Anatomy PDF

ANATOMY
USMLE WORLD STEP 1
ANATOMY
Question List
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Neurology
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Reproductive system
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Head and neck
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Cardiology
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Neurology
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Blood vessels
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Head and neck
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Genitourinary
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Pulmonology
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Cardiology
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Neurology
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Pulmonology
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Cardiology
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Hepatobiliary system
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Genitourinary
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Head and neck
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Musculoskeletal
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Pulmonology
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Head and neck
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Neurology
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Musculoskeletal
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Neurology
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Head and neck
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Renal
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Neurology
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Head and neck
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Neurology
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Neurology
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Renal
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Genitourinary
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Pulmonology
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Pulmonology
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Musculoskeletal
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Musculoskeletal
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Genitourinary
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Head and neck
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Neurology
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Musculoskeletal
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Genitourinary
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Musculoskeletal
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Musculoskeletal
USMLE WORLD STEP 1
ANATOMY
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Neurology
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Musculoskeletal
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Musculoskeletal
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USMLE WORLD STEP 1
ANATOMY
Q NO 1: A 34-year-old female presents to your office with moderate hearing loss

that she noticed several months ago. She also complains of a noise in her right
ear that is very disturbing. Physical examination shows right-sided hearing loss,
an asymmetric smile, and decreased corneal reflex in her right eye. This
patients condition suggests an intracranial mass located in which of the
following locations?
A. Between the medulla and the cerebellar hemispheres
B. Above the diaphragma sellae
C. Over the lateral hemispheric fissure
D. Between the cerebellum and the lateral pans
E. In the parasagittal aspect of the brain convexity
F. Between the cerebellar peduncles
Explanation:
Intracranial schwannomas are most commonly located at the cerebropontine angle,
which is between the cerebellum and lateral pons. Schwannomas of this location
arise from CN VIII and are called acoustic neuromas. CN VII (facial nerve) and CN V
(trigeminal nerve) are in proximity to CN VIII and may also be affected by acoustic
neuromas via compression. The patient in this vignette displays symptoms of CN
VIII involvement as well as CN V and CN VII.
1. The cochlear part of CN VIII mediates hearing. Its compression leads to
sensorineural hearing loss and tinnitus (ear ringing).
2. The vestibular part of CN VIII maintains balance. Its compression causes vertigo,
disequilibrium, and nystagmus.
3. CN VII involvement leads to paralysis of the muscles of facial expression, loss of
taste in the anterior 2/3 of the tongue, and hyperacusis (paralysis of the stapedius).
4. Compression of CN V causes loss of sensation around the mouth and nose, loss of
corneal reflex, and paralysis of the muscles of mastication.
Bilateral acoustic neuromas are associated with neurofibromatosis type 2.
(Choice B) Germ cell tumors arise in the pineal and suprasellar regions. They can
cause aqueductal stenosis (with obstructive hydrocephalus) and Parinaud syndrome
(paralysis of vertical gaze).
(Choices C and E) Meningiomas are commonly found over the lateral hemispheric
fissure and in the parasagittal aspect of the brain convexity. On light microscopy,
meningiomas have a whorled pattern of cell growthalso, psammoma bodies are
present. Clinically, meningiomas may manifest with headache focal deficit, or
seizure.
Educational Objective:
Sensorineural hearing loss, tinnitus, paralysis of facial muscles, and loss of
corneal reflex signify the involvement of CN V, VII, and VIII. Simultaneous
compression of these nerves is caused by tumor of the cerebellopontine
angle, which are most commonly acoustic neuromas.
USMLE WORLD STEP 1
Q NO 2: A 56-year-old male with advanced bladder carcinoma suffers from

compression of a nerve that passes through the obturator foramen. Which
of the following functions would be most affected in this patient?
Abduction of the thigh
B. Adduction of the thigh
C. Flexion of the thigh
D. Extension of the thigh
E. Extension of the leg
ANATOMY
A.
Explanation:
The obturator nerve is the only nerve that exits the pelvis via the obturator foramen.
This nerve innervates the adductor compartment of the thigh after dividing into
anterior and posterior branches subsequent to leaving the pelvis. The anterior
branch innervates the gracilis, pectineus, and the adductors longus and brevis. The
posterior branch innervates the obturator externus and the adductor magnus.
Obturator nerve injury would cause weakness and spasm of the adductor
compartment muscles.
(Choice A) Abduction of the thigh is accomplished by the tensor fascia lata and the
sartorius muscles. These muscles are supplied by the superior gluteal and femoral
nerves, respectively, and lie in the anterior compartment of the thigh.
(Choice C) Flexion of the thigh is accomplished by the psoas, iliacus, tensor fascia
lata, and the sartorius muscles. The psoas is directly innervated by the lumbar
plexus, and the iliacus is innervated by the femoral nerve.
(Choice D) Extension of the thigh is accomplished primarily by the gluteus maximus
muscle, which is supplied by the inferior gluteal nerve. This nerve exits the pelvis
through the greater sciatic foramen below the piriformis.
(Choice E) Extension of the leg is primarily accomplished by the quadriceps femoris
muscle group. These muscles are innervated by the femoral nerve, which gains
access to the thigh deep to the center of the inguinal ligament.
The obturator nerve is the only major nerve that exits the pelvis through
the obturator foramen. This nerve supplies the muscles of the medial
(adductor) compartment of the thigh and can be damaged during pelvic
surgery, especially in procedures such as lymph node dissection.
USMLE WORLD STEP 1
ANATOMY
Q NO 3: A 32-year-old male presents to the ER with sudden-onset heart

palpitations. His blood pressure is 100/70 mmHg, and his heart rate is
160/mm with regular rhythm. The physician instructs the patient to do
the Valsalva maneuver to relieve these symptoms. Which of the
following structures indicated on the pelvic CT image below is most
important in performing the Valsalva maneuver?
A. A
B. B
C. C
D. D
E. E
Explanation:
The patient described in the question stem is experiencing paroxysmal
supraventricular tachycardia. Treatment can be with vagal stimulation, such as
carotid sinus massage or the Valsalva maneuver. Maneuvers that increase vagal
tone increase the refractory period in the AV node and help prevent a reentrant
circuit from conducting. If Valsalva measures fail, intravenous administration of
adenosine is recommended.
The Valsalva maneuver is executed by forcibly exhaling against a closed glottis. This
is done by taking a full inhalation, closing the glottis (i.e. holding ones breath), and
subsequently bearing downwithout exhalingas one would during a bowel
movement. The rectus muscles are recruited in this process, and they (Choice A)
play the largest role in the development of the resultant elevated intraabdominal
and intrathoracic pressure during this maneuver.
(Choice B) This structure is the iliacus muscle a flexor oft he hip that lies over the
iliac fossa.
(Choice C) This structure is the gluteus minimus muscle. This muscle is innervated
by the superior gluteal nerve and has the subtle, but important function of
preventing the contralateral (non-weight-bearing) side of the pelvis from dipping
when that leg is elevated off of the ground, as when one walks.
(Choice D) This structure is the gluteus medius muscle. This muscle has the same
innervation and function as the gluteus minimus.
(Choice E) This structure is the gluteus maximus muscle. This muscle is innervated
by the inferior gluteal nerve and is the major extensor of the thigh at the hip.
The Valsalva maneuver increases vagal tone and can be used to abolish paroxysmal
supraventricular tachycardia. The rectus abdominis is the most important muscle in
achieving the increased intraabdominal and intrathoracic pressure of the Valsalva
maneuver.
USMLE WORLD STEP 1
ANATOMY
Q NO 4: A medical resident performs a diagnostic procedure on 32-year-old male.

He inserts a needle along the upper border of the 10th rib at the right midaxillary
line. Which of the following is most likely to be punctured as a result of the
intervention?
A. Right lower lung lobe
B. Liver
C. Intercostal artery
D. Intercostal nerve
E. Hepatic veins
Explanation:
To avoid complications while performing a thoracentesis, it is necessary to
remember the location of the lungs, pleura, and other organs of the chest and upper
abdomen. The portion of pleura that covers the surface of the lung is called the
visceral pleura. The parietal pleura lines the inner surface of the chest wall and the
diaphragm, and is innervated by somatic sensory nerves. The diaphragm is bound to
the inferior margin of the thorax, and the portion of parietal pleura that covers the
diaphragm extends to the following levels:
The lower border of the lung is usually located two intercostal spaces above the
respective pleural border. Thoracentesis, therefore, should be performed between
5th and 7th ribs along the midclavicular line, the 7th and 9th ribs along the
midaxillary line, and 9th and 11th ribs along the paravertebral line. If the needle is
inserted higher there is a risk of lung injury. Insertion of the needle below the 9th
rib at the middle axillary line on the right may cause liver injury (Choice B).
(Choice A) The lower border of the right lung is located two intercostal spaces above
the pleural border. The lung is not likely to be injured by insertion of a needle into
the 10th intercostal space at the midaxillary line as described.
(Choices C and D) The intercostal vein, artery, and nerve lie in the subcostal groove
on the lower border of the rib. Thoracentesis should be performed along the upper
border of the rib to prevent injury to these structures.
(Choice E) Hepatic veins are not likely to be injured during thoracocentesis.
Thoracocentesis should be performed above the 7th rib in midclavicular line, the 9th
rib along midaxillary line and the 11th rib along posterior scapular line. Insertion of a
needle lower than these points increases the risk of penetrating abdominal
structures, and insertion of the needle on the inferior margin of the rib risks striking
the subcostal neurovascular bundle.
USMLE WORLD STEP 1
ANATOMY
Q NO 5: A 6-month-old female has a head circumference that is in the 97th

percentile for her age. CT scan of the head reveals significant dilation of the
lateral ventricles. Which of the following is the most likely long-term
complication of this patients condition?
Infection
B. Tumor
C. Muscle hypertonicity
D. Lower extremity hyporeflexia
E. Subarachnoid hemorrhage
A.
Explanation:
Hydrocephalus is any increase in cerebrospinal fluid (CSF) volume. In infancy and
early childhood, the cause is usually impaired CSF outflow due to congenital
abnormalities like Type II Arnold-Chiari malformations, hereditary aqueductal
stenosis, and prenatal infections (e.g. toxoplasmosis). Hydrocephalus in early
infancy typically presents with macrocephaly (defined as head circumference greater
than two standard deviations above the mean for gender and age), irritability, poor
feeding, muscle hypertonicity and hyperreflexia. Hypertonicity and hyperreflexia
result from upper motor neuron damage caused by stretching of the periventricular
pyramidal tracts.
(Choices A, B and E) Infection, tumor, and subarachnoid hemorrhage are potential
causes of acquired hydrocephalus but do not result from hydrocephalus.
(Choice D) Lower extremity hyporeflexia would result from damage to the lower
motor neurons of the lower extremities, as can occur in poliomyelitis or WerdnigHoffman disease.
Hydrocephalus in infants presents with irritability, poor feeding increased head
circumference and enlarged ventricles on CT. Long-term sequelae of hydrocephalus
include lower extremity spasticity due to stretching of the periventricular pyramidal
tracts, visual disturbances, and learning disabilities.
USMLE WORLD STEP 1
ANATOMY
Q NO 6: A 34-year-old male is unable tolerate everyday sounds. Injury of which of

the following cranial nerves might be responsible?
A. Hypoglossal
B. Facial
C. Accessory
D. Vagal
E. Glossopharyngeal
Explanation:
The middle ear cavity contains three auditory ossicles (malleus, incus and stapes)
and two skeletal muscles (tensor tympani and stapedius) that participate in the
transmission of sound from the tympanic membrane to the inner ear. The stapedius
muscle arises from the wall of the tympanic cavity and inserts on the neck of the
stapes. The bodys smallest striated muscle, its function is to stabilize the stapes,
the bodys smallest bone. The stapedius muscle is innervated by the stapedius
nerve, a branch of facial nerve (CN VII). Paralysis of the stapedius muscle allows the
stapes to oscillate more widely, producing hyperacusis (increased sensitivity to
sound). Ipsilateral hyperacusis is a common finding in Bells palsy (peripheral facial
nerve paralysis). Other findings in facial nerve paralysis include inability to close the
eye or to smile on the affected side, as well as ipsilateral increased salivation and
loss of taste on the anterior 2/3 of the tongue.
Injury to the other cranial nerves listed in the answer choices does not lead to
hyperacusis. Note also that the tensor tympani muscle arises from the cartilaginous
portion of the auditory tube and the adjoining part of the sphenoid bone and inserts
into the malleus. The tensor tympani draws the tympanic membrane medially,
increasing its tension. This muscle is innervated by the mandibular branch of the
trigeminal nerve (CN V3).
The stapedius muscle is innervated by the stapedius nerve, a branch of facial nerve
(CN VII). Paralysis of the stapedius muscle allows wider oscillation of the stapes, and
leads to increased sensitivity to sound (hyperacusis).
USMLE WORLD STEP 1
ANATOMY
Q NO 7: A 54 year-old alcoholic who has been sober for 6 months falls of the
wagon and imbibes a large amount of isopropyl alcohol. After an unknown
period of time she is found by her neighbor and brought into the emergency
room. The patient eventually arouses but is troubled by a persistent right foot
drop. Prolonged compression of what nerve most likely accounts for her
symptoms?
Common peroneal
B. Femoral
C. Tibial
D. Radial
E. Pudendal
E. Lateral sural cutaneous
A.
Explanation:
The common peroneal nerve is the lateral branch of the sciatic nerve and originates
at the superior aspect of the popliteal fossa. It then traces the lateral aspect of the
fossa, crosses the head of the fibula, and comes into direct contact with the lateral
neck of the fibula as it enters the leg. At this point it divides into the deep peroneal
nerve and superficial peroneal nerve. The deep peroneal innervates the extensor and
the great dorsiflexors. The superficial peroneal branch supplies the peroneal muscles
and the skin of most of the toes. The common peroneal nerve is particularly
susceptible to damage as it traces the lateral neck of the fibula. Damage typical
occurs via compression or leg fracture. The result is inability to dorsiflex the foot.
(Choice B) The femoral nerve (L2-L4) is the largest nerve in the lumbar plexus and
innervates the muscles of the anterior and medial thigh. Damage to the femoral
nerve will result in loss of knee jerk.
(Choice C) The tibial nerve is the larger of the two terminal branches of the sciatic
nerve and it provides motor innervation for the popliteus and the flexors of the foot.
Damage of this nerve would yield difficulty with plantar flexion.
(Choice D) The radial nerve innervates the upper extremity and damage results in
wrist drop.
(Choice E) The pudendal nerve provides the majority of the motor and sensory input
to the pelvic floor.
(Choice F)The lateral sural cutaneous is a cutaneous branch of the tibial nerve and
supplies sensation to the calf.
Common peroneal nerve injury as it traces the lateral aspect of the femoral neck is
common. Bony facture and compression are the most common causes. Clinically this
manifests as foot drop.
USMLE WORLD STEP 1
ANATOMY
Q NO 8: A patient presents to your office with right leg numbness. When he walks,
you notice that he lifts his right foot higher than he does his left, and that his right
foot slaps to the ground with each step. On neurologic exam, you also ascertain
that he is unable to evert the right foot. Which of the following nerves has most
likely been injured?
A.Tibial
B. Common peroneal
C. Superficial peroneal
D. Sural
E. Obturator
Explanation:
The common peroneal nerve is the most commonly injured nerve in the leg. It
begins in the proximal popliteal fossa, where the sciatic nerve divides into the tibial
nerve and common peroneal nerve. From there, the common peroneal nerve courses
laterally into the anterior compartment of the leg, passing superficially around the
head and neck of the fibula. Blunt trauma to the lateral leg and fractures of the neck
of the fibula can injure this nerve.
Patients with common peroneal nerve damage present with an equinovarus
(plantarflexed and inverted) posture of the affected foot due to paralysis of the
peroneus longus and peroneus brevis muscles (mediate foot eversion), paralysis of
the tibialis anterior muscle (mediates dorsiflexion), and paralysis of the extrinsic
extensors of the toes. Injury to this nerve also causes loss of sensation to the
anterolateral leg.
The classic finding on gait exam in patients with common peroneal nerve injury is
toot drop, where the affected leg is lifted high off of the ground while walking due
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ANATOMY
to an inability to dorsiflex the foot. The affected foot will also classically slap to the
ground with each step.
(Choice A) Tibial nerve injury causes dorsiflexion and eversion of the foot with
sensory loss on the sole of the foot.
(Choice C) The superficial peroneal nerve innervates the peroneus longus and
peroneus brevis muscles in the lateral compartment of the leg, which together evert
the foot. It also provides sensory innervation to the skin of the distal anterior leg
and dorsal foot.
(Choice E) Obturator nerve injury classically causes spasms of the adductor muscles
of the thigh.
Common peroneal nerve injury is common and typically results from trauma to the
leg near the head of the fibula. Signs include foot drop and a characteristic highstepping gait.
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ANATOMY
Q NO 9: A 34-year-old male presents to your office complaining of decreased

hearing in both ears. He is a rock musician and has been spending a lot of
time in his studio recently. Where is the most likely location of ear injury in
this patient?
Tympanic membrane
B. Middle ear ossicles
C. Round window
D. Organ of Coil
E. Cupula
F. Auditory nerve
A.
Explanation:
Transduction of mechanical auditory forces into nerve impulses occurs in the organ
of Corti by the following steps: 1) Sound reaches the middle ear by vibrating the
tympanic membrane. 2) This vibration is transferred to the oval window by the
ossicles. 3) Vibration of the oval window causes vibration of the basilar membrane
which in turn causes bending of the hair cell cilia against the tectorial membrane. 4)
Hair cell bending causes oscillating hyperpolarization and depolarization of the
auditory nerve, thus creating nerve impulses from sound.
Noise-induced hearing loss results from trauma to the stereociliated hair cells of the
organ of Corti. Prolonged exposure to noises greater than 85 dB can cause distortion
or fracture of the stereocilia due to shearing forces against the tectorial membrane.
High-frequency hearing is lost first, regardless of the frequency of the sound causing
the damage. Initial damage causes loss of hearing at frequencies of approximately
4000 Hz (speech frequencies = 500-3000 Hz). The acoustic reflex dampens the
effects of prolonged loud noise by causing the stapedius and tensor tympani muscles
to contract, lessening the responsiveness of the ossicles to sound.
(Choice A) Perforation or rupture of the tympanic membrane can occur with
infection, trauma, pressure changes when the eustachian tube is blocked, or sudden
very loud noises. Rupture of the tympanic membrane causes conductive hearing
loss.
(Choice B) Defects of the middle ear ossicles such as otosclerosis can cause
conductive hearing loss.
(Choice C) The round window lies between the middle and inner ear and moves
outward when the stapes causes the oval window to move inward and vice versa.
(Choice E)The cupula lies at the apex of the cochlea and houses the cells that sense
rotation.
(Choice F) The auditory nerve transmits sound impulses to the brainstem via the 8th
cranial nerve. Defects in this nerve can result from trauma mass effect,
demyelination, or local inflammatory processes, and can cause nerve-based hearing
Prolonged exposure to loud noises causes hearing loss due to damage of the
stereociliated hair cells of the organ of Corti.
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ANATOMY
Q NO 10: A 67-year-old male suffers from progressive exertional dyspnea and

fatigue. Cardiac catheterization is planned to measure the left ventricular
systolic and diastolic pressures as well as aortic pressures. The cardiologist
decides to enter the right femoral vein and then access the left heart by
puncturing the fossa ovalis. Which of the following cardiac structures will the
catheter pass first during the procedure?
Tricuspid valve
B. Mitral valve
C. Pulmonic valve
D. Aortic valve
E. Coronary sinus
A.
Explanation:
If the aim of cardiac catheterization is to measure left ventricular and aortic
pressures, the cardiologist must pass the catheter into the left ventricle and the
aorta. The fossa ovalis is an oval-shaped depression on the septal wall of the right
atrium. It lies in the location of the obliterated fetal foramen ovale. The catheter
entered via the femoral vein will follow the venous blood flow to the inferior vena
cava that drains into the right atrium. By puncturing the fossa ovalis, the
cardiologist will pass the catheter from the right atrium directly into the left atrium.
To gain access to the left ventricle from the left atrium, the catheter will pass
through the mitral valve (Choice B). See the diagram below for the catheter route:
(Choice A) The tricuspid valve separates the right atrium from the right ventricle.
(Choice C) The pulmonic valve is located between right ventricle and the pulmonary
artery.
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(Choice D) Aortic valve divides left ventricle and aorta. It is the second valve that
will be passed by the catheter on the way from right atrium to aorta.
(Choice E)The coronary sinus collects blood from the coronary veins. It is located on
the posterior surface of the heart and drains directly into the left atrium.
The fossa ovalis is located in the right atrial wall: it is the remnant of the fetal
foramen ovale, a structure that allows right to left shunting of blood in the fetal
circulation to bypass the fetal lungs. Puncture of the fossa ovalis is used as a means
of gaining access to the left atrium from the right atrium. The route of the catheter
mentioned in this question stem is as follows: right atrium fossa ovaleleft atrium
a mitral valve left ventriclea aortic valvea aorta.
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ANATOMY
Q NO 11: A 45-year-old Caucasian male presents to your office complaining of

