Review Session

Review Session 12/16/2009 6:59:00 AM



*These questions are not indicative of format (first thing he said… yet some

of these are from the quiz)





A 52 year old band director suffered problems in her right arm. Physical

exam reveals wrist drop and weakness of grasp but normal elbow extension.

There is no loss of sensation in the affected limb. Which is most likely

affected?

 Ulnar

o Adduction abduction of fingers affected (interossei, adductor

pollicis- weak grip

 Anterior interosseous

o Deep branch of median nerve (deeper flexors: pronator

quadratus

 Posterior interosseous

o Branch of radial n.; enters forearm through the lateral side of

cubital fossa. Just proximal to CF, find radial n. in between

brachialis and brachioradialis; branches to superficial and

deep; deep branch will dive through the supinator posterior to

interosseous membrane, known as posterior interosseous

o For our intents- know that extensors are innervated by deep

radial

 In lab, be able to ID superficial radial, deep radial, and

if you see a „teensy‟ little nerve in the extensors, call it

the posterior interosseous n.

 Median

 Superficial Radial

o No motor supply, this is all sensory to back of hand

A 22 year old woman is admitted to the ED in an unconscious state. The

nurse takes a radial pulse to determine the HR of the patient. This pulse is

felt lateral to which tendon?

 Palmaris longus

o Not always there; also runs more median

 Flexor pollicis longus

o Not a „bad answer‟; however it would run deeper than FCR

 Flexor digitorum profundus

 Flexor carpi radialis

o Flex wrist against resistance, it‟s the tendon on the lateral

side

 Flexor digitorum superficialis

Which ligament(s) contribute(s) to the anterior wall of the vertebral canal?

 Ligamenta flava

 Anterior longitudinal

 Posterior longitudinal

 All of the above

 None of the above

A 24 year old man is admitted with a wound to the palm of his hand.

Physical exam reveals that he 1: cannot touch the pads of his fingers with

his thumb, 2: can grip a sheet of paper between all fingers, and 3: has no

loss of sensation from the skin of his hand. Which nerve has most likely

been injured?

*Clarification: Gripping a sheet of paper shows adduction, letting us know

that the ulnar n. is fine

 Deep branch of ulnar

 Anterior interosseous

 Median (in the hand)

o After it gives off anterior interosseous, you find the median

nerve deep to FDS, above profundus. It goes through the

carpal tunnel, immediately branches (recurrent goes to

Thenar m.) and innervates lumbricals 1&2 (deep) and

cutaneous (superficial)

 Recurrent branch of median

o Thenar muscle function is compromised

 Deep branch of radial

*Note: consider FPB innervated by the MEDIAN Nerve, despite Sean Figy‟s

best efforts

A 55 year old male is examined in a neighborhood clinic after receiving blunt

trauma to his right axilla in a fall. He has difficulty elevating the right arm

above the level of his shoulder. Physical exam shows inferior angle of his

right scapula protrudes more than the lower part of the left scapula. The

right scapula protrudes far more when the patient pushes against resistance.

What is most likely injured?

 Posterior cord of brachial plexus

 Long thoracic nerve

o This is a long-winded explanation of winging of the scapula,

controlled by the long thoracic nerve

o Also, serratus anterior is involved in abduction past 90

degrees

 Upper trunk of the brachial plexus

o C5, C6: Does share something with Long thoracic.. however

this nerve comes straight from the roots, not the trunk

o If this were in the upper trunk, you would see issues with

suprascapular n

 Site of origin of the middle and lower subscapular nerves

 Spinal nerve roots C7, C8, T1

A quarterback is hit by the left tackle while passing the ball. His arm is

forced backward, resulting in shoulder dislocation. Which structure does

NOT contribute to stability of the glenohumeral joint?

 Inferior glenohumeral joint

o Fibrous capsule

 Coraco-acromial ligament

o Part of coracoacromial arch; prevents superior dislocation

 Coracohumeral ligament

o

 Supraspinatus

o SITS… Rotator cuff muscle

 Coracoclavicular ligament

o Has two parts; more medial than G-H joint

After a forceps delivery of a male infant, the baby presents with his left

upper limb adducted, internally rotated, and flexed at the wrist. Which part

of the brachial plexus was most likely injured during this delivery?

