Q 12.

1:
A patient presents in her fifth pregnancy with a history of numbness and tingling
in her right thumb and index finger during each of her previous four pregnancies.
Currently, the same symptoms are constant, although worse in the early
morning. Symptoms could be somewhat relieved by vigorous shaking of the
wrist. Neurologic examination revealed atrophy and weakness of the abductor
pollicis brevis, the opponens pollicis, and the first two lumbrical muscles.
Sensation was decreased over the lateral palm and the volar aspect of the first
three digits. Numbness and tingling were markedly increased over the first three
digits and the lateral palm when the wrist was held in flexion for 30 seconds. The
symptoms suggest damage to which one of the following?

A.
B.
C.
D.
E.

The radial artery

The median nerve
The ulnar nerve
Proper digital nerves
The radial nerve

Solution
B The patient has a classic case of carpal tunnel syndrome, in which the median
nerve is compressed as it passes through the carpal tunnel formed by the flexor
retinaculum in the wrist. Evidence for involvement of the median nerve is
weakness and atrophy of the thenar muscles (abductor pollicis brevis, opponens
pollicis) and lumbricals 1 to 3. Sensory deficits also follow the distribution of the
median nerve. The median nerve enters the hand, along with the tendons of the
superficial and deep digital flexors, through a tunnel framed by the carpal bones
and the overlying flexor retinaculum. Symptoms are worse in the early morning
and in pregnancy because of fluid retention, resulting in swelling that entraps the
median nerve. Flexing the wrist for an extended period exaggerates the
paresthesia ("Phalen" sign) by increasing pressure on the median nerve.
Neither the ulnar nerve (answer c), radial nerve (answer e), nor radial
artery (answer a)passes through the carpal tunnel. The ulnar nerve supplies the
third and fourth lumbricals and only the short adductor of the thumb. The radial
nerve innervates mostly long and short extensors of the digits and the dorsal
aspect of the hand. Proper digital nerves (answer d) lie distal to the carpal
tunnel, but are only sensory.

Q 12.2:
A tumor in the infratemporal fossa may gain entrance to the orbit through
which of the following?
A. The optic canal (foramen)
B. The inferior orbital fissure
C. The pterygoid canal
D. The ethmoidal sinuses
E. The superior orbital fissure

Solution

B The infratemporal fossa communicates directly with the orbit via the inferior
orbital fissure and the pterygopalatine fossa. The fissure normally carries branches
of the maxillary nerve (V 2 ) and branches of the infraorbital vessels. The optic
canal (answer a) and superior orbital fissure (answer e) open into the middle cranial
fossa and carry the optic nerve (CN II) and the oculomotor (CN III), trochlear (CN IV),
and abducent (CN VI) nerves, respectively. The pterygoid canal (answer c) connects
the middle cranial fossa with the pterygopalatine fossa. The Vidian nerve traverses
the pterygold canal on its way to the pterygopalatine ganglion. The ethmoidal
sinuses (answer d) are mucosa-lined cavities within the ethmoid and adjacent bones.
They drain into the nasal cavity.

Q 12.3:
An 18-year-old gymnast heard a popping sound in her left knee while
practicing for the Olympic Games. Her knee immediately became swollen
and painful. On physical examination, it is obvious that the left knee has
an effusion. Which of the following tests is best to confirm an anterior
cruciate ligament tear?