intermittent pain in his right thigh. Physical examination reveals a bulge below
the inguinal ligament and just lateral to the pubic tubercle. On straining, the
bulge increases in size. The bulge laterally contacts which of the following
structures?
Inferior epigastric vessels
B. Coopers ligament
C. Femoral vein
D. Transversalis fascia
E. Rectus muscle sheath
F. Spermatic cord
A.
Explanation:
There are three types of groin hernias: direct inguinal, indirect inguinal and femoral
hernia. Direct and indirect inguinal hernias occur above the inguinal ligament, while
femoral hernias are located below it.
Femoral hernias protrude through the femoral canal. They are lateral to the pubic
tubercle and lacunar ligament and medial to the femoral vein. Femoral hernias are
more common in females, and tend to occur on the right side. Femoral hernias may
present with upper thigh and groin pain.
As the femoral canal is small, femoral hernias are prone to incarceration.
Incarcerated hernias cannot be reduced; if a segment of bowel is present in the
hernia sac, incarceration can cause bowel obstruction. Impaired blood flow to
contents trapped in the hernia sac occurs a few hours after incarceration causing
strangulation. Ischemia and necrosis of the contents of the hernia sac occur.
(Choice A) Inferior epigastric vessels are located laterally to direct inguinal hernias
and medially to indirect inguinal hernias. They constitute the lateral border of
Hesselbach triangle.
(Choice B) The pectineal (Coopers) ligament is a thickened part of the pectineal
fascia. It overlies the pectineal ridge of the pubic bone and is located posteriorly to
the femoral canal.
(Choice D) Transversalis fascia is found between the inner surface of transversalis
muscle and the extraperitoneal fat. It forms the posterior wall of the inguinal canal.
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A deep inguinal ring is an opening in the transversalis fascia, which is the site of
protrusion of indirect inguinal hernias.
(Choice E) The rectus muscle sheath forms the medial border of Hesselbach triangle.
Direct inguinal hernias are located laterally to the rectus abdominis muscle sheath.
(Choice F) The spermatic cord lies in the inguinal canal. It contains the ductus
deferens, cremasteric, testicular arteries, artery of ductus deferens, pampiniform
venous plexus, genitourinary nerve, and sympathetic and parasympathetic nerves of
the spermatic plexus.
Femoral hernias are inferior to the inguinal ligament lateral to pubic tubercle, and
medial to the femoral vein. They manifest with a bulge on the upper thigh that
enlarges with straining (Valsalva maneuver). Incarceration and strangulation are
common complications of femoral hernia.
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ANATOMY
Q NO 12: A 43-year-old female undergoes brain MRI for a long history of complex
neurological complaints. The findings from the imaging study are shown below.
You suspect that this patient initially suffered from which of the following?
A. Tinnitus and unilateral deafness
B. Headaches and anosmia
C. Progressive leg weakness and
spasticity
D. Unilateral ptosis and gaze palsy
E. Bitemporal visual field defects
Explanation:
The image above shows a tumor adjacent to the falx cerebri and compressing the
medial surface of the hemisphere. This is a typical meningioma location.
Compression of the parasagittal cortex causes contralateral spastic paralysis of the
leg. Focal seizures may also occur.
Meningiomas are the second-most common brain tumors in adults (the most
common is glioblastoma multiforme). These benign and slow-growing tumors arise
from arachnoid villi. On light microscopy, meningiomas are composed of
concentrically-arranged meningothelial cells. Psammoma bodies (concentric laminar
calcifications) are characteristic.
Meningiomas are commonly located in the parasagittal region: they can also be
found adjacent to the lateral convexity of the hemisphere, in the region of the
sphenoid wing and olfactory groove.
(Choice A) Tinnitus and unilateral hearing loss are the common presenting features
of a cerebellopontine angle tumor, such as an acoustic neuroma.
(Choice B) Meningiomas located in the olfactory groove present with headache and
anosmia.
(Choice D) Unilateral ptosis and gaze palsy (down and out gaze) are features of CN
Ill paralysis. CN Ill can suffer damage from compression (by berry aneurysm or
uncal herniation) or via nerve ischemia (diabetes mellitus).
(Choice E) Bitemporal hemianopia occurs due to compression of the central part of
the optic chiasm. Pituitary adenoma and craniopharyngioma are common causes.
Meningiomas are located adjacent to the cerebral surface. Parasagittal meningiomas
cause contralateral spastic paresis of the leg due to compression of the leg-foot
motor area.
17
USMLE WORLD STEP 1
ANATOMY
Q NO 13: Muscle rigidity is observed in an experimental animal that has chemicallydestroyed dopaminergic neurons of the substantia nigra. The animals rigidity fails
to improve with continuous dopamine infusion. Which of the following cell
communications account for the lack of responsiveness to dopamine?
A. Desmosomes
B. Hemidesmosomes
C. Intermediate junctions
D. Fenestrae
E. Gap junctions
F. Tight junctions
Explanation:
The experimental animal is unresponsive to an intravenous dopamine infusion due to
the fact that intravenous dopamine is unable to cross the blood-brain barrier.
Capillaries of the blood-brain barrier are not fenestrated, so paracellular passage of
fluid and dissolved material does not occur in the CNS. The primary mediators of the
blood-brain barrier are tight junctions between the endothelial cells of CNS
capillaries. Tight junctions, also known as zonula occludens, are formed via the
interaction of specialized transmembrane proteins with one another, such as
occludens and claudens, on capillary endothelial cells. Due to tight junctions the only
way that material can pass from the bloodstream to the brain is by transcellular
movement, which is limited by the size and lipophilicity of the molecule and by
carrier-mediated transport.
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USMLE WORLD STEP 1
ANATOMY
(Choice A) Desmosomes are referred to as spot welds and function as anchors

holding adjoining cells together. They are most notable in the skin where they can
be observed microscopically in the stratum spinosum.
(Choice B) Hemidesmosomes are similar to desmosomes, but they serve to bind the
basal layer of epithelial cells to the basement membrane. Diseases of the
hemidesmosome in the skin include bullous pemphigoid and junctional epidermolysis
bullosa.
(Choice C) Intermediate junctions occur on surface epithelial cells below tight
junctions and assist in cell-cell adhesion.
(Choice D) Fenestrae are small pores in endothelial cells that allow free exchange of
intravascular fluid with extravascular fluid in the tissue surrounding the capillary
bed.
(Choice E) Gap junctions are channels between cells that allow the free exchange of
solute and fluid. They are typically formed by connexin proteins.
The tight junctions between endothelial cells in the capillary beds of the CNS form
the blood-brain barrier. Solutes and fluids cannot move freely across the capillary
membrane in the CNS: material can only move transcellularly by diffusing across the
epithelial plasma membranes or by carrier-mediated transport.
19
USMLE WORLD STEP 1
ANATOMY
Q NO 14: A 23-year-old Caucasian male with involuntary movements undergoes an

experimental radioisotope study to localize metabolic abnormalities in his brain. The
study shows abnormal metabolic activity in the caudate nucleus. Which of the
following on the gross brain section slide below corresponds to the location of the
abnormalities in this patient?
A.
B.
C.
D.
E.
A
B
C
D
E
Explanation:
The patient described in the question stem is most likely suffering from Huntingtons
disease. This disease is an autosomal dominant condition that results from an
excessive number of CAG trinucleotide repeats as compared to the unaffected
population. Furthermore, families with this disease experience a process called
amplification which is a progressive expansion of the trinucleotide repeats in
successive generations leading to earlier expression of the disease in affected
children of Huntingtons patients. Imaging studies typically show atrophy of the
caudate, and metabolic imaging studies such as PET scanning show decreased
metabolic activity in the striatum, which is composed of the caudate and putamen.
The caudate nucleus (Choice A) is a curved or C-shaped structure in its complete
form. The head of the caudate can be identified in the inferolateral walls of the
anterior horns of the lateral ventricles. The head of the caudate nucleus is separated
from the globus pallidus and putamen by the internal capsule.
(Choice B) This structure is the internal capsule. The posterior limb of the internal
capsule separates the globus pallidus and putamen from the thalamus and carries
corticospinal motor and somatic sensory fibers as well as visual and auditory fibers.
The function of this limb is the most important to know for the USMLE. The genu, or
knee, of the internal capsule lies between the anterior and posterior branches and
carries corticobulbar fibers. The anterior limb of the internal capsule separates the
caudate nucleus from the globus pallidus and putamen and carries a portion of the
thalamocortical fibers.
(Choice C) This structure is the insular cortex (insula). The insula plays a role in the
limbic system (emotion) as well as in the coordination of some autonomic functions,
particularly of the cardiac system.
(Choice D) This structure is the putamen.
(Choice E) This structure is the globus pallidus.
The head of the caudate lies in the inferolateral wall of the anterior horn of the
lateral ventricle. It is separated from the globus pallidus and putamen by the
internal capsule. The caudate is atrophied in Huntingtons disease.
20
USMLE WORLD STEP 1
ANATOMY
Q NO 15: A patient presents to your office complaining of double vision. On

neurologic examination, he is unable to adduct his left eye and lacks a
corneal reflex on the left side. What is the most likely location of the lesion?
Inferior orbital fissure
B. Optic canal
C. Superior orbital fissure
D. Foramen rotundum
E. Foramen lacerum
F. Foramen ovale
A.
Explanation:
This patients diplopia is explained by his inability to adduct the left eye. Eye
adduction depends on the oculomotor nerve (CN Ill) and the medial rectus muscle.
The oculomotor nerve originates in the oculomotor nucleus of the midbrain, emerges
from the anterior midbrain, and enters the orbit through the superior orbital fissure.
The patient also has loss of the corneal reflex on the left side. The sensory limb of
the corneal reflex is mediated by the nasociliary branch of the first division of the
trigeminal nerve (CN V1). The motor component of the corneal reflex is carried
primarily by the temporal branch of the facial nerve. Like the oculomotor nerve, the
nasociliary nerve enters the orbit through the superior orbital fissure. An injury here
would cause the deficits described.
The trochlear nerve (CN IV), abducens nerve (CN VI), and superior ophthalmic vein
also enter the orbit via the superior orbital fissure.
(Choice A) The maxillary division of the trigeminal nerve, the infraorbital vessels,
and branches from the sphenopalatine ganglion pass through the inferior orbital
fissure but do not enter the orbit.
(Choice B) The optic canal is medial to the superior orbital fissure and transmits only
the optic nerve (CN II) and ophthalmic artery.
(Choice D) The foramen rotundum transmits the maxillary division of the trigeminal
nerve (CN V2) from within the skull.
(Choice E) The foramen lacerum is occluded by cartilage. Only small unnamed blood
vessels pass through it.
(Choice F)The mandibular branch of the trigeminal nerve (CN V3) passes through
the foramen ovale.
The oculomotor nerve (CN Ill), ophthalmic nerve (CN VI) branches, trochlear nerve
(CN IV), abducens nerve (CN VI), and superior ophthalmic vein enter the orbit via
the superior orbital fissure.
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USMLE WORLD STEP 1
ANATOMY
Q NO 16: A 63-year-old male complains of having to strain on urination. The

patient feels much better several weeks after starting doxazosin. Involvement
of which of the following structures is most likely responsible for this patients
symptoms?
A.
B.
C.
D.
E.
F.
A
B
C
D
E
F
Explanation:
The patient described in the question stem is suffering from symptoms of benign
prostatic hyperplasia (BPH). On autopsy, this condition is present in >90% of men
aged eighty and above. Urinary complaints are the primary symptoms in BPHI
including urinary hesitancy, urgency, frequency, incomplete voiding, post-void
leakage of urine, and nocturia. Diagnosis is made from the history and physical,
including the digital rectal exam.
Medical treatment of BPH is with a-adrenergic blockers, which relax the smooth
muscle in the bladder neck, or with 5- reductase inhibitors, which reduce hormonal
influence on the prostate by preventing the conversion of testosterone to
dihydrotestosterone. In the pelvic CT slice given in the question stem, the prostate
is labeled (A). At this level of sectioning, the prostate is located posterior to the
pubic symphysis and anterior to the anal canal (B).
(Choice C) C is the distal end of bladder.
(Choice D) D labels the ischioanal fossa.
(Choice E) E is the rectal abdominus muscle.
(Choice F) F is the gluteus maximus muscle.
BPH is a common, age-related condition that causes urinary symptoms and can be
medically treated with a-adrenergic blockers or 5- reductase inhibitors. The
prostate is located between the pubic symphysis and the anal canal in inferior
sections of the pelvis on CT scan.
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USMLE WORLD STEP 1
ANATOMY
Q NO 17: A 32-year-old Caucasian female presents with epigastric pain, fullness

after meals, and bilious vomiting. These symptoms started after she landed a
role in a soap opera, inspiring her to lose 25 lbs. on a crash diet. On
laparotomy, her superior mesenteric artery is observed to take a sharp angle
from the aorta. Which of the following structures is most likely to be obstructed
by the artery?
Gastric antrum
B. Duodenal bulb
C. Descending portion of the duodenum
D. Transverse portion of the duodenum
E. Ascending portion of the duodenum
F. Duodenojejunal flexure
A.
Explanation:
The superior mesenteric artery (SMA) leaves the aorta at the level of Li and supplies
the intestine from the duodenum and pancreas to the left colic flexure. The
transverse portion of the duodenum lies horizontally at the level of L4, between the
aorta and superior mesenteric artery. Normally, the SMA and aorta form,
approximately, a 45% angle. If this angle diminishes, the transverse portion of the
duodenum can get entrapped between the SMA and aorta, leading to symptoms of
partial intestinal obstruction. This condition is called superior mesenteric artery
syndrome.
Narrowing of the aortomesenteric angle can occur with any condition that causes
diminished mesenteric fat or pronounced lordosis, including low body weight or
recent weight loss of mesenteric fat (due to burns or other catabolic states) and
prolonged bed rest.
Superior mesenteric artery syndrome occurs when the transverse portion of the
duodenum is entrapped between the SMA and aorta causing symptoms of partial
intestinal obstruction. This syndrome occurs when the aortomesenteric angle
critically decreases either from diminished mesenteric fat or pronounced lordosis.
23
USMLE WORLD STEP 1
ANATOMY
Q NO 18: A 56-year-old male smoker is being evaluated for right shoulder pain. You
suspect a malignancy in the location marked by a star below.
Which of the following additional findings is likely to also be present in this patient as
a result of local tumor extension?
A. Bitemporal hemianopsia
B. Unilateral deafness
C. Ptosis
D. Horizontal nystagmus
E. Anosmia
Explanation:
The star on the chest x-ray above marks the pulmonary apex. Apical lung tumors, or
Pancoast tumors (named for the radiologist who first described them), can cause a
variety of symptoms due to invasion of nearby structures. Most commonly, Pancoast
tumors cause shoulder pain due to invasion of the parietal pleura, vertebrae, and
superior ribs. Invasion of the brachial plexus can cause weakness and paresthesias
of the arm, particularly at sites innervated by the inferior trunk. Superiorvena cava
(SVC) compression by tumor can cause SVC syndrome, and recurrent laryngeal
nerve involvement can cause hoarseness. Homer syndrome, the triad of ipsilateral
miosis, ptosis and anhidrosis, occurs in up to 50% of patients with Pancoast tumors,
and occurs due to tumor invasion of the paravertebral sympathetic chain.
(Choice A) Bitemporal hemianopsia classically results from masses within the
hypophysial fossa, such as pituitary tumors. Prolactinomas are the most common
pituitary tumors.
(Choice B) Unilateral deafness can result from many insults including cerumen
impaction, damage to the conductive system, or damage to cranial nerve VIII.
(Choice D) Horizontal nystagmus can result from disease of the peripheral vestibular
system or severe damage to one of the cerebral hemispheres.
(Choice E) Anosmia (loss of the sense of smell) is associated with a variety of
potential causes including Kallman syndrome, toxin exposure, malignancy invading
the olfactory region of the CNS or nasopharynx, etc.
Apical lung tumors are called Pancoast tumors. Pancoast tumors can cause Homer
syndrome, SVC syndrome, arm weakness, arm paresthesias, and hoarseness.
24
USMLE WORLD STEP 1
ANATOMY
Q NO 19: A 53-year-old Caucasian male presents to your office with a dull ache in
his shoulder that interferes with his sleep. Local tenderness is present just below
the acromion. Active abduction of the right arm into an overhead position is
accompanied by severe pain. A tendon of which of the following muscles is most
likely inflamed in this patient?
A. Biceps brachii
B. Supraspinatus
C. Levator scapulae
D. Serratus anterior
E. Deltoid
Explanation:
The rotator cuff is made up of the tendons of the following muscles: supraspinatus,
infraspinatus, subscapularis, and teres minor. The tendons of these rotator cuff
muscles, along with the tendon of the long head of the biceps brachii muscle, and
the ligaments of the glenohumeral joint contribute to the stability of the joint
between the humerus and the glenoid fossa of the scapula. Of these structures the
tendon of the supraspinatus muscle is most commonly affected in rotator cuff
syndrome. Due to its superior location this tendon is vulnerable to chronic repeated
trauma from impingement between the head of the humerus and the
acromioclavicular joint. Motions that typically cause inflammation of this tendon are
simultaneous abduction and flexion of the arm at the shoulder but a traumatic fall
laterally on an outstretched hand can also cause injury. Inflammation is followed by
fibrosis which worsens the problem by increasing friction between the head of the
humerus and the acromion, as well as causing inflammation of the subacromial
bursa.
(Choice A) The tendon of the long head of the biceps brachii muscle passes through
the glenohumeral joint to insert on the supraglenoid tubercle of the scapula. The
short head tendon inserts directly onto the anterior tip of the coracoid process of the
scapula.
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USMLE WORLD STEP 1
ANATOMY
(Choice C) The tendons of the levator scapulae insert on the superomedial border of
the scapula and on the transverse processes of the C1 through C4 vertebrae. The
levator scapulae does not contribute to the stability of the glenohumeral joint.
(Choice D) The serratus anterior muscle courses from the medial border of the
scapula to insert onto the lateral surfaces of the first eight ribs. Injury to the long
thoracic nerve causes paralysis of this muscle and winging of the scapula.
(Choice E)The deltoid originates on the clavicle, the acromion, and the spine of the
scapula as the anterior, medial, and posterior parts of this muscle, respectively.
Together, these parts of the deltoid insert by a common tendon on the lateral
surface of the humerus.
The most commonly injured structure in rotator cuff syndrome is the tendon of the
supraspinatus muscle. This tendon is vulnerable to injury due to impingement
between the acromion and the head of the humerus.
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USMLE WORLD STEP 1
ANATOMY
Q NO 20: A 35-year-old HIV-positive male complains of throat pain. Physical

examination reveals an ulcer located on the median sulcus of the tongue 1
cm distal to the foramen cecum. The pain sensation is most likely carried by:
Glossopharyngeal nerve
B. Vagal nerve
C. Chorda tympani
D. Maxillary division of the trigeminal nerve
E. Mandibular division of the trigeminal nerve
A.
Explanation:
Innervation of the tongue is complex, as there are motor, general sensory and
gustatory (taste) components.
1. Motor innervation of the tongue is provided by the hypoglossal nerve (ON XII),
with the exception of the palatoglossus muscle, which is innervated by the vagus
nerve (ON X).
2. General sensory innervation of the tongue (including touch pain, pressure, and
temperature sensation) is provided by:
Anterior 2/3 of the tongue: mandibular branch of trigeminal nerve (ON V3)
Posterior 1/3 of the tongue: glossopharyngeal nerve (ON IX)
Posterior area of the tongue root: vagus nerve (ONX)
3. Gustatory innervation (taste buds) is as follows:
Anterior 2/3 of the tongue: chorda tympani branch of facial nerve (ON VII)
Posterior 1/3 of the tongue: glossopharyngeal nerve (ON IX)
Posterior area of the tongue root and taste buds of the larynx and upper
esophagus: vagus nerve (ON X)
The patient described above has an ulcer on the anterior 2/3 of the tongue (distal to
the foramen cecum). Pain from this region (as well as sensations of touch pressure,
and temperature) are transmitted by the mandibular branch of the trigeminal nerve.
(Choice A) The glossopharyngeal
nerve transmits taste, pain,
temperature and touch stimuli
from the posterior 1/3 of the
tongue.
(Choice B) The vagus nerve
innervates the far posterior area of
the tongue root, transmitting both
gustatory and general sensory
stimuli.
(Choice C) The chorda tympani
branch of the facial nerve (CN VII)
transmits gustatory sensation from
anterior 213 of the tongue but not
painful stimuli.
(Choice D) The maxillary division of the trigeminal nerve does not participate in
tongue innervation.
General sensation from the anterior 2/3 of the tongue is carried by the mandibular
division of the trigeminal nerve. Gustatory innervation of anterior 2/3 of the tongue
is provided by chorda tympani branch of the facial nerve.
27
USMLE WORLD STEP 1
ANATOMY
Q NO 21: A 23-year-old male is rushed to the emergency room after being involved
in a street fight. Physical examination reveals a stab wound at the left sternal
border in the fourth intercostal space. Which of the following structures is most
likely to have been damaged?
A. Pulmonary trunk
B. Right ventricle
C. Left atrium
D. Left ventricle
E. Inferior vena cava
Explanation:
A penetrating injury at the left sternal border in the fourth intercostal space (level of
the nipple) will pass through the following layers:
1.
2.
3.
4.
5.
6.
7.
8.
9.
Skin and subcutis

Pectoralis major muscle
External intercostal membrane
Internal intercostal muscle
Internal thoracic artery and veins
Transversus thoracis muscle
Parietal pleura
Pericardium
Right ventricular myocardium
It is important to know that the right ventricle composes the majority of the anterior
surface of the heart. The left lung would not be punctured by a stab wound in this
location because there is no middle lobe on the left side and the superior lobe of the
left lung is displaced laterally by the cardiac impression.
(Choice A) The pulmonary trunk could be pierced by a penetrating injury to the
second intercostal space at the left sternal border.
(Choice C)The left atrium is located at the base of the heart and makes up most of
the hearts posterior surface. Only the auricle of the left atrium is visible anteriorly
(protruding between the pulmonary trunk and the left ventricle).
(Choice D) The left ventricle composes the left lateral aspect of the heart. A stab
wound in the fourth intercostal space in the midclavicular line could potentially strike
the left ventricle, but only after passing through the bulk of the left lung.
(Choice E)The inferior vena cava passes through the right side of the central tendon
of the diaphragm at the level of T8. A stab wound to the back to the immediate right
of the vertebral bodies could strike the IVCI but the injury described above would be
unlikely to.
A penetrating injury at the left sternal border in the fourth intercostal space would
puncture the anterior surface of the heart. The right ventricle composes most of the
hearts anterior surface.
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USMLE WORLD STEP 1
ANATOMY
Q NO 22: A 53-year-old female complains of urinary frequency. Studies reveal a

small bladder that contracts with only minimal stretching. Damage to which of
the following structures is likely responsible for this patients symptoms?
Pelvic splanchnic nerves
B. Pudendal nerves
C. Roots of sacral spinal nerves
D. Sacral spinal cord
E. Thoracic spinal cord
A.
Explanation:
This patient is experiencing neurogenic detrusor spasticity, also known as active
neuropathic incontinence. The detrusor muscle is the muscle of the urinary bladder
wall. It is primarily controlled by local reflex arcs, though there is cortical inhibitory
control as well. The reflex arcs include visceral sensory (afferent) neurons that
detect bladder wall stretch and visceral motor neurons that stimulate detrusor
contraction and expulsion of urine. At rest, this reflex is suppressed by upper motor
neurons projecting from supraspinal centers in the pons and cortex, allowing
voluntary control of micturition. Spinal cord injury above the conus medullaris can
damage these cortical regulatory neurons, causing hyperreflexia in response to
stretch (following a brief period of bladder areflexia).
Parasympathetic neurons from the pelvic plexus (S2-S4) provide excitatory motor
innervation to the detrusor muscle and inhibitory innervation to the internal urethral
sphincter. Sympathetic neurons from spinal levels T11-L2 inhibit the detrusor muscle
(Choices A, C and D) The pelvic splanchnic nerves, derived from the S2-S4 spinal
nerves, mediate parasympathetic innervation to the hindgut and pelvic organs.
Pelvic plexus nerves that originate in the sacral micturition center stimulate the
detrusor muscle and are responsible for the bladder stretch-contraction reflex arc.
Cauda equina lesions that damage the sacral micturition center lead to bladder
hypotonia and hyporeflexia and subsequent overflow incontinence.
(Choice B) The pudendal nerve originates from the S2-S4 nerve roots and innervates
the perineum and genitals. It provides voluntary motor control of the sphincter
urethrae and external anal sphincter.
Damage to the upper motor neurons that control the urinary bladder stretchcontraction reflex arc causes neurogenic detrusor instability. Damage at any above
the conus medullaris can cause this problem.
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USMLE WORLD STEP 1
ANATOMY
Q NO 23: A 34-year-old Caucasian female undergoes surgery for a large left-sided

adnexal mass. The surgeon can palpate the left ureter immediately lateral to
which of the following structures?
A. External iliac artery

