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Block IV

Block Iv

by nguyenthanhvuh9, Apr. 2009

Subjects: block iv

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130 Cards in this Set

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	A 63-year-old man comes to an emergency department with back pain, weakness, and shortness of breath. On examination, he has an aneurysm of the abdominal aorta at the aortic hiatus of the diaphragm. Which of the follow-ing pairs of structures would most likely be compressed? (A) Vagus nerve and azygos vein (B) Esophagus and vagus nerve (C) Azygos vein and thoracic duct (D) Thoracic duct and vagus nerve (E) Inferior vena cava and phrenic nerve	C. The aortic hiatus of the diaphragm transmits the azygos vein and thoracic duct. The vagus nerve passes through the esophageal hiatus, and the right phrenic nerve may run through the vena caval hiatus.
	A 36-year-old woman with yellow pigmentation of the skin and sclerae presents at the out-patient clinic. Which of the following conditions most likely is the cause of her obstructive jaundice? (A) Aneurysm of the splenic artery (B) Perforated ulcer of the stomach (C) Obstruction of the main pancreatic duct (D) Cancer in the head of the pancreas (E) Cancer in the body of the pancreas	D. Because the bile duct traverses the head of the pancreas, cancer in the head of the pancreas obstructs the bile duct, resulting in jaundice. Aneurysm of the splenic artery, ob- struction of the main pancreatic duct, a stomach ulcer, and cancer in the body of the pancreas are not closely associated with the bile duct. The tail of the pancreas is located at the hilus of the spleen, which lies far from the bile duct.
	A 2-year-old boy presents with pain in his groin that has been increasing in nature over the past few weeks. He is found to have a degener- ative malformation of the transversalis fascia during development. Which of the following structures on the anterior abdominal wall is likely defective? (A) Superficial inguinal ring (B) Deep inguinal ring (C) Inguinal ligament (D) Sac of a direct inguinal hernia (E) Anterior wall of the inguinal canal	B. The deep inguinal ring lies in the transversalis fascia, just lateral to the inferior epigastric vessels. The superficial inguinal ring is in the aponeurosis of the external oblique muscle. The inguinal ligament and the anterior wall of the inguinal canal are formed by the aponeurosis of the external oblique muscle. The sac of a direct inguinal hernia is formed by the peritoneum.
	A 29-year-old man comes to a local hospital with duodenal peptic ulcer and complains of cramping epigastric pain. Which of the follow- ing structures harbor the cell bodies of abdominal pain fibers? (A) Lateral horn of the spinal cord (B) Anterior horn of the spinal cord (C) Dorsal root ganglion (D) Sympathetic chain ganglion (E) Celiac ganglion	C. Cell bodies of the abdominal pain fibers are located in the dorsal root ganglion. The lateral horn of the spinal cord contains cell bodies of sympathetic preganglionic nerve fibers; the anterior horn contains cell bodies of general somatic efferent (GSE) fibers. The sympathetic chain ganglion contains cell bodies of sympathetic postganglionic fibers, which supply blood vessels, sweat glands, and hair follicles. The celiac ganglion contains cell bodies of sympathetic post-ganglionic fibers, which supply the visceral organs such as stomach and intestine.
	A 42-year-old obese woman with seven children is brought to a local hospital by her daughter. Physical examination and her radiograph reveal that large gallstones have ulcerated through the posterior wall of the fundus of the gallbladder into the intestine. Which of the following parts of the intestine is most likely to initially contain gallstones? (A) Cecum (B) Ascending colon (C) Transverse colon (D) Descending colon (E) Sigmoid colon	C. The fundus of the gallbladder is in contact with the transverse colon and thus gallstones erode through the posterior wall of the gallbladder and enter the transverse colon. They are passed naturally to the rectum through the descending colon and sigmoid colon. Gallstones lodged in the body of the gallbladder may ulcerate through the posterior wall of the body of the gallbladder into the duodenum (because the gallbladder body is in contact with the duodenum) and may be held up at the ileocecal junction, producing an intestinal obstruction.
	A 35-year-old woman comes to a local hospital with abdominal tenderness arid acute pain. On examination, her physician observes that an abdominal infection has spread retroperitoneally. Which of the following structures is most likely affected? (A) Stomach (B) Transverse colon (C) Jejunum (D) Descending colon (E) Spleen	D. The descending colon is a retroperitoneal organ. The rest of the organs are surrounded by peritoneum.
	During an annual health examination of a 46-year-old woman, a physician finds hyper- secretion of norepinephrine from her suprarenal medulla. Which of the following types of nerve fibers are most likely overstimulated? (A) Preganglionic sympathetic fibers (B) Postganglionic sympathetic fibers (C) Somatic motor fibers (D) Postganglionic parasympathetic fibers (E) Preganglionic parasympathetic fibers	A. The suprarenal medulla is the only organ that receives preganglionic sympathetic fibers. No other nerve fibers are involved in secretion of norepinephrine secretion from the suprarenal medulla.
	A 6-year-old girl comes to her pediatrician with constipation, abdominal distention, and vomiting. After thorough examination, she is diagnosed as having Hirschsprung's disease (aganglionic megacolon), which is a congenital disease and leads to dilation of the colon. This condition is caused by an absence of which of the following kinds of neural cell bodies? (A) Sympathetic preganglionic neuron cell bodies (B) Sympathetic postganglionic neuron cell bodies (C) Parasympathetic preganglionic neuron cell bodies (D) Parasympathetic postganglionic neuron cell bodies (E) Sensory neuron cell bodies	D. Aganglionic megacolon (Hirschsprung's disease) is caused by the absence of enteric ganglia (parasympathetic postganglionic neuron cell bodies) in the lower part of the colon, which leads to dilatation of the colon proximal to the inactive segment, resulting in an inability to evacuate the bowels. The other neuron cell bodies listed are not involved in this condition.
	A pediatric surgeon is resecting a possible malignant mass from the liver of a neonate with cerebral palsy. The surgeon divides the round ligament of the liver during surgery. A fibrous remnant of which of the following fetal vessels is severed? (A) Ductus venosus (B) Ductus arteriosus (C) Left umbilical vein (D) Right umbilical vein (E) Umbilical artery	C. The left umbilical vein becomes the round ligament of the liver after birth. The right umbilical vein did not leave a fibrous remnant because it was degenerated during the early embryonic period. The ductus venosus forms the ligamentum venosum; the ductus arterio- sus forms the ligamentum arteriosum; the umbilical artery forms the medial umbilical ligament.
	A 27-year-old woman has suffered a gun-shot wound to her midabdomen. After examining the patient's angiogram, a trauma surgeon locates the source of bleeding from pairs of veins that typically terminate in the same vein. Which of the following veins are damaged? (A) Left and right ovarian veins (B) Left and right gastroepiploic veins (C) Left and right colic veins (D) Left and right suprarenal veins (E) left and right hepatic veins	E. The right and left hepatic veins drain into the inferior vena cava. The right gastroepiploic vein drains into the superior mesenteric vein, but the left one drains into the splenic vein. The right gonadal and suprarenal veins drain into the inferior vena cava, whereas the left ones drain into the left renal vein. The right colic vein ends in the superior mesenteric vein, but the left one terminates in the inferior mesenteric vein.
	A 43-year-old man complains of abdominal pain just above his umbilicus. On examination, a tumor is found anterior to the inferior vena cava. Which of the following structures would most likely be compressed by this tumor? (A) Right sympathetic trunk (B) Left third lumbar artery (C) Third part of the duodenum (D) Left renal artery (E) Cisterna chyli	C. The third part of the duodenum (transverse portion) crosses anterior to the inferior vena cava. The other structures do not cross the inferior vena cava anteriorly.
	A 33-year-old man with a perforated gastric ulcer complains of excruciating pain in his stomach. It is observed that the pain comes from peritoneal irritation by gastric contents in the lesser sac. Which of the following nerves contain sensory nerve fibers that convey this sharp, stabbing pain? (A) Vagus nerves (B) Greater splanchnic nerves (C) Lower intercostal nerves (D) White rami communicantes (E) Gray rami communicantes	C. Pain sensation originating from peritoneal irritation by gastric contents in the lesser sac is carried by lower intercostals nerves. The vagus nerves carry sensory fibers associated with reflexes in the gastrointestinal (GI) tract. The greater splanchnic nerves and white rami cornmunicantes carry pain (general visceral afferent [GVA]) fibers from the wall of the stomach and other areas of the GI tract. The gray rami communicantes contains no sensory fibers but contain sympathetic postganglionic fibers.
	A young boy is brought to the hospital after a bicycle accident and possible pelvic fracture. While awaiting a computed tomography (CT) scan of his pelvis, a physician proceeds with a focal neurologic examination. In testing the child's reflexes, which of the following nerves would carry afferent impulses of the cremasteric reflex? (A) Subcostal nerve (B) Lateral femoral cutaneous nerve (C) Genitofem oral nerve (I)) Iliohypogastric nerve (E) Femoral nerve	C. Stimulation of the cremaster muscle draws the testis up from the scrotum toward the superficial inguinal ring. The efferent limb of the reflex arc is the genital branch of the genitofemoral nerve, whereas the afferent limb is the femoral branch of the genitofemoral nerve. The other nerves are not involved in the cremasteric reflex.
	A 21-year-old man receives a penetrating knife wound in the abdomen and is injured in both the superior mesenteric artery and the vagus nerve. Which portion of the colon would most likely be impaired by this injury? (A) Ascending and descending colons (B) Transverse and sigmoid colons (C) Descending and sigmoid colons (D) Ascending and transverse colons (E) Transverse and descending colons	D. The ascending and transverse colons receive blood from the superior mesen- teric artery and parasympathetic nerve fibers from the vagus nerve. However, the descending and sigmoid colons receive blood from the inferior mesenteric artery and the parasympathetic nerve fibers from the pelvic splanchnic nerve arising from sacral spinal nerves (S2–S4).
	A 42-year-old man with portal hypertension secondary to cirrhosis of the liver and subse- quent massive ascites presents to the emergency department. He refuses to have a transjugular intrahepatic portosystemic shunt (TIPS) proce- dure and prefers surgery. Which of the following surgical connections are involved in the most practical method of shunting portal blood around the liver? (A) Superior mesenteric vein to the inferior mesenteric vein (B) Portal vein to the superior vena cava (C) Portal vein to the left renal vein (D) Splenic vein to the left renal vein (E) Superior rectal vein to the left colic vein	D. Portal hypertension can be reduced by diverting blood from the portal to the caval system. This is accomplished by connecting the splenic vein to the left renal vein or by creating a communication between the portal vein and the inferior vena cava. A connection between an hepatic vein and a branch of the portal vein can be accomplished by the transjugu- lar intrahepatic portosystemic shunt (TIPS) procedure in the treatment of bleeding esophageal varices.
	A 78-year-old man is suffering from is- chemia of the suprarenal glands. Rapid occlu- sion of direct branches of which of the follow- ing arteries results in this condition? (A) Aorta, splenic and inferior phrenic arteries (B) Renal, splenic, and inferior mesenteric arteries (C) Aorta, inferior phrenic and renal arteries (D) Superior mesenteric, inferior mesenteric, and renal arteries (E) Aorta, hepatic and renal arteries	C. The suprarenal gland receives arteries from three sources. The superior suprarenal artery arises from the inferior phrenic artery, the middle suprarenal artery arises from the abdominal aorta, and the inferior suprarenal artery arises from the renal artery. The hepatic, superior mesenteric, inferior mesenteric, and splenic arteries do not supply the suprarenal gland.