A. Lachman test
B. McMurray test
C. Apley grind test
D. Posterior drawer test
E. Ballottement

Solution

A ) The anterior and posterior cruciate ligaments are intra-articular ligaments and
contribute to the stability of the knee. The most likely diagnosis in this gymnast is
tear of the anterior cruciate ligament (ACL). Both the Lachman test (the patient is
placed in the supine position with the knee flexed at 15 while the examiner
stabilizes the distal thigh with one hand and grasps the patient's leg distal to the
tibiofemoral joint with the other hand; the test is positive if the examiner is able to
move the tibia anteriorly) and the anterior drawer test (the foot is immobilized while
the hip and knee are flexed to 90, then the tibia is moved anterior relative to the
femur; a positive test occurs with forward displacement of the tibia of more than 0.5
cm) are positive in this kind of injury. The Lachman test is more sensitive than the
drawer test. Aspirated joint fluid is usually bloody in ACL injuries. An MRI is helpful in
diagnosing this injury. A posterior cruciate ligament (PCL) tear would have a
positive posterior drawer test whereby posterior displacement of the tibia is elicited
on physical examination. Medial meniscus tears are more common than lateral
meniscus tears and are usually due to twisting injuries. Unlike the immediate
swelling seen with tears of vascular structures such as the ACL, the relatively
cartilaginous meniscus causes more gradual swelling and patients often complain of
the knee catching, locking, and clicking.Ballotability of the patella just confirms the
presence of an effusion. Meniscal tears can be detected using the Apley grind
test (clicking or locking when grinding the tibia into the femur with the knee flexed at
90) and the McMurray test (with the patient supine, flex the knee and hold the foot
in one hand; to look for atorn medical meniscus rotate the leg outward and slowly

extend the knee while palpating the posteromedial margin of the joint for a
palpable click as the femur passes over the torn meniscus. To detect a torn lateral
meniscus, palpate the posterolateral margin of the knee joint with the leg in full
internal rotation as the knee is extended.

Q 12.4:
In a given muscle fiber at rest, the length of the I band is 1.0 m and the A
band is 1.5 m. Contraction of that muscle fiber results in a 10%
shortening of the length of the sarcomere. What is the length of the A
band after the shortening produced by the muscle contraction?
A. 1.50 m
B. 1.35 m
C. 1.00 m
D. 0.90 m
E. 0.45 m

Solution

A During contraction, the sarcomere, the distance between adjacent Z lines,

decreases in length, and the length of the A band is almost constant. However, as
the degree of overlap of thick and thin filaments is altered, the thin filaments, which
form the I band and are anchored to the Z line, are pulled toward the center of the
sarcomere. As this occurs, the I band decreases in length and the H band is no
longer visible. The filaments themselves do not decrease in length; they slide past
one another in the sliding-filament model of muscle contraction. The average length
of a sarcomere is 2.5 m. This distance is measured from one Z line to the next Z
line. If the resting length of the A band is 1.5 m and the length of the I band is 1.0
m, then the resting length of the sarcomere is determined by adding the length of
the I band to the length of the A band. If there is a 20% contraction of the muscle
(contraction to 80% of its length), then the sarcomere is reduced in length from 2.5
to 2.0 m. The size of the A band remains unchanged (i.e., whether the contraction
is 10% or 20%), therefore the length of the I band is reduced from 1.0 to 0.5 m and
makes up for the 0.5 m reduction in length during the muscle contraction. The

processes of skeletal muscle contraction and relaxation are shown in the image
below.

The
disc.

adjacent A

Sarcomere extends from Z disc (line) to Z

The H band is located between the ends of
the thin (actin) filaments. The A band is
defined by the the width of the thick
(myosin) filaments. The I bands are not
shown completely on the figure
because they are found between
bands.

Q 12.5:
A 3-year-old child suspected of aspirating a small, cloth-covered metal
button is seen in the emergency room. Although the child
does not complain of pain, there is frequent coughing. Diminished breath
sounds are most likely to be heard in which of the following?

A. In both lungs
B. In the lingula of the left inferior lobe
C. In the right inferior lobe
D. In the left superior lobe
E. In the right superior lobe

Solution

C Large aspirated objects tend to lodge at the carina (both lungs affected) (answer
a). Smaller objects usually lodge in the right inferior lobar bronchus [not
superior (answer e)] because the right mainstem (primary) bronchus is generally
more vertical in its course than the left (answers b and d) and of greater diameter. In
addition, the takeoff angle of the right lower lobe bronchus is less acute than that of
the right middle lobe, thereby continuing in the general direction of both the right

mainstem bronchus and trachea. Blockage of the airway will produce absence of
breath sounds within the lobe and eventual atelectasis, collapse.

Q 12.6:
Specific neurons supplying the head and neck region have their cell bodies
located in ganglia. Cell bodies that bring about accommodation for near
vision are located where?