B. Internal iliac artery
C. Uterine artery
D. Inferior vena cava
E. Gonadal vein
Explanation:
There are a few important landmarks to keep in mind when asked about the ureters.
The ureters originate bilaterally at the renal pelvis and course within the
retroperitoneum inferiorly toward the bladder, initially on top of the psoas muscles.
Midway from the kidney to the pelvic inlet the gonadal artery and vein cross over the
ureter (water under the bridge). The ureters then gain access to the pelvis by
crossing over (anterior to) the external iliac artery and vein medial to the gonadal
vessels and lateral to the internal iliac vessels. The ureters then course through the
uterosacral ligament just deep to the uterine vessels in the female before gaining
access to the bladder. Due to their course and close proximity to other structures,
the ureters are at particular risk of injury during surgery in the pelvis.
(Choice A) The ureter courses anterior to the external iliac artery just after the
common iliac artery splits into its internal and external branches. After coursing over
the external iliac artery, the ureter is considered to be in the pelvis and is medial to
the external iliac vessels.
(Choice C) Before gaining access to the bladder, the ureter must course within the
uterosacral ligament in the female together with the uterine, vaginal, and inferior
vesical arteries. The ureter lies medial and deep to the uterine artery with in this
ligament.
(Choice D) The left ureter lies some distance from the inferior vena cava as the IVC
rests on the right half of the vertebral bodies and the abdominal aorta lies on the left
half of the vertebral bodies.
(Choice E) As mentioned, the gonadal vessels cross over the ureters on both the
right and the left with in the abdominal retroperitoneum before the ureters enter the
pelvis. In the male, the gonadal vessels never enter the true pelvis: they course
around the pelvic brim before entering the deep ring of the inguinal canal. The
ureters enter the true pelvis medial to the ovarian vessels in the female.
The ureters cross over the external iliac vessels and under the gonadal vessels. They
pass lateral to the internal iliac vessels and medial to the gonadal vessels as they
enter the true pelvis.
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USMLE WORLD STEP 1
ANATOMY
Q NO 24: A 63-year-old male with a history of stroke and resultant severe

oropharyngeal dysphagia develops a right lower lobe pneumonia after an
A. The
episode of vomiting. This type of aspiration pneumonia commonly affects
right
the right lower lung lobe because:
main
bronchus is longer than the left main bronchus
B. The right main bronchus is straighter than the left main bronchus
C. The right main bronchus is narrower than the left main bronchus
D. The right lower lobe receives a richer blood supply than the left lower lobe
E. Vascular resistance is higher in the right lower lobe than the right upper lobe
Explanation:
The right main bronchus is more prone to foreign body aspiration than the left main
bronchus because the right main bronchus has a larger diameter, is shorter, and is
oriented more vertically than the left main bronchus. This fact can be remembered
using the mnemonic, Swallow a bite, goes down the right.
Aspirated or inhaled particles are most likely to become lodged in the right main
bronchus or its branches because this bronchus is shorter, wider and more vertically
oriented than the left main bronchus.
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USMLE WORLD STEP 1
ANATOMY
Q NO 25: A 65-year-old male presents to your office complaining of hearing loss. An

audiogram shows impaired hearing of low-frequency sounds. Sensory cells close to
which of the following structures are most likely affected in this patient?
A. Cochlear base
B. Oval window
C. Round window
D. Helicotrema
E. Stapes
Explanation:
The inner ear is a fluid-filled site encased in bone that houses the cochlea, the
semicircular canals, and the vestibule. The cochlea is a cone-shaped spiraling
structure. The base of the cochlea is the widest section of the cone, and it lies near
the oval and round windows. The apex of the cochlea is the tip of the cone which lies
near the helicotrema. The cochlea is composed of three spiraling fluid-filled ducts
known as the scala vestibuli the scala media, and the scala tympani. The scala
media lies between the scala vestibuli and the scala tympani. Both the scala vestibuli
and the scala tympani are filled with perilymph, which has a high sodium
concentration, while the scala media is filled with endolymph having a high
potassium concentration. The scala media is separated from the scala tympani by
the basilar membrane. The scala media is also unique in that it houses the tectorial
membrane and the organ of Corti. The organ of Coil is the specific site where sound
is transduced into the nervous system.
The transduction of mechanical auditory forces into nervous impulses occurs in the
organ of Corti by the following steps. First, sound reaches the middle ear by
vibrating the tympanic membrane. This vibration is transferred to the oval window
by the ossicles. Vibration of the oval window causes movement of the perilymph in
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USMLE WORLD STEP 1
ANATOMY
the scala tympani, and this, in turn, causes the flexible basilar membrane to vibrate.
Vibration of the basilar membrane causes bending of the cilia of the hair cells as fluid
runs past the rigid tectorial membrane. Hair cell bending causes oscillating
hyperpolarization and depolarization, thus creating nervous impulses from sound. At
the base of the cochlea, the basilar membrane is thin and rigid and best responds to
high frequency sound. The basilar membrane at the apex of the cochlea, near the
helicotrema, is large and flexible so it best responds to low frequency sounds. The
helicotrema is the site where the scala vestibuli and the scala tympani meet.
(Choices A, B and C) The cochlear base lies near the round and oval windows; this
segment of the cochlea best responds to high-frequency sound. Older adults do
suffer from high-frequency hearing loss much more often than low-frequency loss.
The oval window transmits vibration to the scala tympani which communicates with
the scala vestibuli at the helicotrema, which then transmits vibration to the round
window. As the oval window moves inward, the round window moves outward.
(Choice E)The stapes is one of the ossicles of the middle ear. The other two are the
malleus and incus.
Low-frequency sound is best detected at the apex of the cochlea near the
helicotrema. High-frequency sound is best detected at the base of the cochlea near
the oval and round windows.
33
USMLE WORLD STEP 1
ANATOMY
Q NO 26: A 54-year-old female with chronic pelvic pain is found to have a rightsided ovarian mass. After the initial evaluation, surgery is planned to remove
the mass. To avoid excessive bleeding during the surgery the surgeon should
ligate which of the following structures?
Round ligament
B. Suspensory ligament
C. Ovarian ligament
D. Transverse cervical ligament
E. Mesosalpinx
A.
Explanation:
The ovaries are the female gonadal organs, located in the pelvis. The ovaries are
covered by the mesovarium, which extends to form the broad ligament of the
uterus. The uterine tube, ovarian ligament, round ligament of the uterus, and a
portion of the suspensory ligament of the ovary are also surrounded by the broad
ligament. The nerves, arteries, veins, and lymphatics supplying the ovary are all
delivered by the suspensory ligament of the ovary.
The ovarian blood supply is provided by the ovarian arteries, which arise from the
abdominal aorta bilaterally. The right ovarian vein drains into the inferior vena cava
and the left ovarian vein drains into the left renal vein. The parasympathetic
innervation of the ovary is derived from the vagus nerve. The ureters course
retroperitoneally in close association with the gonadal vessels. A common
complication in surgeries ligating the ovarian vasculature in the suspensory ligament
is accidental ligation of the ureter.
(Choice A) There are two major round ligaments in the body: the round ligament of
the uterus and the round ligament of the liver. The round ligament of the uterus
courses through the inguinal ligament and links the horns of the uterus to the
external genitalia.
(Choice C) The ovarian ligament carries no named blood vessels. It courses from the
uterine pole of the ovary to the body of the uterus just below the uterine tubes.
(Choice D) The transverse cervical ligament, also known as the cardinal ligament,
extends from the cervix and lateral fornix of the vagina to the lateral pelvic walls.
The uterine artery courses in this tissue and requires ligation during radical
hysterectomy.
(Choice E)The mesosalpinx is the region of the broad ligament of the uterus that lies
between the uterine tube and the ovary.
The nerves and vessels supplying the ovary are delivered through the suspensory
ligament of the ovary.
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USMLE WORLD STEP 1
ANATOMY
Q NO 27: A 19-year-old female presents to your office complaining of right hand

clumsiness. Physical examination reveals decreased sensation over the fifth
finger and a flattened hypothenar eminence. The affected nerve is commonly
injured at which of the following locations?
A. Carpal tunnel
B. Hook of the hamate
C. Surgical neck of the humerus
D. Head of the radius
E. Coracobrachialis muscle
Explanation:
The ulnar nerve is a branch of the medial cord of the brachial plexus derived from
the C7-T1 ventral rami. The ulnar nerve provides sensory innervation to the fifth
digit and the medial half of the fourth digit as well as to the palmar and dorsal
surfaces of the hand. The ulnar nerve also provides motor innervation to the flexor
carpi ulnaris and to the medial section of the flexor digitorum profundis in the
forearm. In the hand, the ulnar nerve innervates all of the palmar and dorsal
interosseus muscles the muscles of the hypothenar eminence, the palmaris brevis
muscle, the fourth and fifth lumbrical muscles, and the adductor pollicis muscle.
The ulnar nerve enters the forearm after passing behind the medial epicondyle of
the humerus where it is covered by a small amount of overlying soft tissue. This
region, sometimes referred to as the funny bone1 is a common site of ulnar nerve
injury. Ulnar nerve injury at this site classically causes a claw hand deformity. In
the wrist, the ulnar nerve passes between the hook of the hamate and the pisiform
bone in a fibroosseous tunnel known as Guyons canal. Ulnar nerve injury at
Guyons canal causes dysesthesia of the ulnar side of the hand and weakness of the
intrinsic muscles of the hand.
(Choice A) In carpal tunnel syndrome, some factor reduces the size of the carpal
tunnel causing median nerve compression. Patients typically experience difficulty
with fine motor control of the thumb.
(Choice C) Fracture of the surgical neck of the humerus may cause axillary nerve
injury leading to paralysis of the deltoid and teres minor muscles as well as loss of
sensation of the lateral upper arm.
(Choice D) The deep branch of the radial nerve can be affected by radial head
subluxation leading to weakness or paralysis of many of the muscles of the extensor
compartment of the forearm.
(Choice E) The coracobrachialis muscle is an arm flexor that lies deep to the biceps
brachii and overlies the median nerve and brachial artery. It is innervated by the
musculocutaneous nerve.
Ulnar nerve injury classically causes a claw hand deformity. The ulnar nerve can be
injured either near the medial epicondyle of the humerus or in Guyons canal near
the hook of the hamate and pisiform bone in the wrist.
35
USMLE WORLD STEP 1
ANATOMY
Q NO 28: A 34-year-old male has difficulty walking after sustaining a traumatic

injury to his right leg. Physical examination reveals a right foot that is
dorsiflexed and everted. The patient is unable to stand on his tiptoes. What is
the most likely area of sensory loss in this patient?
Anterior thigh
B. Medial leg
C. Medial foot
D. Dorsal foot
E. Plantar foot
A.
Explanation:
The tibial nerve is the large medial branch of the sciatic nerve that descends through
the popliteal fossa together with the popliteal vein and artery. Injury to this nerve
can occur after deep penetrating trauma to the popliteal fossa and can cause a
number of different deficits due to its numerous functions. The tibial nerve
innervates the gastrocnemius, soleus and plantaris muscles which are responsible
for plantarflexion of the foot. It also supplies the flexor digitorum longus and flexor
hallucis longus, which are responsible for toe flexion. The tibial nerve also innervates
the tibialis posterior muscle which is responsible for inversion of the foot. (Patients
with injury to the tibial nerve often hold their lower extremity in a
calcaneovalgocavus positionthe foot is dorsiflexed and everted.) After delivering its
motor innervation, the tibial nerve terminates by dividing into the medial and lateral
plantar nerves to provide sensory innervation to the skin of the distal plantar surface
of the foot.
(Choice A) The cutaneous branch of the femoral nerve innervates the majority of the
skin of the anterior thigh.
(Choice B) Cutaneous branches of the saphenous nerve innervate the skin of the
medial leg. The saphenous nerve is a branch of the femoral nerve and courses to the
medial leg together with the great saphenous vein.
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USMLE WORLD STEP 1
ANATOMY
(Choice C)The medial aspect of the foot is innervated by the superficial peroneal
nerve, a branch of the common peroneal nerve, as well as by the saphenous nerve.
(Choice D)The superficial peroneal nerve innervates the dorsum of the foot except
for the skin between the great toe and the second toe, which is innervated by the
deep peroneal nerve.
The tibial nerve innervates the flexors of the lower leg, the extrinsic digital flexors of
the toes, and the skin of the sole of the foot.
37
USMLE WORLD STEP 1
ANATOMY
Q NO 29: The glossopharyngeal nerve is transected accidentally during a surgical

procedure in a 45-year-old male. Which of the following is most likely lost in this
patient?
A. Taste sensation from the anterior two-thirds of the tongue
B. General sensation from the tonsillar lining
C. Salivary secretion from the submandibular gland
D. Protrusion of the tongue
Explanation:
The glossopharyngeal nerve (CN IX) originates in the medulla and exits the cranial
cavity via the jugular foramen. This nerve has numerous functions:
Somatic motor stylopharyngeus muscle only
Parasympathetic: inferior salivatory nucleusCN IXotic ganglion travels along
auriculotemporal nerve (CN V)parotid gland secretion.
General sensory inner surface of tympanic membrane, Eustachian tube, posterior
1/3 of tongue, tonsillar region, and upper pharynx(afferent portion of the gag
reflex), carotid body and carotid sinus
Lesions of the glossopharyngeal nerve result in loss of the gag reflex (afferent limb),
loss of sensation in the upper pharynx, posterior tongue tonsils and middle ear
cavity, and loss of taste sensation on the posterior one-third of the tongue.
(Choice A) Taste sensation from the anterior two-thirds of the tongue is mediated by
the chorda tympani branch of the facial nerve (CN VII).
(Choice C) Salivary secretion from the submandibular gland and the sublingual gland
is mediated by parasympathetic fibers originating in the superior salivatory nucleus
carried on the facial nerve (CN VII) via the chorda tympani nerve, the lingual nerve,
and across the submandibular ganglion.
(Choice D) Protrusion of the tongue is mediated by motor efferent fibers carried by
the hypoglossal nerve (CN XII).
Lesions of the glossopharyngeal nerve result in loss of the gag reflex (afferent limb),
loss of sensation in the upper pharynx, posterior tongue tonsils, and middle ear
cavity, and loss of taste sensation on the posterior one-third of the tongue.
38
USMLE WORLD STEP 1
Q NO 30: A highly agitated 54-year-old male is brought to the emergency

department. He speaks clearly and with conviction but does not appear to
understand the doctors questions. He does not follow oral or written
instructions and cannot repeat simple phrases. Occlusion of which of the
following arteries is most likely responsible for this patients condition?
artery
B. Middle cerebral artery
C. Posterior cerebral artery
D. Anterior inferior cerebellar artery
E. Posterior inferior cerebellar artery
ANATOMY
A.
Anterior
cerebral
Explanation:
This patient has fluent aphasia, which is a form of receptive aphasia characterized by
speech that is fluent, well articulated, and melodic but meaningless. Individuals
stricken with fluent aphasia cannot understand verbal or written language, whether
it is spoken to them or by them. Typically, there is no awareness of this cognitive
deficit on the part of the individual. Fluent aphasia is often produced by a lesion in
Wernickes area, which is located in the auditory association cortex of the
posterosuperior first temporal gyrus in the dominant temporal lobe. Because the left
hemisphere is dominant in most individuals, the left temporal lobe is the typical site
of Wernickes area. The mnemonic used to remember the association between
Wernickes area and fluent aphasia is Wernickes aphasia causes word salad.
The regions of the cerebral cortex supplied by the middle cerebral artery (MCA) are
approximated by the red oval on the diagram below. The inferior terminal MCA
branches supply Wernickes area.
(Choices A, C, D, and E) The

anterior cerebral artery, posterior
cerebral artery, anterior inferior
cerebellar artery, and posterior
inferior cerebellar artery do not
typically service Wernickes area.
Consequently, occlusions of these
arteries would not be associated
with Wernickes aphasia.
A lesion in Wernickes area can cause receptive aphasia, which is characterized by
well-articulated, nonsensical speech paired with a lack of language comprehension
(Wernickes aphasia causes word salad). Wernickes area is located in the auditory
association cortex of the posterosuperior first temporal gyrus in the dominant
temporal lobe and receives its blood supply from the inferior branches of the middle
cerebral artery.
39
USMLE WORLD STEP 1
ANATOMY
Q NO 31: A 24-year-old mountain climber presents to the emergency room with

right shoulder pain following a fall. Physical examination reveals total inability to
extend the right wrist. X-ray reveals a fracture of the right humeral shaft. Which
of the following arteries is likely to be injured in this patient?
Anterior circumflex humeral artery
B. Brachial artery
C. Deep brachial artery
D. Radial collateral artery
E. Common interosseous artery
40
A.
USMLE WORLD STEP 1
ANATOMY
Explanation:
When the midshaft of the humerus is fractured, there is significant associated risk of
injury to the radial nerve and deep brachial artery. The radial nerve innervates most
of the forearm flexors at the elbow and most of the hand flexors at the wrist. It also
innervates the extrinsic extensors of the digits, and the brachioradialis and supinator
muscles. The radial nerve also provides cutaneous sensory innervation to the dorsal
hand, forearm and upper arm. The deep brachial artery branches oft of the brachial
artery high in the arm, passes inferior to the teres major muscle, and courses
posteriorly along the humerus in close association with the radial nerve.
The patient described above is exhibiting signs of radial nerve injury. The
combination of radial nerve deficits with radiographic evidence of a humeral fracture
should raise concern for an associated injury to the deep brachial artery.
(Choice A) The anterior circumflex humeral artery is a branch of the axillary artery
that passes anterior to the surgical neck of the humerus and anastomoses with the
posterior circumflex humeral artery. A fracture to the surgical neck of the humerus
may damage this vessel and the axillary nerve.
(Choice B) The axillary artery gives off the posterior circumflex humeral artery and
becomes the brachial artery. The brachial artery courses anteromedially in the arm
within the bicipital groove and branches into the radial and ulnar arteries after
entering the forearm. Supracondylar fractures of the humerus may injure this artery.
(Choice D)The deep brachial artery divides into the radial collateral artery and
middle collateral artery at the midpoint of the humerus. The radial collateral artery
courses with the radial nerve.
(Choice E)The common interosseous artery is a short branch of the ulnar artery that
gives rise to anterior, posterior and recurrent branches within the proximal forearm.
The deep brachial artery and radial nerve course along the posterior aspect of the
humerus. Fractures of the humerus midshaft risk injury to these structures.
Supracondylar fractures are associated with injury to the brachial artery.
41
USMLE WORLD STEP 1
ANATOMY
Q NO 32: A patient is being evaluated for recurrent urinary tract infections. An

intravenous pyelogram of the patient is shown below.
Which of the following most likely prevented the proper ascent of the anomalous
organ shown above?
A. Superior mesenteric artery
B. Vitellointestinal duct
C. Persistent urachus
E. Inferior mesenteric artery
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USMLE WORLD STEP 1
ANATOMY
Explanation:
This intravenous pyelogram shows the kidneys joined at their lower poles. This is the
most common variant of horseshoe kidney (90%). In the other 10% of cases the
fusion occurs at the upper poles. Horseshoe kidney is found in approximately out of
every 500 autopsies, and may lead to urinary tract obstruction and the development
of hydronephrosis (such as shown on this radiograph).
During embryogenesis, the kidney goes through the stages of pronephros,
mesonephros and metanephros. Fetal metanephros is initially located in the sacral
region, while in the adult the mature kidney is located at vertebral levels T12-L3
(remember that the kidney is slightly lower on the right compared to the left). This
relative ascent of the kidneys from the sacral region to their normal anatomic
position results from the disproportionately rapid growth of the caudal part of the
embryo.
When fusion of the lower or upper poles of the kidney occurs, the central part of the
newly formed horseshoe kidney lies across the midline anterior to the great vessels.
This centrally located isthmus gets trapped by the inferior mesenteric arte during the
ascent of the kidney.
(Choice A) Superior mesenteric artery is located higher than inferior mesenteric
artery. It leaves the aorta at the level of L1 and doesnt serve as an obstacle for the
ascent of a horseshoe kidney.
(Choice B) When vitelline duct persists, the connection between the intestinal lumen
and the outside of the body is formed at the umbilicus. The discharge of meconium
from the umbilicus will be noted in this condition.
(Choice C) A direct connection between the bladder lumen and the outside of the
body at the umbilicus is called persistent urachus or urachal fistula. This condition
would likely have been identified earlier in life.
(Choice D)The inferior vena cava lies behind the isthmus of a horseshoe kidney and
would not obstruct its ascent.
In horseshoe kidney, both kidneys are fused together at the poles in early
embryonic life. The isthmus of horseshoe kidney usually lies anterior to the aorta
and inferior vena cava and posterior to the inferior mesenteric artery. This centrally
located isthmus gets trapped behind the inferior mesenteric artery during the
relative ascent of the kidney.
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USMLE WORLD STEP 1
ANATOMY
Q NO 33: A 43-year-old Caucasian female presents to your office with back pain
after dragging a heavy box. She describes pain in the right posterior thigh and
posterior calf shooting down to the foot. Physical examination reveals symmetric
knee reflexes, but the ankle jerk reflex is slightly diminished on the right. Which
of the following nerve roots is most likely affected in this patient?
L2
B. L3
C. L4
D. L5
E. S1
A.
Explanation:
The patient described in the question stem is suffering symptoms consistent with
sciatic neuropathy, or sciatica. Sciatic neuropathy can result from any irritation of
the sciatic nerve or its roots. Common causes include vertebral disc herniations,
spinal canal stenosis, irritation by bone spurs, and irritation by the piriformis. Classic
symptoms of sciatica include weakness of the posterior thigh muscles as well as
weakness of all muscles below the knee. The sciatic nerve also provides sensory
innervation to the posterior thigh and calf as well as the plantar surface of the foot.
Transection of the sciatic nerve would result in an inability to flex the leg at the knee
and paralysis of the muscles below the knee. The ankle reflex is diminished in sciatic
nerve injury but the patellar reflex is unaffected as this reflex arc is carried by fibers
of the femoral nerve (L2L4).
The sciatic nerve is derived from the L4 through 53 nerve roots, so only choices C,
D, and E are reasonable options. Sciatica most commonly involves L5 or S1. Of
these, compression of the L5 root typically results in posterior and lateral thigh and
leg pain shooting to the inner foot. Compression of the S1 root results in pain strictly
in the posterior thigh and leg shooting to the foot accompanied by weakness of
plantarflexion and loss of the ankle jerk reflex.
(Choices A and B) L2 and L3 contribute to the lateral femoral cutaneous nerve as
well as other nerves such as the femoral, obturator and genitofemoral. The lateral
femoral cutaneous is a purely sensory nerve that enters the thigh deep to the
inguinal ligament and supplies most of the skin of the anterior thigh.
(Choice C) L4 contributes partially to the femoral, sciatic, obturator, superior gluteal,
and quadratus femoris nerves. This nerve provides no sensation to the posterior
thigh or leg. Damage to L4 would result in impairment of the knee jerk reflex.
Sciatica is a painful condition characterized by shooting pain down the posterior
thigh and leg that typically results from impingement of one of the spinal nerves as
it leaves the vertebral column. Compression of the S1 root results specifically in pain
purely in the posterior thigh and leg as well as diminution of the ankle jerk reflex.
44
USMLE WORLD STEP 1
ANATOMY
Q NO 34: A 34-year-old male with a squamous cell carcinoma undergoes surgical

