Download He1. A 72-year-old man presents in the emergency room with

He1. A 72-year-old man presents in the emergency room with dizziness and nystagmus.
Examination reveals a loss of pain and temperature sensation over the right side of the face and
the left side of the body. The patient exhibits ataxia and intention tremor on the right in both the
upper and lower extremities and is unable to perform either the finger-to-nose or heel-to-shin tasks
on the right. In addition, he is hoarse and demonstrates pupillary constriction and drooping of the
eyelid on the right. Finally, the right side of his face is drier than the left. Following vascular
blockage, necrotic damage in which of the following would explain the patient’s hoarseness?
A Nucleus ambiguus
B Lateral spinothalamic tract
C Spinal nucleus of CN V
D Descending sympathetic pathways
E Inferior cerebellar peduncle
He2. A patient suffers from Frey's syndrome manifested by perspiration of the skin covering the
left parotid gland whenever the patient eats. On inquiry, the patient reveals that he suffered deep
injuries on that side of his face and neck in an automobile accident. You explain to him that his
syndrome results from abnormal connections between the great auricular nerve and
parasympathetic secretomotor fibers, which normally innervate only the parotid gland. This
abnormal reinnervation occurred during the healing period after the accident. The parasympathetic
secretomotor fibers to the parotid gland are carried by which of the following?
A auriculotemporal nerve
B buccal branch of the facial nerve
C buccal nerve
D greater petrosal nerve
E lesser petrosal nerve
He3. An 11-year-old girl is brought into her pediatrician's office by her mother. She recently
learned to do back flips on the balance beam, when her foot slipped off and she landed with her
perineum striking the beam. She developed a massive subcutaneous hematoma filling her
perineum that posteriorly formed a straight horizontal line just anterior to her anus. It extended
anteriorly onto the anterior abdominal wall about half way to her umbilicus and above the inguinal
ligament. No blood entered her thighs. She could still urinate and there was no blood in her urine.
The hematoma was contained by what space?
A Ischioanal fossa
B Superficial perineal space
C Deep perineal space
D Femoral sheath
E Inguinal canal
He4. Concerning a patient who presented with nystagmus and a gait ataxia, an MRI detected the
presence of a lesion in the region of the cerebellum. With which functional division of the
cerebellum is the affected region associated?
A Cerebrocerebellum
B Spinocerebellum
C
D
E
Dentate nucleus
Middle cerebellar peduncle
Interposed nuclei
He5. A second-year medical student was asked to see a nursing home patient as a requirement for a
physical diagnosis course. The patient was a 79-year-old man who was apparently in a coma. The
student wasn’t certain how to approach this case, so he asked the patient’s wife, who was sitting at
the bedside, why this patient was in a coma. The wife replied, “Oh, Paul isn’t in a coma.
But he did have a stroke.” Slightly confused, the student leaned over and asked Paul to open his
eyes. He opened his eyes immediately. However, when asked to lift his arm or speak, Paul did
nothing. The student then asked Paul’s wife whether she was certain that his eye opening was not
simply a coincidence and whether he really was in a coma, since he was unable to follow any
commands. Paul’s wife explained that he was unable to move or speak as a result of his stroke.
However, she knew that he was awake because he could communicate with her by blinking his
eyes. The student appeared rather skeptical, so Paul’s wife asked her husband to blink once for
“yes” and twice for “no.” She then asked him if he was at home, and he blinked twice. When
asked if he was in a nursing home, he blinked once. The student then asked him to move his eyes,
and he was able to look in his direction. However, when the student asked him if he could move
his arms or legs, he blinked twice. He also blinked twice when asked if he could smile. He did the
same when asked if he could feel someone moving his arm. The student thanked Paul and his wife
for their time, made notes of his findings, and returned to class. Where in the nervous system
could a lesion occur that can cause paralysis of the extremities bilaterally, as well as in the face,
but not of the eyes?
A High cervical spinal cord bilaterally
B Bilateral thalamus
C Bilateral basal ganglia
D Bilateral basilar pons
E Bilateral frontal lobe
He6. The sinoatrial (SA) node initiates the heartbeat by giving off an impulse about 80 times per
minute. It is located at the junction of the superior vena cava and right atrium. In about 60% of the
cases, the SA node derives its vascular supply from which of the following?
A anterior interventricular artery
B left circumflex artery
C posterior interventricular artery
D right coronary artery
E right marginal branch
He7. Paresthesia, hyperesthesia, or even painful sensation in the anterolateral region of the thigh
may occur in obese persons. It results from an abdominal panniculus adiposus that bulges over the
inguinal ligament and compresses which one of the following underlying nerves?
A Femoral branch of the genitofemoral nerve
B Femoral nerve
C Iliohypogastric nerve
D
E
Ilioinguinal nerve
Lateral femoral cutaneous nerve
He8. A 49-year-old motorcycle rider was brought into the emergency department unconscious
having been found at the side of the highway. He was breathing on his own and his heartbeat was
regular. Upon physical examination he has both biceps and triceps reflexes, but his anal tone is
weak and he has neither patellar tendon nor Achilles tendon reflexes. He is noted to have a
displacement of the spinous process of his mid-to-lower back. An x-ray is taken and is shown
below. If and when the 49-year-old man regains consciousness what should his physician tell him
about his spinal injury?
A Your injury is at T5 and sensation and most movements below your neck have been lost.
B Your injury is at T7 and sensation from your umbilicus inferiorly has been lost.
C Yourinjury is at T7 and most movements from below your umbilicus inferiorly have been
lost.
D Your injury is at T10 and sensation and most movements below your umbilicus have been
lost.
E Your injury is at L2 but you should be able to walk with a cane since the injury is inferior to
where the spinal cord extends.
He9. A patient arrives in the emergency room in shock, with a history of gastric ulcers. Blood
pressure is dropping and you suspect a bleed. If the gastric ulcer is located on the posterior wall of
the stomach and erodes the stomach lining, which artery could be eroded by the stomach’s gastric
contents?
A Inferior vena cava
B Left renal vein
C Portal vein
D Splenic artery
E Superior mesenteric artery
He10.
A 62-year-old rock and roller fell out of a palm tree while vacationing in Fiji. He had
climbed the tree and had fallen while trying to reach one of the coconuts. He didn’t think he had
broken any bones in the fall. While he felt fine the day of the fall, the next morning he awoke with
a bad headache and was relatively incoherent. At the Fiji emergency room both frontal and lateral
skull plain films showed no evidence of any fracture but during the physical exam papilledema
was noted especially in one eye. He was flown to New Zealand where head CT findings were
consistent with which of the following diagnoses?
A epidural hematoma
B Subdural hematoma
C Pituitary tumor
D Grave’s disease
E Trigeminal neuralgia
He11.
Following an industrial accident, a 45-year-old male developed a complete flaccid
paralysis and loss of sensation of the lower limbs. After a week, the patient regained movement of
the limbs but at that time experienced pain in the region of the lower limbs coupled with bladder
dysfunction. All of these defects are most likely the result of which of the following?
A Compression of the dorsal roots at L2
B Compression of the entire spinal cord at L2
C Compression of the dorsal columns at L2
D Compression of the lateral funiculus at L2
E A lesion transecting the corticospinal tracts at T1
He12.
A 42-year-old male previously in good health suddenly became interested in child
pornography, showed diminished impulse control, sought sexual favors from office employees,
and was later charged with molesting a child. At the urging of his family, he sought the help of a
psychiatrist who subsequently referred him to a neurologist. The patient showed evidence of
constructional apraxia and agraphia, but other neurological tests appeared normal. An MRI was
given and a brain tumor was discovered. Which of the following regions is most likely to contain
the tumor?
A Precentral gyrus
B Orbitofrontal cortex
C Angular gyrus
D Superior temporal gyrus
E Supramarginal gyrus
He13.
A patient is diagnosed by the same optometrist as being farsighted. To correct this
person's defect, which of the following lenses should the doctor recommend be put into his
eyeglasses?
A Cylindrical
B Concave
C Convex
D Neutral
E Spherical
He14.
After a hemisection of the spinal cord takes place at T3, a patient experiences marked
weakness in the right leg. Which of the following best accounts for this weakness?
A There was muscle damage in the right leg.
B There was damage in his left frontal lobe.
C There was damage to the right corticospinal tract.
D The dorsal root was damaged.
E There was damage to the right femoral nerve.
He15.
A full-term baby girl presents with a bulge over the right inguinal region extending into
her right labial majora. When the neonatologist gently presses in one area of the inguinal region or
labial majora, the opposite area bulges, suggesting that a cystic structure is being palpated. What
congenital dysmorphology does the baby girl likely have?
A Cryptorchidism
B Cyst in the canal of Nuck
C
D
E
Direct inguinal hernias
Exstrophy of the bladder
Indirect inguinal hernia
He16.
A neurophysiologist was conducting experiments on the retina of a species of animal
lacking a cell type which, in other animals, is responsible for the presence of lateral inhibition
within the retina. Which of the following cell types is lacking in this species under investigation?
A Rod cells
B Cone cells
C Bipolar cells
D Ganglion cells
E Horizontal cells
He17.