	A radiograph of a 32-year-old woman re- veals a perforation in the posterior wall of the stomach in which the gastric contents have spilled into the lesser sac. The general surgeon has opened the lienogastric (gastrosplenic) lig- ament to reach the lesser sac and notes erosion of the ulcer into an artery. Which of the follow- ing vessels is most likely involved? (A) Splenic artery (B) Gastroduodenal artery (C) Left gastric artery (D) Right gastric artery (E) Left gastroepiploic artery	E. The left gastroepiploic artery runs through the lienogastric ligament, hence it is the artery most likely injured. The splenic artery is found in the lienorenal ligament. The right and left gastric arteries run within the lesser omentum. The gastroduodenal artery descends between the duodenum and the head of the pancreas.
	A 35-year-old woman with a history of cholecystectomy arrives in the emergency room with intractable hiccups most likely caused by an abdominal abscess secondary to surgical infection. Which of the following nerves carries pain sensation caused by irrita- tion of the peritoneum on the central portion of the inferior surface of the diaphragm? (A) Vagus nerve (B) Lower intercostal nerve (C) Phrenic nerve (D) Greater splanchnic nerve (E) Subcostal nerve	C. The diaphragm receives somatic motor fibers solely from the phrenic nerves. However, the peritoneum on the central part of the diaphragm receives sensory fibers from the phrenic nerve, and the peripheral part of the diaphragm receives such fibers from the lower intercostal nerves. The subcostal nerve supplies the peritoneum inferior to the diaphragm. The vagus and greater splanchnic nerves do not carry pain fibers from the peritoneum.
	A 16-year-old boy with ruptured spleen comes to the emergency department for splenectomy. Soon after ligation of the splenic artery just distal to its origin, a surgical resident observes that the patient is healing normally. Normal blood flow would occur in which of the following arteries? (A) Short gastric arteries (B) Dorsal pancreatic artery (C) Inferior pancreaticoduodenal artery (D) Left gastroepiploic artery (E) Artery in the lienorenal ligament	C. The inferior pancreaticoduodenal artery is a branch of the superior mesenteric artery. All of other arteries are branches of the splenic artery.
	A 9-year-old boy was admitted to the emergency department complaining of nau- sea, vomiting, fever, and loss of appetite. On examination, he was found to have tenderness and pain on the right lower quadrant. Based on signs and symptoms, the diagnosis of acute appendicitis was made. During an appendec- tomy performed at McBurney's point, which of the following structures is most likely to be injured? (A) Deep circumflex femoral artery (B) Inferior epigastric artery (C) Iliohypogastric nerve (D) Genitofemoral nerve (E) Spermatic cord	C. The iliohypogastric nerve runs medially and inferiorly between the internal oblique and transverse abdominal muscles near the McBurney's point, the point at the junction of the lateral one third of a line between the anterior superior iliac spine and the umbilicus. Other structures are not found near the McBurney's point.
	A 54-year-old man with a long history of alcohol abuse presents to the emergency department with rapidly increasing abdominal disten- tion most likely resulting from an alteration in portal systemic blood flow. Which of the following characteristics is associated with the portal vein or the portal venous system? (A) Lower blood pressure than in the inferior vena cava (B) Least risk of venous varices because of portal hypertension (C) Distention of the portal vein resulting from its numerous valves (D) Caput medusae and hemorrhoids caused by portal hypertension (E) Less blood flow than in the hepatic artery	D. Portal hypertension can cause esophageal varices, caput medusa, and hemorrhoids. The portal vein has higher pressure than systemic veins; the vein and its tributaries have no valves, or, if present, they are insignificant. In addition, the portal vein carries two to three times as much blood as the hepatic artery.
	While examining radiographs and angiograms of a 52-year-old patient, a physician is trying to distinguish the jejunum from the ileum. He has observed that the jejunum has: (A) Fewer plicae circulares (B) Fewer mesenteric arterial arcades (C) Less digestion and absorption of nutrients (D) Shorter vasa recta (E) More fat in its mesentery	B. The jejunum has fewer mesenteric arterial arcades but longer vasa recta than the ileum. The plicae circulares (circular folds) are tall and closely packed in the jejunum and are low and sparse in the ileum, and the lower part of the ileum has no plicae circulares. More digestion and absorption of nutrients occurs in the jejunum than in the ileum, and less fat is found in the mesentery of the jejunum.
	A 67-year-old woman with a long history of liver cirrhosis was seen in the emergency department. In this patient with portal hypertension, which of the following veins is most likely to be dilated? (A) Right colic vein (B) Inferior epigastric vein (C) Inferior phrenic vein (D) Suprarenal vein (E) Ovarian vein	A. The right colic vein belongs to the portal venous system and empties into the superior mesenteric vein, which joins the splenic vein to form the portal vein. The inferior epigastric, inferior phrenic, suprarenal, and ovarian veins belong to the systemic (or caval) venous system and drain directly or indirectly into the inferior vena Cava.
	A 26-year-old patient is admitted to a local hospital with a retroperitoneal infection. Which of the following arteries is most likely to be infected? (A) Left gastric artery (B) Proper hepatic artery (C) Middle colic artery (D) Sigmoid arteries (E) Dorsal pancreatic artery	E. The pancreas is a retroperitoneal organ, except for a small portion of its tail. The dorsal pancreatic artery would be the infected artery because it arises from the splenic artery and runs ret roperitoneally along the superior border of the pancreas behind the peritoneum. The other arteries run within layers of the peritoneum. The left gastric arteries run within the lesser omentum; the proper hepatic artery runs within the free margin of the lesser omentum; the middle colic artery runs within the transverse mesocolon; the sigmoid arteries run within the sigmoid mesocolon.
	A pediatric surgeon has resected a structure that is a fibrous remnant of embryonic or fetal artery in a 5-year-old child. Which of the fol- lowing structures is most likely to be divided? (A) Lateral umbilical fold (B) Medial umbilical told (C) Median umbilical fold (D) Ligamentum teres hepatis (E) Ligamentum venosum	B. The medial umbilical fold or ligament contains a fibrous remnant of the umbilical artery. The median umbilical fold contains a fibrous remnant of the urachus, The lat- eral umbilical fold (ligament) contains the inferior epigastric artery and vein, which are adult blood vessels. The ligamentum venosum contains a fibrous remnant of the ductus venosus and the ligamentum teres hepatic contains a fibrous remnant of the left umbilical vein.
	A 57-year-old patient has a tumor in the body of the pancreas that obstructs the inferior mesenteric vein just before joining the splenic vein. Which of the following veins is most likely to be enlarged? (A) Middle colic vein (B) Left gastroepiploic vein (C) Inferior pancreaticoduodenal vein (D) Ileocolic vein (E) Left colic vein	E. The left colic vein is a tributary of the inferior mesenteric vein. The middle colic, inferior pancreaticoduodenal, and ileocolic veins drain into the superior mesenteric vein. The lett gastroepiploic vein empties into the splenic vein.
	An elderly man with prostatic hypertrophy returns to his urologist with another case of epididymitis. An acute infection involving the dartos muscle layer of the scrotum most likely leads to an enlargement of which of the following lymph nodes? (A) Preaortic nodes (B) Lumbar nodes (C) External iliac nodes (D) Superficial inguinal nodes (E) Common iliac nodes	D. The superficial inguinal lymph nodes receive lymph from the scrotum, penis, buttocks, and lower part of the anal canal, and their efferent vessels enter primarily to the external iliac nodes and ultimately to the lumbar (aortic) nodes. The deep inguinal nodes receive lymph from the testis and upper parts of the vagina and anal canal, and their efferent vessels enter the external iliac nodes.
	A patient with cryptogenic cirrhosis is scheduled for liver transplant surgery. During the operation rounds, the transplant physi- cian explains to his residents that one of the reasons a surgeon must pay close attention to the anatomic location of the liver is that this organ: (A) Receives blood only from the hepatic arteries (B) Manufactures red blood cells in an adult (C) Drains bile from the quadrate lobe into the right hepatic duct (D) Drains venous blood into the hepatic veins (E) Functions to concentrate and store bile	D. The liver receives blood from the hepatic artery and portal vein and drains its venous blood into the hepatic veins. The liver manufactures red blood cells in the fetus. The liver plays important roles in bile production and secretion. The quadrate lobe drains bile into the left hepatic duct, not the right hepatic duct, whereas the caudate lobe drains bile into the right and left hepatic ducts. The gallbladder functions to concentrate and store bile.
	A 41-year-old woman is brought to the emergency room by her family because of acute onset of right upper quadrant pain, nausea, and vomiting. For this case, it important to remember that the bile duct: (A) Drains bile into the second part of the duodenum (B) Can be blocked by cancer in the body of the pancreas (C) Joins the main pancreatic duct, which carries hormones (D) Is formed by union of the right and left hepatic duct (E) Lies posterior to the portal vein in the right free edge of the lesser omentum	A. The bile duct is formed by union of the common hepatic and cystic ducts, lies lateral to the proper hepatic artery and anterior to the portal vein in the right free margin of the lesser omentum, traverses the head of the pancreas, and drains bile into the second part of the duodenum at the greater papilla. The endocrine part of the pancreas secretes the hormones insulin and glucagon, which are transported through the bloodstream. The main pancreatic duct carries pancreatic juice containing enzymes secreted from the exocrine part of the pancreas.
	A patient with diverticulosis of the colon presents for follow-up to his primary care physician with ongoing complaints of left lower quadrant pain and occasionally bloody stools. His physician begins workup with appropriating test by recalling that the sigmoid colon: (A) Is drained by systemic veins (B) Is a retroperitoneal organ (C) Receives parasympathetic fibers from the vagus nerve (D) Receives its blood from the superior mesenteric artery (E) Has teniae coli and epiploic appendages	E. The sigmoid colon has teniae coli and epiploic appendages. The sigmoid colon receives blood from the inferior mesenteric artery, drains its venous blood through the por- tal tributaries, has its own mesentery (sigmoid mesocolon; therefore, is not a retroperitoneal organ), and receives parasympathetic preganglionic fibers from the pelvic splanchnic nerve.
	A 19-year-old man with ruptured appendix is sent to the emergency department for surgery. To cut off the blood supply to the appendix (if collateral circulation is discounted), a surgeon should ligate which of the following arteries? (A) Middle colic artery (B) Right colic artery (C) Ileocolic colic artery (D) Inferior mesenteric artery (E) Common iliac artery	C. The appendicular artery is a branch of the ileocolic artery. The other arteries do not supply the appendix. The middle colic and right colic arteries are branches of the superior mesenteric artery. The Inferior mesenteric artery passes to the left behind the peritoneum and distributes to the descending and sigmoid colons and the upper portion of the rectum. The com- mon iliac arteries are bifurcations from the aorta.
	Because of an inflammatory bowel disease (Crohn's disease) and a small bowel obstruction leading to bowel ischemia, an elderly woman requires bypass of her ileum and jejunum and is scheduled for a gastrocolostomy. The surgeon will ligate all arteries that send branches to the stomach. Which of the following arteries may be spared? (A) Splenic artery (B) Gastroduodenal artery (C) Inferior pancreaticoduodenal artery (D) Left gastroepiploic artery (E) Proper hepatic artery	C. The inferior pancreaticoduodenal artery does not supply the stomach. All of the other arteries supply the stomach. Gastrocolostomy is used to establish a communication between the stomach and colon, bypassing the small intestine when the patient has Crohn's disease (inflammation disease) and small bowel obstruction.
	A 38-year-old woman with peptic ulcer disease of the stomach experiences severe abdom- inal pain. Which of the following nervous structures would most likely be involved? (A) Greater splanchnic nerve (B) Ventral roots of the spinal nerve (C) Lower intercostal nerve (D) Vagus nerve (E) Gray ramus communicans	A. The greater splanchnic nerve carries pain fibers from the upper gastrointestinal (GI) tract. Neither the ventral roots of the spinal nerves nor the gray rami corn municantes contain sensory nerve fibers. The vagus nerve contains sensory fibers associated with reflexes, but it does not contain pain fibers. The lower intercostals nerves carry general somatic afferent (GSA) pain fibers from the diaphragm, abdominal wall, and peritoneum but not general visceral afferent (GVA) pain fibers from the GI tract.