neck dissection. While attempting to ligate the inferior thyroid artery the surgeon
accidentally damages a nerve that lies in close proximity to it. Which of the
following nerves was most likely damaged?
A. Superior laryngeal nerve
B. Recurrent laryngeal nerve
C. Ansa cervicalis
D. Hypoglossal nerve
E. Accessory nerve
Explanation:
The inferior thyroid artery arises from the thyrocervical trunk, a branch of the
subclavian artery. Along with the superior thyroid arteries (branches of the external
carotid arteries)the inferior thyroid arteries provide blood to the thyroid gland and
other structures of the anterior neck.
From the thyrocervical trunk the inferior thyroid artery courses deep to the vagus
nerve, common carotid artery and internal jugular vein before turning toward the
thyroid. Just before meeting the thyroid gland, this artery courses just superficial to
the recurrent laryngeal nerve. The recurrent laryngeal nerve is a branch of the vagus
nerve that loops below the aortic arch on the left and below the subclavian artery on
the right to provide motor innervation to the muscles of the larynx (all except the
cricothyroid muscle). Unilateral injury to this nerve causes hoarseness; bilateral
injury causes respiratory difficulty due to airway obstruction by immobile vocal folds.
(Choice A) The superior laryngeal nerve is a branch of the vagus nerve that gives oft
internal and external branches. The superior thyroid artery courses with the external
branch of this nerve; ligation of this artery during surgery may damage the external
laryngeal nerve.
(Choice C) The ansa cervicalis is a loop of the cervical plexus that receives
contributions from C1 C2 and C3. It courses deep to the sternocleidomastoid muscle
and loops around the internal jugular vein. Branches from the ansa cervicalis
innervate the sternohyoid, sternothyroid and omohyoid muscles.
(Choice D) The hypoglossal nerve (CN XII) exits the cranium through the
hypoglossal canal and innervates all of the intrinsic muscles of the tongue except the
palatoglossus.
(Choice E) The spinal accessory nerve (CN XI) exits the jugular foramen and courses
on top of the levator scapulae muscle to innervate the sternocleidomastoid and
trapezius muscles on either side.
The recurrent laryngeal nerve travels in close approximation to the inferior thyroid
artery and can be injured in surgical procedures of the anterior neck (e.g.
thyroidectomy), resulting in laryngeal muscle paralysis, hoarseness and dyspnea.
45
USMLE WORLD STEP 1
ANATOMY
Q NO 35: A 12-year-old boy falls from a tree he is climbing, but catches himself on
a branch with his right hand. He swings by his right arm and jumps to the ground.
Several hours later he presents to the emergency room with right hand clumsiness.
Which of the following structures has he most likely injured?
A. Axillary nerve
B. Radial nerve
C. Musculocutaneous nerve
D. Long thoracic nerve
E. Brachial plexus, lower trunk
Explanation:
Of the choices listed, only injury to the lower trunk of the brachial plexus would
cause hand weakness. Sudden upward jerking of the arm at the shoulder, as
occurred in this patient, can cause injury to the lower trunk of the brachial plexus.
The lower trunk of the brachial plexus carries nerve fibers from the CS and Ti spinal
levels that ultimately contribute to the median and ulnar nerves. Together these
nerves innervate all of the intrinsic muscles of the hand. Thus injury to the lower
trunk of the brachial plexus can cause hand clumsiness or paralysis.
(Choice A) Shoulder dislocations or fractures of the proximal humerus can cause
axillary nerve injury. Weakness of the deltoid and teres minor muscles may result.
(Choice B) Fractures at the midshaft of the humerus commonly cause radial nerve
injury. Patients may experience posterior arm numbness and paralysis of the arm
and forearm extensors.
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USMLE WORLD STEP 1
ANATOMY
(Choice C) The musculocutaneous nerve may be damaged in injuries involving the

upper trunk of the brachial plexus. The upper trunk of the brachial plexus is
classically injured when the head and shoulder are violently stretched apart. The
musculocutaneous nerve innervates the biceps brachii and brachialis muscles, so
injury to this nerve would cause weakness of forearm flexion at the elbow.
(Choice D) Long thoracic nerve injury classically occurs during axillary lymph node
dissection and results in paralysis of the serratus anterior muscle leading to
scapular winging on physical examination.
Sudden upward stretching on the arm at the shoulder can damage the lower trunk of
the brachial plexus. This trunk carries nerves from the CS and Ti spinal levels that
ultimately form the median and ulnar nerves. These nerves innervate all of the
intrinsic muscles of the hand.
47
USMLE WORLD STEP 1
ANATOMY
Q NO 36: A 25-year-old male fractures his right tibia in a motor vehicle accident.
His right leg is fixed in a cast, and he requires crutches to ambulate. Two weeks
later, he presents with difficulty extending his arm. Injury to which of the
following nerves is most likely responsible?
A. Suprascapular nerve
B. Long thoracic nerve
C. Axillary nerve
D. Accessory nerve
E. Radial nerve
Explanation:
This patient is suffering from a pressure-induced radial nerve injury, most likely
caused by improperly fitted crutches. The radial nerve is derived from the C5-T1
spinal nerves, and is one of the two final branches of the posterior cord of the
brachial plexus. The radial nerve initially courses medial to the surgical neck of the
humerus inferior to the teres major muscle within the axilla before entering the
posterior arm to course between the long head of the triceps brachii and the
posterior humerus.
The radial nerve can be injured at its superficial location within the axilla by
repetitive pressure and trauma caused by an ill-fitting crutch (crutch palsy). The
radial nerve and deep brachial artery can also be injured by midshaft humerus
fractures. Injury to the radial nerve at either location causes weakness or paralysis
of the extensor muscles of the forearm and wrist as well as to the extrinsic
extensors of the digits, a motor deficit described clinically as wrist drop.
(Choice A) The suprascapular nerve innervates the supraspinatus and infraspinatus
muscles. These muscles function to abduct and laterally rotate the arm, respectively.
48
USMLE WORLD STEP 1
ANATOMY
(Choice B) Damage to the long thoracic nerve causes paralysis of the serratus
anterior muscle and winging of the scapula. This nerve is often injured during lymph
node dissection in patients undergoing radical mastectomy.
(Choice C) Fracture of the surgical neck of the humerus and anterior dislocation of
the glenohumeral joint can cause injury to the axillary nerve. The resultant paralysis
of the deltoid and teres minor muscles causes weakness of abduction extension
flexion and lateral rotation of the arm at the shoulder.
(Choice D)The spinal accessory nerve (CN XI) exits the jugular foramen and courses
over the levator scapulae muscle to innervate the sternocleidomastoid and trapezius
muscles bilaterally.
Improperly fitted crutches can cause radial nerve injury resulting in weakness of all
forearm, wrist and finger flexors
(Wristdrop).
49
USMLE WORLD STEP 1
ANATOMY
Q NO 37: An infant born to a 22-year-old female has difficulty feeding because of

an underdeveloped mandible. Development of which of the following structures is
likely also impaired in this patient?
A. Styloid process
B. Lesser horn of the hyoid
C. Stapes
D. Malleus
E. Thyroid cartilage
Explanation:
The infant described in the question is suffering a defect in development of the first
pharyngeal (branchial) arch. There are six branchial arches in the developing
embryo, and all but the fifth arch contributing structures to the adult; the fifth arch
regresses completely. Each pharyngeal arch is associated with a cranial nerve, and
knowledge of which nerve is paired with which arch can assist in remembering which
adult structures are derived from each arch. In addition, note that the muscular
elements are formed by mesoderm and the bony elements are formed by neural
crest cells that migrate in.
The first arch is associated with the trigeminal nerve (CN V). The neural crest cells of
the first arch form the bones associated with this structure, which include the
maxilla, zygoma, mandible vomer, palatine, incus, and malleus (Choice D). Aberrant
neural crest cell migration into the first arch can cause bony deformities as described
in the question stem. Mesodermal derivatives include all muscles of mastication,
anterior belly of the digastric, mylohyoid, tensor tympani and tensor veli palatini.
(Choices A, B and C) The styloid process, lesser horn of the hyoid, and the stapes
are all neural crest derivatives of the second pharyngeal arch. The second arch is
associated with the facial nerve (CN VII) and gives rise to the muscles of facial
expression the styloid, the stapedius, and the posterior belly of the digastric.
(Choice E) The fourth and sixth arches together make up the cartilaginous structures
of the larynx.
The first arch can be poorly formed during embryonic development resulting in first
arch syndrome. Abnormalities include malformation of the mandible, maxilla,
malleus, incus, zygoma, vomer, palate, and temporal bone. The first arch is
associated with the trigeminal nerve.
50
USMLE WORLD STEP 1
ANATOMY
Q NO 38: A 24-year-old male presents to your office complaining of lower

abdominal discomfort. Physical examination reveals right-sided testicular
enlargement that feels like a bag of worms when the patient stands up.
The venous blood from the affected testicle drains directly into the:
A. Right internal iliac vein

B. Inferior mesenteric vein
C. Right renal vein
D. Hemiazygous vein
E. Inferior vena cava
Explanation:
This patient has a varicocele of the right testicle, as indicated by the bag of worms
texture of the scrotum on the affected side. This texture is produced by the reticular
network of veins that drain the testicles the pampiniform plexus. Failure of the
venous valves leads to pooling of blood in the testicles due to their dependent
location causing varicoceles. Varicoceles can also result from upstream compression
of the veins that drain the testes by abdominal or pelvic masses or other forces.
Recall that the venous drainage of the testes is not bilaterally symmetric. The right
testicular vein drains in to the inferior vena cava (IVC) whereas the left testicular
vein drains into the left renal vein which drains into the IVC. The left testicle is more
commonly affected by varicocele, perhaps because the left renal vein passes
between the aorta and the superior mesenteric artery(SMA), and enlargement or
hardening of the SMA may cause compression of the left renal vein and pooling of
blood in the left testicle.
(Choice A) The right internal iliac vein receives drainage from the pelvic viscera and
genitalia (other than the gonads) and the gluteal region and regions served by the
pudendal circulation.
(Choice B) The inferior mesenteric vein drains the structures of the hindgut.
(Choice C) The right renal vein drains only the right kidney. The right suprarenal
gland drains directly into the IVC as opposed to the left suprarenal gland which
drains primarily into the left renal vein.
(Choice D)The hemiazygous vein drains blood from the posterior walls of the thorax
and abdomen. Together with the azygous vein and accessory hemiazygous vein, the
hemiazygous vein provides an alternate path way for blood to return to the heart
bypassing the IVC.
The right testicular vein drains directly into the IVC while the left testicular vein
drains into the left renal vein.
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Q NO 39: A 26-year-old male presents to the ER with a sharp pain in his neck and
shoulder. He has some breathing difficulty secondary to pain with inspiration. His
past medical history is not significant except for a mild respiratory disease a few
days ago. His blood pressure is 120/70 mmHg and his heart rate is 100/mm. The
pain experienced by this patient is most likely carried by which of the following
nerves?
A. Phrenic
B. Accessory
C. Vagus
D. Superior epigastric
E. Long thoracic
Explanation:
Pleuritic chest pain can result from any condition that causes inflammation of the
pleura. The pleura is divided into segments, as follows:
1. Visceral pleura: The visceral pleura, or pulmonary pleura, cover all surfaces of the
lungs, including the surfaces within the pulmonary fissures.
2. Parietal pleura: This represents the remainder of the pleura that is not in contact
with the lungs and can be subdivided as follows:
Costal pleura: Covers the thoracic wall including the ribs, sternum, intercostal
spaces, costal cartilages, and the sides of the thoracic vertebrae.
Mediastinal pleura: Covers the mediastinum
Diaphragmatic pleura: Covers the surface of the diaphragm located within the
thoracic cavity
Cervical pleura: Extends with the apices of the lung into the neck.
The parietal pleura is innervated by somatic sensory (sensory afferent) nerves which
allow the sensation of sharp and localized pain. The phrenic nerve, which is derived
from the C3-C5 nerve roots, delivers motor innervation to the diaphragm and
additionally carries pain fibers from the diaphragmatic and mediastinal pleura.
Irritation of the pleura in either of these areas will cause a sharp pain worsened by
inspiration that will be referred to the C3-C5 distribution, which lies at the base of
the neck and over the shoulder. Sensory innervation of the remainder of the parietal
pleura is accomplished by intercostal nerves.
(Choice B) The spinal accessory nerve is the 11th cranial nerve and provides motor
innervation to the sternocleidomastoid and trapezius muscles.
(Choice C) The vagus nerve is the 10th cranial nerve and is the major source of
parasympathetic innervation to the viscera of the chest wall and the foregut.
(Choice D)There is no superior epigastric nerve. The superior epigastric artery and
vein course over the superior half of the abdominal wall and anastomose with the
internal thoracics and the inferior epigastrics.
(Choice E) The long thoracic nerve innervates the serratus anterior. Damage to this
nerve causes winged scapula.
Irritation of the mediastinal or diaphragmatic parietal pleura will cause sharp pain,
worse on inspiration, in the C3-C5 distribution. Pain sensation from these areas is
carried by the phrenic nerve.
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Q NO 40: An 11-year-old boy presents to the ER after a basketball injury caused

acute right shoulder pain. Imaging studies suggest clavicular dislocation at the
acromioclavicular joint. Which of the following acts to prevent the dislocation
described in this patient?
A. Sternoclavicular ligament
B. Costoclavicular ligament
C. Acromioclavicular ligament
D. Coracoclavicular ligament
F. Levator scapulae muscle
Explanation:
The clavicle is anchored laterally to the scapula at the shoulder by two major
ligaments: the acromioclavicular ligament superiorly and the coracoclavicular
ligament inferiorly. The acromioclavicular ligament provides the strongest support
between these structures and overlies a synovial joint where the clavicle and
acromion meet (acromioclavicular joint, or AC joint). The coracoclavicular ligament is
actually composed of two distinct bands of ligamentous tissue known as the
trapezoid ligament and the conoid ligament. As the name implies, this ligament
binds the coracoid process of the scapula to the clavicle. Trauma to the shoulder can
separate the scapula and clavicle. This injury is known as acromioclavicular
subluxation, or shoulder separation, and is a unique entity from shoulder dislocation.
In this type of injury, either ligament, or both, can rupture. If both ligaments are
torn, the arm and scapula fall away from the clavicle from the force of gravity,
making the clavicle quite prominent on physical examination.
(Choices A and B) The anterior and posterior sternoclavicular ligaments and
costoclavicular ligaments anchor the clavicle to the sternum and ribs in the midline.
There is also an interclavicular ligament in this region that binds the medial ends of
each clavicle to one another.
(Choice E)The levator scapulae muscle attaches to the transverse processes of the
C1-C4 vertebrae and the superomedial border of the scapula. It functions to elevate
and rotate the scapula and has no function in supporting the shoulder or AC joint.
The scapula and clavicle are firmly bound together distally and superiorly by the
acromioclavicular ligament and joint: they are bound more proximally and inferiorly
by the coracoclavicular ligament. Rupture of these ligaments can occur with trauma
to the shoulder, which will cause the arm and scapula to fall away from the clavicle.
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Q NO 41: A 54-year-old female undergoes thyroidectomy for several thyroid

nodules that were suspicious for malignancy on fine needle aspiration. While
ligating the superior thyroid artery, the surgeon accidentally severs a nearby
nerve. Which of the following muscles is denervated as a result of this
injury?
Thyroarytenoid
B. Lateral cricoarytenoid
C. Posterior cricoarytenoid
D. Cricothyroid
E. Aryepiglotticus
A.
Explanation:
The superior thyroid artery, a branch of the common carotid artery, and the inferior
thyroid artery, a branch of the thyrocervical trunk, provide the blood supply to the
thyroid and parathyroid glands. The superior thyroid artery, superior thyroid vein
and external branch of the superior laryngeal nerve course together in a
neurovascular triad that originates superior to the thyroid gland and lateral to the
thyroid cartilage. Because the external branch of the superior laryngeal nerve
courses just deep to the superior thyroid artery, it is at risk of injury during
thyroidectomy. The cricothyroid muscle is the only muscle innervated by his nerve.
The remaining laryngeal muscles are innervated by the recurrent laryngeal nerves,
which also provide sensory innervation to the larynx below the vocal folds. The
internal branch of the superior laryngeal nerve does not innervate any muscles, but
provides sensory innervation to the laryngeal mucosa above the vocal folds.
(Choices A, B, C and E)These muscles are all innervated by the recurrent laryngeal
nerve.
The external branch of the superior laryngeal nerve is at risk of injury during
thyroidectomy due to its proximity to the superior thyroid artery and vein. This
nerve innervates the cricothyroid muscle.
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Q NO 42: A 26-year-old female presents to your office with a three-month hi stow

of amenorrhea. She also notes that during this time her breasts have become
engorged. She is taking a drug that helps her not to hear voices and
acetaminophen for occasional headaches. You proceed with giving her a
pregnancy test that returns with a negative result. Which of the following
dopaminergic pathway disturbances are most likely responsible for this patients
symptoms?
A. Mesolimbic-mesocortical
B. Nigrostriatal
C. Tuberoinfundibular
D. Periventricular
E. Incerthypothalamic
Explanation:
The patient appears to be suffering from galactorrhea, a non-puerperal secretion of
watery or milky fluid that contains neither pus nor blood. The tuberoinfundibular
dopaminergic pathway connects the hypothalamus and the pituita gland and is
responsible for dopamine-dependent prolactin tonic inhibition. The neurotransmitter
dopamine is secreted from these neural axons and inhibits prolactin secretion from
the posterior pituita gland. Some antipsychotic drugs block dopamine in the
tuberoinfundibular pathway, which can cause an increase in blood prolactin levels,
leading to hyperprolactinemia and abnormal lactation (galactorrhea), disruptions to
the menstrual cycle in women, and sexual dysfunction.
(Choice A) The mesolimbic-mesocortical pathway is primarily involved in regulating
behavior. This area is hyperactive in schizophrenia. Antipsychotic action of the
neuroleptics is by primarily blocking the dopamine in the mesolimbic-mesocortical
(frontal cortex) pathway.
(Choice B) In the nigrostriatal system the neurons are projected from the substancia
nigra to the caudate nucleus and putamen. This pathway primarily regulates
coordination of voluntary movements. In this pathway dopamine inhibits the release
of acetylcholine. Degeneration of the substantia nigra thus causes decreased
dopamine and subsequent increased acetylcholine; this leads to hyperkinetic
disorders such as Parkinsonism. Administering high potency antipsychotics can
cause some dopamine antagonism in this pathway resulting in drug-induced
Parkinsonism.
(Choices D and E)The other 2 pathways are not really well defined and not important
for purpose of board examination.
Remember the 3 important Dopaminergic systems:
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Q NO 43: A 23-year-old Caucasian female suffers from an acute attack of multiple

sclerosis. Impulse transmission along the left optic nerve is hindered by an area of
demyelinization. Which of the following is the most likely finding during the
physical exam?
Explanation:
The patient described in the question stem is experiencing a very common adverse
effect of multiple sclerosis: demyelinization of the optic nerve (CN II). The examiner
in the question stem is testing the light reflex pathway. The optic nerve carries the
afferent (sensory) limb of this pathway. The efferent limb (motor) is carried by the
oculomotor nerve (CN Ill). In brief light enters the eye and generates a signal that is
transmitted from the retina along the optic nerve to synapse in the ipsilateral
pretectal nucleus located in the superior colliculus. Fibers then project from the
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pretectal nucleus to the ipsilateral and contralateral Edinger-Westphal nuclei.

Decussating fibers traverse from the ipsilateral pretectal nucleus to the contralateral
Edinger-Westphal nucleus within the posterior commissure. The Edinger-Westphal
nucleus is the site of parasympathetic preganglionic neurons. These neurons project
fibers within the oculomotor nerve to synapse on parasympathetic postganglionic
(para/post) neurons in the ciliary ganglion. From the ciliary ganglion, para/post
fibers project to innervate the sphincter of the iris. When light enters one eye, both
pupils constrict: a phenomenon called the consensual response.
As with many patients suffering from MS, this patients injury is isolated to only one
optic nerve. Thus, light entering the affected eye (in this case, the left one) will not
be transmitted to the midbrain, and neither pupil will respond. Light in the
contralateral eye, however, will be transmitted normally to the midbrain, and the
response will be transmitted along the unaffected oculomotor nerves to constrict the
pupils of both eyes.
The afferent limb of the light reflex pathway is the optic nerve; the efferent limb lies
in parasympathetic fibers of the oculomotor nerve. When an optic nerve is damaged,
light in that eye will cause neither pupil to constrict (the nerve cant sense the light);
however, light in the contralateral eye will cause both pupils to constrict (because
the motor function of the iris is conserved).
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Q NO 44: A 12-year-old soccer player presents to the emergency room with acute
right knee pain after sustaining a kick injury to an extended leg. The trauma
caused anterior displacement of her tibia with respect to her femur. Which of the
following ligaments was most likely injured?
A. Fibular (lateral) collateral
B. Tibial (medial) collateral
C. Patellar
D. Anterior cruciate
E. Posterior cruciate
F. Oblique popliteal
Explanation:
The anterior cruciate ligament (ACL) connects the lateral femoral condyle to the
anteromedial tibial head. The ACL prevents anterior motion of the tibia with respect
to the femur. Damage to the ACL can be assessed on physical examination with the
anterior drawer test, a maneuver that involves flexing the lower extremity to
approximately 900 and pulling the tibia anteriorly with the femur held fixed. Laxity
indicates ACL injury. This patient appears to have sustained force on the anterior
tibia greater than the ACL could bear, causing ligament rupture.
Athletes who play contact sports are at risk for the unhappy triad of knee injuries,
which includes simultaneous damage to the tibial (medial) collateral ligament,
medial meniscus, and ACL. These injuries generally result from a forceful blow to the
lateral knee while the lower extremity is fully extended and the foot is rigidly
planted. Extreme force to the lateral knee causes tearing of the tibial (medial)
collateral ligament. Because this ligament is attached to the medial meniscus, there
is frequently also tearing of the medial meniscus. The ACL can also be injured by
this mechanism due to anterior and medial movement of the tibia with respect to the
femur.
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(Choice A) The fibular (lateral) collateral ligament is extremely strong and is rarely
injured. Injury o this ligament would require a forceful blow to the medial knee while
the leg is extended.
(Choice C)The patellar ligament is the inferior projection of the quadriceps femoris
tendon. Injury causes difficulty with leg extension.
(Choice E)The posterior cruciate ligament extends from the medial condyle of the
femur to the posterior head of the tibia. It functions to prevent posterior movement
of the tibia with respect to the femur. Damage is assessed using the posterior
drawer test.
(Choice F)The oblique popliteal ligament is a wide fibrous band that connects the
posterior distal femur to the posterior proximal tibia. It has small openings for
nerves, vessels, and muscle insertions.
The anterior cruciate ligament (ACL) can be damaged by forceful anterior motion of
the tibia with respect to the femur. ACL injury can occur as part of the unhappy
triad, which also includes injury to the medial meniscus and medial collateral
ligament.
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Q NO 45: A 34-year-old Caucasian female has difficulty abducting her right arm
past the horizontal position. An abnormal prominence of the right inferior
scapular angle is also observed. Which of the following is the most likely cause
of this patients condition?
Thyroidectomy
B. Anterior dislocation of the shoulder joint
C. Violent stretch between the head and the shoulder
D. Clavicular fracture
E. Mastectomy
A.
Explanation:
The patient described in the question stem is exhibiting symptoms consistent with
paralysis of the serratus anterior muscle due to long thoracic nerve injury. Paralysis
of the serratus anterior causes two classic signs. First, when a patient is asked to
press anteriorly against a wall scapular winging can be observed. A winged scapula
results from an inability of the serratus anterior to hold the medial border and
inferior angle of the scapula against the posterior chest wall. Second, patients with
serratus anterior paralysis are unable to abduct the arm higher than the horizontal
position. The deltoid and supraspinatus muscles abduct the arm up to the horizontal
position but at that point the action of the serratus anterior is required to rotate the
glenoid cavity superiorly thereby allowing complete abduction of the arm over the
head. The long thoracic nerve injury can occur during penetrating trauma or
iatrogenically during axillary lymph node dissections as may occur during a radical
mastectomy.
(Choice A) Thyroidectomy carries many risks due to the complicated anatomy of the
midline neck. Nerve injuries that can occur with this procedure include damage to
the recurrent laryngeal nerve during ligature of the inferior thyroid artery and
damage to the external branch of the superior laryngeal nerve during ligature of the
superior thyroid artery.
(Choice B) Anterior dislocation of the shoulder joint or a fracture of the neck of the
humerus can injure the axillary nerve, resulting in paralysis of the deltoid and teres
minor and some sensory loss to the upper lateral arm.
(Choice C) Violent stretch between the head and the shoulder can occur during
delivery or by trauma in the adult. This results in damage to the upper trunk of the
brachial plexus and the classic Erb-Duchenne palsy. This palsy results from damage
to the musculocutaneous and suprascapular nerves and causes a waiters tip
posturing of the arm (shoulder adducted, arm pronated, and elbow extended).
(Choice D) Clavicular fracture does not cause any characteristic nerve palsies, but it
is important to note that these fractures typically occur in the middle third of the
clavicle due to the strength of the ligamentous structures at either end of this bone.
Mastectomy is a commonly tested cause of long thoracic nerve injury, but any
trauma or surgery in the axillary region is at risk of damaging this nerve. Injury to
this nerve causes winging of the scapula and inability to abduct the shoulder past 90
degrees.
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Q NO 46: A 65-year-old female is evaluated for progressive dyspnea and

cardiomegaly. She also complains of occasional dysphagia. Her
dysphagia is potentially explained by enlargement of the:
A. Right ventricle
B. Right atrium
C. Left ventricle
D. Left atrium
E. Pulmonary artery
Explanation:
Given her history of dyspnea and cardiomegaly, this patients dysphagia maybe
second arqto a cardiac cause. Cardiovascular dysphagia is uncommon, but when it
does occur, it is usually the result of left atrial enlargement. (The left atrium is
located posteriorly, directly overlying the esophagus.) Left atrial enlargement most
commonly occurs in the setting of mitral stenosis and left ventricular failure.
Increasing pressures in the left atrium cause distention of this chamber and pressure
on the underlying esophagus.
(Choice A) The right ventricle is located on the right lateral aspect of the heart and
abuts the right lung.
(Choice B)The right atrium is located on the anterior and superior right aspect of the
heart and receives blood from the inferior and superior venae cavae as well as the
coronary sinus.
(Choice C)The left ventricle is located on the left lateral side of the heart and abuts
the left lung.
(Choice E)The pulmonary artery emerges from the right ventricle and branches into
the right and left pulmonary arteries below the arch of the aorta.
Cardiovascular dysphagia can result from pressure on the esophagus by a dilated
left atrium. The left atrium is commonly enlarged in patients with mitral stenosis and
left ventricular failure.
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Q NO 47: A 23-year-old female is examined by an obstetrician in the delivery room.