A 76-year-old woman has a 10-year history of high blood pressure and diabetes. One
day, as she was reaching for a jar of flour to make an apple pie, her right side suddenly gave out,
and she collapsed. While trying to get up from the floor, she noticed that she was unable to move
her right arm or leg. She attempted to cry for help because she was unable to reach the telephone;
however, her speech was slurred and rather unintelligible. She lay on the floor and waited for help
to arrive. Her son began to worry about his usually prompt mother when she didn’t arrive with her
apple pie. After several attempts to telephone her apartment without getting an answer, he drove
there and found her lying on the floor. She attempted to tell him what had happened, but her
speech was too slurred to comprehend. Assuming that his mother had had a stroke, the son called
an ambulance. A neurology resident was called to see the patient in the emergency room because
the physicians there likewise thought that she had a stroke. The resident noted that she followed
commands very well, and, although her speech was very slurred, it was logical in organization.
The lower two-thirds of her face drooped on the right. Her tongue pointed to the right side when
she was asked to protrude it. Her right arm and leg were severely, but equally, weak; her left side
had normal strength. She felt a pin and a vibrating tuning fork equally on both sides. Where in the
central nervous system (CNS) did the patient's stroke most likely occur?
A Left precentral gyrus
B Right precentral gyrus
C Left basilar pons or left internal capsule
D Right putamen or globus pallidus
E Left thalamus
He18.
One morning, an 82-year-old male found that it was difficult for him to walk as his left
foot collapsed. He called 911 for assistance and noticed that his speech was slurred. The
emergency room physician noted, in addition to his speech, the following deficits: his left arm and
leg were markedly weak, and muscle tone was flaccid. Reflexes were depressed on the left side
but normal on the right side. All sensory modalities were depressed on the left side. His left side of
the face drooped and he consistently looked to the right side. When asked to look to the left, his
eyes would not move beyond the midline. Likewise, when asked to raise his left hand, he raised
his right hand. When asked if his left hand belonged to him, he replied that it didn’t. The physician
drew a circle depicting a clock and the patient was asked to fill in the numbers in the clock. The
numbers 1 through 12 were all placed on the right side of the clock. The physician also asked the
patient to draw a vertical line that bisected a horizontal line drawn by the physician. The patient
drew a vertical line on the right side of the line. When the physician waved his hand in front of the
temporal visual field of the left eye or the nasal visual field of the right side, the patient did not
blink. Aside from the drooping of the left side of the face (in which the forehead was spared),
other cranial nerve functions appeared normal. The physician ordered a CT scan of the patient’s
head and then admitted him to the hospital for further testing. Which of the following neurological
deficits did the patient display?
A Left hemiparesis, hemineglect, left homonymous hemianopsia, left hemisensory loss
B Left hemiparesis, right superior quadrantanopsia
C Left hemiparesis, left hemisensory loss, hemineglect, left superior quadrantanopsia
D Left hemisensory loss, hemineglect, bitemporal hemianopsia
E Left hemisensory loss, hemineglect, left superior quadrantanopsia
He19.
A 19-year-old man was in a barroom brawl and was punched squarely in the right eye.
He comes to the emergency room the next day and complains of diplopia. An X-ray reveals
fracture of the orbital floor. Neurological examination shows loss of sensation of the skin of the
right face below the right eye and the upper gums. Which of the following nerves may be injured?
A frontal nerve
B infraorbital nerve
C nasociliary nerve
D supraorbital nerve
E trochlear nerve
He20.
When performing a cardiac catheterization of the right heart chambers you need to
remember that the carotid sheath contains which of the following?
A Internal carotid artery (lateral), internal jugular vein (medial), and sympathetic chain
B Internal carotid artery (medial), external jugular vein (lateral), and sympathetic chain
C Internal carotid artery (medial), external jugular vein (lateral), and phrenic nerve
D Internal carotid artery (lateral), internal jugular vein (medial), and phrenic nerve
E Internal carotid artery (medial), internal jugular vein (lateral), and the vagus nerve
He21.
A football player was simultaneously tackled from the front above the knee and from the
back below the knee. In the emergency room, he displays a positive anterior drawer test which
becomes negative if the knee is internally or externally rotated. Which of the following has
ruptured?
A anterior cruciate ligament
B fibula
C fibular (lateral) collateral ligament
D posterior cruciate ligament
E tibial (medial) collateral ligament
He22.
A 63-year-old man is on your hospital service for workup of a stiff neck and the “worse
headache” of his life and general malaise. Two days earlier, he had had a spinal tap, which was
bloodless and consistent with viral meningitis. This morning on rounds you note that he seems to
have to turn his whole head towards you when he looks at you as you enter his hospital room.
While his headache is getting better, you notice that both his eyes have reduced ability to move
laterally; rather he tends to turn his head. When you get out your ophthalmoscope and look at his
fundi, there is no evidence of papilledema. You check his back at the site of his spinal tap that had
been performed two days earlier and it seems OK. The rest of the cranial nerve exam is normal.
Which of the following is the most likely cause of his reduced eye movement?
A Viral meningitis
B Stretching of cranial nerve VI
C Excess cerebral spinal fluid that is stretching just cranial nerves III
D Bilateral tumors at the superior orbital fissures
E Normal stiffening process following hospitalization for couple of days
He23.
A 67-year-old female who complained of headaches was given an MRI and found to
have a small tumor situated on the dorsolateral roof of the midbrain. Which of the following
deficits is most likely to occur as a result of this tumor?
A Inability to move the eyes in a horizontal direction
B Inability to move the eyes upward
C Loss of the accommodation reflex
D Double vision upon attempt at downward gaze
E Nystagmus upon attempt at moving the eyes horizontally
He24.
A 37-year-old man was pinned against the wall of a loading dock when a forklift backed
into him, breaking two ribs and causing a hemothorax. A negative pressure drain (chest tube) must
be inserted into the pleural space in order to remove blood from his pleural cavity. What would be
a typical location for placement of the chest tube?
A At the apex of the pleural space between the clavicle and first rib
B Costomediastinal recess on the left, adjacent to the xiphoid process
C Right fourth intercostal space in the midclavicular line
D Right sixth intercostal space in the midaxillary line
E Right eighth intercostal space in the midaxillary line
He25.
One of the new staff members at a skilled nursing facility asks the physician to examine
a 92-year-old woman. She has suddenly developed a very large cylindrical mass between her legs.
The woman tells the physician that she has 7 children and 22 grandchildren and has been
constipated lately. Upon examining the woman she appears to have a perineal procidentia, with no
rectal involvement. What is the correct list of structures that were compromised to produce this
condition?
A Stretching of the cardinal and round ligaments of the uterus and suspensory ligaments of the
ovary
B Stretching of the urachus, medial and lateral umbilical ligaments/folds
C Stretching of the median, medial and lateral umbilical ligaments/folds
D Stretching of the cardinal ligaments of the uterus, the round ligament of the ovaries, and the
suspensory ligament of the ovaries.
E
Stretching of the vaginal wall, cardinal and round ligaments of the uterus
He26.
A patient reports that he spent two weeks on a desert island as part of a television
survival show. It rained and was cool the last 5 days, and he developed a cough. He is now in the
emergency department with a productive cough that produces rusty and bloodstained sputum. He
complains of significant pain that appears to be pleural in origin. Pneumococcal lobar pneumonia
is suspected. From the accompanying CT scan at the T4 level, which one of the following lung
lobes (indicated by the asterisk) is involved with the pneumonia?
A Right upper lobe
B Right middle lobe
C Right lower lobe
D Left upper lobe
E Left lower lobe
He27.
A patient is diagnosed by an optometrist as being nearsighted. To correct this person's
defect, which of the following lenses should the doctor recommend be put into his eyeglasses?
A Cylindrical
B Concave
C Convex
D Neutral
E Rectangular
He28.
An overworked surgical resident is resecting an acinic cell carcinoma from the inferior
aspect of the parotid gland when he makes a careless incision and nicks a branch of the facial
(seventh cranial) nerve. Which of the following muscles may be affected by this injury?
A omohyoid
B sternohyoid
C sternothyroid
D stylohyoid
E thyrohyoid
He29.
A patient is admitted to the emergency room following what appears to be a stroke. He
presents with an ipsilateral paralysis of lateral gaze, a facial paralysis, and Horner syndrome.
Damage to which of the following regions of the
CNS best accounts for the constellation of dysfunctions described in this case?
A Rostral aspect of the lateral medulla
B Rostral aspect of the lateral medulla
C Caudal aspect of the lateral pons
D Rostral aspect of the lateral pons
E Caudal aspect of the lateral midbrain
He30.
A 16-year-old male suffers a blunt-force trauma to the side of his head, resulting in a
fractured jaw. Several weeks following the incident, the patient complains of numbness in his chin.
You are concerned he will have trouble chewing food. Muscles of mastication are innervated by
which cranial nerve?
A Trigeminal nerve
B Facial nerve
C Hypoglossal nerve
D Glossopharyngeal nerve
E Vagal nerve
He31.
A 67-year-old female suffers a stroke limited to a region of the superior temporal gyrus.
Which of the following structures provides the primary input to the superior temporal gyrus?
A CM thalamic nucleus
B Medial geniculate thalamic nucleus
C Lateral geniculate thalamic nucleus
D Dorsomedial thalamic nucleus
E Anterior thalamic nucleus
He32.
A 52-year-old man is brought to the emergency room after being found in the park,
where apparently he had lain overnight after a fall. He complains of severe pain in the left arm.