	Before beginning a cesarean section (C- section) in a pregnant woman with a genital herpes infection, the obstetrician noted that she had an aponeurosis of the transverse abdominal muscle. This aponeurosis most likely contributes to the formation of which of the following? (A) Anterior layer of the rectus sheath below the arcuate line (B) Anterior layer of the rectus sheath above the umbilicus (C) Posterior layer of the rectus sheath below the arcuate line (D) Deep inguinal ring (E) Lacunar ligament	A. The anterior layer of the rectus sheath below the arcuate line is formed by aponeuroses of the external and internal oblique and transverse abdominal muscles, but there is no posterior layer of the rectus sheath below the arcuate line. The anterior layer of the rectus sheath above the umbilicus is formed by aponeuroses of the external and internal oblique abdominal muscles. The deep inguinal ring lies in the transversalis fascia. The lacunar ligament is formed by the external oblique abdominal aponeurosis.
	Examination of a 54-year-old man reveals an isolated tumor located at the porta hepatis. This tumor most likely compresses which of the following structures? (A) Cystic duct (B) Hepatic veins (C) Common hepatic artery (D) Left gastric artery (E) Branches of the portal vein	E. The porta hepatis is the transverse fissure (doorway) in the liver and contains the hepatic ducts, hepatic arteries, and branches of the portal vein. "the other structures are not found in the porta hepatis.
	A patient is rushed to the operating room for an emergent cholecystectomy (resection of a gallbladder) because of cholecystitis. While locating landmarks before surgical resection of an infected gallbladder, the surgeon recalls that one pair of veins forms a portal-caval anasto- mosis. Which of the following pairs of veins form a portal-caval anastomosis? (A) Hepatic veins and inferior vena cava (B) Superior and middle rectal vein (C) Left and right gastric veins (D) Inferior and superficial epigastric veins (E) Suprarenal and renal veins	B. Portal-caval anastomoses occur between the left gastric vein and esophageal vein of the azygos, the superior rectal and middle or inferior rectal veins, paraumbilical and superficial epigastric veins, and retrocolic veins and twigs of the renal vein. The hepatic veins and the inferior vena cava are systemic or caval veins. The left and right gastric veins belong to the por- tal venous system. The inferior and superficial epigastric veins and the suprarenal and renal veins are systemic veins.
	Mrs. Jones is undergoing a routine colonoscopy for colon cancer prevention. The gastroenterologist finds a Meckel's diverticulum. Which of the following statements is true about the diverticulum? (A) It is found 2 feet distal to the ileocecal junction (B) It is located on the mesenteric side of the ileum (C) It occurs in about 20% of the population (D) It is a persistent remnant of the embryonic yolk sac (E) It may contain renal and suprarenal tissues	D. The Meckel's diverticulum is a persistent remnant of the yolk stalk (vitelline duct) and located 2 feet proximal to the ileocecal junction on the antimesenteric border of the ileum. It is about 2 inches long, occurs in about 2% of the population, and contains two types of mucosal (gastric and pancreatic) tissues in its wall.
	A 54-year-old man comes to a hospital with abdominal pain, jaundice, loss of appetite, and weight loss. On examination of his radiograms and computed tomography (CT) scans, a physician finds a slowly growing tumor in the uncinate process of the pancreas. Which of the following structures is most likely compressed by this tumor? (A) Main pancreatic duct (B) Splenic artery (C) Portal vein (D) Superior mesenteric artery (E) Superior pancreaticoduodenal artery	D. The uncinate process of the pancreas is a projection of the lower part of the head to the left behind the superior mesenteric vessels. The superior pancreaticoduodenal artery runs between the duodenum and the head of the pancreas. The main pancreatic runs transversely through the entire pancreas superior to the uncinate process. The splenic artery runs along the superior border of the pancreas. The portal vein runs behind the neck of the pancreas.
	A 6-year-old boy comes to his pediatrician with a lump in the groin near the thigh and pain in the groin. On examination, the physician makes a diagnosis of a direct inguinal hernia because the herniated tissue: (A) Enters the deep inguinal ring (B) Lies lateral to the inferior epigastric artery (C) Is covered by spermatic fasciae (D) Descends into the scrotum (E) Develops after birth	E. A direct hernia is acquired (develops after birth), whereas an indirect inguinal hernia is congenital. The direct hernia does not enter the deep inguinal ring but occurs through the posterior wall of the inguinal canal, lies medial to the inferior epigastric artery, is covered only by peritoneum, and does not descend into the scrotum.
	A 21-year-old young man was lifting heavy boxes while moving into his new house. During the repair of his resulting hernia, the urologist recalls that the genitofemoral nerve: (A) Runs in front of the quadratus lumborum (B) Is a branch of the femoral nerve (C) Supplies the testis (D) Passes through the deep inguinal ring (E) Gives rise to an anterior scrotal branch	D. The genitofemoral nerve descends on the anterior surface of the psoas muscle and gives rise to a genital branch, which enters the inguinal canal through the deep inguinal ring to supply the cremaster muscle, and a femoral branch, which supplies the skin of the femoral triangle. The genitofemoral nerve is not a branch of the femoral nerve but arises from the lumbar plexus, and does not supply the testis. It is the ilioinguinal nerve that gives rise to an anterior scrotal branch.
	An oncologist is reviewing a computed tomography (CT) scan of a 74-year-old man with newly diagnosed hepatocellular carci- noma. He locates the affected quadrate lobe of the liver that: (A) Lies between the inferior vena cava and ligamentum venosum (B) Receives blood from the right hepatic artery (C) Drains bile into the left hepatic duct (D) Is a medial superior segment (E) Is functionally a part of the right lobe	C. The quadrate lobe of the liver drains bile into the left hepatic duct and receives blood from the left hepatic artery. It lies between the gallbladder fossa and the liga- mentum teres hepatic, is a medial inferior segment, and is a part of the left lobe,
	A 58-year-old man is presented with edema of the lower limb and enlarged superficial veins of the abdominal wall. Examination of radi- ographs and angiograms reveals obstruction of the inferior vena cava just proximal to the origin of the renal vein. This venous blockage may result in dilation of which of the following veins? (A) Left suprarenal vein (B) Right inferior phrenic vein (C) Right hepatic vein (D) Left gastric vein (E) Portal vein	A. The veins distal to obstruction are dilated, but the veins proximal to ob- struction are not dilated but have low blood pressure. The suprarenal vein drains into the left renal vein and thus is dilated because of high pressure. The right phrenic and right hepatic veins drain into the inferior vena cava above the obstruction. The left gastric vein joins the portal vein, which enters the liver.
	A physical fitness trainer for a young Hollywood movie star explains the reasons for 100 stomach crunches a day. The young star, a medical student before "hitting it big" reaffirms to his trainer that the lateral margin of the rectus abdominis, the muscle responsible for a wash- board stomach, defines which one of the following structures? (A) Linea alba (B) Linea semilunaris (C) Linea semicircularis (D) Transversalis fascia (E) Falx inguinalis	B. The linea semilunaris is a curved line along the lateral border of the rectus abdominis. The linea alba is a tendinous median raphe between the two rectus abdominis muscles. The linea semicircularis is an arcuate line of the rectus sheath, which is the lower limit of the posterior layer of the rectus sheath. The falx inguinalis (conjoint tendon) is formed by aponeuroses of the in- ternal oblique and transverse abdominal muscles (otherwise known as the transversalis fascia).
	During surgical treatment of portal hypertension of a 59-year-old man with liver cirrhosis, a surgeon inadvertently lacerates the dilated paraumbilical veins. The veins must be repaired to allow collateral flow. Which of the following ligaments is most likely severed? (A) Lienorenal ligament (B) Lienogastric ligament (C) Gastrophrenic ligament (D) Ligamentum teres hepatis (E) Ligamentum venosum	D. The paraumbilical veins and the ligamentum teres hepatis are contained in the free margin of the falciform ligament. The lienorenal ligament contains the splenic vessels and a small portion of the tail of the pancreas. The lienogastric ligament contains the left gas- troepiploic and short gastric vessels. The gastrophrenic ligament contains no named structures. The hepatoduodenal ligament, a part of the lesser omentum, contains the bile duct, proper hepatic artery, and portal vein in its free margin.
	A 43-year-old woman is admitted to a hospital because of deep abdominal pain in her epigastric region. On examination, it is ob- served that a retroperitoneal infection erodes an artery that runs along the superior border of the pancreas. Which of the following arteries is likely injured? (A) Right gastric artery (B) Left gastroepiploic artery (C) Splenic artery (D) Gastroduodcnal artery (E) Dorsal pancreatic artery	C. The splenic artery arises from the celiac trunk, runs along the superior border of the pancreas, and enters the spleen through the lienorenal ligament and the hilus of the spleen. The right gastric artery runs along the lesser curvature of the stomach, and the left gastroepiploic artery runs along the greater curvature of the stomach. "I he gastroduodenal artery runs behind the first part of the duodenum. The dorsal pancreatic artery descends behind the neck of the pancreas and divides into right and left branches to supply the pancreas.
	A 19-year-old young woman with a long history of irritable bowel syndrome presents for the possibility of surgical resection of the gas- trointestinal (GI) tract where the vagal parasympathetic innervation terminates. Which of the following sites is most appropriate for surgical resection? (A) Duodenojejunal junction (B) Ileocecal junction (C) Right colic flexure (D) Left colic flexure (E) Anorectal junction	D. The vagus nerve supplies parasympathetic nerve fibers to the gastrointestinal (GI) tract and terminates approximately at the left colic flexure (junction of the transverse colon and the descending colon). The duodenojejunal junction, ileocecal junction, and right colic flexure are supplied by the vagus nerve. The descending colon, sigmoid colon, rectum, anal canal, and anorectal junction are supplied by the pelvic splanchnic nerve for parasympathetic innervation.
	A 58-year-old man is admitted to a hospital with severe abdominal pain, nausea, and vomiting resulting in dehydration. Emergency com- puted tomography (CT) scan reveals a tumor located between the celiac trunk and the superior mesenteric artery. Which of the following structures is likely compressed by this tumor? (A) Fundus of the stomach (B) Neck of the pancreas (C) Transverse colon (D) Hepatopancreatic ampulla (E) Duodenojejunal junction	B. The pyloric canal and the neck of the pancreas are situated anterior to the abdominal aorta between the origin of the celiac trunk and the superior mesenteric artery. The transverse colon passes anterior to the superior mesenteric artery and the third part of the duode- num. The other structures are not located in front of the aorta.
	An emergent hernia repair is scheduled. As the attending physician is driving to the hospi- tal, the medical student assisting on the case quickly reviews his anatomy atlas and is trying to commit to memory that the internal oblique abdominis muscle contributes to the formation of which of the following structures? (A) Inguinal ligament (B) Deep inguinal ring (C) Falx inguinalis (D) Internal spermatic fascia (E) Reflected inguinal ligament	C. The falx inguinalis (conjoint tendon) is formed by the aponeuroses of the internal oblique and transverse muscles of the abdomen. The inguinal ligament is formed by aponeurosis of the external oblique abdominal muscle and the reflected inguinal ligament is formed by certain fibers of the inguinal ligament reflected from the pubic tubercle upward toward the linea alba. The deep inguinal ring lies in the transversalis fascia, and the internal spermatic fascia is formed by the transversalis fascia.