Starling intravaginally, he injects lidocaine solution near the tip of the ischial spine.
Which of the following nerves is most likely blocked by the injection?
A. Genitofemoral
B. Iliohypogastric
C. Lateral femoral cutaneous
D. Obturator
E. Pudendal
F. Inferior gluteal
Explanation:
A pudendal nerve block is one method of providing anesthesia during childbirth, and
this is the block that is described in this scenario. Sometimes this method is used if
a woman has progressed too far in labor to receive epidural anesthesia. The
pudendal nerve is derived from the 32 - 34 nerve roots and provides sensory
innervation to the perineum and genitals (of both sexes) as well as motor
innervation to the sphincter urethrae and the external anal sphincter.
When administering a pudental nerve block the physician generally palpates
intravaginally for the ischial tuberosity and attempts to administer the anesthetic
agent in that location.
(Choice A) The genitofemoral nerve originates at L1 and L2 and courses on the
anterior surface of the psoas muscle. It splits into the genital and femoral branches,
innervating the scrotum / labia majora and cutaneously innervating the femoral
triangle, respectively.
(Choice B) The iliohypogastric nerve is derived from T12 / L1 and courses in that
dermatome to innervate the skin overlying the iliac crests.
(Choice C) The lateral femoral cutaneous nerve is derived from L2 and L3. It courses
deep to the inguinal ligament to innervate the skin on the anterolateral thigh.
(Choice D) The obturator nerve is derived from LB and L4 and serves to provide
motor innervation to the medial thigh (adductors).
(Choice F) The inferior gluteal nerve is derived from L5 - 32 roots and provides
motor innervation to the gluteus maximus.
A pudendal nerve block can be performed by injecting anesthetic intravaginally in
the region of the ischial spine. Blocking the pudental nerve provides anesthesia to
the majority of the perineum; additional blockade of the genitofemoral and
ilioinguinal nerves would provide complete perineal and genital anesthesia.
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Q NO 48: A 30-year-old male presents to the emergency room after being involved
in a street fight. There is significant soft tissue swelling around the left eye. The
imaging study above reveals a left orbital floor fracture with fluid accumulation in
the:
A. Ethmoid cells
B. Maxillary sinus
C. Frontal sinus
D. Sphenoid sinus
E. Inferior conchae
Explanation:
The orbit is bound superiorly by the thick orbital plate of the frontal bone and
laterally by the thick bone of the zygoma and greater and lesser sphenoid wings. In
contrast, the orbital floor is composed of a very thin layer of bone that separates the
orbit from the air-filled maxillary sinus. Similarly, the orbits medial wall is composed
of the thin ethmoid and lacrimal bones, which separate it from the ethmoid air cells.
Blunt trauma to the eye causes a rapid increase in pressure that typically does not
rupture the globe but is transmitted posteriorly into the orbit. The weakest plates of
bone in the orbit, the medial and inferior walls, are common sites of fracture.
Fracture is typically evident on radiographic imaging, and fluid (blood) can usually
be visualized in the normally air-filled adjacent sinuses. On the right side of the
image above (corresponding to the patients left side), the maxillary sinus (below
the orbital floor) is filled with fluid.
(Choice A) The ethmoid air cells are medial to the orbit. Here they are unaffected,
but they can be affected in blowout fractures of the orbits medial wall.
(Choice C) The frontal sinus is not pictured above. It lies in the medial part of the
supraorbital frontal bone.
(Choice D) The sphenoid sinuses (not pictured above) lie anterior to the optic chiasm
and are not in close relation to the orbit.
(Choice E) The inferior nasal conchae form part of the nasal turbinate system. They
are not air-filled sinuses.
Blunt trauma to the globe can cause orbital blow out fractures. These fractures most
commonly involve the medial or inferior orbital walls, because the bone bordering
the ethmoid and maxillary sinuses is thin.
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Q NO 49: A 56-year-old female with a long history of gallstones presents to the

emergency room complaining of cramping mid-abdominal pain, abdominal
distention and vomiting for the last 12 hours. Abdominal X-ray reveals air in
the gallbladder and biliary tree. In which of the following sites is a gallstone
most likely lodged?
Cystic duct
B. Common bile duct
C. Duodenum
D. Jejunum
E. Ileum
A.
Explanation:
This patient is most likely suffering from gallstone ileus, a condition that occurs in
patients with longstanding cholelithiasis (often middle-aged to elderly females). A
large (typically 2.5cm or greater) gallstone causes the formation of a
cholecystenteric fistula between the gallbladder and adjoining gut tissue due to
persistent pressure on these tissues. The fistula ultimately allows passage of the
gallstone into the small bowel, and the resulting communication between the
gallbladder and small bowel allows intestinal gas to enter the gallbladder and biliary
tree. Often this gas can be observed on abdominal X-rays.
After entering the small bowel, the gallstone typically passes freely through the
duodenum jejunum and ileum until it encounters the ileocecal valve. The ileocecal
valve typically handles material in a liquid state, and the large gallstones associated
with gallstone ileus are generally unable to pass through this valve. Obstruction of
the small bowel at the ileocecal valve leads to the classic signs and symptoms of
small bowel obstruction including abdominal pain and distention, vomiting,
tenderness to palpation and tinkling bowel sounds.
The diagnosis can be made with an upper GI series to demonstrate the
cholecystenteric fistula and small bowel obstruction. Treatment is by surgical
removal of the offending stone. Cholecystectomy and repair of the fistula are rarely
necessary.
(Choices A and B) Obstruction of the cystic duct or common bile duct by a gallstone
is referred to as choledocholithiasis. This can lead to biliary colic, jaundice and
cholangitis. Signs and symptoms of cholangitis include fever, right upper quadrant
abdominal pain, and an inspiratory pause during right upper quadrant palpation
(Murphys sign). Free air is typically not seen in the biliary tree. Right upper
quadrant ultrasound will reveal stones in the biliary ducts.
(Choices C and D)The caliber of the duodenum and jejunum is typically sufficient to
allow the passage of the larger gallstones that cause gallstone ileus.
Gallstone ileus results from the passage of a large gallstone (typically greater than
2.5 cm) through a cholecystenteric fistula into the small bowel where it ultimately
causes obstruction at the ileocecal valve. Gas is seen within the gallbladder and
biliary tree on abdominal X-ray due to the presence of the fistula, and patients
present with signs and symptoms of small bowel obstruction.
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Q NO 50: A 46-year-old gardener presents to your office with knee pain. He reports
that he spends hours on his knees several times per week while gardening. Which
of the following bursae do you most expect to be affected in this patient?
A. Suprapatellar bursa
B. Prepatellar bursa
C. Anserine bursa
D. Semimembranous (popliteal) bursa
E. Gastrocnemius bursa
Explanation:
The prepatellar bursa is located between the patella and the overlying skin and
prepatellar tendon. It is lined by synovium and contains very little fluid. Its function
is to diminish friction and ensure maximal range of motion at the knee. Chronic
trauma from repeated kneeling is one cause of prepatellar bursitis, also called
housemaids knee. It is common in roofers, plumbers and carpet layers.
Symptoms of prepatellar bursitis include knee pain, swelling, redness and inability to
flex the knee on the affected side. The symptoms are usually relieved by rest.
Physical examination reveals tenderness to palpation, erythema, crepitance, and
fluctuant edema over the lower pole of the patella.
(Choices A, D and E) Prolonged kneeling is not associated with inflammation of the
suprapatellar, popliteal or gastrocnemius bursae. Popliteal and gastrocnemius
bursitis can be associated with the formation of Bakers cysts.
(Choice C) Anserine bursitis (pes anserinus bursitis) presents with pain along the
medial aspect of the knee. It results from overuse in athletes or from chronic trauma
in patients with heavy body habitus. There is typically tenderness to palpation
approximately 4 cm distal to the anteromedial joint margin of the knee.
Repeated and prolonged kneeling can cause prepatellar bursitis. Dubbed
housemaids knee, today it is most commonly seen in roofers, carpenters and
plumbers. Signs and symptoms of prepatellar bursitis include knee pain, erythema,
swelling and inability to knee on the affected side.
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Q NO 51: A 52-year-old male presents to your office with a painless mass in his
groin. On physical examination, you palpate several hard lymph nodes in the
right inguinal area. Lymph node biopsy reveals malignant cells that most likely
originated from the:
Testes
B. Prostate
C. Bladder
D. Anal canal
E. Sigmoid colon
A.
Explanation:
This patient has palpable firm superficial inguinal lymph nodes. The superficial
inguinal lymph nodes drain all cutaneous lymph from the umbilicus to the feet,
including the external genitalia and anus (up to the beginning of the rectum, the
dentate line), but excluding the posterior calf which drains to the popliteal lymph
nodes. The superficial inguinal lymph nodes lie in a region bounded by the inguinal
ligament, sartorius muscle, and adductor longus muscle, and overlie the femoral
nerve, artery and vein.
(Choice A) In general, lymph vessels follow the paths of the arteries and veins
supplying a particular structure. The testes receive their blood supply from the
testicular arteries, which arise directly from the abdominal aorta just inferior to the
renal arteries. The lymph vessels that drain the testes follow a path from the testes
to the abdominal aortic lymph nodes.
(Choice B) Lymph from the prostate drains primarily to the internal iliac nodes, but
also to the external iliac nodes and sacral nodes (minor pathways).
(Choice C) Lymph from the superior potion of the bladder drains to the external iliac
nodes while lymph from the inferior portion of the bladder drains to the internal iliac
nodes.
(Choice E) Lymph from the sigmoid colon drains to the inferior mesenteric lymph
nodes.
All skin from the umbilicus down, including the anus (up to the dentate/pectinate
line) but excluding the posterior calf, drains to the superficial inguinal lymph nodes.
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Q NO 52: A 22-year-old male presents to your office complaining of occasional

headaches. On exam, you note several pigmented spots on his trunk. You also
discover a few rubbery cutaneous tumors on his neck. The cells composing
these skin tumors most likely originated from which of the following
structures?
Surface ectoderm
B. Neuroectoderm
C. Neural crest
D. Mesoderm
E. Endoderm
P. Notochord
A.
Explanation:
This patient has pigmented lesions that are most likely a caf-au-lait macules, and
headaches that could be due to a gliomaboth of which are common presentations
of Neurofibromatosis Type I.
The tumors of interest in the question stem are neurofibromas. Neurofibromas are
tumors of Schwann cells, which are derived from the neural crest. On exam,
cutaneous neurofibromas are skin-colored or pink nodules with a rubbery texture
that exhibit pathognomonic buttonholing. The latter refers to the examiners
perception that these tumors buttonhole down through the skin with gentle
pressure.
(Choice A) The surface ectoderm gives rise to the skin and its appendages, the nasal
and oral epithelium, the anal epithelium to the dentate line, and the lens and
cornea.
(Choice B)The neuroectoderm gives rise to all neurons of the CNSI the
neurohypophysis, the retina, the pineal gland, preganglionic autonomic fibers,
astrocytes, ependymal cells, and the choroid plexus.
(Choice D) The mesoderm is divided into paraxial, intermediate, and lateral sections
and gives rise to muscles, bones, blood, genital tissues, the dermis, and most organ
systems. Notably, the mesoderm does not give rise to any epithelial surfaces.
(Choice E)The endoderm gives rise to thyroid tissues (descendent from the base of
the tongue) and the epithelial linings of the Gl tract, lung, urethra, bladder, and
outer and middle ear. The endoderm also gives rise to the bulk of the liver,
pancreas, and lungs, as these structures form from outpouchings of the primitive gut
tube.
(Choice F)The notochord almost completely regresses in humans. The only major
vestige is the nucleus pulposus in the intervertebral disks. Vertebrae form from the
paraxial mesoderm.
Neurofibromatosis Type l (NF1, or von Recklinghausens disease) is a common
autosomal-dominant disorder resulting from a defect in the NF-i gene on
chromosome 17. Cutaneous and subcutaneous neurofibromas are common in this
condition and are tumors of Schwann cells, which are embryologically derived from
the neural crest.
67
USMLE WORLD STEP 1
ANATOMY
Q NO 53: A 53-year-old male complains of a strange feeling in his right hand. On

physical examination, there is loss of sensation over the 5th digit. Which of the
following nerves has most likely been injured?
A. Ulnar
B. Median
C. Radial
D. Musculocutaneous
E. Axillary
Explanation:
Loss of sensation in the 5th digit can only be due to injury of the ulnar nerve. The
ulnar nerve innervates the flexor carpi ulnaris and the medial portion of the flexor
digitorum profundus as well as most of the intrinsic muscles of the hand. Injury to
the ulnar nerve results in a claw hand deformity as well as anesthesia over the
medial 1-1/2 digits.
The ulnar nerve is a branch of the medial cord of the brachial plexus (C8-T1) that
courses posteromedially in the upper arm and enters the forearm after passing
posterior to the medial epicondyle of the humerus. This site the funny bone is a
common site of ulnar nerve injury. The ulnar nerve is also often injured where it
passes between the hook of the hamate and the pisiform bone in the wrist with in
Guyons canal.
(Choice B) Median nerve injury classically results from carpal tunnel syndrome or
fractures of the supracondylar humerus. Patients lose sensory innervation to the
majority of the palmar and dorsal is through 3rd digits. Motor deficits include loss of
extrinsic finger flexion, loss of thumb movement and loss of pronation. There may
be flattening of the thenar eminence due to denervation atrophy, producing an ape
hand deformity.
(Choice C)The radial nerve innervates the extensor compartment of the forearm.
Injury causes wrist drop. Patients also lose sensation to the posterior arm, posterior
forearm, and a small portion of the dorsal thumb.
(Choice D) Musculocutaneous nerve injury causes loss of sensation over the lateral
forearm and paralysis of the forearm flexors at the elbow.
(Choice E) Axillary nerve injury can result from fracture of the surgical neck of the
humerus or other shoulder trauma. Patients lose sensation over the lateral upper
arm.
Ulnar nerve injury causes sensation loss to the medial 1% digits of the hand.
68
USMLE WORLD STEP 1
ANATOMY
Q NO 54: A 63-year-old male with a history of gastrointestinal bleed has developed

a sudden onset shortness of breath. Evaluation shows pulmonary embolism. A filter
placement is planned to prevent further embolization. The filter will most likely be
placed in which of the following structures?
A.
B.
C.
D.
E.
A
B
C
D
E
Explanation:
The IVC filter is designed to prevent the travel of deep vein thrombosis from the legs
to the lung vasculature. Inferior vena cava filter is used to prevent pulmonary
embolism in patients who have contraindications to anticoagulation. This abdominal
computed tomography (CT) scan is taken at the level of L2. The bilateral kidneys are
viewed in section:
the inferior pole of the right lobe of the liver is noted on the left side of the above
image anterior to the right kidney and posterolateral to the large bowel.
Choice A represents the lumen of the second part of the duodenum, which classically
lies at the level of L2.
Choice B is medial to the descending part of the duodenum and lies anterior to the
right side of the vertebral body. This structure is the inferior vena cava. The right
renal vein drains into the IVC near this plane of section.
Choice C represents the abdominal aorta. The bifurcation of the abdominal aorta
occurs at the level of L4. Choice D, if observed carefully, looks like a figure eight.
This structure represents two segments of the ileum lying next to one another.
Choice E represents the left renal vein. The left renal vein receives drainage from the
left gonadal vein and courses anterior to the aorta, but posterior to the superior
mesenteric artery, before draining into the inferior vena cava.
The inferior vena cava courses through the abdomen and inferior thorax in a location
anterior to the right half of the vertebral bodies. The renal veins join the IVC at the
level of L1/L2, and the common iliac veins merge to become the IVC at the level of
L4.
69
USMLE WORLD STEP 1
ANATOMY
Q NO 55: A 45-year-old Caucasian female presents to your office with numbness of

the right palm. Alter taking a detailed history and doing a physical examination you
suspect a median nerve lesion at the wrist. Before reaching the wrist the median
nerve courses between the:
A. Biceps and coracobrachialis muscles
B. Flexor carpi ulnaris and flexor digitorum profundus
C. Flexor digitorum superficialis and flexor digitorum profundus
D. Olecranon and the medial epicondyle of the humerus
E. Supinator muscle and the head of the radius
Explanation:
The median nerve receives contributions from the C5 through T1 spinal nerves and
emerges as a distinct structure from a combination of fibers from the lateral and
medial cords of the brachial plexus. From this location the median nerve courses
with the brachial artery in the groove between the biceps brachii and the
coracobrachialis / brachialis muscles. It gains access to the forearm in the medial
aspect of the antecubital fossa and immediately courses between the humeral and
ulnar heads of the pronator teres muscle. It then courses between the flexor
digitorum superficialis and the flexor digitorum profundus muscles before entering
the wrist and hand within the flexor retinaculum. Injury of the median nerve at the
wrist can result from suicide attempts carpal tunnel syndrome, and other traumatic
insults to the anterior wrist. Denervation atrophy leads to loss of the thenar
eminence and an ape hand deformity. Sensation is also lost on the palmar surface
of the first three and one-half fingers (including the thumb).
(Choice A) The musculocutaneous nerve courses directly between the biceps brachii
and the coracobrachialis muscles. Injury to this nerve leads to paralysis of the biceps
and the brachialis, which results in an inability to flex the forearm.
(Choice B) The ulnar nerve courses between the flexor carpi ulnaris and flexor
digitorum profundus in the forearm. Injury to this nerve leads to a clawhand
deformity due to paralysis of most of the intrinsic muscles of the hand.
(Choice D) The ulnar nerve also courses between the olecranon and the medial
epicondyle of the humerus. This is the location of the funny bone and is a common
site of injury to the ulnar nerve due to the superficial location of the nerve in this
region.
(Choice E)The radial nerve courses through the supinator muscle near the head of
the radius. Injury to this nerve causes wrist drop due to the fact that the radial
nerve innervates the extensors of the hand at the forearm.
The median nerve courses between the humeral and ulnar heads of the pronator
teres muscle and then runs between the flexor digitorum superficialis and the flexor
digitorum profundus muscles before entering the wrist and hand within the carpal
tunnel.
70
USMLE WORLD STEP 1
ANATOMY
Q NO 56: A 34-year-old male begins treatment with combination chemotherapy for

