is the relationship of the radial nerve to the humerus at this point?

Answer 49

Anterolateral

The radial nerve lies anterolateral to the humerus in the supracondylar area.

Question 50

171 of 610

Which of the following fingers is not a point of attachment for the palmar interossei?

Answer 50

Middle finger(Right)

Little finger

Ring finger

Index finger

None of the above
……………………………………………..
The middle finger has no attachment of the palmar interosseous.

Question 50

170 of 610

A 33 year old man sustains an injury to his forearm and wrist. When examined in clinic he is unable to adduct his thumb. What is the most likely underlying nerve lesion?

Answer 50

Deep branch of the ulnar nerve

Damage to the deep branch of the ulnar nerve may result in an inability to adduct the thumb. This is tested clinically by trying to withdraw a piece of paper from a patients hand grasped between thumb and index

Question 51

172 of 610

A 73 year old lady is admitted with right iliac fossa pain. A plain abdominal x-ray is taken and the caecal diameter measured. Which of the following caecal diameters is pathological?

Answer 51

10cm

8 cm is still within normal limits. However, caecal diameters of 9 and 10 are pathological and should prompt further investigation.

Question 52

173 of 610

A 73 year old lady with long standing atrial fibrillation develops a cold and pulseless white arm. A brachial embolus is suspected and a brachial embolectomy is performed. Which of the following structures is at greatest risk of injury during this procedure?

Answer 52

Median nerve

The median nerve lies close to the brachial artery in the antecubital fossa. This is the usual site of surgical access to the brachial artery for an embolectomy procedure. The median nerve may be damaged during clumsy application of vascular clamps to the artery.

Question 52

174 of 610

A 43 year old lady is undergoing an axillary node clearance for breast cancer. The nodal disease is bulky. During clearance of the level 3 nodes there is suddenly brisk haemorrhage. The most likely vessel responsible is:

Answer 52

Thoracoacromial artery

The thoracoacromial artery pierces the pectoralis major and gives off branches within this space. The level 3 axillary nodes lie between pectoralis major and minor.Although the thoracodorsal trunk may be injured during an axillary dissection it does not lie within the level 3 nodes.

There are three levels of axillary lymph nodes (the nodes in the underarm or “axilla” area):
- Level I is the bottom level, below the lower edge of the pectoralis minor muscle.
- Level Il is lying underneath the pectoralis minor muscle.
- Level Ill is above the pectoralis minor muscle.

Question 52

175 of 610

A 63 year old man is undergoing a right pneumonectomy for carcinoma of the bronchus. As the surgeons approach the root of the lung, which structure will lie most posteriorly (in the anatomical plane)?

Answer 52

Vagus nerve

The vagus nerve is the most posteriorly located structure at the lung root. The phrenic nerve lies most anteriorly.

Question 53

176 of 610

The transversalis fascia contributes to which of the following?

Answer 53

Deep inguinal ring

The internal spermatic fascia (derived from transversalis fascia) invests:
Ductus deferens
Testicular vessels

The principal outpouching of the transversalis fascia is the internal spermatic fascia. The mouth of the outpouching is the deep inguinal ring.

Question 54

177 of 610

The motor nucleus of cranial nerve V supplies all except which of the following muscles?

Answer 54

Masseter

Posterior belly of digastric(Right)

Temporalis

Tensor tympani

Tensor veli palatini
………………………………………….
The posterior belly of digastric is supplied by the branchial motor component of the facial nerve. All of the other muscles are supplied by axons from the motor nucleus of cranial nerve V.

Question 55

178 of 610

Which of the following nerves is the primary source of innervation to the anterior scrotal skin?

Answer 55

Ilioinguinal nerve

The pudendal nerve may innervate the posterior skin of the scrotum. The anterior innervation of the scrotum is primarily provided by the ilioinguinal nerve. The genital branch of the genitofemoral nerve provides a smaller contribution.

Question 56

179 of 610

Which of the following statements relating to the gallbladder is untrue?

Answer 56

The fundus is usually intra peritoneal

Arterial supply is from the cystic artery

The cystic artery is usually located in Calots triangle

Calots triangle may rarely contain an aberrant hepatic artery

Cholecystokinin causes relaxation of the gallbladder(Right)
…………………………………………….
CCK causes gallbladder contraction.

Question 56

181 of 610
A 32 year old lady is admitted with weakness, visual disturbance and peri orbital pain. On examination, she is noted to have mydriasis and diminished direct response to light shone into the affected eye. The consensual response is preserved when light is shone into the unaffected eye. Which of the cranial nerves listed below is responsible for the diminished direct response?

Answer 56

Optic

This describes a relative afferent pupillary defect (RAPD). RAPD is a defect in the direct response to light. It is due to damage in optic nerve or severe retinal disease. If an optic nerve lesion is present the affected pupil will not constrict to light when light is shone in the that pupil during the swinging flashlight test. However, it will constrict if light is shone in the other eye (consensual response).

The most likely cause for this is an optic neuritis (not really surgical!). Other causes include ischemic optic disease or retinal disease, severe glaucoma causing trauma to optic nerve and direct optic nerve damage (trauma, radiation, tumor).

Question 56

180 of 610

An 22 year old soldier is shot in the abdomen and amongst his various injuries is a major disruption to the abdominal aorta. There is torrential haemorrhage and the surgeons decide to control the aorta by placement of a vascular clamp immediately inferior to the diaphragm. Which of the following vessels may be injured in this maneouvre?

Answer 56

Inferior phrenic arteries

As the first branches of the abdominal aorta the inferior phrenic arteries are at greatest risk. The superior phrenic arteries lie in the thorax. The potential space at the level of the diaphragmatic hiatus is a potentially useful site for aortic occlusion. However, leaving the clamp applied for more than about 10-15 minutes usually leads to poor outcomes.