Physical examination suggests a broken humerus that is confirmed radiologically. The patient can
extend the forearm at the elbow, but supination appears to be somewhat weak; the hand grasp is
very weak compared with the uninjured arm. Neurologic examination reveals an inability to
extend the wrist (wrist-drop). Because these findings point to apparent nerve damage, the patient
is scheduled for a surgical reduction of the fracture. The observation that extension at the elbow
appears normal, but supination of the forearm appears weak, warrants localization of the nerve
lesion to which of the following?
A Posterior cord of the brachial plexus in the axilla
B Posterior divisions of the brachial plexus
C Radial nerve at the distal third of the humerus
D Radial nerve in the midforearm
E Radial nerve in the vicinity of the head of the radius
He33.
A 72-year-old male patient has suffered a cerebral infarct affecting the left cerebral
hemisphere. On examination of the patient, it is noticed that his verbal output is fluent and
paraphasic. His comprehension of speech is normal but repetition is severely impaired. Naming is
also impaired, although when given a list, the patient is able to select the correct name. Special
consultation with a neurologist results in a diagnosis of conduction aphasia. Which of the
following brain structures is affected?
A arcuate fasciculus
B Broca's area
C nucleus ambiguus
D red nucleus
E Wernicke's area
He34.
A patient is diagnosed with sensory neglect because he is unable to notice the left side of
his body. Which of the following regions of the cerebral cortex is most likely damaged in this
patient?
A Left anterior frontal cortex
B Right anterior frontal cortex
C Right posterior frontal cortex
D Right posterior parietal cortex
E Right anterior parietal cortex
He35.
Which of the following statements is true of cardiac development?
A During formation of the heart loop, a single-tube heart remains suspended by a complete
dorsal mesocardium (mesentery)
B The atria are represented by cranial portions of the endocardial tubes
C The heart bends into an S-shape because the caudal regions of the endocardial tubes grow
faster than the cranial regions
D The left and right sides of the heart result directly from the side-by-side apposition of the left
and right endocardial tubes
E The sinus venosus becomes incorporated into the atrium prior to the formation of the heart
loop
He36.
A vascular occlusion of a region of the brain damaged the overwhelming numbers of
fibers that supply the basal ganglia. Which of the following regions constitute the receiving area of
the overwhelming majority of fibers that supply the basal ganglia?
A Paleostriatum
B Neostriatum
C Subthalamic nucleus
D Substantia nigra
E Claustrum
He37.
A 64-year-old woman presents with a new complaint of back pain. She was previously diagnosed
with rheumatoid arthritis, and is managed with antirheumatic and non-steroidal anti-inflammatory
drugs (NSAIDs). The back pain is worse after activity, such as square dancing. Examination
reveals no muscular pain with a little muscle guarding within the erector spinae muscles. The
spinous process and supraspinous ligament are all pain free. Her physician can elicit back pain up
and down the spinal column, lateral to the spinous processes, but medial to the transverse
processes when the patient twists. Bending and flexing of the spinal column is less painful than
standing and twisting and there is no radicular pain. What are the most likely nerves that perceive
the pain?
A Anterior rami of the spinal nerve
B Articular branches of the dorsal rami
C Meningeal branches of the ventral rami of spinal nerves
D Recurrent meningeal nerves that innervate the intervertebral disks
E Referred pain from cervical nerves that innervate the nuchal ligament
He38.
A spiral fracture of the humerus in the region marked Z on the accompanying radiograph
had severely injured a major nerve that passes on the dorsal aspect of the bone. Which of the
following is most likely to occur as a result of this injury?
A Wrist-drop palsy
B Total clawing of the hand
C Waiter’s tip palsy
D Clawing of digits 4 and 5
E Dupuytren’s contracture
He39.
A 32-year-old woman was brought into the ED from a car accident. She was conscious,
but had been knocked unconscious for a couple of minutes by the force of a car that had run a stop
sign, broad-siding her vehicle. She has a hematoma over the parietal bone on the left side of her
head. She complains of a stiff neck and tilts her head slightly to the right. While performing a
cranial nerve examination, it is noted that her left eye has difficulty moving inferiorly from a fully
adducted horizontal position, when she looks down at her feet. A head CT is ordered with specific
imaging of which one of the following cranial nerves?
A Right cranial nerve III
B Left cranial nerve III
C Right cranial nerve IV
D Left cranial nerve IV
E Left cranial nerve VI
He40.
A perilunate fracture dislocation is a devastating closed injury of the wrist. It usually
results from a fall where the weight of the body is transferred onto the wrist. The hand is caught in
the hyperextended and ulnar deviated position. The fracture dislocation involves rupture of
interosseous ligaments, joints, and ultimately dislocation/fracture of the lunate bone. In the
anatomical position, which carpal bone lies directly distal to the lunate?
A capitate
B hamate
C scaphoid
D trapezoid
E triquetrum
He41.
A routine eye examination reveals the presence of inflammation limited to the left optic
disk, probably due to neuritis of this region. Which of the following is the likely visual deficit
resulting from this disorder?
A Total blindness of the left eye
B Left homonymous hemianopsia
C Left heteronymous hemianopsia
D Left enlargement of the blind spot
E Left upper quadrantanopia
He42.
A 36-year-old man complained to his primary care physician of occasional dull,
throbbing pain associated with the right testis and scrotum. Examination indicated varicocele of
the pampiniform plexus. The physician remarked that in all probability the patient had this
condition since adolescence and should not be bothered by it. The patient was emphatic that the
condition had arisen within the last few months and sought a second opinion from an urologist.
The urologist ordered an abdominal and pelvic CT. Factors that the urologist considered include
which of the following in regard to varicocele of the pampiniform plexus on the right side?
A It is very uncommon
B It occurs about as often as that on the left side
C It may be the result of testicular torsion
D It may be associated with a long, redundant mesorchium
E
He43.
The structure indicated by arrow 2 in Fig. 1-9 is which of the following?
A ethmoidal sinus
B inferior nasal meatus
C infratemporal fossa
D maxillary sinus
E sphenoidal sinus
He44.
The bone marked
B in the lateral plain film of the right foot is which one of the following?
A Talus
B Navicular
C Calcaneus
D Cuboid
E Fifth metatarsal
He45.
A 38-year-old female patient suffers from pleurisy and requires pleural fluid sampling
(thoracentesis). The attending physician asks you to perform the procedure at the midaxillary line
on the right side. Which of the following would be the appropriate level to perform the procedure?
A above the level of the 7th rib
B at the level of the 10th rib
C at the level of the 5th rib
D below the level of the 10th rib
E between the level of the 8th and 10th ribs
He46.
A 24-year-old man becomes intoxicated and gets into a barfight, during which he is
stabbed in the back. He is taken to the emergency room and following a thorough neurological
examination, it is determined that the knife wound destroyed the right half of the spinal cord at the
level of the lower cervical cord. Which of the following deficits will most likely result from the
knife wound?
A Impaired bladder functions only
B Impaired movements of the lower limb only
C Impaired movements of the upper limb only
D Loss of sensory functions of the lower limb only
E Loss of sensory and motor functions of upper and lower limbs
He47.
Neurons that are capable of responding to the direction or orientation of a given visual
stimulus that is moved along a receptive field would be identified in which of the following?
A Spinal cord
B Medulla
C Pons
D Thalamus
E Cerebral cortex
He48.
A patient was thrown from a tractor, which partially ran over him and caused injury to
the base of the skull. The origin of the internal jugular vein at the jugular foramen was
compromised. Which of the following cranial nerves courses through the jugular foramen?
A abducens (sixth cranial) nerve
B facial (seventh cranial) nerve
C hypoglossal (twelfth cranial) nerve
D spinal accessory nerve (eleventh cranial) nerve
E Vestibuleocochlear (eighth cranial) nerve
He49.
A previously healthy 62-year-old man is brought to a neurologist by his daughter
because of increasing difficulty in walking. His daughter noticed that for the past year, he had
difficulty getting out of a chair and took a lot of time to begin to walk. When he did walk, he
walked with a slow, shuffling gait. In addition, she had noticed some changes in his face, and that
he had been drooling excessively. His signature on checks became progressively smaller from the
beginning of his name to the end, and he had developed a new tremor. She brought him in to make
sure this was not just "aging." The neurologist examines the patient and notices immediately that
his facial expression was masklike, with few eyeblinks. When asked to write a sentence, the letters
become progressively smaller toward the end of the sentence. His speech is soft and monotonous,
and he has a slow, resting pill-rolling tremor in both of his hands. He has very little spontaneous
movement, and his arms, legs, and trunk were stiff. When the neurologist tries to flex his arm, he
feels many catches, similar to a cog-wheel. There is no weakness, sensory problems, or
abnormalities in his reflexes. When asked to walk, the patient takes many tries to rise from his
chair. When he finally stands up, his posture is stooped and flexed. His gait is slow, his feet shuffle
when he walks, and his arms do not swing with his steps. The neurologist tells the patient's
daughter that she is correct that this is not just aging and explains to her all of the details about a
new medication that her father needs to take. The blood supply of which of the main structure is
damaged?
A Lenticulostriate branches of the middle cerebral and anterior cerebral arteries
B Perforating branches of the basilar and vertebral arteries
C Anterior choroidal artery and anterior cerebral artery
D Branches of posterior cerebral and posterior communicating arteries
E Anterior cerebral and anterior communicating arteries
He50.
A child complaining of headaches and exhibiting signs of neurologic deficits is sent for
an MRI. Initial findings indicate hydrocephalus caused by a tumor obstruction located at the
interventricular foramen. Which structures are most likely enlarged?