Hodgkins lymphoma. Shortly there after, he experiences severe vomiting and
requires intravenous fluid supplementation. Which of the following brain sites is
responsible for his symptoms?
A.
B.
C.
D.
E.
A
B
C
D
E
Explanation:
The vomiting that results from administration of systemic chemotherapy is believed
to be triggered by the chemoreceptor trigger zone (CTZ) located on the dorsal
surface of the medulla at the caudal end of the fourth ventricle (Choice D) in a
region known as the area postrema. The area postrema receives blood from
fenestrated vessels (absent blood-brain barrier), which allows it to sample chemicals
circulating in the blood.
(Choice A) This is the thalamus, which helps to coordinate the sensory and motor
systems.
(Choice B) This dorsal midbrain site is the location of the superior and inferior
colliculi. The third ventricle is located dorsal to these structures.
(Choice C) This is the ventral pons. Fibers of cranial nerves V-VIII, the corticospinal
tract, the medial lemniscus, and the lateral spinothalamic tract course through this
region.
(Choice E) This is the site of the inferior cerebellar peduncle of the inferior medulla.
Damage to this peduncle results in ipsilateral motor incoordination.
Acute nausea following administration of systemic chemotherapy results from
stimulation of the chemoreceptor trigger zone (CTZ), which lies in the area postrema
of the dorsal medulla near the fourth ventricle.
71
USMLE WORLD STEP 1
ANATOMY
Q NO 57: Shown below are the cerebral arteriography findings from a 45-year-old
patient.
Occlusion of the artery labeled X would most likely result in an inability to:
A. Climb stairs
B. Grip
C. Whistle
D. Swallow food
Explanation:
This cerebral angiogram image is projected axially with the top of the image
representing anterior regions and the bottom representing posterior regions. The
yew large vessels seen bilaterally are the internal carotid arteries. Each gives off a
middle cerebral artery to supply more lateral regions and an anterior cerebral artery,
which extends medially. The above X marks an anterior cerebral artery. Each
anterior cerebral artery supplies the medial region of the ipsilateral hemisphere from
the frontal pole to the parietooccipital sulcus. Occlusion of the anterior cerebral
artery would affect motor function of the contralateral leg and foot.
(Choices B, C and D) Motor control of the hand head and neck would be affected by
occlusion of the middle cerebral arteri.
The anterior cerebral arteries supply the medial portions of the two hemispheres.
Occlusion causes weakness of the contralateral legs and sensory deficits of the
contralateral legs, trunk and genitals. There may also be behavior and mood
changes due to injury of frontal lobe structures.
72
USMLE WORLD STEP 1
ANATOMY
Q NO 58: A patient presents to the emergency room complaining of worsening

headaches, confusion, and intermittent vomiting. She is admitted, but later
dies in the hospital. Examination of the brain at autopsy shows enlargement of
the lateral and third ventricles and a normal-sized fourth ventricle. Where is
the most likely site of obstruction in this patient?
Inter ventricular foramina of Monro
B. Cerebral aqueduct
C. Medial foramen of Magendie
D. Lateral foramina of Luschka
E. Arachnoid villi
A.
Explanation:
This patient had findings consistent with noncommunicating hydrocephalus resulting
from obstruction of cerebrospinal fluid (CSF) flow at the cerebral aqueduct.
CSF is formed by the choroid plexus in each of the four ventricles. The choroid
plexus is composed of ependymal cell- covered outgrowths of the pia mater blood
vessels. The ependymal epithelium is a simple ciliated columnar layer. Choroid
plexus capillaries are fenestrated unlike the other CNS capillaries. The ependymal
cells form tight junctions with one another and selectively allow certain materials
from the blood to enter the CSE.
Once formed CSF flows from the lateral ventricles to the third ventricle via the
interventricular foramina of Monro. It then circulates to the fourth ventricle through
the cerebral aqueduct (of Sylvius). CSE then exits the fourth ventricle and enters the
subarachnoid space via one of three foramina, the lateral foramina of Luschka or the
medial foramen of Magendie. CSE is returned to the venous circulation via the
arachnoid villi (granulations).
Other forms of hydrocephalus are briefly as follows:
1. Communicating hydrocephalus: No blockage to CSF flow within the brain or
brainstem. The blockage is in the subarachnoid space where flow may be restricted
by fibrosis following inflammation.
2. Normal pressure hydrocephalus: CSF is not absorbed by the arachnoid villi.
3. Hydrocephalus ex vacuo: Increased CSF volume occurring in conditions of brain
atrophy.
4. Pseudotumor cerebri: A condition that classically occurs in over weight young
females and is related to decreased CSF outflow at the arachnoid villi.
CSE flows from the third ventricle to the fourth ventricle via the cerebral aqueduct of
Sylvius.
73
USMLE WORLD STEP 1
ANATOMY
Q NO 59: A 54-year-old Caucasian male dies from a progressive neurological

disorder. A brain section of the patient is shown below.
Which of the following corresponds to the structure with cystic degeneration (black
arrow)?
A. Globus pallidus
B. Putamen
C. Internal capsule
D. Caudate nucleus
E. Amygdala
Explanation:
Many progressive
neurologic diseases may be
associated with cystic
degeneration of the putamen, but Wilsons disease is the most likely of these to be
emphasized on the USMLE.
The putamen (Choice B) can be identified on coronal sections (either in gross
specimens as above or on imaging studies) in a location immediately deep (medial)
to the insula and lateral to the globus pallidus and internal capsule.
(Choice A) The globus pallidus is the orange-colored structure on the above image
immediately medial to the degenerated putamen. Itis considered part of the basal
ganglia along with the caudate and putamen.
(Choice C) The internal capsule is the white matter structure that separates the
globus pallidus and putamen from the caudate nucleus anteriorly and from the
thalamus posteriorly on coronal sections.
(Choice D) In its full three dimensional structure, the caudate nucleus is a curved or
C-shaped structure that can be identified in the inferolateral walls of the anterior
horns of the lateral ventricles. However only a small cross-section is visible in the
image above next to the lateral ventricles. This structure is affected in Huntingtons
disease.
(Choice E) The amygdala is a group of neurons in the medial temporal lobe located
adjacent to the hippocampus that plays a role in the limbic system. The amygdala
can be identified on the image above as the circular grey matter
structures in the medial temporal lobe immediately inferior to the globus pallidus
and putamen. The amygdala mediates fear and some sympathetic stimulation in
humans.
Wilsons disease can cause cystic degeneration of the putamen as well as damage to
other basal ganglia structures. The putamen is located medial to the insula and
lateral to the globus pallidus on coronal sections.
74
USMLE WORLD STEP 1
ANATOMY
Q NO 60: A 45-year-old male presents with left arm clumsiness. Physical

examination reveals motor weakness and increased muscle tone in the
left arm. Specifically, with passive extension of the left arm there is
initial resistance then sudden release when maximum extension is
reached. Pathology within which of the following brain structures is most
likely responsible?
A.
B.
C.
D.
E.
A
B
C
D
E
Explanation:
This patient has clasp knife spasticity characterized by initial jerking resistance to
passive extension followed by sudden release of resistance. This form of spasticity is
typical of an upper motor neuron lesion. Potential sites for upper motor neuron
lesions include the corticospinal tracts of the spinal cord: the medulla pons and
midbrain: the posterior limb of the internal capsule; or the precentral gyrus (primary
motor cortex). Of these the internal capsule is the only structure labeled above
(Choice B). In general, upper motor neuron lesions cause spastic paresis,
hyperreflexia, and a positive Babinski sign. The clasp knife phenomenon is a form of
spasticity that results from a lack of upper motor neuron inhibitory control on the
spinal muscle stretch reflex arc.
(Choice A) This is the caudate nucleus, the structure affected by Huntingtons
disease.
(Choice C) This is the insular cortex (insula), which plays a role in the limbic system
(emotion).
(Choice D) This is the putamen.
(Choice E) This is the globus pallidus.
Upper motor neuron lesions cause spastic rigidity, hyperreflexia, and paresis.
Corticospinal tract, internal capsule
(Posterior limb), and primary motor cortex lesions can cause these symptoms.
75
USMLE WORLD STEP 1
ANATOMY
Q NO 61: A 54-year-old male presents to your office complaining of periodic, tight,

burning substernal chest pain. A thallium stress test shows hypoperfusion of the
cardiac muscle forming the diaphragmatic surface of the heart. Which of the
following coronary arteries is most likely occluded in this patient?
A. Left anterior descending
B. Left circumflex
C. Left main
D. Right
E. Acute marginal
Explanation:
The right and left main coronary arteries arise directly from the root of the aorta and
provide the blood supply to the heart. The left main coronary artery divides into the
left anterior descending (LAD) and circumflex coronary arteries, which supply most
of the anterior and left lateral surfaces of the heart. In 85-90% of individuals, the
right coronary artery gives rise to the posterior descending artery. These patients
are said to have right dominant coronary circulation. In approximately 10% of
patients the posterior descending artery arises from the circumflex branch of the left
main coronary artery these patients have left dominant circulation. The posterior
descending artery supplies most of the inferior wall of the left ventricle, which forms
the diaphragmatic surface of the heart. The right coronary artery also gives rise to
the SA and AV nodal arteries in most patients.
(Choice A) The LAD coronary artery normally supplies the anterior 2/3 of the
interventricular septum (septal branches), the anterior wall of the left ventricle
(diagonal branches) and part of the anterior papillary muscle.
(Choice B)The left circumflex coronary artery supplies the lateral and posterior
superior walls of the left ventricle via obtuse marginal branches.
(Choice C) The left main coronary artery gives rise to the LAD and left circumflex
coronary arteries. It only gives rise to the posterior descending artery in about 10%
of individuals and thus is not the artery most likely occluded here.
(Choice E)The acute marginal branches arise from the right coronary artery to
supply the wall of the right ventricle. They may provide collateral circulation in
patients with LAD occlusion.
The inferior wall of the left ventricle forms most of the diaphragmatic surface of the
heart. The posterior descending artery supplies this area. In 85-90% of individuals
the posterior descending artery derives from the right coronary artery.
76
USMLE WORLD STEP 1
ANATOMY
Q NO 62: A 23-year-old male who has been previously healthy is brought to the FR
after a street fight. He has a stab wound at the fifth intercostal space along the left
midclavicular line. Which of the following is most likely punctured in this patient?
A. Left lung
B. Left atrium
C. Right ventricle
E. Azygous vein
Explanation:
Most of the volume of the thoracic cavity is occupied by the lungs. The apex of each
lung extends into the neck approximately three to four centimeters above the first
rib. The lung bases are in direct contact with diaphragm which separates the right
lung from the right lobe of the liver and the left lung from the left lobe of the liver
the stomach, and the spleen. The mediastinal surface of each lung has a cardiac
impression that accommodates the heart.
The heart is located behind the sternum and is partially covered by the lungs. The
apex is formed by the left ventricle and is covered by the left lung. It lies behind the
fifth left intercostal space on the level of left midclavicular line. The sternocostal
(anterior) surface or the heart is formed chiefly by the right ventricle. The
diaphragmatic (inferior) surface is formed by left and right ventricles, and is in
contact with the central tendon of the diaphragm. The posterior surface of the heart
is formed mainly by the left atrium.
Penetrating injury in the fifth intercostal space at the left midclavicular line would
most likely injure the left lung (Choice A). Penetration of the left lung in this location
could lead to injury of the apex of the heart as well if the wound was deep enough.
All other heart chambers lie medial to the left midclavicular line and would not be
affected.
(Choice B)The left atrium is located posterior to the left ventricle and forms the base
of the heart.
(Choice C) Right ventricle forms the anterior (sternal) surface of the heart and its
inferior border. It lies medially to the left midclavicular line.
(Choice D) The inferior vena cava is located in the mediastinum, lies to the right of
midline and drains into the right atrium.
(Choice E) The azygous vein lies in the posterior mediastinum immediately to the
left of midline. It drains blood from the posterior intercostal veins into the superior
vena cava.
The left ventricle forms the apex of the heart and reaches as far as the fifth
intercostal space in the left midclavicular line. The other chambers of the heart lie to
the right of the left midclavicular line and would not be affected by penetrating
injury in this location.
77
USMLE WORLD STEP 1
ANATOMY
Q NO 63: A patient with a long history of excessive alcohol consumption presents to

your office with abdominal distention. The distension clears with a low-salt diet and
spironolactone therapy. Which of the following structures labeled on the image
below is expected to have an increased pressure in this patient?
A.
B.
C.
D.
E.
A
B
C
D
E
Explanation:
The patient described in the question stem is likely suffering from alcoholic cirrhosis.
Alcoholic cirrhosis is a form of micronodular cirrhosis associated with hepatocyte
death followed by fine fibrosis of the liver. As cirrhosis worsens and the number of
functioning hepatocytes decreases the functional ability of the liver diminishes. In
advanced disease portal blood has an increasingly difficult time passing through the
liver because the vasculature becomes compromised by the progressive fibrosis,
causing portal hypertension. The effects of prolonged portal hypertension include
varices at the four sites of portocaval anastomoses (esophagus, rectum umbilicus
and retroperitoneal), as well as ascites. Of the structures identified on the image
above only the portal vein (Choice C) is a part of the portal system. In this patient
high pressure would be expected within the portal vein.
(Choice A) The descending abdominal aorta will have elevated pressures in patients
with systemic hypertension.
(Choice B)The inferior vena cava experiences increased pressure in cases of heart
failure.
(Choice D)The celiac trunk emerges from the aorta at this level (T12/L1).
(Choice E) The splenic artery pressure would increase under conditions of elevated
systemic blood pressure. The splenic vein however would experience increased
pressure with portal hypertension due to the fact that it drains directly into the
portal vein (after receiving blood from the inferior mesenteric vein).
The portal vein can be identified on cross-sectional scans lying in or near the right
side of the liver and anterior to the inferior vena cava. The pressure in the portal
system is elevated in liver cirrhosis.
78
USMLE WORLD STEP 1
ANATOMY
Q NO 64: A patient drinking hot tea at a restaurant experiences a burning sensation

at the tip of his tongue. This sensation is transmitted by which of the following?
A. Trigeminal nerve
B. Chorda tympani
C. Glossopharyngeal nerve
D. Hypoglossal nerve
E. Vagus nerve
Explanation:
The innervation of the tongue is complex because it involves motor, general somatic
sensory and special sensory functions. Somatic sensation includes pain touch
temperature and pressure; the same sensations felt by the skin. The lingual nerve, a
branch of the mandibular division of the trigeminal nerve (CN V3) provides somatic
sensory innervation to the anterior 2/3 of the tongue. CN V3 also provides somatic
sensory innervation to the skin of the face. The glossopharyngeal (CN IX) nerve
provides somatic sensory innervation to the posterior 1/3 of the tongue.
(Choice B)The chorda tympani is a branch of the facial nerve that passes along the
deep surface of the tympanic membrane and through the petrotympanic fissure
before merging with the lingual nerve to deliver taste sensation to the anterior 2/3
of the tongue.
(Choice C) The glossopharyngeal nerve (CN IX) delivers somatic sensory and taste
innervation to the posterior 1/3 of the tongue.
(Choice D)The hypoglossal nerve (CNXII) innervates all intrinsic muscles of the
tongue except the palatoglossus muscle which is innervated by the vagus nerve (CN
X).
(Choice E) The vagus nerve (CN IX) innervates the palatoglossus muscle and carries
taste signals from the pharynx and epiglottis. It does not carry taste signals from
the tongue however.
A branch of the mandibular division of the trigeminal nerve (CN V3) provides
somatic sensory innervation to the anterior 2/3 of the tongue. The chorda tympani
branch of the facial nerve provides taste sensation from the anterior 2/3 of the
tongue. The glossopharyngeal nerve (CN IX) provides somatic sensory and taste
innervation to the posterior portion of the tongue.
79
USMLE WORLD STEP 1
ANATOMY
Q NO 65: A 43-year-old male presents to your office with difficulty walking. On gait
examination you note that he leans to the right side while walking. When he is
asked to stand on his left foot, his right hip tilts significantly downward. Which of
the following nerves is most likely injured in this patient?
A. Superior gluteal
B. Inferior gluteal
C. Obturator
D. Femoral
E. Sciatic
Explanation:
This patient demonstrates a positive Trendelenburg sign. The Trendelenburg test
involves observing a patient standing facing away from the examiner while lifting
each foot off of the ground. The sign is positive when the hip dips downward when
the ipsilateral leg is lifted off of the ground. This can occur due to weakness of the
gluteus medius and gluteus minimus muscles because these muscles function to pull
the pelvis down and abduct the thigh. These muscles are supplied by the superior
gluteal nerve.
Patients with injury of the superior gluteal nerve may exhibit a waddling gait ora
characteristic limp known as the gluteus medius limp. The Trendelenburg sign and
gluteus medius limp can also be seen in patients with injuries to the gluteus medius
and gluteus minimus muscles themselves as well as in patients with injuries to the
hip joint.
(Choice B) The inferior gluteal nerve innervates the gluteus maximus muscle. This
muscle is responsible for extension of the thigh at the hip and external rotation of
the thigh. Injury of the inferior gluteal nerve causes difficulty rising from the seated
position and climbing stairs.
(Choice C) injury of the obturator nerve causes deficits of thigh adduction as well as
medial thigh sensory loss.
(Choice D)The femoral nerve innervates the muscles responsible for flexion of the
thigh at the hip (iliacus and sartorius muscles) and extension of the leg at the knee
(quadriceps femoris). It also supplies sensory innervation to the skin on the anterior
thigh and medial leg. Injury results in loss of the knee reflex and anterior thigh
sensory loss.
(Choice E)The sciatic nerve innervates all of the knee flexors (hamstrings) except
the short head of the biceps femoris. It subsequently divides into the tibial and
common peroneal nerves, which each go on to provide motor and sensory
innervation to the leg and foot.
1) Injury to the superior gluteal nerve causes weakness of the gluteus medius and
gluteus minimus muscles, producing a positive Trendelenburg test.
2) The inferior gluteal nerve innervates the gluteus maximus muscle. Injury of the
inferior gluteal nerve causes difficulty rising from the seated position and climbing
stairs.
80
USMLE WORLD STEP 1
ANATOMY
Q NO 66: A 45-year-old male is brought to the ER after a motor vehicle accident. He

is diagnosed with a left hemothorax and a pelvic fracture. The patient is unable to
void and complains of a sensation of full bladder. Foley catheter placement does not
produce any urine. The patient is likely to have an injury of which of the following
labeled structures:
A.
B.
C.
D.
E.
A
B
C
D
E
Explanation:
Inability to void despite sensation of a full bladder in the scenario presented in this
vignette suggests urethral trauma. Urethral injuries are divided into trauma to the
anterior or the posterior urethra. The posterior urethra is located above the
urogenital diaphragm while the anterior urethra lies below it.
Injury to the anterior urethra is the most common form of urinary tract trauma. This
form of urinary tract injury most frequently occurs due to a saddle injury where the
perineum is struck forcefully such as by falling on the crossbar of the bicycle or on
the top of the fence. The symptoms of this form of trauma are difficulty with or
inability to void in spite of a full bladder, and the presence of blood at the urethral
meatus. Injury of the anterior urethra causes blood and urine to extravasate into the
superficial perineal space of the penis, scrotum and anterior abdominal wall. This
hematoma is called butterfly-like, as it does not extend to the thighs and anal
triangle due to the firm attachment of the superficial perineal fascia with the fascia
lata.
Posterior urethral trauma most commonly occurs in association with pelvic fracture
(choice C). Such injury commonly causes a hematoma below the prostate and
upward displacement of that gland. It also causes rupture of the posterior urethra
that is firmly connected to both the prostate and the pubic arch. Posterior urethral
injury presents with inability to void despite a full bladder and an elevated (high
riding) prostate on rectal examination. A typical presentation of posterior urethral
trauma is described in this clinical vignette. If urethral trauma is suspected,
placement of Foley catheter should be avoided and retrograde urethrogram should
be preformed to demonstrate urethral injury.
(Choice A) Anterior bladder wall rupture is associated with blunt abdominal trauma
causing compression of a full bladder. It is associated with intraperitoneal
extravasation of urine, abdominal pain and guarding, and inability to void.
(Choice B) Superior bladder wall rupture also occurs in association with pelvic
fracture. It manifests with difficulty with or inability to void, gross hematuria and
suprapubic pain. Urine extravasates extra peritoneally with in the retropubic space
of Retzius.
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(Choice D) Trauma to the urethra below the urogenital diaphragm results from
saddle injuries. It presents with blood at the urethral meatus, a butterfly
hematoma of the perineum, and an inability to void despite a full bladder.
(Choice E) injury to the penile urethra results from trauma to the erect penis.
Symptoms include swelling and hematoma of the penis and perineum, inability to
void and blood at the external urethral meatus.
Injury to the posterior urethra is associated with pelvic fracture. It presents with
inability to void despite a full bladder, and a high riding prostate on rectal
examination.
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Q NO 67: A 52-year-old Caucasian male is brought to the ER after repeated coffeeground vomiting. After initial stabilization, endoscopy is performed revealing a
deep, bleeding ulcer on the posterior wall of the duodenal bulb. This ulcer has most
likely penetrated which of the following arteries?
A. Common hepatic
B. Right gastroepiploic
C. Left gastric
D. Gastroduodenal
E. Inferior pancreaticoduodenal
F. Splenic
G. Superior mesenteric
Explanation:
Duodenal ulcers are more common than gastric ulcers. Duodenal ulcers tend to
occur anteriorly. Notably, ulcers located on the anterior wall of the duodenal bulb are
more prone to perforation, while those on the posterior wall are more likely to cause
hemorrhage.
These complications are explained by the relationship of the duodenal bulb to
adjacent organs. The bulb begins at the pylorus, ends at the neck of the gallbladder,
and rests anterior to the gallbladder and liver. The gastroduodenal artery, common
biliary duct, and vena porta lie behind the duodenal bulb; the head of the pancreas
is located below. When an ulcer of the posterior wall of the duodenal bulb penetrates
the posterior wall, the ulcer is likely to corrode the gastroduodenal artery.
The gastroduodenal artery arises from the proper hepatic artery and perfuses both
the pylorus and the proximal part of the duodenum. Damage to the gastroduodenal
artery can cause significant upper gastrointestinal bleeding.
(Choice A) The common hepatic artery arises from the celiac trunk bifurcates into
the proper hepatic and gastroduodenal artery. It passes superiorly to the duodenal
bulb and is not eroded by duodenal ulcers.
(Choices B and C) The right gastroepiploic and left gastric arteries supply blood to
the stomach. They dont lie in close proximity to the duodenal bulb.
(Choice E)The inferior pancreaticoduodenal artery is a branch of the superior
mesenteric artery. It supplies blood to the lower duodenum and to the head of the
pancreas. This artery does not have any close relation to the duodenal bulb.
(Choice G) The superior mesenteric artery lies anterior to the transverse part of the
duodenum. It arises from the anterior surface of the abdominal aorta and supplies
the intestine from the duodenum to the left colic flexure. It also supplies the
pancreas.
The gastroduodenal artery lies along the posterior wall of the duodenal bulb and is
likely to be eroded by posterior duodenal ulcers. Ulceration into the gastroduodenal
artery can be a source of life-threatening hemorrhage.
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Q NO 68: A 48-year-old male presents to your office with recent weight loss and
vague abdominal pain. He admits to drinking alcohol regularly, but denies any
past medical problems. A 72-hour stool collection reveals excessive excretion of
neutral fat. Involvement of which of the following structures is most likely
responsible for this patients symptoms?
A.
B.
C.
D.
E.
A
B
C
D
E
Explanation:
The patient described in the question stem is suffering from exocrine pancreatic
insufficiency, which is evidenced by his bodys inability to normally metabolize fat.
People who suffer from chronic pancreatitis, often caused by alcoholism, have severe
abdominal pain, stool that floats in the toilet bowl (due to excess fat content) and
weight loss.
The head, neck, and body of the pancreas are retroperitoneal, while the tail is
peritoneal. The head of the pancreas lies in the curve of the duodenum and overlies
the L2 vertebra. The body overlies the L1 and L2 vertebrae and makes contact
posteriorly with the aorta the superior mesenteric vessels. and the left kidney. The
tail of the pancreas courses within the splenorenal ligament alongside the splenic
vessels.
(Choice A) This structure is the second (descending) part of the duodenum.
(Choice C) This structure is the inferior vena cava (IVC). The IVC lies on the right
side of the vertebrae in a retroperitoneal position.
(Choice D) This structure labels the abdominal aorta. The aorta in this region lies on
the left side of the vertebrae in a retroperitoneal position.
(Choice E)These structures are loops of the jejunum. At this level in the abdominal
cavity, loops of small bowel represent jejunum. If this CT slice were of the inferior
(lower) abdomen the small bowel would more likely be the ileum.
On abdominal CT scans the pancreas can be identified by its head in close
association with the second part of the duodenum: by its body overlying the left
kidney aorta, IVC and superior mesenteric vessels: and also by the tail lying in the
splenorenal ligament.
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Q NO 69: A patient presents to the emergency room with weak wrist extension. On
physical examination, sensation to the arm is intact. The affected nerve was most
likely injured at which of the following locations?
A. Carpal tunnel
B. Hook of the hamate
C. Surgical neck of the humerus
D. Head of the radius
E. Coracobrachialis
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Explanation:
The radial nerve arises from the posterior cord of the brachial plexus. It innervates
the muscles of the posterior (extensor) compartment of the arm. After innervating
the extensor compartment of the upper arm, the radial nerve enters the forearm. At
the lateral epicondyle of the humerus (where the humerus articulates with the
radius), the radial nerve divides into superficial and deep branches. The superficial
branch of the radial nerve is purely sensory it provides somatic sensory innervation
to the radial half of the dorsal hand. (It does not, however, provide sensory
innervation to the dorsal portions of the distal first through third digits. Sensory
innervation of the palmar and dorsal surfaces of the distal 3 1/2 digits is provided by
the lateral and medial branches of the median nerve.)
Radial head subluxation (nursemaids elbow) is a common injury in children that
can result from sudden outward pulling on an extended and pronated arm (e.g.
when an adult attempts to pull a child upward by the arm). Radial head subluxation
can damage the deep branch of the radial nerve, leading to weakness or paralysis of
forearm extensor compartment muscles. Wrist drop commonly results from radial
nerve injury. The deep branch of the radial nerve does not carry any somatic
sensory innervation.
(Choice A) Carpal tunnel syndrome can result from any factor (e.g. inflammation)
that reduces the size of the carpal tunnel, compressing the median nerve. In
addition to pain, patients classically experience difficulty with fine motor control of
the thumb.
(Choice B) In the wrist, the ulnar nerve passes between the hook of the hamate and
the pisiform bone in a fibroosseous tunnel known as Guyons canal. Ulnar nerve
injury at this site causes dysesthesias of the ulnar side of the hand and weakness of
the intrinsic muscles of the hand.
(Choice C) Fracture of the surgical neck of the humerus may cause axillary nerve
injury leading to paralysis of the deltoid and teres minor muscles as well as loss of
sensation on the lateral upper arm.
(Choice E) The coracobrachialis muscle is an arm flexor that lies deep to the biceps
brachii and overlies the median nerve and brachial artery. Itis innervated by the
musculocutaneous nerve.
The deep branch of the radial nerve arises near the lateral epicondyle of the
humerus where the humerus articulates with the head of the radius. Radial head
subluxation can damage the deep branch of the radial nerve, causing weakness of
the forearm and hand extensors but no sensory deficits.
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Q NO 70: A 55-year-old Caucasian male is referred to a surgeon for a bulge above