A. Ciliary ganglion
B. Geniculate ganglion
C. Otic ganglion
D. Pterygopalatine (sphenopalatine) ganglion
E. Semilunar ganglion
F. Submandibular ganglion

Solution

A The ciliary ganglion receives preganglionic parasympathetic nerves from the

Edinger-Westphal nucleus (cranial nerve III) that synapse in the ciliary ganglion.
Those collections of postganglionic parasympathetic nerve cell bodies innervate the
sphincter pupillae muscles, which constrict the pupil, closing it during bright-light

conditions. The geniculate ganglion (answer b) houses the pseudounipolar cell

bodies that receive taste information from the presulcal (anterior 2/3) of the tongue.
The otic ganglia(answer c) is a parasympathetic ganglia that contains postganglionic
parasympathetic nerves to stimulate the parotid salivary gland (preganglionic fibers
from cranial nerve IX). The pterygopalatine (sphenopalatine) ganglion (answer
d) contains postganglionic parasympathetic nerves to stimulate the lacrimal gland
and glands of the nose and paranasal sinuses (preganglionic parasympathetic fibers
from cranial nerve VII). The semilunar (trigeminal) ganglion (answer e) contains
pseudounipolar cell bodies that receive pain, touch and temperature information
from the face via the trigeminal nerve. The submandibular ganglion (answer
f) contains postganglionic parasympathetic nerves to stimulate the submandibular
and sublingual salivary glands (preganglionic parasympathetic fibers from cranial
nerve VII).

Q 12.7:
A patient with ankle pain and swelling, photosensitivity, oral ulcers, and a
raised erythematous rash complains of intermittent ankle pain and
swelling, photosensitivity, and oral ulcers. On physical examination, she
has a raised erythematous rash over her nose and cheeks, sparing her
nasolabial folds. Select the most likely diagnosis.
A. Behet syndrome
B. Drug-induced lupus
C. Systemic lupus erythematosus
D. Sjgren syndrome
E. Thromboangiitis obliterans

Solution

C A patient with ankle pain and swelling, photosensitivity, oral ulcers, and a raised
erythematous rash has 4 of the 11 criteria (see following discussion) for systemic
lupus erythematosus. Drugs may also cause lupus, such as dilantin, procainamide,
quinidine, hydralazine, and isoniazid. Patients with drug-induced lupus are usually
older, have fever, malaise, arthritis, serositis, and rash, but renal involvement is
rare.Sjgren syndrome almost exclusively affects women and the most common
symptoms arekeratoconjunctivitis sicca DRY EYES ) and xerostomia (dry mouth),
which may cause dental caries, especially at the gum line. The Schirmer test can be
used to measure the quantity of tears secreted.Behet syndrome is a multisystem
disorder that involves the eye and causes painful oral and genital ulcerations. The
nondeforming arthritis of Behet syndrome affects the knees and
ankles.Thromboangiitis obliterans, or Buerger disease, is an inflammatory peripheral
vascular disease of the upper and lower extremities that usually affects men under
the age of 40 who smoke. Patients may complain of extremity claudication or
Raynaud phenomenon. The treatment of Buerger disease is to quit smoking
cigarettes.
The American College of Rheumatology criteria for SLE (need 4 of the 11: BRAIN
SOAP M.D.) are the following:
Blood or hematologic (hemolytic
anemia, thrombocytopenia, or
lymphopenia)

Serositis (pericarditis, pleuritis)

Renal (proteinuria or cellular casts)

Arthritis that is nonerosive and

involves more than two joints

ANA (abnormal antinuclear antibody

titer)
Immunologic (anti-dsDNA Ab or antiSmith Ab and/or antiphospholipid Ab)
Neurologic (seizures or psychosis)

Oral ulcers

Photosensitivity
Malar rash
Discoid rash

Q 12.8:
A 12-year-old boy is brought to your office 2 days after a fracture of the
humerus in its distal third. The patient complains that he is unable to
extend the wrist. On examination he has a wristdrop but his distal pulses
in his arm are intact. Which of the following structures was most likely
damaged?
A. Median nerve
B. Ulnar nerve
C. Radial nerve
D. Axillary nerve
E. Artery supplying the brachial plexus

Solution

C The radial nerve lies next to the shaft of the humerus in the spiral groove. It may
be injured as a result of humeral fractures, especially those involving the distal third
of the humerus, or as a result of deep sleep during intoxication ("Saturday night
palsy"). The radial nerve (C6-C8) supplies the extensor muscles of the wrist; damage
to it results in wristdrop, a condition in which the patient is unable to extend the
wrist. Clawhand is due to paralyzed interosseous and lumbrical muscles from
an ulnar nerve (C8-T1) injury. The median nerve (C6-T1) supplies most of the flexors in
the forearm (motor branches) and supplies sensory branches to the radial part of
the hand; an injury will cause carpal tunnel syndrome and thenar atrophy.
The axillary nerve carries fibers from C5-C6 and may be injured in anterior shoulder
dislocations, causing paralysis of the deltoid, teres minor or the long head of the
triceps. Lack of arterial supply to the brachial plexus can cause unilateral weakness
and burning in an upper extremity.