A Both lateral ventricles and the third ventricle
B Both the lateral ventricles
C Only the third ventricle
D Only the fourth ventricle
E The lateral ventricles, the third ventricle, and the fourth ventricle
He51.
A 71-year-old grandmother fell half way down the basement stairs while carrying a
laundry basket after dinner. She didn’t lose consciousness, but sat at the bottom of the stairs
gathering her wits and the scattered laundry. She didn’t think she had broken any bones as she
could move all her limbs. Her husband, who had heard the noise and came to check on her, helped
her stand up. It was then that she felt a slight pain in her left hip when she placed weight on it. She
limped about for the rest of the day. The next morning her husband brought her into your family
practice office where you could clearly see that she walked with her pelvis tilted as if her left leg
was slightly shorter. She still had left hip pain. You order a plain film of the left femur from hip to
knee expecting to find which of the following?
A Femoral neck fracture with compression
B Femoral neck fracture with complete displacement
C A spiral fracture of the femoral shaft
D A transverse supracondylar fracture
E An intercondylar fracture
He52.
During a neck dissection, the styloid process is used as a landmark. Which one of the
following statements correctly pertains to one of the five structures that attach to the styloid
process?
A The stylohyoid muscle attaches to the lesser horn of the hyoid bone.
B The styloglossus muscle acts to protrude the tongue.
C The stylohyoid ligament attaches to the lingula of the mandible.
D Distally the stylopharyngeus muscle is split by the digastric muscle.
E The stylomandibular ligament attaches to the lingula of the mandible.
He53.
A 67-year-old woman slipped on a scatter rug and fell with her right arm extended in an
attempt to ease the impact of the fall. She experienced immediate severe pain in the region of the
right clavicle and in the right distal arm. Painful movement of the right arm was minimized by
holding the arm close to the body and by supporting the elbow with the left hand. There is marked
tenderness and some swelling in the region of the clavicle about one-third of the distance from the
sternum. The examining physician can feel the projecting edges of the clavicular fragments. The
radiograph confirms the fracture and shows elevation of the proximal fragment with depression
and subluxation of the distal fragment. Traction by which one of the following muscles causes the
most subluxation with the distal fragment underriding the proximal fragment?
A Deltoid muscle
B Pectoralis major muscle
C Pectoralis minor muscle
D Sternocleidomastoid muscle
E
Trapezius muscle
He54.
A 30-year-old male suffers a serious injury of the central nervous system that results
from an industrial accident. A neurological evaluation suggests that the major input to the
flocculonodular lobe is damaged. Which of the following structures that provides the major input
to the flocculonodular lobe was damaged?
A Nucleus dorsalis of Clarke
B Red nucleus
C Vestibular nuclei
D Cerebral cortex
E Midbrain reticular formation
He55.
A patient delays initiation of movement, displays an uneven trajectory in moving her
hand from above her head to touch her nose, and is uneven in her attempts to demonstrate rapid
alternation of pronating and supernating movements of the hand and forearm. Which of the
following regions most likely contains the lesion?
A Hemispheres of the posterior cerebellar lobe
B Flocculonodular lobe of the cerebellum
C Vermal region of the anterior cerebellar lobe
D Fastigial nucleus
E Ventral spinocerebellar tract
He56.
Which of the following is the most direct route for spread of infection from the
paranasal sinuses to the cavernous sinus of the dura mater?
A Pterygoid venous plexus
B Superior ophthalmic vein
C Frontal emissary vein
D Basilar venous plexus
E
Parietal emissary vein
He57.
A 75-year-old man was rushed to the hospital from his retirement community when he
suddenly became confused and could not speak but could grunt and moan. The patient could
follow simple commands and did recognize his wife and children although he could not name
them or speak to them. Additional immediate examination revealed weakness of the right upper
extremity. Several days later, a more comprehensive examination revealed weakness and paralysis
of the right hand and arm with increased biceps and triceps reflexes. Paralysis and weakness were
also present on the lower right side of the face. Pain, temperature, and touch modalities were
mildly decreased over the right arm, hand, and face, and proprioception was reduced in the right
hand. The patient had regained the ability to articulate a few simple words with great difficulty,
but could not repeat even simple two or three word phrases. Which artery or major branch of a
large artery suffered the occlusion that produced the observed symptoms?
A Anterior choroidal artery
B Middle cerebral artery
C Posterior communicating artery
D
E
Ophthalmic artery
Anterior cerebral artery
He58.
The central nervous system is bathed in 135 to 150 mL of cerebrospinal fluid (
CSF). In adults, this fluid is produced at the rate of 450 to 500 mL per day from the choroid plexus
within the ventricular system and should have a pressure of less than 20 cm of water. Most of the
absorption of cerebrospinal fluid occurs at arachnoid villi. The arachnoid villi allow cerebrospinal
fluid to pass between which of the following two spaces?
A Choroid plexus and subdural space
B Subarachnoid space and subdural space
C Subarachnoid space and superior sagittal sinus
D Subdural space and cavernous sinus
E Superior sagittal sinus and jugular vein
He59.
A 86-year-old female suffered a stroke that left her paralyzed over her right side of the
body, including both arm and leg. In addition, the lower jaw deviated to the right and her tongue
also extended to the right when asked to protrude it. When she was asked to raise her eyebrows,
her forehead appeared symmetric. Which of the following best explains why Helen’s forehead was
spared from weakness?
A The forehead is innervated by different fibers originating in the postcentral gyrus
B There are two cranial nerves innervating the forehead
C The forehead is represented bilaterally at the cortical level
D The forehead is stronger than the rest of the face
E Thalamic regions receiving inputs from the forehead contain few inhibitory neurons
He60.
When a physician examines the "corneal reflex" in a patient, she/he touches the cornea
with a wisp of cotton that causes the eyelid to rapidly shut.
As with most reflexes, one is testing both the afferent information that is carried back to the
central nervous system and the reflex motor response. What specific cranial nerve branches are
responsible for both the afferent and efferent parts of the corneal reflex?
A Short ciliary nerve (CN III); zygomatic and temporal branches of the facial nerve (
CN VII)
B Short ciliary nerve (CN III); oculomotor nerve (CN III)
C Long ciliary nerve (CN V1); zygomatic branches of the facial nerve (CN VII)
D Long ciliary nerve (CN V1); infraorbital branch of the trigeminal nerve (CN V2)
E Infraorbital nerve (CN V2); zygomatic branches of the facial nerve (CN VII)
He61.
A 45-year-old plumber presented in the clinic complaining of long-standing pain in the
elbow. Subsequent examination revealed normal flexion/ extension at both the elbow and the wrist,
but weakened abduction of the thumb and extension at the metacarpophalangeal joints of the
fingers. Those symptoms were found to be caused by entrapment of the posterior interosseus
nerve. Which of the following muscles could itself cause entrapment of the posterior interosseus
nerve?
A Extensor carpi ulnaris
B
C
D
E
Extensor indices
Anconeus
Extensor digitorum
Supinator
He62.
A 62-year-old man who smoked two packs of cigarettes per day for 35 years was
suffering from a chronic cough that was attributed to his smoking habit by his physician. One day
the patient noticed that his right eyelid drooped slightly and that his right pupil was smaller than
the left. He also noticed that the inner side of his right hand was numb and that he had begun to
drop things from his right hand. He had no other symptoms. He consulted his physician, who
directed him to a neurologist. The neurologist noted that although the right pupil was smaller than
the left, it was still reactive to light. Although the patient's right eyelid drooped slightly, he could
close his eyes tightly when asked to do so. The neurologist noted that the patient did not sweat on
the right side of his face. He was unable to feel a pinprick on the inner surface of his right hand,
and his right triceps and hand muscles were weak. If the damage included part of the
CNS, which of the following structures could have been involved?
A Left oculomotor nerve
B Right oculomotor nerve
C Edinger-Westphal nucleus
D Descending hypothalamic sympathetic fibers
E Parasympathetic fibers coursing from the Edinger-Westphal nucleus
He63.
An elderly male suffered a stroke that appeared to involve the left internal capsule rather
than the cerebral cortex. It resulted in paralysis of the right arm and leg, the tongue deviated to the
right side when he was asked to protrude it; lower (jaw) facial expression on the right side was lost,
and his speech was slurred, but fluent and grammatically correct. Which of the following best
describes the speech deficit in this patient?
A Wernicke’s aphasia
B Broca’s aphasia
C Anomia
D Dysarthria
E Conduction aphasia
He64.
An investigator sought to determine the primary neuronal target structure in the brain
which receives inputs from the inferior olivary nucleus. In order to complete this study, the
investigator microinjected a tracer substance into the inferior olivary nucleus which was then
transported from the cell bodies in the inferior olivary nucleus down the axons to their target
structures. Which of the following structures would contain the tracer substance indicating that it
constitutes a principal projection target of the inferior olivary nucleus?
A Cerebral cortex
B Midbrain periaqueductal gray
C Vestibular nuclei
D Dorsal column nuclei
E Cerebellar cortex
He65.
A 50-year-old associate professor is scheduled for a routine physical examination for
increased life insurance coverage. He has never had a digital rectal examination or PS
A level determined so the physician recommends both to him. The physician has him hop off the
examination table, turn away and face the table, then bend at the waist while she gently inserts a
lubricated gloved finger into his anus. Typically what part of three reproductive organs can a
physician palpate through the anterior wall of the rectum during a digital rectal examination?