the inguinal ligament that increases in size on straining. Surgery is scheduled.
Which of the following landmarks will most aid the surgeon in distinguishing an
indirect from a direct inguinal hernia?
A. Inferior epigastric vessels
B. Coopers ligament
C. Femoral vein
D. Transversalis fascia
E. Rectus muscle sheath
P. Spermatic cord
Explanation:
Inguinal hernias are common in men; in fact 25% of men are found to have an
inguinal hernia at some point of their life (versus 2% of women). Both direct and
indirect inguinal hernias are located above the inguinal ligament. The table below
shows anatomic landmarks that help to distinguish these types of hernias.
Indirect inguinal hernias are more common than direct. They occur in 213 cases of
inguinal hernias, and tend to appear on the right side. Indirect inguinal hernias occur
due to failure of the process us vaginal is to obliterate, allowing abdominal contents
to protrude through the deep inguinal ring. Abdominal contents follow the path of
the inguinal canal and may exit through the superficial inguinal ring into the
scrotum. On examination, these hernias can be detected by deep palpation at the tip
of the finger.
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Direct inguinal hernias protrude through the Hesselbach triangle, which is a weak
spot of the anterior abdominal wall. Hesselbachs triangle is bounded by the rectus
abdominis muscle medially, inferior epigastric vessels laterally, and inguinal ligament
inferiorly. Direct inguinal hernias do not descend in to the scrotum. Direct inguinal
hernias are felt with the pulp of the examiners finger on deep palpation.
(Choice B) Coopers (pectineal) ligament will be posterior to a femoral hernia.
(Choice C) The femoral vein will be laterally to a femoral hernia.
(Choice D) The transversalis fascia lies posteriorly to indirect inguinal hernias.
(Choice E) The rectus abdominis muscle sheath is medial to direct inguinal hernias.
(Choice F) The spermatic cord passes through the inguinal canal and may be
included in the indirect inguinal hernia sac.
Indirect inguinal hernias are located laterally to the interior epigastric vessels. They
can continue into the scrotum and are felt by deep palpation with the tip of the
finger in the inguinal canal. On the contrary direct inguinal hernias are located
medially to the interior epigastric vessels. They never protrude into the scrotum and
are felt with the pulp of an examiners finger.
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Q NO 71: An 8-year-old male is brought to your office because of an enlarged right

testicle. Transillumination reveals a fluid accumulation within the scrotum. This
fluid accumulation is most likely confined to the:
A. External spermatic fascia
B. Cremasteric fascia
C. Internal spermatic fascia
D. Tunica albuginea
E. Tunica vaginalis
Explanation:
This patients clinical presentation is consistent with hydrocele. Hydrocele occurs
when serous fluid collects within the tunica vaginalis.
During embryogenesis, the testis descends through the inguinal canal, drawing a
diverticulum of peritoneum into the scrotum as it descends. This peritoneal tissue is
known as the processus vaginalis. Normally, the communication between the
processus vaginalis and the peritoneum is obliterated, and the tunica vaginalis is the
tissue that remains overlying the testis and epididymis. Congenital hydrocele, as
described in the question stem, results when the processus vaginalis remains patent,
allowing fluid from the peritoneum to accumulate in the scrotum.
(Choice A) The external spermatic fascia is derived from the aponeurosis of the
external oblique abdominal muscle. This is the outermost layer of the spermatic cord
and lies deep to the dartos muscle and scrotal fascia.
(Choice B) The cremasteric fascia arises from the internal oblique abdominal muscle
and aponeurosis.
(Choice C) The internal spermatic fascia is derived from the transversalis fascia. This
layer immediately overlies the spermatic cord and tunica vaginalis.
(Choice D) The tunica albuginea is the fibrous tissue that overlies the corpus
spongiosum and corpora cavernosa of the penis.
Testicular hydrocele results when serous fluid accumulates within the tunica
vaginalis. The tunica vaginalis is embryologically derived from the peritoneum; when
it remains in communication with the peritoneum, a communicating hydrocele
results.
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Q NO 72: A 39-year-old female is brought to the emergency room after a motor

vehicle collision. Upon arrival she is determined to be stable, but complains of
mild abdominal pain. CT scan of the abdomen reveals a retroperitoneal
hematoma. Trauma of which of the following anatomic structures is most likely
responsible for this finding?
Abdominal aorta
B. Transverse colon
C. Liver
D. Spleen
E. Pancreas
A.
Explanation:
The retroperitoneum is the space located behind the peritoneal cavity. It includes
the following structures:
1. Major vessels: abdominal aorta inferior vena cava and their branches.
2. Solid organs: pancreas (except the tail), kidneys, adrenal glands.
3. Hollow organs: parts 2 & 3 and a portion of part 4 of the duodenum the ascending
and descending colon (secondarily retroperitoneal), rectum ureters and bladder.
4. Vertebral column and pelvic muscles.
Retroperitoneal hematomas are commonly associated with abdominal and pelvic
trauma: they develop in up to half of patients with blunt abdominal trauma.
Pancreatic injury with formation of a retroperitoneal hematoma can occur due to
severe blunt or penetrating abdominal trauma. It can frequently be caused by direct
abdominal blows from malpositioned seat belts or by steering wheels during
automobile collisions. Pancreatic injury can cause mild symptoms or be
asymptomatic. An abdominal CT scan should be performed in stable patients with
blunt abdominal trauma to exclude the possibility of retroperitoneal hematoma.
(Choice A) Though the abdominal aorta is a retroperitoneal structure rupture of the
abdominal aorta would most likely result in massive and rapid blood loss leading to
hemorrhagic shock.
(Choices B, C and D) The transverse colon, liver and spleen are intraperitoneal
organs. Lacerations or rupture of these organs can occur in blunt abdominal trauma
but these injuries would lead to hemoperitoneum (free blood in the peritoneal space)
not retroperitoneal hematoma.
Retroperitoneal hematoma in a stable patient is likely to occur due to pancreatic
injury. Lt may present with mild symptoms be asymptomatic or be masked by
symptoms from other injuries related to trauma. Abdominal CT is the diagnostic
modality of choice. Frequently nonexpanding hematomas in this location will be
treated conservatively (i.e. non-operatively).
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Q NO 73: A 23-year-old Caucasian female is brought to the ER unconscious altera

motor vehicle accident. A linear skull fracture in the area of junction of frontal
parietal temporal, and sphenoid bones is seen on X-ray. A branch of which of the
following arteries is most likely severed in this patient?
A. Occipital
B. Maxillary
C. Ophthalmic
D. Middle cerebral
E. Sphenopalatine
F. Facial
Explanation:
The patient described in the question stem has suffered a fracture where the frontal
parietal, temporal, and sphenoid bones meet in the skull. This site is known as the
pterion and is medically relevant due to the fact that the bone is thin in this region
and the middle meningeal artery courses within the skull deep to this point. As such,
fractures to this region of the skull are at risk of damaging the middle meningeal
artery and causing an epidural hematoma. Epidural hematomas require prompt
treatment because they are under systemic arterial pressure and can expand rapidly
leading to transtentorial herniation and palsy of the oculomotor nerve.
The middle meningeal artery is a branch of the maxillary artery, which itself is a
branch of the external carotid artery.
(Choice A) The occipital artery arises opposite the facial artery from the external
carotid, coursing posteriorly instead of anteriorly. This vessel serves the posterior
scalp and the stemocleidomastoids.
(Choice C)The ophthalmic artery is the first branch of the internal carotid artery,
serving the eye and orbital contents as well as the eyelids, forehead, nose, and nasal
mucosa. The internal carotid artery has no branches in the neck.
(Choice D)The middle cerebral artery is a branch of the internal carotid artery and
supplies much of the parietal and temporal regions of the brain. Injury to this artery
or its branches can cause a subarachnoid or intracerebral hemorrhage.
(Choice E)The sphenopalatine artery is a branch of the third part of the maxillary
artery that supplies much of the nasal mucosa. It anastomoses with branches of the
ophthalmic and facial arteries within the anterior part of the nasal septum in a
region known as Kiesselbachs plexus a frequent site of nosebleeds.
(Choice F) The facial artery is a branch of the external carotid artery that courses
over the mandible anterior to the insertion of the masseter muscle to supply the oral
region and nose as well as the buccal region of the cheeks.
The middle meningeal artery is a branch of the maxillary artery that enters the skull
at the foramen spinosum and courses intracranially deep to the pterion. Skull
fractures at this site may cause laceration of this vessel leading to an epidural
hematoma.
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Q NO 74: A 17-year-old football player comes to the ER hopping on his right foot.
An X-ray of the left leg shows a fracture of the neck of the fibula. Which of the
following findings do you most expect on physical examination?
A. Loss of plantarflexion of the left foot
B. Weakened inversion of the left foot
C. Loss of sensation on the sole of the left foot
D. Loss of sensation on the medial aspect of the left leg
E. Loss of sensation on the dorsum of the left foot
Explanation:
The common peroneal nerve is the most commonly injured nerve in the leg due to
its superficial location where it courses laterally around the neck of the fibula. This
location makes the common peroneal nerve susceptible to injury when a traumatic
insult results in fracture of the neck of the fibula. The sciatic nerve branches into the
common peroneal (fibular) nerve and the tibial nerve posteriorly on the thigh just
proximal to the popliteal fossa. After coursing around the neck of the fibula the
common peroneal nerve divides into superficial and deep branches. The superficial
branch innervates the muscles of the lateral compartment of the leg which function
primarily to evert the foot. The deep peroneal nerve innervates the anterior
compartment of the leg whose muscles mainly act as dorsiflexors of the foot and
toes, though they also participate in some inversion. The superficial peroneal nerve
gives off branches that provide sensory innervation to the majority of the dorsum of
the foot while the deep peroneal nerve provides sensory innervation only to the
region between the first and second digits of the foot. Injury to the common
peroneal nerve from a proximal fibula fracture would cause loss of sensation in both
of these regions as well as motor deficits resulting in a clinical presentation with toot
drop.
(Choices A, B and C) Loss of plantarflexion of the left foot could result from injury of
the tibial nerve as it courses through the middle of the popliteal fossa. Such an
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injury would also cause weakness of inversion of the foot as well as sensory loss on
the sole.
(Choice D) Loss of sensation on the medial aspect of the left leg would result from a
lesion of the saphenous nerve. The saphenous nerve is the largest purely sensory
branch of the femoral nerve.
The common peroneal nerve is vulnerable to injury where it courses around the neck
of the fibula. Fibular neck fractures can lesion this nerve, causing weakness of
dorsiflexion (deep peroneal nerve) and eversion (superficial peroneal nerve) of the
foot as well as loss of sensation over the dorsum of the foot. Inversion and
plantarflexion would remain intact due to the action of the tibial nerve.
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ANATOMY
Q NO 75: A 52-year-old golfer presents to your office with right shoulder pain that
has started to interfere with his daily activities, such as getting dressed. Imaging
studies suggest calcification of the supraspinatus tendon. Which of the following is
most likely to provoke pain in this patient?
A. Flexion of the humerus

B. Extension of the humerus
C. Adduction of the humerus
D. Abduction of the humerus
E. Medial rotation of the humerus
Explanation:
The rotator cuff is made up of the tendons of the supraspinatus, infraspinatus,
subscapularis, and teres minor muscles. These tendons along with the tendon of the
long head of the biceps brachii muscle and the ligaments of the glenohumeral joint.
contribute to the stability of the joint. In rotator cuff syndrome, the most commonly
injured tendon is the supraspinatus because this tendon is prone to repeated
impingement trauma between the humeral head and the acromion. The
supraspinatus originates on the supraspinous fossa of the scapula and inserts on the
superior portion of the head of the humerus and is primarily an abductor of the arm.
Therefore, rotator cuff syndrome is most commonly associated with pain during
abduction of the humerus.
(Choice A) Flexion of the humerus at the shoulder is not accomplished by any of the
rotator cuff muscles. The anterior segment of the deltoid is an important flexor of
the humerus.
(Choice B) Extension of the humerus is not accomplished by any of the rotator cuff
muscles.
(Choice C) Adduction of the humerus is not accomplished by any of the rotator cuff
muscles. The main adductor of the humerus is the latissimus dorsi muscle.
(Choice E) Medial rotation of the humerus is accomplished by the subscapularis
muscle which originates on the subscapular fossa and inserts onto the lesser
tubercle of the head of the humerus.
The most commonly injured structure in rotator cuff syndrome is the tendon of the
supraspinatus muscle. Because the supraspinatus is an abductor of the humerus
injury to its tendon causes pain on abduction of the arm.
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Q NO 76: A 47-year-old male with a long history of heartburn complains of feeling

like food is sticking in his throat. He has changed his diet to accommodate this
and now only consumes liquid foods. Which of the following structures in the
computed tomography (CT) image below is responsible for this patients
symptoms?
A.
B.
C.
D.
E.
A
B
C
D
E
Explanation:
This patient suffers from gastroesophageal reflux disease (GERD), a condition that
affects the esophagus (labeled B above). In the thorax, the esophagus courses
between the trachea and the vertebral bodies and is typically collapsed with no
visible lumen. The trachea (Choice C) serves as a good landmark here because the
radiolucency of the air in this structure allows one to differentiate it from the
esophagus posteriorly and the great vessels anteriorly.
(Choice A) This is the descending aorta.
(Choice D)This is the arch of the azygous vein.
(Choice E)This is a section of the right pulmonary artery.
Educational Objective: The esophagus is located between the trachea and the
vertebral bodies in the superior thorax. It is typically collapsed with no visible lumen
on CT images of the chest.
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Q NO 77: A 54-year-old male undergoes evaluation for neurological symptoms. MRI

scan shows bilateral infarcts in the thalami. Which of the following sensory
pathways reaches the cortex without relay nuclei in the thalami?
A. Proprioception
B. Pain
C. Smell
D. Vision
E. Hearing
E. Taste
Explanation:
The thalamus is a part of diencephalon and has multiple functions. It translates
information from all sensory pathways other than olfaction and selectively distributes
those impulses to appropriate parts of the cortex (relay function). The following
thalamic nuclei receive input from sensory pathways:
1. Ventral posterolateral nucleus (VPL) receives input from the spinothalamic tract
(pain and temperature sensation) and medial lemniscus (position and
proprioception). It transmits impulses to primary somatosensory cortex (Brodmann
areas 3, 1 & 2).
2. Ventral posteromedial nucleus (VPM) receives inputs from the trigeminal and
gustatory pathways and transmits them to the primary sensory cortex (Brodmanns
areas 3, 1 & 2).
3. Lateral geniculate body is a relay nucleus for the vision pathway. It receives
impulses from the optic nerve and transmits them via the optic radiations to the
visual cortex (calcarine sulcus).
4. Medial geniculate body is a part of the auditory pathway. It receives impulses
from the superior olivary nucleus and the inferior colliculus of the pons, and projects
them to the auditory cortex of the temporal lobe (Brodmann areas 41 & 42).
The olfactory tract is the only sensory pathway where input is not processed through
the thalamus.
All sensory pathways except olfaction (smell) have relay nuclei in the thalamus. The
VPL receives impulses from spinothalamic and medial lemniscus pathways, the VPM
from the trigeminal and gustatory pathways, and the lateral and medial geniculate
bodies are relay nuclei for the visual and auditory pathways respectively.
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Q NO 78: A 34-year-old swimmer presents to your office with external ear infection.
While inspecting the patient you insert a speculum in to the external auditory meat
us in close contact with its posterior wall. The patient faints during the procedure.
Irritation of which of the following nerves was most likely induced by the procedure?
A. Vestibulocochlear
B. Vagal
C. Trigeminal
D. Facial
E. Accessory
Explanation:
The patient described in the question has experienced a vasovagal syncope after
stimulation of his posterior external auditory canal by an otoscope speculum. In this
form of syncope, parasympathetic outflow via the vagus nerve (CNX) leads to
decreased heart rate and blood pressure.
The posterior part of the external auditory canal is innervated by the small auricular
branch of the vagus nerve. Most of the remainder of the external auditory canal,
including the external portion of the tympanic membrane, is innervated by the
mandibular division of the trigeminal nerve via its auriculotemporal branch. The
inner surface of the tympanic membrane is innervated by the glossopharyngeal
nerve (CN IX) via its tympanic branch.
(Choice A) The vestibulocochlear nerve (CN VIII) mediates hearing and vestibular
proprioception. It does not mediate any cutaneous sensation.
(Choice C)The mandibular branch of the trigeminal nerve (CN V3) does carry
sensation to the majority of the external auditory meatus, except for the posterior
wall.
(Choice D) The facial nerve is represented in the middle ear by one of its branches,
the chorda tympani nerve. The chorda tympani nerve carries the afferent taste fibers
from the anterior two-thirds of the tongue as well as efferent parasympathetic
preganglionic fibers that will ultimately innervate the submandibular and sublingual
salivary glands. CN VII has a small motor component to the stapedius and behind
the ear but does not carry cutaneous sensory information.
(Choice E) The accessory nerve (CN Xl) provides voluntary motor innervation to the
trapezius and the sternocleidomastoid.
The vagus nerve provides some cutaneous sensation to the posterior external
auditory canal via its small auricular branch. Sensation to the rest of the canal is
from CN V3. A vasovagal syncopal episode results from stimulation of the vagus
nerve, leading to a decrease in blood pressure and heart rate.
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Q NO 79: A 21-year-oldfootball player is brought to the emergency room

complaining of back pain. An X-ray shows a fractured 12th rib on the left
side. Which of the following structures is most likely to be lacerated by
the broken rib?
B. Spleen
C. Liver
D. Visceral pleura
E. Pancreas
ANATOMY
A. Left
kidney
Explanation:
The 12th rib overlies the parietal pleura medially and the kidney laterally. Recall that
the 11th and 12th ribs are floating ribs, meaning that they are not bound to the
anterior rib cage by cartilage as are the more superior false ribs. For this reason
the distal tip of the left 12th rib can be displaced into the retroperitoneum when
fractured lacerating the left kidney.
(Choice B) The spleen lies in the posterior superior portion of the left abdominal
cavity. The left 8th, 9th and 10th ribs overlie the spleen.
(Choice C) The liver occupies much of the right upper quadrant of the abdominal
cavity. The 8th, 9th 10th and 11th ribs over lie the livers posterior surface on the
right. The positions of both the liver and spleen shift slightly with diaphragmatic
movement during inhalation and exhalation.
(Choice D)The visceral pleura envelop the lungs. At rest the inferior margin of the
left lung lies at the level of the 10th rib in the mid scapular line. During maximal
inhalation the lung may descend to the level of the most medial portion of the 12th
rib but fractures of the 1st through 6th ribs have the greatest chance of damaging
the visceral pleura.
(Choice E) The pancreas is a partially retroperitoneal organ that overlies the body of
the second lumbar vertebra. Classically crushing abdominal trauma is the injury that
causes pancreatic damage.
The left kidney lies immediately deep to the tip of the 12th rib on the left.
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Q NO 80: A 22-year-old male is brought to the emergency room after being

involved in a fight in a nearby bar. His blood pressure is 100/70 mmHg and
his heart rate is 100/mm. Physical examination reveals a penetrating rightsided neck injury just above the clavicle and lateral to the manubrium
sterni. Which of the following structures was most likely injured?
Inferior thyroid artery
B. Ansa cervicalis
C. Lung pleura
D. Accessory nerve
E. Carotid body
A.
Explanation:
The patient likely has a tension pneumothorax, a condition where air enters the
pleural cavity during inspiration but is not expelled during exhalation. An increasing
volume of air accumulates within the pleural space, ultimately causing deviation of
the lungs and mediastinum to the opposite side of the chest. The increased pressure
within the chest cavity causes decreased systemic venous return to the heart leading
to decreased cardiac output. Signs and symptoms of tension pneumothorax include
tachycardia, hypotension, tachypnea, hypoxia, and absence of breath sounds and
hyperresonance to percussion on the affected side. A chest X-ray will confirm the
diagnosis; treatment is emergent needle thoracostomy or chest tube.
In patients with neck injuries itis important to remember that the lung apices and
cervical pleura extend above the clavicle and first rib through the superior thoracic
aperture into the neck. As the above radiograph illustrates stab wounds immediately
above the clavicle and lateral to the manubrium can puncture the pleura and cause
pneumothorax, tension pneumothorax or hemothorax.
(Choice A) The inferior thyroid artery arises from the thyrocervical trunk, which itself
arises from the subclavian artery. The inferior thyroid artery courses posterior to the
carotid artery and jugular vein and supplies the inferior pole of the thyroid gland.
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(Choice B) The ansa cervicalis arises from the C1, C2 and C3 nerve roots and
innervates the sternohyoid, sternothyroid and omohyoid muscles of the anterior
neck. Penetrating trauma to the neck superior to the cricoid cartilage might injure
this nerve.
(Choice D) The accessory nerve (CN XI) innervates the sternocleidomastoid and
trapezius muscles. This nerve may be injured during surgery involving the posterior
triangle of the neck (a region bounded by the sternocleidomastoid muscle trapezius
muscle and clavicle).
(Choice E)The carotid body which contains O2, CO2 and H+ chemoreceptors, lies at
the bifurcation of the common carotid artery (just inferior to the hyoid bone).
The lung apices extend above the level of the clavicle and first rib through the
superior thoracic aperture. Penetrating injury in this area may lead to
pneumothorax.
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ANATOMY
Q NO 81: A 24-year-old male complains of clumsiness of his right arm. The patient
is asked to face a wall and push against it with both hands. Abnormal prominence of
the right inferior scapular angle is observed during the maneuver. Which of the
following muscles is most likely denervated in this patient?
A. Serratus anterior
B. Latissimus dorsi
C. Deltoid
D. Rhomboid major
E. Teres major
Explanation:
Injury to the long thoracic nerve results in paralysis of the serratus anterior. This
presents as a winged scapula which means that the medial border and inferior angle
sticks out posteriorly like a birds wing when the patient presses anteriorly against a
wall.
(Choice B)The latissimus dorsi muscle is innervated by the thoracodorsal nerve and
serves to adduct and extend the humerus.
(Choice C)The deltoid is innervated by the axillary nerve and has three segments
that act to flex extend, and abduct the arm.
(Choice D)The rhomboid major is innervated by the dorsal scapular nerve and acts
to draw the scapula medially at its medial border.
(Choice E) The teres major is innervated by the subscapular nerve and acts to
adduct and medially rotate the arm. This muscle is nota part of the rotator cuff.
The serratus anterior muscle serves to fix the scapula against the posterior chest
wall and rotate the scapula to allow abduction of the arm over the head. Paralysis of
this muscle occurs with injury to the long thoracic nerve and results in winging of
the scapula.
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Q NO 82: A left-sided mass identified on an abdominal CT image in a 54-year-old