	A 9-year-old girl has crashed into her neighbor's brick fence while riding her bike and is brought to the emergency department with a great deal of abdominal pain. Her radi- ogram and angiogram show laceration of the superior mesenteric artery immediately distal to the origin of the middle colic artery. If col- lateral circulation is discounted, which of the following organs may become ischemic? (A) Descending colon (B) Duodenum (C) Pancreas (D) Ascending colon (E) Transverse colon	D. The right colic and ileocolic arteries arise from the superior mesenteric artery distal to the origin of the middle colic artery. The right colic artery may arise from the ileocolic artery and supplies the ascending colon. The duodenum and pancreas receive blood from the inferior pancreaticoduodenal artery and superior pancreaticoduodenal. The pancreas is also supplied by the splenic artery of the celiac trunk. The transverse colon receives blood from the middle colic artery. The descending colon is supplied by the left colic artery, which is a branch of the inferior mesenteric artery.
	A 53-year-old woman with known kidney disease presents to a hospital because her pain has become increasingly more severe. A physician performing kidney surgery must remember that: (A) The left kidney lies a bit lower than the right one (B) The peri-renal fat lies external to the renal fascia (C) The renal fascia does not surround the suprarenal gland D) The left renal vein runs anterior to both the aorta and the left renal artery (E) The right renal artery is shorter than the left one	D. The left renal vein runs anterior to both the aorta and the left renal artery. The renal fascia lies external to the perirenal fat and internal to the pararenal fat, and it also sur- rounds the suprarenal gland. The right renal artery runs behind the inferior vena cava and is longer than the left renal artery. Because of the large size of the right lobe of the liver, the right kidney lies a little lower than the left.
	A 68-year-old woman with uterine carcinoma undergoes surgical resection. This cancer can spread directly to the labia majora in lym- phatics that follow which of the following structures? (A) Pubic arcuate ligament (B) Suspensory ligament of the ovary (C) Cardinal (transverse cervical) ligament (D) Suspensory ligament of the clitoris (E) Round ligament of the uterus	E. The round ligament of the uterus runs laterally from the uterus through the deep inguinal ring, inguinal canal, and superficial inguinal ring and becomes lost in the subcutaneous tissues of the labium majus. Thus, carcinoma of the uterus can spread directly to the labium majus by traveling in lymphatics that follow the ligament. The pubic arcuate ligament at- taches across the inferior aspect of the pubic symphysis and attaches to the medial borders of the inferior pubic rami. The suspensory ligament of the ovary runs from the ovary to the pelvic wall and transmits the ovarian vessels. The cardinal (transverse cervical) ligament runs from the cervix and the vagina to the pelvic walls. The suspensory ligament of the clitoris runs from the pubic symphysis and the arcuate pubic ligament to the deep fascia of the body of the clitoris.
	A 17-year-old boy suffers a traumatic groin injury during a soccer match. The urologist no- tices tenderness and swelling of the boy's left testicle that may be produced by thrombosis in which of the following veins? (A) Left internal pudendal vein (8) Left renal vein (C) Inferior vena cava (D) Left inferior epigastric vein (E) Left external pudendal vein	B. A tender swollen left testis may be produced by thrombosis in the left renal vein, because the left testicular vein drains into the left renal vein. The right testicular vein drains into the inferior vena cava. The left internal pudendal vein empties into the left internal iliac vein. The left inferior epigastric drains into the left external iliac vein and the left external pudendal vein empties into the femoral vein.
	On a busy Saturday night in Chicago, a 16-year-old boy presents to the emergency room with a stab wound from a knife that enters the pelvis above the piriformis muscle. Which of the following structures is most likely to be damaged? (A) Sciatic nerve (B) Internal pudendal artery (C) Superior gluteal nerve (D) Inferior gluteal artery (E) Posterior femoral cutaneous nerve	C. The superior gluteal nerve leaves the pelvis through the greater sciatic foramen, above the piriformis. The sciatic nerve, internal pudendal vessels, inferior gluteal vessels and nerve, and posterior femoral cutaneous nerve leave the pelvis below the piriformis.
	A 22-year-old woman receives a deep cut in the inguinal canal 1 inch lateral to the pubic tubercle. Which of the following ligaments is lacerated within the inguinal canal? (A) Suspensory ligament of the ovary (B) Ovarian ligament (C) Mesosalpinx (D) Round ligament of the uterus (E) Rectouterine ligament	D. The round ligament of the uterus is found in the inguinal canal along its course. Other ligaments are not passing through the inguinal canal.
	A 29-year-old carpenter sustains severe injuries of the pelvic splanchnic nerve by a deep puncture wound, which has become contaminated. The injured parasympathetic preganglionic fibers in the splanchnic nerve are most likely to synapse in which of the following ganglia? (A) Ganglia in or near the viscera or pelvic plexus (B) Sympathetic chain ganglia (C) Collateral ganglia (D) Dorsal root ganglia (E) Ganglion impar	A. The pelvic splanchnic nerves carry preganglionic parasympathetic general visceral efferent (GVE) fibers that synapse in the ganglia of the inferior hypogastric plexus and in terminal ganglia in the muscular walls of the pelvic organs. The sympathetic preganglionic fibers synapse in the sympathetic chain (paravertebral) ganglia or in the collateral (prevertebral) gan- glia. The dorsal root ganglia contains cell bodies of general somatic afferent (GSA) and general visceral afferent (GVA) fibers and have no synapsis. The two sympathetic trunks unite and terminate in the ganglion impar (coccygeal ganglion), which is the most inferior, unpaired ganglion located in front of the coccyx.
	A 59-year-old woman comes to a local hospital for uterine cancer surgery. As the uterine artery passes from the internal iliac artery to the uterus, it crosses superior to which of the following structures that is sometimes mistakenly ligated during such surgery? (A) Ovarian artery (B) Ovarian ligament (C) Uterine tube (D) Ureter (E) Round ligament of the uterus	D. The ureter runs under the uterine artery near the cervix; thus, the ureter is sometimes mistakenly ligated during pelvic surgery. The other structures mentioned are not closely related to the uterine artery near the uterine cervix.
	A 29-year-old woman is admitted to a hospital because the birth of her child is several days overdue. Tearing of the pelvic diaphragm during childbirth leads to paralysis of which of the following muscles? (A) Piriformis (B) Sphincter urethrae (C) Obturator internus (D) Levator ani (E) Sphincter ani externus	D. The pelvic diaphragm is formed by the levator ani and coccygeus, whereas the urogenital diaphragm consists of the sphincter urethrae and deep transverse perinei muscles. The piriformis passes through the greater sciatic notch and inserts on the greater trochanter of the femur. The obturator internus forms the lateral wall of the ischiorectal fossa. The sphincter ani externus is composed of three layers, including the subcutaneous (corrugator cutis ani), superficial, and deep portions and maintains a voluntary tonic contracture.
	A 37-year-old small business manager receives a gunshot wound in the pelvic cavity, resulting in a lesion of the sacral splanchnic nerves. Which of the following nerve fibers would primarily be damaged? (A) Postganglionic parasympathetic fibers (B) Postganglionic sympathetic fibers (C) Preganglionic sympathetic fibers (D) Preganglionic parasympathetic fibers (E) Postganglionic sympathetic and parasym- pathetic fibers	C. The sacral splanchnic nerves consist primarily of preganglionic sympathetic neurons and also contain general visceral afferent (GVA) fibers. None of the other fibers listed are contained in these nerves.
	A young couple is having difficulty conceiving a child. Their physician at a reproduction and fertility clinic explains to them that: (A) The ovary lies within the broad ligament (B) The glans clitoris is formed from the cor- pus spongiosum (C) Erection of the penis is a sympathetic re- sponse (D) Ejaculation follows parasympathetic stim- u lation (E) Fertilization occurs in the infundibulum or ampulla of the uterine tube.	E. Fertilization takes place in the infundibulum or ampulla of the uterine tube. The glans clitoris is derived from the corpora cavernosa, whereas the glans penis is the expanded terminal part of the corpus spongiosum. Erection of the penis is caused by parasympathetic stimulation, whereas ejaculation is mediated via the sympathetic nerve. The ovaries are not enclosed in the broad ligament, but their anterior surface is attached to the posterior surface of the broad ligament.
	A 46-year-old woman has a history of infection in her perineal region. A comprehensive examination reveals a tear of the superior boundary of the superficial perineal space. Which of the following structures would most likely be injured? (A) Pelvic diaphragm (B) Colles' fascia (C) Superficial perineal fascia (D) Deep perineal fascia (E) Perineal membrane (E) Posterior wall of the bladder 15. A 37-year-old man is suffering from carci- noma of the skin of the glans penis. Cancer cells are likely to metastasize directly to which of the following lymph nodes? (A) External iliac nodes (B) Internal iliac nodes (C) Superficial inguinal nodes (D) Aortic (lumbar) nodes Common iliac nodes	E. The superior (deep) boundary of the superficial perineal space is the perineal membrane (inferior fascia of the urogenital diaphragm). Colles' fascia is the deep membranous layer of the superficial perineal fascia. The deep perineal fascia essentially divides the superficial perineal space into a superficial and deep compartment. The pelvic diaphragm consists of the levator ani and coccygeus muscles.
	A 58-year-old man is diagnosed as having a slowly growing tumor in the deep perineal space. Which of the following structures would most likely be injured? (A) Bulbourethral glands (B) Crus of penis (C) Bulb of vestibule (D) Spongy urethra (E) Great vestibular gland	A. The deep perineal space contains the bulbourethral (Cowper's) glands. The crus of the penis, bulb of the vestibule, spongy urethra, and great vestibular gland are found in the superficial perineal space.
	An elderly man with benign enlargement of his prostate experiences difficulty in urination, urinary frequency, and urgency. Which of the following lobes of the prostate gland is commonly involved in benign hypertrophy that obstructs the prostatic urethra? (A) Anterior lobe (B) Middle lobe (C) Right lateral lobe (D) Left lateral lobe (E) Posterior lobe	B. The middle lobe of the prostate gland is commonly involved in benign prostatic hypertrophy, resulting in obstruction of the prostatic urethra, whereas the posterior lobe is commonly involved in carcinomatous transformation. The anterior lobe contains little glandular tissue, and the two lateral lobes on either side of the urethra form the major part of the gland.
	A 59-year-old man is diagnosed with prostate cancer following a digital rectal examination. For the resection of prostate cancer, it is important to know that the prostatic ducts open into or on which of the following structures? (A) Membranous part of the urethra (B) Seminal colliculus (C) Spongy urethra (D) Prostatic sinus (E) Prostatic utricle	D. Ducts from the prostate gland open into the prostatic sinus, which is a groove on either side of the urethral crest. The prostate gland receives the ejaculatory duct, which opens into the prostatic urethra on the seminal colliculus (a prominent elevation of the urethral crest) just lateral to the prostatic utricle, which is a small blind pouch. The bulbourethral gland lies on the lateral side of the membranous urethra within the deep perineal space, but its duct opens into the bulbous portion of the spongy (penile) urethra.
	A 29-year-old woman with a ruptured ectopic pregnancy is admitted to a hospital for culdocentesis. A long needle on the syringe is most efficiently inserted through which of the following structures? (A) Anterior fornix of the vagina (B) Posterior fornix of the vagina (C) Anterior wall of the rectum (D) Posterior wall of the uterine body (E) Posterior wall of the bladder	B. A needle should be inserted through the posterior fornix, just below the posterior lip of the cervix while the patient is in supine position, to aspirate abnormal fluid in the cul-de-sac of Douglas (rectouterine pouch). Rectouterine excavation is not most efficiently aspi-rated by puncture of other structures.