Question 57

182 of 610

Which of the following is a recognised tributary of the retromandibular vein?

Answer 57

Maxillary vein

The retromandibular vein is formed from the union of the maxillary and superficial temporal vein

Question 57

183 of 610

A 44 year old lady has undergone a mastectomy and axillary node clearance. Post operatively, she notices a patch of anaesthesia of her axillary skin when she applies an underarm deodorant. Which nerve has most likely been affected?

Answer 57

Intercostobrachial

The intercostobrachial nerves traverse the axilla and innervate the overlying skin. These can be injured or divided during axillary surgery and the result is anaesthesia of the overlying skin.

Question 58

184 of 610

During a tricuspid valve repair the right atrium is opened, following establishment of cardiopulmonary bypass. Which of the following structures do not lie within the right atrium?

Answer 58

Crista terminalis

Tricuspid valve

Fossa ovalis

Trabeculae carnae(Right)

Musculi pectinati
………………………………………………..
Structures within the right atrium:
· Musculi pectinati
· Crista terminalis
. Opening of the coronary sinus
. Fossa ovalis

The trabeculae carnae are located in the right ventricle.

Question 58

185 of 610

A 63 year old man is undergoing an upper GI endoscopy for dysphagia. At 33 cm (from the incisors) a malignant looking stricture is encountered. The endoscopist attempts a balloon dilatation.Unfortunately the tumour splits through the oesophageal wall. Into which region will the oesophageal contents now drain?

Answer 58

Posterior mediastinum

At this position the oesophagus is still likely to be intrathoracic and located in the posterior mediastinum.

Question 59

186 of 610

A 78 year old man develops a carcinoma of the scrotum. To which of the following lymph node groups may the tumour initially metastasise?

Answer 59

Inguinal

The scrotum is drained by the inguinal nodes.

Question 60

188 of 610

The space between the vocal cords is referred to as which of the following?

Answer 60

Rima glottidis

The rima glottidis is the narrowest part of the laryngeal cavity.

Question 60

187 of 610

At what level does the sciatic nerve usually bifurcate into the tibial and common peroneal nerves?

Answer 60

At the superior aspect of the popliteal fossa

The sciatic nerve passes vertically downwards over the posterior surface of the obturator internus and quadratus femoris to the hamstring compartment of the thigh, here it is crossed posteriorly by the long head of biceps femoris. In the buttock it lies under the cover of gluteus maximus. It separates into its tibial and common peroneal components at the upper aspect of the popliteal fossa.

Question 61

189 of 610

During a gangland gunfight a man is shot in the chest. The bullet passes through the posterior mediastinum (from left to right). Which of the following structures is least likely to be injured

Answer 61

Arch of the azygos vein

The arch of the azygos vein lies in the middle mediastinum.

Question 62

190 of 610

A 24 year female is admitted to A&E with tingling of her hand after a fall. She is found to have a fracture of the medial epicondyle. What is the most likely nerve lesion?

Answer 62

Ulnar nerve

The radial nerve is located near the lateral epicondyle.

Question 62

191 of 610

A 25 year old man is being catheterised, prior to a surgical procedure. As the catheter enters the prostatic urethra which of the following changes will occur?

Answer 62

Resistance will decrease

The prostatic urethra is much wider than the membranous urethra and therefore resistance will decrease. The prostatic urethra is inclined superiorly.

Question 63

192 of 610

Which of the following structures are at risk of direct injury following a fracture dislocation of the femoral condyles?

Answer 63

Popliteal artery

The heads of gastrocnemius will contract to pull the fracture segment posteriorly.
The popliteal artery lies against the bone and mav be damaded or comnressed.

Question 64

194 of 610

The inferior aspect of the vagina drains to which of the following lymph node groups?

Answer 64

Superficial inguinal nodes

Question 65

193 of 610

When performing minor surgery in the scalp, which of the following regions is considered a danger area as regards spread of infection into the CNS?

Answer 65

Loose areolar tissue

This area is most dangerous as infections can spread easily. The emissary veins that drain this area may allow sepsis to spread to the cranial cavity.

Question 66

195 of 610

Which of the following is not contained within the deep posterior compartment of the lower leg?

Answer 66

Tibialis posterior muscle

Posterior tibial artery

Tibial nerve

Sural nerve(Right)

Flexor hallucis longus
………………………………….
The deep posterior compartment lies anterior to soleus. The sural nerve is superficially sited and therefore not contained within it.

Question 67

196 of 610

The thebesian veins contribute to the venous drainage of the heart. Into which of the following structures do they primarily drain?

Answer 67

Atrium

The thebesian veins are numerous small veins running over the surface of the heart they drain into the heart itself. Usually this is to the atrium directly.

Question 68

197 of 610

Which of the following muscles lies medial to the long thoracic nerve?

Answer 68

Serratus anterior

Question 68

199 of 610

What is embryological origin of the pulmonary artery?

Answer 68

Sixth pharyngeal arch

The proximal part of the sixth right pharyngeal arch gives origin to the right pulmonary artery. The distal part gives origin to the left pulmonary artery and the ductus arteriosus.

Question 68

198 of 610

A 53 year old lady presents with pain and discomfort in her hand. She works as a typist and notices that the pain is worst when she is working. She also suffers symptoms at night. Her little finger is less affected by the pain. Which of the nerves listed below is most likely to be affected?

Answer 68

Median

Motor supply: LOAF

L ateral 2 lumbricals
O pponens pollicis
A bductor pollicisbrevis
F lexor pollicis brevis

The most likely diagnosis here is carpal tunnel syndrome, the median nerve is compressed in the wrist and symptoms usually affect the fingers and wrist either at night or when the hand is being used (e.g. as a typist).