A Ejaculatory ducts, main peripheral portion of the prostate gland, prostatic utricle
B Ejaculatory ducts, main peripheral portion of the prostate gland, seminal colliculus
C Main peripheral portion of the prostate gland, seminal vesicles, ampulla of the vas deferens
D Main peripheral portion of the prostate gland, seminal vesicles, epididymal ducts
E Seminal vesicles, periurethral portion of the prostate gland, prostatic utricle
He66.
A 62-year-old man reports to you that at times he has some chest pain and thinks that his
heart is not beating at an appropriate rate, mainly too slowly, but occasionally too quickly. You
send him for a 64 slice helical CT to look at the blood supply to the sinoatrial node. The sinoatrial
artery supplies blood to the sinoatrial node. Which of the following is the best description of the
blood supply for the sinoatrial nodal artery?
A Blood always comes from the right coronary artery
B Blood always comes from the left coronary artery
C About 60% of the time blood comes from the right coronary artery and about 40% of the time
blood comes from the left circumflex artery
D About 60% of the time blood comes from the right marginal artery and 40% of the time from
the left marginal artery
E Blood usually comes from the posterior interventricular artery regardless of whether that has
originated from the right or left coronary artery
He67.
Concerning a patient who is unable to salivate nor express a gag or uvular reflex, which
of the following best characterizes the neurons associated with loss of these functions?
A General somatic efferent and special visceral efferent
B General visceral efferent and special visceral efferent
C General somatic efferent and general visceral efferent
D General visceral efferent and general visceral afferent
E Special visceral efferent and special visceral afferent
He68.
A patient presents with cerebellar ataxia and nystagmus. An MRI later identifies the site
of the lesion. To which of the following deep cerebellar nucleus or related structure do the neurons
in the damaged region project?
A Globose nucleus
B Emboliform nucleus
C Fastigial nucleus
D Dentate nucleus
E Superior cerebellar peduncle
He69.
A 65-year-old female has weakness when attempting to flex her left knee and extend the
hip. Neurophysiological analysis of the affected regions reveals a reduced number of motor units
firing with fasciculations and slowed conduction velocity. There is no depression of tendon
reflexes or muscle wasting. Likewise, plantar and abdominal reflexes are normal, there is little
sensory loss, and there are no signs of sphincter disturbances. Which of the following is the best
explanation for this disturbance?
A Peripheral neuropathy of nerves on the left side of the body that exit the spinal cord at L4–S1
B Damage of the neuromuscular junctions associated with nerves that exit the left side of the
spinal cord between T8 and L3
C Degeneration of nerve cells in the ventral horn of the left side of the spinal cord between T8
and T12
D Degeneration of fibers contained in the lateral funiculus of the left side of the thoracic spinal
cord
E Damage to the dorsal horn of the spinal cord of the left side between L1 and L4
He70.
A 50-year-old man comes in for a physical so he can attend a boy scout camp with one
of his sons. You suggest a colonoscopy after he returns from camp. He agrees, but wants you to
describe the procedure and potential risks and complications. You explain that the goal of a
colonoscopy is to look at the entire length of the large intestine from the anus to the small intestine
(ileocecal junction), observing polyps or diverticuli with a flexible fiber optic colonoscope
inserted through the anus. There is a small risk of perforating the bowel especially when the colon
takes a sudden turn or twists on itself at regions where it is intraperitoneal rather than attached to
the posterior abdominal wall (retroperitoneal). Which of the following regions of the colon
generally poses the greatest risk for perforation because the bowel takes either a sudden change in
direction or is suspended by a mesentery?
A Rectum, sigmoid colon and descending colon
B Sigmoid colon, descending colon and splenic flexure
C Sigmoid colon, splenic flexure and descending colon
D Sigmoid colon, splenic flexure and hepatic flexure
E Descending colon, transverse colon and ascending colon
He71.
A 12-year-old girl has no history of medical problems. One day, while in the kitchen
with her mother, she told her mother that she felt very frightened all of a sudden and had a funny
feeling in her stomach. Immediately after this, she turned her head to the right, stared persistently,
and began to chew. Her mother called her name several times, but the child, who was usually very
obedient, did not answer. After approximately 1 minute of staring, the girl slowly turned her head
back to her mother. Apparently confused, she asked her mother where she was. Over the next
10–15 minutes, she became less and less confused, and by the time she was in the car being driven
to the pediatrician by her mother, she felt like she was back to normal. The pediatrician listened to
the mother’s story when they arrived. He examined the patient and could find no abnormalities on
general physical examination or on neurological examination. The pediatrician told her mother
that he would refer her to a pediatric neurologist for further evaluation, as well as further
evaluation of the need for medication. From which area of the brain is this problem most likely
emanating?
A
B
C
D
E
Medulla
Occipital lobe
Temporal lobe
Thalamus
Midbrain
He72.
In a presurgical patient, the great saphenous vein is cannulated in the vicinity of the
ankle. During the procedure, the patient experiences severe pain that radiates along the medial
border of the foot. Which one of the following nerves was accidentally included in a ligature
during this procedure?
A Medial femoral cutaneous nerve
B Saphenous nerve
C Superficial fibular nerve
D Sural cutaneous nerve
E Tibial nerve
He73.
A 45-year-old woman is brought to her local hospital's emergency room by her husband
because of several days of progressive weakness and numbness in her arms and legs. Her
symptoms began with tingling in her toes, which she assumed to be her feet "falling asleep."
However, this feeling did not disappear, and she began to feel numb, first in her toes on both feet,
then ascending to her calves and knees. Two days later, she began to feel numb in her fingertips
and had difficulty lifting her legs. When she finally was unable to climb the stairs of her house
because of her leg weakness, had difficulty gripping the banister, and experienced shortness of
breath, her husband urged her to go to the emergency room. The neurologist who examines the
patient in the emergency room notices that she was short of breath while sitting in bed. He asked
the respiratory therapist to measure her vital capacity (the greatest volume of air that can be
exhaled from the lungs after a maximal inspiration), and the value for this was far lower than
would be expected for her age and weight. Her neurological examination showed that her arms
and legs were very weak, so she had difficulty lifting them against gravity. She was unable to feel
a pin or a vibrating tuning fork at all on her legs and below her elbows, but was able to feel the pin
on her upper chest. The neurologist could not elicit any reflexes from her ankles or knees. He
subsequently advises the emergency room staff that the patient needed to have a spinal tap and be
admitted to the intensive care unit immediately. Where in the nervous system is the damage most
likely to be found?
A Frontal lobe
B Temporal lobe
C Peripheral nerves and nerve roots
D Spinal cord
E Parietal lobe
He74.
The course of the vertebral arteries is best described by which of the following
statements?
A They arise from the common carotid artery on the left and the brachiocephalic artery on the
right
B
C
D
E
They enter the cranium via the anterior condylar canals
They enter the cranium via the posterior condylar canals
They pass through the transverse processes of several cervical vertebrae
They directly give rise to the posterior cerebral arteries
He75.
A man comes to your office because he thinks he has bilateral hernias and bilateral pain
in the inguinal area. Upon physical examination he does not have a direct nor indirect inguinal
hernia, but does have bilateral palpable superficial inguinal lymph nodes, which are tender. You
formulate a differential diagnosis of locations from which lymph drains into the superficial
inguinal lymph nodes. Which anatomical region or structure does not drain into the superficial
inguinal lymph nodes and thus should be excluded from your differential diagnosis list?
A Penis
B Scrotum
C Testicles
D Anus
E Epididymides
He76.
A very concerned mother brings her teenager into your pediatric office. The teenager
awoke in the morning with a large swollen mass that filled part of his upper eyelid and medial
forehead just above his left eye. His eyelid was so swollen he could barely keep it open. His
history reveals that he suffers from indoor allergies and a head cold of about a week’s length.
During your physical examination you note purulent nasal discharge and extreme tenderness to
percussion over his paranasal sinuses. The large swollen mass in his eyelid and forehead is quite
pliable. You prescribe intravenous antibiotics and give which of the following explanations to the
very concerned mother and the teenager?
A He suffers from trigeminal neuralgia that affects the ophthalmic portion of cranial nerve V
B He suffers from tic douloureux that affects the ophthalmic portion of cranial nerve V
C He suffers from sinusitis, which has eroded through the wall on the frontal sinus, and since
the frontalis muscle is not attached to bone, allowed pus to leak into the upper eyelid
D He has Bell’s palsy, which is generally caused by herpes simplex virus infection of the facial
nerve within the facial canal that caused the loss of ability to raise the upper eyelid and thus allow
fluid to accumulate within it
E He suffers from a sty, which is an inflammation of Meibomian or tarsal glands, which lies on
the inner surface of the eyelid
He77.
A 45-year-old female patient develops Parinauds syndrome (vertical gaze palsy) and an
MRI shows a large tumor of her pineal gland. The tumor is not only compressing her tectum,
causing the vertical gaze palsy, but also obstructing the underlying cerebrospinal fluid pathway
causing progressive noncommunicating hydrocephalus. The obstruction causes immediate
accumulation of cerebrospinal fluid in which of the following?
A cerebral aqueduct of Sylvius
B fourth ventricle
C lateral ventricle
D subarachnoid space
E
third ventricle
He78.
A 55-year-old patient is involved in a severe motor vehicle accident and admitted to the
emergency room. The patient complains of abnormal sensations such as burning and tingling in
the left arm. A neurological examination further reveals little change in motor or other sensory
functions. Which of the following regions was most likely affected by the accident?