male compresses the renal vein. Based on these CT scan findings, which of the
following would you expect most in this patient?
A. Esophageal varices
B. Rectal varices
C. Varicocele
D. Left-sided ankle swelling
E. Periumbilical venous distention
Explanation:
A left-sided abdominal mass compressing the left renal vein would be expected to
cause venous hypertension, varicosities, and edema in any upstream structures. In
contrast to the right renal vein the left renal vein drains the left suprarenal gland
and the left gonad in addition to the kidney. The renal veins do not participate in
portal circulation. The patient described in the case above is a male, so venous
hypertension due to obstruction of the left renal vein would eventually cause
incompetence of the valves of the testicular veins and engorgement of the
pampiniform plexus of veins around the testis. Leading to a left-sided varicocele.
Varicocele is most common on the left side due to this anatomy. Varicocele arising
from idiopathic failure of the valves of the testicular vein is generally left untreated
unless it becomes symptomatic or is felt to be causing problems with fertility.
(Choices A, B and E) Esophageal varices, rectal varices, and periumbilical venous
distension are all signs of portal venous hypertension. The renal veins are nota part
of the portal system.
(Choice D) Unilateral left-sided ankle swelling can result from many causes including
obstruction of the left common iliac vein, left external iliac vein, left femoral vein, or
any of the other major veins of the left leg.
The left gonadal (testicular or ovarian) vein drains into the left renal vein, commonly
leading to left-sided varicoceles in males with obstructions of the left renal vein. The
right gonadal vein drains directly into the inferior vena cava.
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Q NO 83: A 56-year-old male is undergoing evaluation for fatigue, vague abdominal

discomfort, and bloody stools. Colonoscopy reveals a mass in the descending colon.
Surgical removal of the mass requires proper ligation of the:
A. Celiac trunk
B. Superior mesenteric artery
C. Inferior mesenteric artery
D. Internal iliac artery
E. External iliac artery
Explanation:
This patient has a tumor in the descending colon. The distal 1/3 of the transverse
colon, descending colon sigmoid colon, and rectum are all hindgut derivatives.
Hindgut structures receive arterial blood from the inferior mesenteric artery (IMA), a
branch of the aorta. These structures are drained by the inferior mesenteric vein
(IMV)I which does not course with the IMA. The IMV drains blood from the hindgut
into the splenic vein, which drains into the portal vein.
(Choice A) The celiac trunk supplies blood to most foregut structures with the
exception of the mouth pharynx and proximal esophagus. The foregut encompasses
all structures from the mouth to the second part of the duodenum. Foregut
derivatives include the liver pancreas gallbladder and spleen.
(Choice B) The superior mesenteric artery supplies blood to the midgut which spans
from the third part of the duodenum to the proximal 2/3 of the transverse colon.
(Choice D)The internal iliac arte supplies portions of the gut through branches like
the middle rectal artery and the inferior rectal artery (a branch of the pudendal
artery, which arises from the internal iliac artery).
(Choice E) Branches of the external iliac artery supply the lower extremity and
anterior abdominal wall.
The hindgut encompasses the distal 1/3 of the transverse colon the descending
colon the sigmoid colon and the rectum. These structures receive their main arterial
blood supply from the inferior mesenteric artery.
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Q NO 84: A 7-year-old male has a right leg cast alter a bicycle accident. After
wearing the cast for some time he complains of pain and numbness of the
dorsum of his right foot and cannot dorsiflex his right ankle. Which of the
following is the most likely site of nerve compression in this patient?
Popliteal fossa
B. Fibular head
C. Lateral compartment of the leg
D. Anterior compartment of the leg
E. Medial malleolus
A.
Explanation:
The common peroneal (fibular) nerve is the most commonly injured nerve in the leg
due to its superficial location where it courses laterally around the neck of the fibula.
This location makes this nerve susceptible to trauma resulting from lateral blows to
the knee as well as from tightly applied plaster casts and other devices. The sciatic
nerve branches into the common peroneal nerve and the tibial nerve posteriorly in
the thigh just proximal to the popliteal fossa. After coursing around the neck of the
fibula, the common peroneal nerve divides into superficial and deep branches. The
superficial branch innervates the muscles of the lateral compartment of the leg,
which function primarily to evert the foot. The deep peroneal nerve innervates the
anterior compartment of the leg whose muscles act as dorsiflexors of the foot and
toes. The superficial peroneal nerve gives oft branches that provide sensory
innervation to the majority of the foot while the deep peroneal nerve provides
sensory innervation only to the region between the first and second digits of the
foot. Injury to the common peroneal nerve would cause a clinical presentation of
foot drop due to weakness of the dorsiflexors. The foot would also be held in
inversion due to weakness of the muscles of the lateral compartment.
(Choice A) The popliteal artery and vein, as well as the tibial nerve, course through
the middle of the popliteal fossa. The tibial nerve provides plantar flexi on and
inversion: therefore injury to the tibial nerve would result in unopposed dorsiflexion
and eversion of the foot.
(Choices C and D)The lateral and anterior compartments of the leg are innervated by
the superficial and deep peroneal nerves, respectively. These nerves lie deep within
their respective compartments and are unlikely to be injured by superficial pressure.
(Choice E) Several important structures course near the medial malleolus. The
saphenous nerve and great saphenous vein lie anteriorly while the posterior tibial
artery, the tibial nerve, and the tendons of the flexor digitorum longus, flexor
hallucis longus, and tibialis posterior course posteriorly.
Trauma or sustained pressure to the neck of the fibula can cause injury to the
common peroneal nerve as it courses superficially and laterally to this structure.
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Q NO 85: A surgeon transplants a donor kidney into a 45-year-old patient with endstage renal disease. The upper 1/3 of the ureter of the transplanted kidney is
retained and attached to the recipient patients bladder. However, soon after
transplantation, the ureter becomes necrotic. Which of the following arteries is the
major source of blood supply to the upper ureter?
A. Common iliac artery
B. Phrenic artery
C. Internal iliac artery
D. Renal artery
E. Lumbar arteries
F. Superior vesical artery
Explanation:
In a kidney transplant operation the native kidneys are typically left in place, and
the donor kidney is placed retroperitoneally in the right iliac fossa. Blood supply to
the donor organ is typically established by anastomosing the donor renal artery with
the recipients external iliac artery. Similarly the donor renal vein is connected to the
recipients external iliac vein. The proximal 1/3 of the donor ureter is preserved and
used to establish continuity from the collecting system of the kidney to the
recipients bladder. This portion of the ureter receives its blood supply from branches
of the renal artery. (More distally, the ureters are supplied by branches from the
aorta and iliac, gonadal and vesical arteries.) Ureteric ischemia occurs in
approximately 2% of renal transplant patients.
(Choice A) Small branches from the common iliac artery may supply the ureters
midportion.
(Choice B)The inferior phrenic arteries are branches of the aorta that supply the
diaphragm and provide branches to the suprarenal glands. These arteries do not
supply the ureters.
(Choice C) An alternate method of providing blood supply to a transplanted kidney is
end-to-end anastomosis with the internal iliac artery. The internal iliac artery does
not directly contribute to the blood supply of the ureter.
(Choice E) The lumbar arteries like the intercostal arteries arise directly from the
aorta to supply the lumbar vertebrae and surrounding structures. They do not supply
the ureters.
(Choice F) The superior vesical artery is a branch of the internal iliac artery that
supplies blood to the superior portion of the urinary bladder. It also provides
branches to the distal ureter.
The proximal 1/3 of the ureter receives its blood supply from branches of the renal
artery. For this reason this portion of the donor ureter is typically viable after renal
transplantation.
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Q NO 86: A 56-year-old male with recent recurrent vomiting and weight loss is
found to have a malignancy originating from the third part of the duodenum.
Which of the following structures is at greatest risk for direct penetration by
tumor?
A. Common bile duct

B. Ureter
C. Superior mesenteric artery
D. Portal vein
F. Gastroduodenal artery
Explanation:
The first part of the duodenum, the portion emerging from the pylorus of the
stomach, is horizontally oriented and overlies the first lumbar vertebra. It is the only
part of the duodenum that is not retroperitoneal. The second part of the duodenum
courses inferiorly from the level of Li to L3. This part of the duodenum is in close
relation to the head of the pancreas. The ampulla of Vater, the site where the
pancreatic and common bile ducts provide their secretions, is in the second part of
the duodenum. The third part of the duodenum courses horizontally over the third
lumbar vertebra, abdominal aorta, and inferior vena cava. Itis in close association
with the uncinate process of the pancreas and the superior mesenteric artery and
vein, which puts these structures at high risk for direct invasion by a tumor in the
third part of the duodenum. The fourth part of the duodenum courses superiorly and
to the left of the L2 and L3 vertebrae and becomes the jejunum past the ligament of
Treitz.
(Choice A) The common bile duct is formed when the common hepatic bile duct and
the cystic duct join in the porta hepatis region of the hepatogastric ligament. This
common bile duct courses interiorly posterior to the pylorus and within the head of
the pancreas to drain into the second part of the duodenum.
(Choice B)The left ureter has no relation to the duodenum. The right ureter courses
retroperitoneally posterior to the second part of the duodenum for a short length.
(Choice D) The portal vein is formed retroperitoneally, posterior to the pancreas at
the level of the first lumbar vertebra, by the fusion of the superior mesenteric and
splenic veins. The portal vein is not in contact with the duodenum at any point.
(Choice E)The gastroduodenal artery arises from the common hepatic artery and
courses inferiorly, posterior to the first part of the duodenum where it then splits
into the anterior superior pancreaticoduodenal artery and the right gastroepiploic
artery.
Educational Objective: The third part of the duodenum courses horizontally across
the abdominal aorta and inferior vena cava at the level of the third lumbar vertebra.
Here itis in close association with the uncinate process of the pancreas and the
superior mesenteric vessels.
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Q NO 87: A 53-year-old Caucasian male comes to the ER with severe low back pain
of sudden onset. Pinprick in the perianal area does not cause rapid contraction of
the anal sphincter in this patient. This finding indicates involvement of which of the
following nerve roots?
A. T12
B. L2
C. L4
D. L5
E. S1
E. S4
Explanation:
In the adult, the spinal cord terminates in a tapering fashion at the conus medullaris
at approximately the L2 vertebral level. After this point, spinal nerves course from
the conus medullaris inferiorly to exit through their respective intervertebral
foramina. This collection of spinal nerves, which at this point are considered
peripheral nerves, is referred to as the cauda equina (horses tail).
Cauda equina syndrome typically results from a massive rupture of an intervertebral
disc that is capable of causing compression of many or all of the spinal nerves of the
cauda equina, but it can also occur due to any trauma or space- occupying lesion of
the lower vertebral column. Symptoms classic of cauda equina syndrome include
saddle anesthesia and loss of the anocutaneous reflex as described in the question,
as well as bowel and bladder dysfunction and symptoms of sciatica. Of the spinal
nerves potentially involved, a lesion of S2 through S4 will specifically result in the
symptoms described in the question stem as they reflect impairment of the pudendal
nerve that innervates the perineum.
(Choice A) Compression atTl2would result in impingement of the spinal cord itself in
the region of origin of the lumbar spinal nerves.
(Choice B) L2 lesions would cause anesthesia or paresthesias posteriorly in the
gluteal region inferior to the iliac crests and anteriorly on the thigh inferior to the
femoral triangle and inguinal ligament.
(Choice C) The L3 and L4 spinal levels contribute to the femoral nerve and mediate
the quadriceps (knee-jerk, patellar) reflex. A lesion to these levels would cause loss
of this reflex as well as paresthesias and weakness over the anterior thigh.
(Choice D) L5 lesions would cause a loss of sensation or paresthesias over the
anterior leg.
(Choice E) S1 and S2 mediate the Achilles (ankle-jerk) reflex, which tests for the
integrity of the sciatic nerve. A lesion of these roots would cause sensory loss or
paresthesias over the posterior leg and thigh.
Saddle anesthesia and loss of the anocutaneous reflex are symptoms of the cauda
equina syndrome, associated with damage to the S2 through S4 nerve roots.
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Q NO 88: A 34-year-old female presents to the emergency room after falling in the
bathroom. She complains of wrist pain and numbness in her right palm. Based on
her symptoms. you suspect that she has dislocated the lunate bone in the wrist.
Identify the lunate bone on the X-ray below.
A. A
B. B
C. C
D. D
E. E
Explanation:
A fall on an outstretched, dorsiflexed hand is the classic injury that causes lunate
dislocation. The lunate (Choice D) is one of the proximal carpal bones. It can be
identified on an X-ray of the hand as the more medial of the two bones that
articulate with the radius. The scaphoid is the other (more lateral) bone that
articulates with the radius (Choice C). Injuries that cause lunate dislocation also
often cause fracture of the scaphoid. A potential late sequela of such an injury is
avascular necrosis of the proximal scaphoid fracture fragment.
(Choice A) The trapezium is the most lateral of the distal carpal bones. Recall that
the thumb swings on the trapezium.
(Choice B)The capitate bone lies in the center of the wrist.
(Choice E) The triquetrum bone is located in the proximal medial wrist and together
with the lunate forms the small articular surface between the distal ulna and the
carpal bones.
The lunate bone can be identified on a hand X-ray as the more medial of the two
carpal bones that articulate with the radius. It lies immediately medial to the
scaphoid bone.
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Q NO 89: A 34-year-old male presents to the emergency room complaining of

severe right shoulder pain after falling from a tree. X-ray reveals a fracture in
the middle third of the right clavicle. The medial end of the fractured clavicle
is displaced upward due to traction by the:
Rhomboid muscles
B. Sternocleidomastoid muscle
C. Pectoralis minor muscle
D. Serratus anterior muscle
E. Subclavius muscle
P. Sternoclavicular ligaments
A.
Explanation:
Several muscles insert on the clavicle, including the pectoralis major muscle on the
inferior medial aspect, the deltoid muscle on the inferior lateral aspect, the
subclavius muscle on the inferior lateral aspect, the trapezius muscle on the superior
lateral aspect, and the sternocleidomastoid muscle on the superior medial aspect.
The sternocleidomastoid muscle is responsible for the upward traction on the medial
section of the fractured clavicle described above. Recall that the sternocleidomastoid
muscle has three points of insertion (described in its name): sternothe muscle
inserts inferiorly on the manubrium of the sternum cleidothe muscle inserts
inferiorly on the medial part of the clavicle, mastoidthe muscle inserts on the
mastoid process of the skull.
(Choice A) Both the major and the minor rhomboid muscles originate on the
vertebral bodies/spines and insert on the scapular spine.
(Choice C)The pectoralis minor muscle originates on the coracoid process of the
scapula and inserts on the 34th and 5th ribs.
(Choice D)The serratus anterior muscle originates laterally on the through 8th ribs
and inserts onto the medial border of the scapula. This muscle is innervated by the
long thoracic nerve injury to which causes winging of the scapula.
(Choice E)The subclavius muscle originates on the 1st rib and inserts on the inferior
lateral aspect of the clavicle.
(Choice F)The sternoclavicular ligaments join the clavicle to the manubrium. These
ligaments would tend to hold the medial fragment of the clavicle in place.
The sternocleidomastoid muscle originates on the medial clavicle and manubrium
and inserts on the mastoid process of the skull. Itis innervated by CN Xl and
functions to turn the head in the opposite direction.
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Q NO 90: A 43-year-old male received a deep intramuscular injection two days ago
and now presents with difficulty walking. You note that his right hip drops every
time he raises his right foot. At which location did this patient most likely receive
his injection?
A. Superomedial quadrant of the buttock

B. Superolateral quadrant of the buttock
C. Inferomedial quadrant of the buttock
D. Inferolateral quadrant of the buttock
E. Posterior thigh
Explanation:
All injections into the gluteal region should target the superolateral quadrant to
avoid damage to the gluteal nerves and sciatic nerve. This patient is exhibiting the
classic gluteus medius gait i.e. the hip dips downward when the ipsilateral foot is
lifted off of the ground. This gait is observed when there is injury to the superior
gluteal nerve or to the gluteus medius muscle itself. The superior gluteal nerve is
derived from the L4-S1 ventral rami and leaves the pelvis through the greater sciatic
foramen above the level of the piriformis. Injection in the superomedial quadrant of
the buttock is likely to injure this nerve.
(Choice B)The superolateral quadrant of the buttock is a safe site for intramuscular
injections.
(Choice C) The sciatic nerve courses through the inferomedial quadrant of the
buttock, thus nerve damage can occur with injections to this site.
(Choice D)The inferolateral quadrant of the buttock is the site where many of the
muscles of the gluteal region have their tendinous insertions.
(Choice E) The sciatic nerve courses just below the biceps femoris muscle in the
posterior thigh. The sciatic nerve innervates all of the knee flexors (hamstrings) with
the exception of the short head of the biceps femoris.
Injections given in the superomedial part of the buttock risk injury to the gluteal
nerves, Injections given in the inferomedial part of the buttock risk injury to the
sciatic nerve. The superolateral quadrant of the buttock is a safe site for
intramuscular injections.
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Q NO 91: A young athlete presents to your office after sustaining an injury to the
right upper extremity. Physical examination reveals weak right forearm flexion
and an absent biceps reflex. Given these findings, sensation loss in which of the
following areas is most likely to be found in this patient?
A. Posterior arm
B. Posterior forearm
C. Lateral forearm
D. Medial forearm
E. Thenar eminence
Explanation:
This patient has symptoms suggestive of injury the musculocutaneous nerve. The
musculocutaneous nerve is derived from the C5-C7 ventral rami. As its name implies
the musculocutaneous nerve provides both motor innervation and somatic sensory
innervation to the arm. It innervates the major upper arm flexors including the
biceps brachii, coracobrachialis, and brachialis muscles. After innervating these
muscles, the remaining fibers continue as the lateral cutaneous nerve of the
forearm, providing sensory innervation to the skin of the lateral forearm.
(Choice A) The posterior arm is innervated by a branch of the radial nerve (posterior
cutaneous nerve of the arm). (Choice B)The posterior forearm is innervated by a
branch of the radial nerve (posterior cutaneous nerve of the forearm).
(Choice D)The medial forearm is innervated by a branch of the ulnar nerve (medial
cutaneous nerve of the forearm).
(Choice E) The thenar eminence is innervated by the superficial branch of the radial
nerve.
The musculocutaneous nerve innervates the flexor muscles of the upper arm and
provides sensory innervation to the lateral forearm. The musculocutaneous nerve is
derived from the upper trunk of the brachial plexus and can be injured by forceful
injuries that cause separation of the neck and shoulder.
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Q NO 92: A 55-year-old Caucasian male is brought to the ER with profuse upper

gastrointestinal bleeding. His past medical history is non-contributory. His blood
pressure is 70/40 mmHg, and his heart rate is 120/mm. The patient dies one
hour after admission, despite resuscitation efforts. Autopsy shows a deep peptic
ulcer in the lesser curvature of the stomach. The ulcer most likely penetrated
which of the following arteries?
Common hepatic
B. Right gastroepiploic
C. Left gastric
D. Gastroduodenal
E. Inferior pancreaticoduodenal
F. Splenic
G. Superior mesenteric
A.
Explanation:
The majority of gastric ulcers arise at the lesser curvature of the stomach. They are
usually located at the transitional zone between the acid-secreting epithelium of the
body of the stomach and gastrin-producing epithelium of the antrum. Glands in the
body of the stomach contain parietal cells that produce HCI and intrinsic factor;
mucosal glands in the antrum contain G-cells that secrete gastrin.
A number of arteries supply the stomach. They are summarized in the table below:
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ANATOMY
Left and right gastric arteries perfuse the lesser curvature of the stomach the most
common site of gastric ulcers. These arteries run along the lesser curvature and are
likely to be penetrated by ulcers, leading to hemorrhage.
(Choice A) The common hepatic artery perfuses the liver, pylorus, duodenum, and
pancreas. It arises from the celiac trunk and ends when it bifurcates in the hepatic
proper and gastroduodenal arteries.
(Choice B) The right gastroepiploic artery arises from gastroduodenal artery and
perfuses the distal greater curvature of the stomach. Gastric ulcers dont commonly
occur in the greater curvature.
(Choice D)The gastroduodenal artery supplies blood to the pylorus and the proximal
part of the duodenum. It arises from the common hepatic artery.
(Choice F) The splenic artery arises from the celiac trunk and supplies blood to the
spleen. It gives rise to the left gastroepiploic artery and a number of short gastric
arteries that perfuse proximal greater curvature of the stomach.
(Choices E and G) The superior mesenteric and the inferior pancreaticoduodenal
arteries do not perfuse the stomach.
The great majority of gastric ulcers occur at the lesser curvature, at the border
between acid-secreting and gastrin secreting mucosa. Left and right gastric arteries
run along the lesser curvature and are likely to be damaged, causing gastric
bleeding.
113

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ANATOMY

USMLE WORLD STEP 1

Head and neck

Head and neck

Head and neck

Head and neck

Head and neck

Head and neck

Head and neck

Head and neck

USMLE WORLD STEP 1

USMLE WORLD STEP 1

Q NO 1: A 34-year-old female presents to your office with moderate hearing loss

USMLE WORLD STEP 1

Q NO 2: A 56-year-old male with advanced bladder carcinoma suffers from

USMLE WORLD STEP 1

Q NO 3: A 32-year-old male presents to the ER with sudden-onset heart

USMLE WORLD STEP 1

Q NO 4: A medical resident performs a diagnostic procedure on 32-year-old male.

USMLE WORLD STEP 1

Q NO 5: A 6-month-old female has a head circumference that is in the 97th

USMLE WORLD STEP 1

Q NO 6: A 34-year-old male is unable tolerate everyday sounds. Injury of which of

USMLE WORLD STEP 1

USMLE WORLD STEP 1

USMLE WORLD STEP 1

USMLE WORLD STEP 1

Q NO 9: A 34-year-old male presents to your office complaining of decreased

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Q NO 10: A 67-year-old male suffers from progressive exertional dyspnea and

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USMLE WORLD STEP 1

Q NO 11: A 45-year-old Caucasian male presents to your office complaining of

USMLE WORLD STEP 1

USMLE WORLD STEP 1

USMLE WORLD STEP 1

USMLE WORLD STEP 1

(Choice A) Desmosomes are referred to as spot welds and function as anchors

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Q NO 14: A 23-year-old Caucasian male with involuntary movements undergoes an

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Q NO 15: A patient presents to your office complaining of double vision. On

USMLE WORLD STEP 1

Q NO 16: A 63-year-old male complains of having to strain on urination. The

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Q NO 17: A 32-year-old Caucasian female presents with epigastric pain, fullness

USMLE WORLD STEP 1

USMLE WORLD STEP 1

USMLE WORLD STEP 1

USMLE WORLD STEP 1

Q NO 20: A 35-year-old HIV-positive male complains of throat pain. Physical

USMLE WORLD STEP 1

Skin and subcutis

USMLE WORLD STEP 1

Q NO 22: A 53-year-old female complains of urinary frequency. Studies reveal a

USMLE WORLD STEP 1

Q NO 23: A 34-year-old Caucasian female undergoes surgery for a large left-sided