	A 37-year-old man is suffering from carcinoma of the skin of the glans penis. Cancer cells are likely to metastasize directly to which of the following lymph nodes? (A) External iliac nodes (B) Internal iliac nodes (C) Superficial inguinal nodes (D) Aortic (lumbar) nodes (E) Common iliac nodes	C. The superficial inguinal nodes receive lymph from the penis, scrotum, buttocks, labium majus, and the lower parts of the vagina and anal canal. These nodes have efferent vessels that drain primarily into the external iliac and common iliac nodes and ultimately to the lumbar (aortic) nodes. The internal iliac nodes receive lymph from the upper part of the rectum, vagina, uterus, and other pelvic organs, and they drain into the common iliac and then to the lumbar (aortic) nodes.
	A 42-year-old woman who has had six children develops a weakness of the urogenital diaphragm. Paralysis of which of the following muscles would cause such a symptom? (A) Sphincter urethrae (B) Coccygeus (C) Superficial transversus perinei (D) Levator ani (E) Obturator internus	A. The urogenital diaphragm consists of the sphincter urethrae and deep transverse perineal muscles. Weakness of the muscles, ligaments, and fasciae of the pelvic floor such as the pelvic diaphragm, urogenital diaphragm, and cardinal (transverse cervical) ligaments occurs as result of multiple child delivery, advancing age, and menopause. The pelvic diaphragm is composed of the levator ani and coccygeus muscles. The superficial transverses perinei is one of the superficial perineal muscles and the obturator internus forms the lateral wall of the ischiorectal fossa.
	A 43-year-old man has a benign tumor located near a gap between the arcuate pubic ligament and the transverse perineal ligament. Which of the following structures is most likely compressed by this tumor? (A) Perineal nerve (B) Deep dorsal vein of the penis (C) Superficial dorsal vein (D) Posterior scrotal nerve (E) Deep artery of the penis	B. The deep dorsal vein, dorsal artery, and dorsal nerve of the penis pass through a gap between the arcuate pubic ligament and the transverse perineal ligament. The perineal nerve divides into a deep branch, which supplies all of the perineal muscles, and superficial branches as posterior scrotal nerves that supply the scrotum. The superficial dorsal vein of the pe- nis empties into the greater saphenous vein. The deep artery of the penis runs in the corpus cav- ernosum penis.
	An obstetrician performs a median episiotomy on a woman before parturition to prevent uncontrolled tearing. If the perineal body is damaged, the function of which of the following muscles might be impaired? (A) Ischiocavernosus and sphincter urethrae (B) Deep transverse perineal and obturator internus (C) Bulbospongiosus and superficial trans- verse perineal (D) External anal sphincter and sphincter urethrae (E) Bulbospongiosus and ischiocavernosus	C. The perineal body (central tendon of the perineum) is a fibromuscular node at the center of the perineum. It provides attachment for the bulbospongiosus, the superficial and deep transverse perineal muscles, and the sphincter ani externus muscles. Other muscles (ischio- cavernosus, sphincter urethrae, and obturator internus) are not attached to the perineal body.
	A 22-year-old man has a gonorrheal infection that has infiltrated the space between the inferior fascia of the urogenital diaphragm and the superficial perineal fascia. Which of the following structures might be inflamed? (A) Greater vestibular gland (B) Bulbourethral gland (C) Membranous part of the male urethra (D) Deep transverse perineal muscle (E) Sphincter urethrae	A. The greater vestibular gland is located in the superficial perineal space between the inferior fascia of the urogenital diaphragm and the membranous layer of the superficial perineal fascia (Colles' fascia). All of the other structures are found in the deep perineal pouch.
	A 39-year-old man is unable to expel the last drops of urine from the urethra at the end of micturition because of paralysis of the exter- nal urethral sphincter and bulbospongiosus muscles. This condition may occur as a result of injury to which of the following nervous structures? (A) Pelvic plexus (B) Prostatic plexus (C) Pudendal nerve (D) Pelvic splanchnic nerve (E) Sacral splanchnic nerve	C. The perineal branch of the pudendal nerve supplies the external urethral sphincter and bulbospongiosus muscles in the male. All other nervous structures do not supply skeletal muscles but supply smooth muscles in the perineal and pelvic organs. The pelvic and prostatic plexuses contain both sympathetic and parasympathetic nerve fibers. The pelvic splanchnic nerve carries preganglionic parasympathetic fibers, whereas the sacral splanchnic nerve transmits preganglionic sympathetic fibers.
	A 21-year-old marine biologist asks about her first himanual examination arid it is explained to her that the normal position of the uterus is: (A) Anteflexed and anteverted (B) Retroflexed and anteverted (C) Anteflexed and retroverted (D) Retroverted arid retroflexed (E) Anteverted and retroverted	A. The normal position of the uterus is anteverted (i.e., angle of 90 degrees at the junction of the vagina and cervical canal) and anteflexed (i.e., angle of 160 to 170 degrees at the junction of the cervix and body).
	After his bath, but before getting dressed, a 4-year-old boy was playing with his puppy. The boy's penis was bitten by the puppy and the deep dorsal vein was injured. The damaged vein: (A) Lies deep to Buck's fascia (B) Drains into the prostatic venous plexus (C) Lies lateral to the dorsal artery of the penis (D) Is found in the corpus spongiosum (E) Is dilated during erection	B. The deep dorsal vein of the penis lies medial to the dorsal artery of the penis on the dorsum of the penis and superficial to Buck's fascia, drains into the prostatic plexus of veins, and is compressed against the underlying deep fascia of the penis during erection.
	A 62-year-old man is incapable of penile erection after rectal surgery with prostatectomy. The patient most likely has a lesion of which of the following nerves? (A) Dorsal nerve of the penis (B) Perineal nerve (C) Hypogastric nerve (D) Sacral splanchnic nerve (E) Pelvic splanchnic nerve	E. The pelvic splanchnic nerve contains preganglionic parasympathetic fibers, whereas the sacral splanchnic nerve contains preganglionic sympathetic fibers. Parasympathetic fibers are responsible for erection, whereas sympathetic fibers are involved with ejaculation. The right and left hypogastric nerves contain primarily sympathetic fibers and visceral sensory fibers. The dorsal nerve of the penis and the perineal nerve provide sensory nerve fibers.
	A 23-year-old massage therapist who specializes in women's health attends a lecture at an annual conference on techniques of mas- sage. She asks which of the following structures is drained by the lumbar (aortic) lymph nodes? (A) Perineum (B) Lower part of the vagina (C) External genitalia (D) Ovary (E) Lower part of the anterior abdominal wall	D. The lymphatic vessels from the ovary ascend with the ovarian vessels in the suspensory ligament and terminate in the lumbar (aortic) nodes. Lymphatic vessels from the perineum, external genitalia, and lower part of the anterior abdominal wall drain into the superficial inguinal nodes.
	A sexually active adolescent presents with an infection within the ischiorectal fossa. Which of the following structures is most likely injured? (A) Vestibular bulb (B) Seminal vesicle (C) Greater vestibular gland (D) Inferior rectal nerve (E) Internal pudendal artery	D. The ischiorectal fossa contains the inferior rectal nerves and vessels arid adipose tissue. The bulb of the vestibule and the great vestibular gland are located in the superfi- cial perineal space, whereas the bulbourethral gland is found in the deep perineal space. The in- ternal pudendal artery runs in the pudendal canal, but its branches pass through the superficial and deep perineal spaces.
	A first-year resident in the urology department reviews pelvic anatomy before seeing patients. Which of the following statements is correct? (A) The dorsal artery of the penis supplies the glans penis (B) The seminal vesicles store spermatozoa (C) The duct of the hulbourethral gland opens into the membranous urethra (D) The duct of the greater vestibular gland opens into the vagina (E) The anterior lobe of the prostate gland is prone to carcinomatous transformation	A. The dorsal artery of the penis supplies the glans penis. The seminal vesicles store no spermatozoa. The duct of the bulbourethral gland opens into the bulbous portion of the spongy urethra, whereas the greater vestibular gland opens into the vestibule between the labium minora and the hymen. The anterior lobe of the prostate is devoid of glandular substance, the middle lobe is prone to benign hypertrophy, and the posterior lobe is prone to carcinomatous transformation.
	A 43-year-old woman presents with a prolapsed uterus. Repair of a prolapsed uterus requires knowledge of the supporting structures of the uterus. Which of the following structures plays the most important role in the sup- port of the uterus? (A) Levator ani (B) Sphincter urethrae (C) Uterosacral ligament (D) Ovarian ligament (E) Arcuate pubic ligament	A. The pelvic diaphragm, particularly the levator ani, provides the most important support for the uterus, although the urogenital diaphragm and the uterosacral and ovarian ligaments support the uterus. The arcuate pubic ligament arches across the inferior aspect of the pubic symphysis.
	A 16-year-old boy presents to the emergency department with rupture of the penile urethra. Extravasated urine from this injury can spread into which of the following structures? (A) Scrotum (B) Ischiorectal fossa (C) Pelvic cavity (D) Testis (E) Thigh	A. Extravasated urine from the penile urethra below the perineal membrane spreads into the superficial perineal space, scrotum, penis, and anterior abdominal wall. However, it does not spread into the testis, ischiorectal fossa, pelvic cavity, and thigh because Scarpa's fascia ends by firm attachment to the fascia lata of the thigh.
	A 23-year-old woman visits her obstetrician for an annual checkup. During vaginal examination, which of the following structures may be palpated? (A) Apex of the urinary bladder (B) Fundus of the uterus (C) Terminal part of the round ligament of the uterus (D) Body of the clitoris (E) Uterine cervix	E. In addition to the uterine cervix, the uterus, uterine tubes, ovaries, and ureters can be palpated. The apex of the urinary bladder is the anterior end of the bladder; thus, it cannot be palpated. The fundus of the uterus is anterosuperior part of the uterus. The terminal part of the round ligament of the uterus emerges from the superficial inguinal ring and becomes lost in the subcutaneous tissue of the labium majus.
	A 53-year-old bank teller is admitted to a local hospital for surgical removal of a benign pelvic tumor confined within the broad ligament. There is a risk of injuring which of the following structures that lies in this ligament? (A) Ovary (B) Proximal part of the pelvic ureter (C) Terminal part of the round ligament of the uterus (D) Uterine tube (E) Suspensory ligament of the ovary	D. The uterine tubes lie in the broad ligament. The anterior surface of the ovary is attached to the posterior surface of the broad ligament of the uterus. The ureter descends retroperitoneally on the lateral pelvic wall but is crossed by the uterine artery in the base (in the inferomedial part) of the broad ligament. The terminal part of the round ligament of the uterus becomes lost in the subcutaneous tissue of the labium majus. The suspensory ligament of the ovary is a band of peritoneum that extends superiorly from the ovary to the pelvic wall.
	A 72-year-old man comes to his physician for an annual check-up. Which of the following structures is most readily palpated during rectal examination? (A) Prostate gland (B) Epididymis (C) Ejaculatory duct (D) Ureter (E) Testis	A. The prostate gland may be palpated on rectal examination. The ejaculatory duct runs within the prostate gland and cannot be felt. In the male, the pelvic part of the ureter lies lateral to the ductus deferens and enters the posterosuperior angle of the bladder, where it is situated anterior to the upper end of the seminal vesicle, and thus cannot be palpated during rectal examination. However, in the female the ureter can be palpated during vaginal examination because it runs near the uterine cervix and the lateral fornix of the vagina to enter the posterosuperior angle of the bladder. The testis are examined during a routine annual check-up but obviously not during a rectal examination.
	A 48-year-old college football coach undergoes a radical prostatectomy for a malignant tumor in his prostate. Following surgery, he is incapable of achieving an erection. Which of the following nerves is most likely damaged during the surgery? (A) Sacral splanchnic nerve (B) Pelvic splanchnic nerve (C) Pudendal nerve (D) Dorsal nerve of the penis (E) Posterior scrotal nerve	B. Parasympathetic preganglionic fibers in the pelvic splanchnic nerve are responsible for erection of the penis. Sympathetic preganglionic fibers in the sacral splanchnic nerve are responsible for ejaculation. The pudendal nerve supplies the external anal sphincter and perineal muscles and supplies general somatic afferent (GSA) fibers to the perineal region. The dorsal nerve of the penis is a terminal branch of the pudendal nerve and supplies sensation of the penis. The posterior scrotal nerves are superficial branches of the perineal nerve and supply sen- sory fibers to the scrotum.