A Dorsal horn of the spinal cord
B Ventral horn of the spinal cord
C Ascending pathways in lateral funiculus of the left spinal cord
D Dorsal columns of spinal cord
E Nerve roots associated with the cervical cord
He79.
Which of the following arteries may occasionally arise as a branch of the external iliac
artery or inferior epigastric artery instead of as a branch of the internal iliac artery?
A Internal pudendal artery
B Obturator artery
C Superior gluteal artery
D Umbilical artery
E Uterine artery
He80.
A 79-year-old female patient was admitted to the hospital, presenting with fever,
vomiting, dehydration, and distension of the abdomen. of vasa recta of the jejunum. Which of the
following arteries supply branches to the involved vasa recta?
A ileocolic artery
B inferior pancreaticoduodenal artery
C right colic artery
D right gastroepiploic artery
E superior mesenteric artery
He81.
Wrist-drop (flexion) results in a very weak hand grasp. This is why self-defense classes
teach students to flex the wrist of an attacker holding an object to loosen their grip on that object.
The strength of the hand grasp is greatest with the wrist in the extended position for which one of
the following reasons?
A Flexor digitorum superficialis and profundus muscles are stretched when the wrist and
metacarpophalangeal joints are extended.
B Lever arms of the interossei are longer when the metacarpophalangeal joints are extended.
C Lever arms of the lumbrical muscles are longer when the metacarpophalangeal joints are
extended.
D Line of action of the extensor digitorum muscle is most direct in full extension.
E Radial half of the flexor digitorum profundus muscle is paralyzed because it is innervated by
the radial nerve.
He82.
The following test is administered to a patient: a cotton applicator is gently applied to
the cornea of the eye as the patient is asked to look upward. The patient does not blink in response
to stimulation of the cornea. Which of the following cranial nerves are normally involved in this
reflex?
A Nerves II and III
B Nerves III and IV
C Nerves III and V
D Nerves V and VII
E Nerves VII and IX
He83.
A 13-year-old adolescent was vacationing with his parents in Mexico on spring break.
He developed nausea and vomiting 4 days into the trip despite caution about what he ate and
drank. He switched to a clear liquid diet. None of the others on the trip were sick. On his flight
back to the United States, he developed a fever and increased abdominal pain, especially in the
paraumbilical region. His parents took him to their pediatrician the next day as he was feeling
worse and could barely move. During the physical examination the pediatrician noted tenderness
around the umbilicus and rebound tenderness over McBurney point. The patient was sent for an
abdominal CT. Where is McBurney point and what is the likely diagnosis?
A At the right costal margin at the mid-clavicular line; ruptured gallbladder
B On a line drawn between the anterior superior iliac spine and umbilicus on the right;
appendicitis
C On a line drawn between the anterior superior iliac spine and umbilicus on the left;
appendicitis
D On a line drawn between the anterior superior iliac spine and the pubic tubercle on the right;
kidney stone
E On a line drawn between the anterior superior iliac spine and the pubic tubercle on the left;
kidney stone
He84.
A 27-year-old female was suffering from excruciating pain that could not be reduced or
eliminated through drug treatment. A decision was made by the neurosurgeon to attempt to
alleviate the pain by surgically cutting pathway mediating pain impulses to the thalamus. In a case
similar to that, a patient was also suffering from excruciating pain. However, the neurosurgeon
decided to try another approach to alleviate the pain. This approach involved the application of
deep electrical stimulation to selected regions of the brain. Which of the following regions was
selected for the application of stimulation in order to produce analgesia?
A Anterior nucleus of thalamus
B Caudate nucleus
C Ventral horn of spinal cord
D Dorsomedial hypothalamus
E Periaqueductal gray
He85.
An 83-year-old female was admitted to the emergency room following a stroke.
Sometime after she regained consciousness, a neurological examination revealed that the
application of mild tactile stimulation on the right arm was extremely painful, while the remainder
of the neurological examination was relatively normal for an individual of her age. Which of the
following regions of the central nervous system constitutes the primary origin of the neurons that
provide sensory input into the region affected by the stroke?
A Lateral medulla
B Medial medulla
C Midbrain periaqueductal gray
D Spinal cord
E Dorsomedial pons
He86.
Structure(s) that normally transit the diaphragm by way of the esophageal hiatus include
which of the following?
A Azygos vein
B Hemiazygos vein
C Azygos and hemiazygos veins
D Anterior and posterior vagal trunk
E Thoracic duct
He87.
An 18-year-old male is hit on the side of his head, including the face region, as a result
of being tackled in a football game. The next day, he has trouble displaying expression on the right
side of his face. He is seen by a neurologist. During the examination, he is asked to protrude his
tongue and it does not deviate to either side, but if he closes his eyes and sugar water is placed on
the right side of the anterior portion of his tongue, he cannot identify it. Where was the damage
that most likely produced the defect in taste in the anterior two-thirds of his tongue?
A Trigeminal ganglion
B Proximal aspect of glossopharyngeal nerve
C Distal aspect of lingual nerve
D Solitary nucleus
E Proximal aspect of the chorda tympani nerve
He88.
A 34-year-old female began to experience vision difficulties and received an
ophthalmological examination. The patient was later seen by a neurologist and was diagnosed
with demyelinating disease affecting the optic nerve and optic tracts.
As a result of the demyelinating disease, there was degeneration of the optic tracts. Which of the
following structures were devoid of inputs from the optic tracts?
A The lateral geniculate nucleus only
B The lateral geniculate nucleus and the pretectal area
C The lateral geniculate nucleus, the pretectal area, and the superior colliculus
D The lateral geniculate nucleus, the pretectal area, the superior colliculus, and the
suprachiasmatic nucleus
E The lateral geniculate nucleus, the pretectal area, the superior colliculus, the suprachiasmatic
nucleus, and the nuclei of cranial nerves III and IV
He89. A 35-year-old man who had optic neuritis (an inflammation of the optic nerve causing
blurred vision) for several years was told that he had a 50% chance of eventually developing
multiple sclerosis (MS), a degenerative disease of the CNS white matter. One day he noticed that
he had double vision and felt weak on his right side. Although he noted that the symptoms were
becoming steadily worse throughout the day, he attributed this to stress from his job as a
stockbroker, and in order to relax he decided to take a drive in his car. While he was driving, his
vision became steadily worse. As he was about to pull over to the side of the road, he saw two
trees on the right side of the road. Uncertain which was the actual image, he attempted to place his
right foot on the brake pedal. He suddenly realized that he was unable to lift his right leg, and his
car collided with the tree. A pedestrian on the side of the road called the emergency medical
service (EMS), and the man was brought to a nearby emergency room. A neurologist is called to
see the patient because the emergency room physicians thought he might have had a stroke,
despite his young age. The neurologist speaks to him, then examines him. He finds that his left eye
was deviated to the left and down. When the patient attempts to look to his right, his right eye
moves normally, but his left eye is unable to move farther to the right than the midline. His left
pupil is dilated and does not contract to light from a penlight. His left eyelid droops, and he has
difficulty raising it. In addition, the right side of his mouth remains motionless when he attempts
to smile, but his forehead is symmetric when he raises his eyebrows. His right arm and leg are
markedly weak. The neurologist tells the patient that he is not certain that this was necessarily a
stroke, but admits him to the hospital for observation and tests. A lesion in which of the following
nerves most likely caused the patient's double vision?"
A Optic nerve
B Oculomotor nerve
C Cervical sympathetic fibers
D Trochlear nerve
E Abducens nerve
He90.
Mucosal necrosis of the rectum usually will not result from occlusion of the inferior
mesenteric artery for which of the following reasons?
A Arterial supply to the rectum is from anastomotic connections from the superior mesenteric
artery
B Arterial supply to the rectum is from the left colic artery with anastomoses to branches of the
internal iliac artery
C The inferior mesenteric artery does not supply the rectum
D A principal branch of the external iliac artery is a major supplier to the rectum
E The middle rectal artery, a branch of the internal iliac artery, supplies the rectum
He91.
A 65-year-old female has weakness when attempting to flex her left knee and extend the
hip. Neurophysiological analysis of the affected regions reveals a reduced number of motor units
firing with fasciculations and slowed conduction velocity. There is no depression of tendon
reflexes or muscle wasting. Likewise, plantar and abdominal reflexes are normal, there is little
sensory loss, and there are no signs of sphincter disturbances. Which of the following is the best
explanation for this disturbance?
A Peripheral neuropathy of nerves on the left side of the body that exit the spinal cord at L4 to
S1
B Damage to the neuromuscular junctions associated with nerves that exit the left side of the
spinal cord between T8 and L3
C Degeneration of nerve cells in the ventral horn of the left side of the spinal cord between T8
and T12
D Degeneration of fibers contained in the lateral funiculus of the left side of the thoracic spinal
cord
E Damage to the dorsal horn of the spinal cord of the left side between L1 and L4
He92.
A 67-year-old man suffers an infarct of the geniculothalamic branch of the posterior
cerebral artery. In particular, there is involvement of nuclei of the posterior thalamus. To which of
the following regions would the neurons affected by this infarction normally project?
A Hypothalamus and midbrain
B Parietal and occipital cortices
C Precentral and postcentral gyri
D Basal ganglia and premotor cortex
E Prefrontal cortex and medial aspect of the frontal lobe
He93.
A middle-aged male is involved in an automobile accident that causes brain damage
affecting a region of the cerebral cortex, resulting in loss of the conscious perception of smell.