Q 12.9:
A 55-year-old woman presents to the ED complaining of right knee pain.
The patient states she was working in a distribution warehouse when her
leg got pinned between a fork lift and the wall. She states that her knee
popped out and then popped back in. She is complaining of severe pain
in the knee. She has not ambulated since the incident. On exam, her vital
signs are within normal limits. Right lower extremity examination shows a
large joint effusion. There is no tenderness to palpation with manipulation
of the patella. Flexion and extension of the knee are limited secondary to
pain. The dorsalis pedis and posterior tibial pulses are slightly diminished.
What is the most feared complication of this injury?
A. Meniscal injury
B. Patellar dislocation
C. Popliteal artery injury
D. Medial collateral ligament tear
E. Patellar tendon rupture

Solution
C (Tintinalli) The most feared complication of posterior knee dislocation is injury to the
popliteal artery. Posterior knee dislocations often reduce spontaneously prior to the
patients arrival to the ED. Angiography is indicated if posterior knee dislocation is
suspected. Meniscal injuries (a) often occur by themselves or in conjunction with
other ligamentous injuries. The medical meniscus is twice as likely as the lateral
meniscus to be injured. The mechanism of injury usually involves squatting, cutting,
or twisting maneuvers. Patients may experience locking of the knee joint on either
flexion or extension, which can limit activity. Patellar dislocations (b) result from a
twisting injury on an extended knee. The patella is deplaced laterally of over the
lateral femoral condyle. Reduction is achieved by flexing at the hip and
hyperextending at the knee and then gently sliding the patella back in place. Patellar
dislocation is not associated with posterior knee dislocations. Medial collateral
ligament tears (d) are most often seen in conjunction with anterior cruciate ligament

tears. Physical diagnosis of these injuries is difficult and MRI is the diagnostic test of
choice. With posterior knee dislocation, the anterior and posterior cruciate
ligaments are usually disrupted. Patellar tendon rupture (e) usually occurs from
falling on a flexed knee. Patients have pain, swelling, and are unable to extend the
flexed knee against mild resistance. This injury is not associated with posterior knee
dislocation.

Q 12.10:
A 36-year-old male bartender is brought by ambulance to your emergency
room because a patron jumped over the bar, grabbed an ice pick, and
stabbed him in the chest rather than pay his bar tab at the end of the
night. The ice pick entered the chest about 2 cm to the left of the sternum
in between the fourth and fifth rib. Upon examining the bartender, you
note very little blood is coming from the puncture wound and normal lung
sounds from both the right and left lung. However, his heart is beating
rapidly at 100 beats per minute, his external jugular veins are bulging, and
you have difficulty hearing his heart sounds. You order a PA and lateral
chest film because you suspect which of the following?
A. Hemothorax
B. Pneumothorax
C. Cardiac tamponade
D. Aortic valve stenosis
E. Deep venous thrombosis

Solution

C The ice pick likely penetrated the left ventricle of the heart, causing blood to leak
into the pericardial sac. The rapid filling of the pericardial space does not allow the
heart to fully expand between contractions leading to increased venous
hypertension. The result is filling of the external jugular veins. Since the heart can
only pump small quantities of the blood with each beat, it speeds up (tachycardia).
The heart sounds and apical heartbeat soften because the blood surrounding the

heart absorbs the sounds. A hemothorax (answer a) and pneumothorax (answer

b) are unlikely since both right and left lungs sounds are normal and because of the
location of the ice pick injury. Aortic valve stenosis (answer d) would not result from a
puncture wound. Deep venous thrombosis (answer e) generally occurs in the lower
extremity and results in leg pain and is not caused by a puncture wound.