	While performing a pelvic exenteration, the surgical oncologist notices a fractured or ruptured boundary of the pelvic inlet. Which of the following structures is most likely damaged? (A) Promontory of the sacrum (B) Anterior-inferior iliac spine (C) Inguinal ligament (D) Iliac crest (E) Arcuate pubic ligament	A. The pelvic inlet (pelvic brim) is bounded by the promontory and the anterior border of the ala of the sacrum, the arcuate line of the ilium, the pectineal line, the pubic crest, and the superior margin of the pubic symphysis.
	A 32-year-old patient with multiple fractures of the pelvis has no cutaneous sensation in the urogenital triangle. The function of which of the following nerves is most likely to be spared? (A) Ilioinguinal nerve (B) Iliohypogastric nerve (C) Posterior cutaneous nerve of the thigh (D) Pudendal nerve (E) Genitofemoral nerve	B. The iliohypogastric nerve innervates the skin above the pubis. The skin of the urogenital triangle is innervated by the pudendal nerve, perineal branches of the posterior femoral cutaneous nerve, anterior scrotal or labial branches of the ilioinguinal nerve, and the gen- ital branch of the genitofemoral nerve.
	A 22-year-old victim of an automobile accident has received destructive damage to structures that form the boundary of the per- ineum. Which of the following structures is spared? (A) Pubic arcuate ligament (B) Tip of the coccyx (C) Ischial tuberosities (D) Sacrospinous ligament (E) Sacrotuberous ligament	D. The sacrospinous ligament forms a boundary of the lesser sciatic foramen. The pubic arcuate ligament, tip of the coccyx, ischial tuberosities, and sacrotuberous ligament all form part of the boundary of the perineum.
	A 32-year-old man undergoes vasectomy as a permanent birth control. A physician performing the vasectomy by making an incision on each side of the scrotum should remember which of the following statements is most applicable to the scrotum? (A) It is innervated by the ilioinguinal and genitofemoral nerves (B) It receives blood primarily from the testic- ular artery (C) Its venous blood drains primarily into the renal vein on the left (D) Its lymphatic drainage is primarily into upper lumbar nodes (E) Its dartos tunic is continuous with the perineal membrane	A. The scrotum is innervated by branches of the ilioinguinal, genitofemoral, pudendal, and posterior femoral cutaneous nerves. The scrotum receives blood from the posterior scrotal branches of the internal pudendal arteries and the anterior scrotal branches of the external pudendal arteries, but it does not receive blood from the testicular artery. Similarly, the scro- tum is drained by the posterior scrotal veins into the internal pudendal vein. The lymph vessels from the scrotum drain into the superficial inguinal nodes, whereas the lymph vessels from the testis drain into the upper lumbar nodes. The dartos tunic is continuous with the membranous layer of the superficial perineal fascia (Colles' fascia).
	A 37-year-old woman complains of a bearing-down sensation in her womb and an increased frequency of and burning sensation on urination. On examination by her gynecologist, she is diagnosed with the uterine prolapse. Which of the following structures provides the primary support for the cervix of the uterus? (A) External anal sphincter (B) Broad ligament of the uterus (C) Cardinal (transverse cervical) ligament (D) Round ligament of the uterus (E) Suspensory ligament of the ovary	C. The cardinal (transverse cervical) ligament provides the major ligamentous support for the uterus. The sphincter ani externus does not support the uterus. The broad and round ligaments of the uterus provide minor supports for the uterus. The suspensory ligament of the ovary does not support the uterus.
	A woman is delivering a breech baby. The obstetrician decides it is best to perform a mediolateral episiotomy. Which of the follow- ing structures, should the obstetrician avoid incising? (A) Vaginal wall (B) Superficial transverse perineal muscle (C) Bulbospongiosus (D) Levator ani (E) Perineal membrane	D. An obstetrician should avoid incising the levator ani and the external anal sphincter. The levator ani is the major part of the pelvic diaphragm, which forms the pelvic floor and supports all of the pelvic organs. None of the other choices applies here.
	During pelvic surgery, a surgeon notices severe bleeding from the artery that remains within the true pelvis. Which of the following arteries is most likely to be injured? (A) Iliolumbar artery (B) Obturator artery (C) Uterine artery (D) Internal pudendal artery (E) Inferior gluteal artery	C. Of all the arteries listed, the uterine artery remains within the pelvic cavity.
	A neurosurgeon performs surgical resection of a rare meningeal tumor in the sacral region. He tries to avoid an injury of the nerve that arises from the lumbosacral plexus and re- mains within the abdominal or pelvic cavity. To which of the following nerves should he pay particular attention? (A) Ilioinguinal nerve (B) Genitofemoral nerve (C) Lumbosacral trunk (D) Femoral nerve (E) Lateral femoral cutaneous nerve	C. The lumbosacral trunk is formed by part of the ventral ramus of the fourth lumbar nerve and the ventral ramus of the fifth lumbar nerve. This trunk contributes to the formation of the sacral plexus by joining the ventral ramus of the first sacral nerve in the pelvic cavity and does not leave the pelvic cavity. All other nerves leave the abdominal and pelvic cavities. The ilioinguinal nerve accompanies the spermatic cord or the round ligament of the uterus, continues through the inguinal canal, and emerges through the superficial inguinal ring. The gen- itofemoral nerve divides into a genital branch, which enters the inguinal canal through the deep inguinal ring and exits through the superficial inguinal ring and supplies the cremaster muscle and the scrotum or labium majus, and a femoral branch, which passes deep to the inguinal ligament and enters the femoral triangle. The femoral nerve enters the femoral triangle deep to the inguinal ligament and lateral to the femoral vessels and divides into numerous branches. The lateral femoral cutaneous nerve runs in front of the iliacus and behind the inguinal ligament and innervates the skin of the anterior and lateral thigh.
	After repair of a ruptured diverticulum, a 31-year-old patient begins to spike with fever and complains of abdominal pain. An infection in the deep perineal space would most likely damage which of the following structures? (A) Ischiocavernosus muscles (B) Superficial transverse perineal muscles (C) Levator ani (D) Sphincter urethrae (E) Bulbospongiosus	D. The sphincter urethrae is found in the deep perineal space, whereas the other structures are located in the superficial perineal space.
	A radiologist interprets a lymphangiogram for a 29-year-old patient with metastatic carcinoma. Upper lumbar nodes most likely receive lymph from which of the following structures? (A) Lower part of the anal canal (B) Labium majus (C) Clitoris (D) Testis (E) Scrotum	D. Lymphatic vessels from the testis and epididymis ascend along the testicular vessels in the spermatic cord through the inguinal canal and continue upward in the abdomen to drain into the upper lumbar nodes. The lymph from the other structures drains into the superficial inguinal lymph nodes.
	A 49-year-old woman has a large mass on the pelvic brim. Which of the following structures was most likely compressed by this mass when crossing the pelvic brim? (A) Deep dorsal vein of the penis (B) Uterine tube (C) Ovarian ligament (D) Uterine artery (E) Lumbosacral trunk	E. All of the listed structures do not cross the pelvic brim except the lum- bosacral trunk, which arises from L4 and L5, enters the true pelvis by crossing the pelvic brim, and contributes to the format ion of the sacral plexus. The deep dorsal vein of the penis enters the pelvic cavity by passing under the symphysis pubis between the arcuate and transverse perineal ligaments.
	A 26-year-old man comes to a hospital with fever, nausea, pain, and itching in the perineal region. On examination by an urologist, he is diagnosed as having infected bulbourethral (Cowper's) glands. Which of the following structures is affected by this infection? (A) Superficial perineal space. (B) Sphincter urethrae. (C) Production of sperm. (D) Testis (E) Seminal vesicles	B. The bulbourethral glands lie on either side of the membranous urethra, embedded in the sphincter urethrae. Their ducts open into the bulbous part of the penile urethra. Semen—a thick, yellowish white, viscous, spermatozoa-containing fluid—is a mixture of the se- cretions of the testes, seminal vesicles, prostate, and bulbourethral glands. Sperm, or spermato- zoa, are produced in the seminiferous tubules of the testis and matured in the head of the epi- didymis. The seminal vesicles are lobulated glandular structures, produce the alkaline constituent of the seminal fluid that contains fructose and choline, and lie inferior and lateral to the ampullae of the ductus deferens against the fundus (base) of the bladder.
	A 21-year-old man is involved in a high-speed motor vehicle accident. As a result, he has extensive damage to his sphincter urethrae. Which of the following statements best explains the injured sphincter urethrae? (A) Smooth muscle (B) Innervated by the perineal nerve (C) Lying between the perinea] membrane and CoIles' fascia (D) Enclosed in the pelvic fascia (E) Part of the pelvic diaphragm	B. The sphincter urethrae is striated muscle that lies in the deep perineal space and forms a part of the urogenital diaphragm but not the pelvic diaphragm. It is not enclosed in the pelvic fascia. It is innervated by a deep (muscular) branch of the perineal nerve.
	An obstetrician is about to perform a pudendal block so a woman can experience less pain when she delivers her child. He recalls what he learned in medical school about this nerve: (A) It passes superficial to the sacrotuberous ligament (B) It innervates the testis and epididymis in a male (C) It provides motor fibers to the coccygeus (D) It can be blocked by injecting an anes- thetic near the inferior margin of the ischial spine (E) It arises from the lumbar plexus	D. The pudendal nerve, which arises from the sacral plexus, provides sensory innervation to the labium majus (or scrotum in a male). It leaves the pelvis through the greater sciatic foramen and enters the perineum through the lesser sciatic foramen near the inferior margin of the ischial spine. Therefore, it can be blocked by injection of an anesthetic near the inferior margin of the ischial spine.
	A trauma surgeon in the emergency room at a local center examines a 14-year-old boy with extensive pelvic injuries after a hit and run accident. The surgeon inspects the ischiorectal fossa because it: (A) Accumulates urine leaking from rupture of the bulb of the penis (B) Contains the inferior rectal vessels (C) Has a pudendal canal along its medial wall (D) Is bounded anteriorly by the sacrotuber- ous ligament (E) Contains a perineal branch of the fifth lumbar nerve	B. The ischiorectal fossa is bounded posteriorly by the gluteus maximus and the sacrotuberous ligament. It contains fat, the inferior rectal nerve and vessels, and perineal branches of the posterior femoral cutaneous nerve. The pudendal canal runs along its lateral wall. Urine leaking from a ruptured bulb of the penis does not spread into the ischiorectal fossa because Scarpa's fascia ends by firm attachment to the fascia lata of the thigh.
	An elderly man with prostatitis is seen at an internal medicine clinic. The seminal colliculus of his prostate gland is infected, and its fine openings are closed. Which of the following structures is most likely to be disturbed? (A) Ducts of the prostate gland (B) Prostatic utricle (C) Ducts of the bulbourethral glands (ID) Ejaculatory ducts (E) Duct of the seminal vesicles	D. The ejaculatory ducts, which open onto the seminal colliculus, may be injured. The prostate ducts open into the urethral sinus, the bulbourethral ducts open into the bulbous part of the penile urethra, and the ducts of the seminal vesicle join the ampulla of the ductus deferens to form the ejaculatory duct. The prostatic utricle is a minute pouch on the summit of the seminal colliculus.