Which of the following regions of the cortex is most likely affected?
A Temporal neocortex
B Posterior parietal lobule
C Cingulate gyrus
D Prefrontal cortex
E Precentral gyrus
He94.
A 34-year-old woman is brought into the ED following a car accident in which she hit a
patch of ice and slammed into the back of a trash truck. She is unable to walk because she has
intense pain in her left knee and hip. She thinks her knee hit the left side of the dashboard as she
twisted under the seat belt when she was thrown forward. She reports severe pain as the physician
moves her hip. A plain film of the leg up to the pelvis is ordered and it shows no broken bones, but
posterior displacement of the head of the femur out of the acetabulum. She is sedated in order to
forcefully relocate the femoral head back into the acetabulum. Despite successful relocation there
is concern that she has damaged which one of the following nerves, which may take several
months to regain function?
A Obturator
B Pudendal
C Sciatic
D Femoral
E Superior gluteal
He95. A patient presents with an ipsilateral paralysis involving an inability to move his eye
vertically, and the affected eye is also abducted. The patient also presents with an upper motor
neuron paralysis that includes part of the face. The lesion, determined from an MRI, is depicted at
C in the diagram. Which of the following structures are affected by this lesion?
A Substantia nigra and crus cerebri
B Red nucleus and crus cerebri
C
D
E
Crus cerebri and cranial nerve III
Red nucleus and substantia nigra
Substantia nigra and cranial nerve III
He96.
Why is the sacral hiatus not used as an access point for spinal taps?
A Because it is covered by a thick anterior sacrococcygeal ligament
B Because CSF only flows down as inferiorly as S2, and thus is too cranial to be reached
C Because sacral hiatus is just anterior to anus which contains lots of bacteria, increasing the
chances of unintentional contamination
D Because the filum terminale would likely be damaged
E Because the caudal posterior sacral foramina would be easier points of access to CSF
He97.
Which of the following thalamic nuclei subserves a motor function?
A dorsomedial nucleus
B lateral geniculate nucleus
C medical geniculate nucleus
D ventral lateral nucleus
E ventral posterior medial nucleus
He98.
In a classic experiment performed by Sherrington on the cat, he utilized an experimental
brain surgical technique to produce an animal preparation that displayed marked bilateral rigidity
of the limbs. Which of the following pathways best accounts for the rigidity when its actions were
unopposed?
A Rubrospinal tract
B Lateral vestibulospinal tract
C Corticospinal tract
D Medial vestibulospinal tract
E Lateral reticulospinal tract
He99.
A 65-year-old male with a history of heart disease is admitted to the emergency room
after having been found unconscious in his home. When the patient regains consciousness and is
examined by a neurologist, it was discovered that he cannot identify the presence of a tuning fork,
pencil, or pressure applied to his left leg. In addition, the patient is unable to move his left leg or
arm. Other clinical signs are not apparent. Which of the following regions most likely accounts for
the deficits described?
A Ventromedial aspect of medulla-spinal cord border
B Rostral aspect of the ventromedial medulla
C Dorsolateral aspect of the caudal aspect of medulla
D Dorsomedial aspect of the pontine tegmentum
E Dorsomedial aspect of the midbrain tegmentum
He100. The abdominal aorta provides for the major blood supply in this region and its branches
are organized into paired or unpaired and visceral or parietal branches. Which of the following are
paired visceral branches of the abdominal aorta?
A
B
C
D
E
celiac trunk
gonadal arteries
inferior phrenic arteries
lumbar arteries
superior mesenteric artery
He101. The following test is administered to a patient: a cotton applicator is gently applied to
the cornea of the eye as the patient is asked to look upward. The patient does not blink in response
to stimulation of the cornea. Which of the following cranial nerves are normally involved in this
reflex?
A Nerves II and III
B Nerves III and IV
C Nerves III and V
D Nerves V and VII
E Nerves VII and IX
He102. A boy was severely bitten by a dog and later developed a rabies infection which was not
treated. The infection affected and destroyed a group of anatomical structures subserving
short-term memory functions, thus resulting in severe memory deficits. Which of the following
groups of structures were most likely destroyed?
A Hippocampal formation, mammillary bodies, anterior thalamic nucleus, prefrontal cortex
B Hippocampal formation, septal area, hypothalamus, midbrain periaqueductal gray
C Hippocampal formation, mammillary bodies, anterior thalamic nucleus, cingulate gyrus
D Amygdala, hippocampal formation, mammillary bodies, septal area, prefrontal cortex
E Prefrontal cortex, hippocampal formation, septal area, medial hypothalamus, prefrontal
cortex
He103. A previously healthy, 62-year-old man is brought to a neurologist by his daughter
because of increasing difficulty in walking. His daughter noticed that for the past year, he had
difficulty getting out of a chair and took a lot of time to begin to walk. When he did walk, he
walked with a slow, shuffling gait. In addition, she had noticed some changes in his face, and that
he had been drooling excessively. His signature on checks became progressively smaller from the
beginning of his name to the end, and he had developed a new tremor. She brought him in to make
sure this wasn’t just “aging.” The neurologist examines the patient and notices immediately that
his facial expression is masklike, with few eyeblinks. When asked to write a sentence, the letters
become progressively smaller toward the end of the sentence. His speech is soft and monotonous,
and he has a slow, resting pill-rolling tremor in both of his hands. He has very little spontaneous
movement, and his arms, legs, and trunk are stiff. When the neurologist tries to flex his arm, he
feels many catches, similar to a cogwheel. There is no weakness, sensory problems, or
abnormalities in his reflexes. When asked to walk, the patient takes many tries to rise from his
chair. When he finally stands up, his posture is stooped and flexed. His gait is slow, his feet shuffle
when he walks, and his arms don’t swing with his steps. The neurologist tells the patient’s
daughter that she was correct that this isn’t aging and explains to her all of the details about a new
medication that her father needs to take. What is the blood supply of the main structure damaged?
A
B
C
D
E
Lenticulostriate branches of the middle cerebral and anterior cerebral arteries
Perforating branches of the basilar and vertebral arteries
Anterior choroidal artery and anterior cerebral artery
Branches of posterior cerebral and posterior communicating arteries
Anterior cerebral and anterior communicating arteries
He104. A 79-year-old man was brought to the emergency room because his family was worried
that he suddenly was not using his right arm and leg and seemed to have a simultaneous behavior
change. He was unable to write a reminder note to himself, even with his left hand, and he put his
shoes on the wrong feet. A neurologist was called to the emergency room to examine the patient. A
loud bruit was heard with a stethoscope over the left carotid artery in his neck. When asked to
show the neurologist his left hand, he pointed to his right hand, since it could not move. The
neurologist asked him to add numbers, and he was unable to do this, despite having spent his life
as a bookkeeper. The patient was unable to name the fingers on either hand, and he could not form
any semblance of a letter using his left hand. The patient’s eyes did not blink when the neurologist
waved his hands close to them in the left temporal and right nasal visual fields. The right lower
two-thirds of his face drooped. There was some asymmetry of his reflexes between the right and
left sides, and there was a positive Babinski’s response of his right toe. Where in the CNS is the
damage?
A Right frontal and parietal lobes
B Left frontal and parietal lobes
C Right frontal lobe
D Left frontal lobe
E Right temporal lobe
He105. An 84-year-old female fainted while attending a family party and was immediately
taken to the emergency room of a local hospital. When she regained consciousness, she presented
with an upper motor neuron paralysis on one side of her body and weakness of muscles on the
other side of her face. An occlusion of which of the following arteries would result in the lesion at
B in the diagram shown in the previous question?
A Paramedian branch of the basilar artery
B Circumferential branch of the basilar artery
C Superior cerebellar artery
D Anterior inferior cerebellar artery
E Anterior spinal artery
He106. A patient has an infarct involving the medial branches of the basilar root of the posterior
cerebral artery. The primary region affected includes nuclei of the medial thalamus. The probable
basis for the effects of the infarct is the loss of processing of information from which of the
following structures?
A Hypothalamus
B Parietal cortex
C Reticular formation
D
E
Basal ganglion
Hippocampal formation
He107. During a boxing match, a 23-year-old boxer sustains a direct blow to his right ear. He
presents with dizziness, vertigo, imbalance, nausea, vomiting, tinnitus, and fullness in the ears. His
vertigo increases with activity and is relieved by rest. He has some hearing loss. The symptoms
worsen with coughing, sneezing, or blowing his nose, as well as with exertion and activity. He is
diagnosed with a perilymphatic fistula. The fistula allows leakage of perilymph. In which of the
following structures is perilymph normally found?
A Utricle
B Saccule
C Semicircular canals
D Scala media
E Scala tympani
He108. A man, the victim of a superficial knife wound to the lower abdomen during a barroom
brawl, subsequently develops a direct inguinal hernia.
Damage to which of the following nerves is most likely responsible for the predisposing weakness
of the abdominal wall?
A Genitofemoral nerve
B Ilioinguinal nerve
C The subcostal nerve
D Pelvic splanchnic nerves
E The nerve of the tenth intercostal space (T10)
He109. A patient is diagnosed by an optometrist as being nearsighted. To correct this person's
defect, the doctor recommends he put concave lenses into his eyeglasses. This corrective lens is
applied because of which of the following conditions?
A Retinal damage.
B The eyeball is too long.
C The eyeball is too short.
D The eyeball is oblong.
E The lens resists change.
He110. When removing blood from the left pleural space, a chest tube is placed into the pleural
space typically below the normal extent of the lung. The chest tubes are most conveniently placed
at the midaxillary line through intercostal muscles midway between the ribs to avoid damaging
subcostal nerve arteries and veins and their collateral branches.
At the midaxillary line, to which rib does the left lung normally extend?
A Sixth
B Eighth
C Tenth
D Twelfth
E
He111. A patient's eyes are seen to be deviated to the left and he is unable to move his eyes to
the right. An MRI reveals a brain infarction. Which of the following regions or structures is most
likely affected to account for this deficit?
A Right frontal lobe
B Left frontal lobe
C Right vestibular nuclei
D Right oculomotor nucleus
E Left abducens nucleus
He112. The structure indicated by arrow 1 in Fig. 1-2 is which of the following vessels?
A brachiocephalic artery
B left brachiocephalic vein
C left common carotid artery
D right brachiocephalic vein
E superior vena cava
He113.
A female 44-year-old patient suffers from acute bacterial sinusitis localized to the frontal sinus.
The patient displays a mucopurulent greenish discharge from the nose bilaterally, with associated
fever and malaise. The patient also complains of pain over the forehead with headache. Which of
the following innervates the frontal sinus?
A anterior ethmoidal nerve
B lacrimal nerve
C nasociliary nerve
D posterior ethmoidal nerve
E supraorbital nerve
He114. While moving furniture, an 18-year-old teenager experiences excruciating pain in his
right groin.
A few hours later he also develops pain in the umbilical region with accompanying nausea.
At this point he seeks medical attention.
Examination reveals a bulge midway between the midline and the anterior superior iliac spine, but
superior to the inguinal ligament. On coughing or straining, the bulge increases and the inguinal
pain intensifies. The bulge courses medially and inferiorly into the upper portion of the scrotum
and cannot be reduced with the finger pressure of the examiner. It is decided that a medical
emergency exists, and the patient is scheduled for immediate surgery. Nausea and diffuse pain
referred to the umbilical region in this patient most probably are due to which of the following?
A Compression of the genitofemoral nerve
B Compression of the ilioinguinal nerve
C Dilation of the inguinal canal
D Ischemic necrosis of a loop of small bowel
E Ischemic necrosis of the cremaster muscle
He115.
Which one of the following best describes the function of the organ from the
reproductive system shown below?
A Passage of urine and sperm in the male
B Passage of urine from the urethra to the vestibule in the female
C Passage of urine from the bladder to the urethrae in males and females
D Passage of sperm from the epididymis to the urethra
E Storage of sperm and absorption of fluid
He116. The bone marked B in the lateral plain film of the right foot is which of the following?
A Talus
B Navicular
C Calcaneus
D Cuboid
E Fifth metatarsal
He117. Concerning the case described in the previous question, which of the following
structures were most likely affected by the stroke?
A Nucleus of facial nerve and basilar pons
B Nucleus of trochlear nerve and dorsal midbrain tegmentum
C Nucleus of oculomotor nucleus and cerebral peduncle
D Nucleus of trigeminal nucleus and basilar pons
E Internal capsule and optic tract
He118. An 8-year-old boy is referred to a neurologist by his family physician because he has
developed progressive slow and clumsy walking. On examination, the patient has difficulty with
standing and running. While standing, he adopts a wide-based gait with constant shifting of
position to maintain his balance. Sitting or standing, he also displays a constant tremor of the head
and trunk. When asked to walk, his feet strike the ground in an uneven and irregular rhythm; if he
attempts to correct his imbalance, he displays wild and abrupt movements. A magnetic resonance
image (MRI) reveals demyelination in the dorsal columns, corticospinal and spinocerebellar tracts.
The child is diagnosed with Friedreich's ataxia, an autosomal recessive neurological disorder
resulting from mutation of a gene locus on chromosome 9. Second-order neurons of the dorsal
(posterior) spinocerebellar tracts are located in which of the following?
A deep cerebellar nuclei
B dorsal root ganglion
C nucleus cuneatus
D nucleus dorsalis (Clarke's column)
E Rexed's lamina IX of the spinal cord
He119. A 53-year-old banker develops paralysis on the right side of the face, which produces an
expressionless and drooping appearance. He is unable to close the right eye and also has difficulty
chewing and drinking. Examination shows loss of blink reflex in the right eye to stimulation of
either right or left cornea. Lacrimation appears normal on the right side, but salivation is
diminished and taste is absent on the anterior right side of the tongue. There is no complaint of
hyperacusis. Audition and balance appear to be normal. Where is the lesion located?
A
B
C
D
E
In the brain and involves the nucleus of the facial nerve and superior salivatory nucleus
Within the internal auditory meatus
At the geniculate ganglion
In the facial canal just distal to the genu of the facial nerve
Just proximal to the stylomastoid foramen
He120. When removing blood from the left pleural space, a chest tube is placed into the pleural
space sometimes below the normal extent of the lung. The chest tubes are most conveniently
placed at the midaxillary line through intercostal muscles midway between the ribs to avoid
damaging subcostal nerve arteries and veins and their collateral branches. At the midaxillary line,
to which rib does the left lung normally extend?
A Fourth
B Sixth
C Eighth
D Tenth
E Twelfth
He121. A 75-year-old male college graduate is brought to a neurologist by his family because he
is having problems with his gait, suffers from urinary incontinence (for the past 6 months) and
recently began to have problems with his short-term memory and paying his bills. The gait
problem manifests itself mainly as difficulty climbing stairs and frequent falls. The patient has no
past medical history other than a subarachnoid hemorrhage resulting from a ruptured cerebral
aneurysm many years earlier. When the neurologist examines him, she finds he cannot remember
three objects 5 minutes after they are shown to him, even when prompted. He is unable to figure
out how many quarters are in $1.75, and he spells the word “world” incorrectly. A grasp reflex
(squeezing the examiner’s hand as a reflex reaction to stroking of the palm) is present. Although
his motor strength is full in all of his extremities, when asked to walk, he takes many steps in the
same place without moving forward, and then starts to fall. His cranial nerve, sensory, and
cerebellar examinations are normal. The patient has a grasp reflex and dementia. A lesion in which
of the following regions can cause this deficit?
A Occipital lobe
B Frontal lobe
C Medulla
D Thalamus
E Pons
He122. In elderly patients (over 60 years of age), fractures of the neck of the femur following a
fall are common. Arterial branches supplying the femoral head and neck are vulnerable to injury
during these fractures, and the resulting posttraumatic avascular necrosis affects the head of the
femur. In the adult, the most important direct vascular source to the femoral head and neck is
which of the following?
A artery to the head of the femur
B femoral artery
C lateral circumflex femoral artery
D
E
medial circumflex femoral artery
superior gluteal artery
He123. A 74-year-old female was brought to the hospital after she suffered a stroke. Several
days later, a neurological examination revealed that she was unable to perform certain types of
learned, complex movements (referred to as apraxia). Which of the following regions of the
cerebral cortex was most likely affected by the stroke?
A Precentral gyrus
B Postcentral gyrus
C Premotor cortex
D Prefrontal cortex
E Cingulate gyrus
He124. An individual is diagnosed by an optometrist as being farsighted. To correct this
person’s defect, which of the following lenses should the doctor recommend be put into his
eyeglasses?
A Cylindrical
B Concave
C Convex
D Neutral
E Spherical
He125. A 70-year-old female suffered a stroke affecting parts of the left frontal lobe of the
cerebral cortex. Upon testing, the patient was later unable to move her eyes to the right when
requested to do so. Which of the following pathways if disrupted, could best account for this
deficit?
A Frontal lobe projections to the ipsilateral superior colliculus
B Frontal lobe projections to the contralateral occipital cortex
C Frontal lobe projections to the ipsilateral trochlear nucleus
D Frontal lobe projections to the contralateral oculomotor complex
E Frontal lobe projections to the contralateral pontine gaze center
KEY:
He1. A
He7.E
He14. C
He21. A
He28. D
He35.C
He42.A
He49.D
He56.B
He63.D
He2.A
He8. D
He15. B
He22. B
He29. C
He36.B
He43.A
He50.B
He57.B
He64.E
He3.B
He9.D
He16. E
He23. D
He30. A
He37.B
He44.B
He51.A
He58.C
He65.C
He4.B
He10.B
He17. C
He24. D
He31. B
He38.A
He45.E
He52.A
He59.C
He66.C
He11.B
He18. A
He25. E
He32. C
He39.D
He46.E
He53.B
He60.C
He67.B
He5.D
He12.B
He19. B
He26. D
He33. A
He40.A
He47.E
He54.C
He61.E
He68.C
He6.D
He13. C
He20. E
He27. B
He34. D
He41.D
He48.D
He55.A
He62.D
He69.A
He70.D
He77.E
He84.E
He91.A
He98.B
He105A
He112D
He119D
He71.C
He78.E
He85.D
He92.B
He99.B
He106C
He113E
He120C
He72.B
He79.B
He86.D
He93.D
He100B
He107E
He114D
He121B
He73.C
He80.E
He87.E
He94.C
He101D
He108B
He115D
He122D
He74.D
He81.A
He88.D
He95.C
He102C
He109B
He116B
He123C
He75.C
He82.D
He89.B
He96.B
He103D
He110B
He117C
He124C
He76.C
He83.B
He90.E
He97.
He104B
He111C
He118D
He125E