	A general surgeon is giving a lecture to a team of surgery residents. She describes characteristics of structures above the pectinate line of the anal canal, which include (A) Stratified squamous epithelium (B) Venous drainage into the caval system (C) Lymphatic drainage into the superficial inguinal nodes (D) Visceral sensory innervation (E) External hemorrhoids	D. The pectinate line is a point of demarcation between visceral and somatic portions of the anal canal. Characteristics above the pectinate line include columnar epithelium, venous drainage into the portal system, lymphatic drainage into the internal iliac nodes, visceral sensory innervation, and internal hemorrhoids.
	A 78-year-old man has carcinoma of the rectum. The cancer is likely to metastasize via the veins into which of the following structures? (A) Spleen (B) Kidney (C) Liver (D) Duodenum (E) Suprarenal gland	C. Cancer cells from the rectal cancer are likely to metastasize to the liver via the superior rectal, inferior mesenteric, splenic, and portal veins. Cancer cells are not directly spread to the other organs listed. The spleen and duodenum drain their venous blood to the por- tal venous system and the kidney and suprarenal gland empty into the caval (inferior vena cava) system.
	During an outbreak of meningitis at a local college, a 20-year-old young student presents to a hospital emergency room complain- ing of headache, fever, chills, and stiff neck. On examination, it appears that he may have meningitis and needs a lumbar puncture or a spinal tap. Cerebrospinal fluid (CSF) is nor- mally withdrawn from which of the following spaces? (A) Epidural space (B) Subdural space (C) Space between the spinal cord and pia mater (D) Subarachnoid space (E) Space between the arachnoid and dura maters	D. Cerebrospinal fluid (CSF) is found in the subarachnoid space, which is a wide interval between the arachnoid layer and the pia mater. The epidural space contains the in- ternal vertebral venous plexus and epidural fat. The subdural space between the arachnoid and the dura contains a little fluid to moisten the meningeal surface. The pia mater closely covers the spinal cord and en meshes blood vessels on the surfaces of the spinal cord. Thus, the space between the spinal cord and the pia is a potential space.
	A 23-year-old jockey falls from her horse and complains of headache, backache, and weakness. Radiologic examination would reveal blood in which of the following spaces if the internal vertebral venous plexus was ruptured? (A) Space deep to the pia mater (B) Space between the arachnoid and dura maters (C) Subdural space (D) Epidural space (E) Subarachnoid space	D. The space between the vertebral canal and the dura mater is the epidural space, which contains the internal vertebral venous plexus. The spinal cord and blood vessels lie deep to the pia mater. The space between the arachnoid and dura maters is the subdural space, which contains a film of fluid. The subarachnoid space contains cerebrospinal fluid (CSF).
	A 42-year-old woman with metastatic breast cancer is known to have tumors in the intervertebral foramina between the fourth and fifth cervical vertebrae and between the fourth and fifth thoracic vertebrae. Which of the following spinal nerves may be damaged? (A) Fourth cervical and fourth thoracic nerves (B) Fifth cervical and fifth thoracic nerves (C) Fourth cervical and fifth thoracic nerves (D) Fifth cervical and fourth thoracic nerves (E) Third cervical and fourth thoracic nerves	D. All cervical spinal nerves exit through the intervertebral foramina above the corresponding vertebrae, except the eighth cervical nerves, which run inferior to the seventh cervical vertebra. All other spinal nerves exit the intervertebral foramina below the correspon- ding vertebrae. Therefore, the fifth cervical nerve passes between the fourth and fifth cervical vertebrae and the fourth thoracic nerve runs between the fourth and fifth thoracic vertebrae.
	A 39-year-old woman with headaches presents to her primary care physician with a possible herniated disk. Her magnetic resonance imaging (MRI) scan reveals that the posterolateral protrusion of the intervertebral disk between L4 and L5 vertebrae would most likely affect nerve roots of which of the following spinal nerves? (A) Third lumbar nerve (B) Fourth lumbar nerve (C) Fifth lumbar nerve (D) First sacral nerve (E) Second sacral nerve	C. A posterolateral herniation of the intervertebral disk at disk level L4–L5 affects the fifth lumbar nerve not the fourth lumbar nerve. The first seven cervical nerves exit above the corresponding vertebra, and the eighth cervical nerve exits below the seventh cervical vertebra because there are eight cervical nerves but only seven cervical vertebrae. The rest of the spinal nerves exit below their corresponding vertebrae.
	A 57-year-old woman comes into her physician's office complaining of fever, nausea, vomiting, and the worst headache of her life. Tests and physical examination suggest hydrocephalus (widening ventricles) resulting from a decrease in the absorption of cerebrospinal fluid (CSF). A decrease of flow in the CSF through which of the following structures would be responsible for these findings? (A) Choroid plexus (B) Vertebral venous plexus (C) Arachnoid villi (D) Internal jugular vein (E) Subarachnoid trabeculae	C. Cerebrospinal fluid (CSF) is absorbed into the venous system primarily through the arachnoid villi projecting into the cranial dural venous sinuses, particularly the su- perior sagittal sinus. CSF is produced by the choroid plexuses of the ventricles of the brain and is circulated in the subarachnoid space, in which subarachnoid trabeculae are also found. The vertebral venous plexus and internal jugular vein are not involved in absorption of CSF.
	After his car was broad-sided by a large truck, a 26-year-old man is brought to the emergency department with multiple fractures of the transverse processes of the cervical and upper thoracic vertebrae. Which of the follow- ing muscles might be affected? (A) Trapezius (B) Levator scapulae (C) Rhomboid major (D) Serratus posterior superior (E) Rectus capitis posterior major	B. The levator scapulae arises from the transverse processes of the upper cervical vertebrae and inserts on the medial border of the scapula. The other muscles are attached to the spinous processes of the vertebrae.
	A 27-year-old mountain climber falls from a steep rock wall and is brought to the emergency department. His physical examination and computed tomography (CT) scan reveal dislocation fracture of the upper thoracic vertebrae. The fractured body of the T4 vertebra articulates with which of the following parts of the ribs? (A) Head of the third rib (B) Neck of the fourth rib (C) Tubercle of the fourth rib (D) Head of the fifth rib (E) Tubercle of the fifth rib	D. The body of vertebra T4 articulates with the heads of the fourth and fifth ribs. The body of the T3 vertebra articulates with the head of the third and fourth ribs. The neck of a rib does not articulate with any parts of the vertebra. The transverse process of the vertebra articulates with the tubercle of the corresponding rift Therefore, the transverse process of vertebra T4 articulates with the tubercle of the fourth rib.
	A young toddler presents to her pediatrician with rather new onset of bowel and bladder dysfunction and loss of the lower limb function. Her mother had not taken enough folic acid (to the point of a deficiency) during her pregnancy. On examination, the child has protrusion of the spinal cord and the meninges and is diagnosed with which of the following conditions? (A) Spina bifida occulta (B) Meningocele (C) Meningomyelocele (D) Myeloschisis (E) Syringomyelocele	C. Meningomyelocele is protrusion of the meninges and spinal cord through the unfused arch of the vertebra. Sufficient amount of folic acid during pregnancy is shown to prevent these kind of neural tube defects. Spina bifida occulta is failure of the vertebral arch to fuse (bony defect only). Meningocele is protrusion of the meninges through the defective vertebral arch. Syringomyelocele is protrusion of the meninges and a pathologic tubular cavity in the spinal cord or brain.
	A 34-year-old woman crashes into a tree during a skiing lesson and is brought to a hospital with multiple injuries that impinge the dorsal primary rami of several spinal nerves. Such lesions could affect which of the following muscles? (A) Rhomboid major (B) Levator scapulae (C) Serratus posterior superior (D) Iliocostalis (E) Latissimus dorsi via which of the following openings? (A) Intervertebral foramen (B) Sacral hiatus (C) Vertebral canal (D) Dorsal sacral foramen (E) Ventral sacral foramen 14. In a freak hunting accident, a 17 year-old boy was shot with an arrow that penetrated into his suboccipital triangle, injuring the sub-	D. The dorsal primary rami of the spinal nerves innervate the deep muscles of the back, including the iliocostalis. The other muscles are the superficial muscles of the back, which are innervated by the ventral primary rami of the spinal nerves.
	During a domestic dispute, a 16-year-old boy receives a deep stab wound around the superior angle of the scapula near the medial border, which injures both the dorsal scapular and spinal accessory nerves. Such an injury could result in paralysis or weakness of which of the following muscles? (A) Trapezius and serratus posterior superior (B) Rhomboid major and trapezius (C) Rhomboid minor and latissimus dorsi (D) Splenius cervicis and sternocleidomastoid (E) Levator scapulae and erector spinae	B. The dorsal scapular nerve innervates the levator scapulae and rhomboid muscles, whereas the accessory nerve innervates the trapezius and sternocleidomastoid muscles. The serratus posterior superior is innervated by ventral primary rami of the spinal nerves, whereas the splenius cervicis and erector spinae are innervated by dorsal primary rami of the spinal nerves.
	An elderly man at a nursing home is known to have degenerative brain disease. When cerebrospinal fluid (CSF) is withdrawn by lumbar puncture for further examination, which of the following structures is most likely penetrated by the needle? (A) Pia mater (B) Filum terminale externum (C) Posterior longitudinal ligament (D) Ligamentum flavum (E) Anulus fibrosus	D. The cerebrospinal fluid (CSF) is located in the subarachnoid space, between the arachnoid layer and pia mater. In a lumbar puncture, the needle penetrates the skin, fascia, ligamentum flavum, epidural space, dura mater, subdural space, and arachnoid mater. The pia mater forms the internal boundary of the subarachnoid space; thus, it cannot be penetrated by needle. The posterior longitudinal ligament lies anterior to the spinal cord; thus, it is not penetrated by the needle. The filum terminate externum is the downward prolongation of the spinal dura mater from the second sacral vertebra to the dorsum of the coccyx. The anulus fibrosus con- sists of concentric layers of fibrous tissue and fibrocartilage surrounding and retaining the nucleus pulposus of the intervertebral disk, which lies anterior to the spinal cord.
	A 27 year-old-stuntman is thrown out of his vehicle prematurely when the car used for a particular scene speeds out of control. His spinal cord is crushed at the level of the fourth lumbar spinal segment. Which of the following structures would most likely be spared from destruction? (A) Dorsal horn (B) Ventral horn (C) Lateral horn (D) Gray matter (E) Pia mater	C. The lateral horns, which contain sympathetic preganglionic neuron cell bodies, are present between the first thoracic and second lumbar spinal cord levels (T1–L2). The lateral horns of the second, third, and fourth sacral spinal cord levels (S2–S4) contain parasympathetic preganglionic neuron cell bodies. The entire spinal cord is surrounded by the pia mater and has the dorsal horn, ventral horn, and gray matter. Note that the fourth lumbar spinal cord level is not the same as the fourth vertebral level.
	A 24-year-old woman comes to a hospital to deliver her baby. Her obstetrician uses a caudal anesthesia during labor and childbirth to block the spinal nerves in the epidural space. Local anesthetic agents are most likely injected via which of the following openings? (A) Intervertebral foramen (B) Sacral hiatus (C) Vertebral canal (D) Dorsal sacral foramen (E) Ventral sacral foramen	B. Caudal (epidural) anesthesia is used to block the spinal nerves in the epidural space by injecting local anesthetic agents via the sacral hiatus located between the sacral cornua. An intervertebral foramen transmits the dorsal and ventral primary rami of the spinal nerves. The vertebral canal accommodates the spinal cord. Dorsal and ventral sacral foramina transmit the dorsal and ventral primary rami of the sacral nerves.
	In a freak hunting accident, a 17 year-old boy was shot with an arrow that penetrated into his suboccipital triangle, injuring the suboccipital nerve between the vertebral artery and the posterior arch of the atlas. Which of the following muscles would be unaffected by such a lesion? (A) Rectus capitis posterior major (B) Semispinalis capitis (C) Splenius capitis (D) Obliquus capitis superior (E) Obliquus capitis inferior	C. The splenius capitis is innervated by dorsal primary rami of the middle and lower cervical nerves. The suboccipital nerve (dorsal primary ramus of C1) supplies the muscles of the suboccipital area including the rectus capitis posterior major, obliquus capitis superior and inferior, and the semispinalis capitis.
	A 26-year-old heavyweight boxer is punch- ed on his mandible, resulting in a slight sub- luxation (dislocation) of the atlantoaxial joint. The consequence of the injury was decreased range of motion at that joint. What movement would be most affected? (A) Extension (B) Flexion (C) Abduction (D) Adduction (E) Rotation	E. The atlantoaxial joints are synovial joints that consist of two plane joints and one pivot joint and are involved primarily in rotation of the head. Other movements do not occur at this joint.
	A crush injury of the vertebral column can cause the spinal cord to swell. What structure would be trapped between the dura and verte- bral body by the swelling spinal cord? (A) Anterior longitudinal ligament (B) Alar ligament (C) Posterior longitudinal ligament (D) Cruciform ligament (E) Ligamentum nuchae	E. The ligamentum nuchae is formed by supraspinous ligaments that extend from the seventh cervical vertebra to the external occipital protuberance and crest. The anterior longitudinal ligament runs anterior to the vertebral bodies. The alar and cruciform ligaments also lie anterior to the spinal cord. Although the posterior longitudinal ligament interconnects the vertebral bodies and intervertebral disks posteriorly, it runs anterior to the spinal cord within the vertebral canal.
	A 44-year-old woman comes to her physician and complains of headache and backache. On examination, she is found to have fluid accumulated in the spinal epidural space because of damage to blood vessels or meninges. Which of the following structures is most likely ruptured? (A) Vertebral artery (B) Vertebral vein (C) External vertebral venous plexus (D) Internal vertebral venous plexus (E) Lumbar cistern	D. The internal vertebral venous plexus is located in the spinal epidural space. The vertebral artery and vein occupy the transverse foramina of the upper six cervical vertebrae. The external vertebral venous plexus consists of the anterior part, which lies in front of the vertebral column, and the posterior part, which lies on the vertebral arch. The lumbar cistern is the enlargement of the subarachnoid space between the inferior end of the spinal cord and the inferior end of the subarachnoid space.
	A 69-year-old man has an abnormally increased curvature of the thoracic vertebral column. Which of the following conditions is the most likely diagnosis? (A) Lordosis (B) Spina bifida occulta (C) Meningocele (D) Meningomyelocele (E) Kyphosis	E. Kyphosis (hunchback or humpback) is an abnormally increased thoracic curvature, usually resulting from osteoporosis. Lordosis is an abnormal accentuation of the lumbar curvature. Spina bifida occulta is failure of the vertebral arch to fuse (bony defect only). Meningocele is a protrusion of the meninges through the unfused arch of the vertebra, whereas meningomyelocele is a protrusion of the spinal cord and the meninges.
	During a snowstorm, a 52-year-old man is brought to the emergency department after a multiple car pile-up. Which of the following conditions is produced by a force that drives the trunk forward while the head lags behind in a rear-end automobile collision? (A) Scoliosis (B) Hangman's syndrome (C) Meningomyelocele (D) Whiplash injury (E) Herniated disk	D. Whiplash injury of the neck is produced by a force that drives the trunk forward while the head lags behind. Scoliosis is a lateral deviation resulting from unequal growth of the spinal column. Hangman's syndrome is a fracture of the neural arch through the pedicle of the axis that may occur as a result of hanging or motor vehicle accidents. Meningomyelocele is a protrusion of the spinal cord and its meninges. A herniated disk compresses the spinal nerve roots when the nucleus pulposus is protruded through the anulus fibrosus.
	A 37-year-old man is brought to the emergency department with a crushed second cervical vertebra (axis) he suffered after a stack of pallets fell on him at work. Which of the following structures would be intact after the accident? (A) Alar ligament (B) Apical ligament (C) Semispinalis cervicis muscle (D) Rectus capitis posterior minor (E) Obliquus capitis inferior	D. The rectus capitis posterior minor arises from the posterior tubercle of the atlas and inserts on the occipital bone below the inferior nuchal line. The alar ligament extends from the apex of the dens to the medial side of the occipital bone, The apical ligament extends from the dens of the axis to the anterior aspect of the foramen magnum of the occipital bone. The semispinalis cervicis arises from the transverse processes and inserts on the spinous processes. The obliquus capitis inferior originates from the spine of the axis and inserts on the transverse process of the atlas.
	A middle-aged coal miner injures his back after an accidental explosion. His magnetic resonance imaging (MRI) scan reveals that his spinal cord has shifted to the right because the lateral extensions of the pia mater were torn. Function of which of the following structures is most likely impaired? (A) Filum terminale internum (B) Coccygeal ligament (C) Denticulate ligament (D) Choroid plexus (E) Tectorial membrane	C. The denticulate ligament is a lateral extension of the pia mater. The filum terminate (internum) is an inferior extension of the pia mater from the tip of the conus medullaris. The coccygeal ligament, which is also called the filum terminate externum or the filum of the dura, extends from the tip of the dural sac to the coccyx. The vascular choroid plexuses produce the cerebrospinal fluid (CSF) in the ventricles of the brain. The tectorial membrane is an upward extension of the posterior longitudinal ligaments from the body of the axis to the basilar part of the occipital bone.
	A 25-year-old man with congenital abnormalities at birth has a lesion of the dorsal scapular nerve, making him unable to adduct his scapula. Which of the following muscles is most likely paralyzed? (A) Semispinalis capitis (B) Rhomboid major (C) Multifidus (D) Rotator longus (E) Iliocostalis	B. The rhomboid major is a superficial muscle of the back; is innervated by the dorsal scapular nerve, which arises from the ventral primary ramus of the fifth cervical nerve; and adducts the scapula. The semispinalis capitis, multifidus, rotator longus, and iliocostalis mus- cles are deep muscles of the back; innervated by dorsal primary rami of the spinal nerves; and have no attachment to the scapula.
	After an automobile accident, a back muscle that forms the boundaries of the triangle of auscultation and the lumbar triangle, receives no blood. Which of the following muscles might be ischemic? (A) Levator scapulae (B) Rhomboid minor (C) Latissimus dorsi (D) Trapezius (E) Splenius capitis	C. The latissimus dorsi forms boundaries of the auscultation and lumbar triangles and receives blood from the thoracodorsal artery. The levator scapulae, rhomboid minor, and splenius capitis muscles do not form boundaries of these two triangles. The trapezius muscle forms a boundary of the auscultation triangle but not the lumbar triangle. The levator scapulae, rhomboid minor, and trapezius muscles receive blood from the transverse cervical artery. The splenius capitis muscle receives blood from the occipital and transverse cervical arteries,
	A 38-year-old woman with a long history of shoulder pain is admitted to a hospital for surgery. Which of the following muscles becomes ischemic soon after ligation of the su- perficial or ascending branch of the transverse cervical artery? (A) Latissimus dorsi (B) Multifidus (C) Trapezius (D) Rhomboid major (E) Longissimus capitis	C. The trapezius receives blood from the superficial branch of the transverse cervical artery. The latissimus dorsi receives blood from the thoracodorsal artery. The rhomboid major receives blood from the deep or descending branch of the transverse cervical artery. The multifidus and longissimus capitis receive blood from the segmental arteries.
	A 25-year-old soldier suffers a gunshot wound on the lower part of his back and is unable to move his legs. A neurologic examination and magnetic resonance imaging (MRI) scan reveal injury of the cauda equina. Which of the following is most likely damaged? (A) Dorsal primary rami (B) Ventral primary rami (C) Dorsal roots of the thoracic spinal nerves (D) Ventral roots of the sacral spinal nerves (E) Lumbar spinal nerves	D. The cauda equina is the collection of dorsal and ventral roots of the lower lumbar and sacral spinal nerves below the spinal cord. Dorsal and ventral primary rami and dorsal roots of the thoracic spinal nerves and lumbar spinal nerves do not participate in the formation of the cauda equina.
	A middle-aged coal miner injures his back after an accidental explosion. His magnetic resonance imaging (MRI) scan reveals that his spinal cord has shifted to the right because the lateral extensions of the pia mater were torn. Function of which of the following structures is most likely impaired? (A) Filum terminale internum (B) Coccygeal ligament (C) Denticulate ligament (D) Choroid plexus (E) Tectorial membrane	C. The denticulate ligament is a lateral extension of the pia mater. The filum terminate (internum) is an inferior extension of the pia mater from the tip of the conus medullaris. The coccygeal ligament, which is also called the filum terminate externum or the filum of the dura, extends from the tip of the dural sac to the coccyx. The vascular choroid plexuses produce the cerebrospinal fluid (CSF) in the ventricles of the brain. The tectorial membrane is an upward extension of the posterior longitudinal ligaments from the body of the axis to the basilar part of the occipital bone.
	A 25-year-old man with congenital abnormalities at birth has a lesion of the dorsal scapular nerve, making him unable to adduct his scapula. Which of the following muscles is most likely paralyzed? (A) Semispinalis capitis (B) Rhomboid major (C) Multifidus (D) Rotator longus (E) Iliocostalis	B. The rhomboid major is a superficial muscle of the back; is innervated by the dorsal scapular nerve, which arises from the ventral primary ramus of the fifth cervical nerve; and adducts the scapula. The semispinalis capitis, multifidus, rotator longus, and iliocostalis mus- cles are deep muscles of the back; innervated by dorsal primary rami of the spinal nerves; and have no attachment to the scapula.
	After an automobile accident, a back muscle that forms the boundaries of the triangle of auscultation and the lumbar triangle, receives no blood. Which of the following muscles might be ischemic? (A) Levator scapulae (B) Rhomboid minor (C) Latissimus dorsi (D) Trapezius (E) Splenius capitis	C. The latissimus dorsi forms boundaries of the auscultation and lumbar triangles and receives blood from the thoracodorsal artery. The levator scapulae, rhomboid minor, and splenius capitis muscles do not form boundaries of these two triangles. The trapezius muscle forms a boundary of the auscultation triangle but not the lumbar triangle. The levator scapulae, rhomboid minor, and trapezius muscles receive blood from the transverse cervical artery. The splenius capitis muscle receives blood from the occipital and transverse cervical arteries,
	A 38-year-old woman with a long history of shoulder pain is admitted to a hospital for surgery. Which of the following muscles becomes ischemic soon after ligation of the su- perficial or ascending branch of the transverse cervical artery? (A) Latissimus dorsi (B) Multifidus (C) Trapezius (D) Rhomboid major (E) Longissimus capitis	C. The trapezius receives blood from the superficial branch of the transverse cervical artery. The latissimus dorsi receives blood from the thoracodorsal artery. The rhomboid major receives blood from the deep or descending branch of the transverse cervical artery. The multifidus and longissimus capitis receive blood from the segmental arteries.
	A 25-year-old soldier suffers a gunshot wound on the lower part of his back and is unable to move his legs. A neurologic examination and magnetic resonance imaging (MRI) scan reveal injury of the cauda equina. Which of the following is most likely damaged? (A) Dorsal primary rami (B) Ventral primary rami (C) Dorsal roots of the thoracic spinal nerves (D) Ventral roots of the sacral spinal nerves (E) Lumbar spinal nerves	D. The cauda equina is the collection of dorsal and ventral roots of the lower lumbar and sacral spinal nerves below the spinal cord. Dorsal and ventral primary rami and dorsal roots of the thoracic spinal nerves and lumbar spinal nerves do not participate in the formation of the cauda equina.

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