 Lateral cord

 Medial cord

 Roots of lower trunk

 Roots of middle trunk

 Roots of upper trunk

o Erb‟s Palsy… classic waiter‟s tip position

o By definition, an upper brachial plexus injury

o If you don‟t remember the palsy; think about what is affected

 Adduction indicates that aBduction is affected

(Supraspinatus (Suprascapular C5-C6, Deltoid (Axillary

C5-C6))

 Flexion indicates that extensors can not counteract

During shoulder surgery on a 56 year old woman the vascular bundle along

the medial border of the scapula is damaged. Which artery will most likely

compensate for the blood supply to the scapula that was lost during the

procedure?

 Dorsal scapular

o Normally supplies the medial border (rhomboids and levator

scapulae)

o Generally found deep to rhomboid minor, typically not found

in lab

o If you see a structure on the medial border of the scapula,

please label it “dorsal scapular”

o FYI also contributing to this anastamoses would be the

circumflex scapular

 Suprascapular

o On the “superior border” of the scapula

 Posterior circumflex humeral

 Lateral thoracic

 Thoracodorsal

A 17 year old male has weak elbow flexion and supination of the left forearm

after sustaining a knife wound in that arm in a street fight. Examination in

the ED indicates that a nerve has been severed. Which condition will also

most likely be seen during physical examination?

 Inability to adduct and abduct his fingers

 Inability to flex his fingers

 Inability to flex his thumb

 Sensory loss over lateral surface of forearm

o Musculocutaneous nerve damage (flexion and supination from

biceps brachii)

o Brachioradialis is still intact (radial n.)

o Musculocutaneous n. continues as lateral cutaneous n. of

forearm

 Sensory loss over medial surface of forearm

Review session 12/16/2009 6:59:00 AM



He calls Dr. Hankin “Dr. Supinator,” which is awesome

A 35 year old woman complains of a progressive facial flushing, headaches,

dyspnea, edema of the upper extremities, pain, dysphagia, and several

episodes of syncope. MRI revealed a tumor compressing the base of the

superior vena cava to the brachiocephalic v. Which of the following

mediastinum is this tumor located?

 Superior

 Anterior

 Middle

 Posterior

 1 and 2

 1 and 3

o Remember divisions of mediastinum. Base of the great veins

and arteries are in the MIDDLE, which is why the answer is

both 1 and 3

o Question: Where is arch of azygous?

 Sternal angle contains

 Arch of aorta

 Pericardial extent

 Arch of azygous: Superior

 Bifurcation of trachea (carina)

2 and 4

All

vignette about carotid artery… The carotid artery formed by:

Clinical

Aortic arch 1

o Maxillary

 Aortic arch 2

o Stapedial

 Aortic arch 3

o Carotid artery

 Aortic arch 4

o Arch of aorta

 Aortic arch 5

o OBLITERATES

 Aortic arch 6

o Pulmonary

*Talks for a while about the cardinal, vitelline and umbilical veins. Cardinal

forms most of the veins of the body, including SVC and MOST of the IVC.

Vitelline forms all of the digestive veins of the body, and the stump of the

IVC that comes from the liver. IF he tags the IVC in the thorax… that is

VITELLINE. Umbilical veins; Right obliterates, Left enlarges to form ductus

venosus, which closes after birth.





Clinical vignette…. Shortness of breath, ECG revealed absence of P wave.

Which of the following is probably affected?

 Atria

 Ventricle

 AV node

o PR segment. Problem here will increase P R segment

 His bundle

 Purkinje fibers

 SA Node

o P wave absence indicates problem with SA node, and possibly

the atria as well

 Right Bundle Branch

*SA node gets 55% of blood supply from the RCA, 45% from the LCA

*Lots of discussion about dominance vs % supply





Clinical vignette introducing cardiac tamponade… The first layer of

pericardium cut by the surgeon is

 Parietal serous

 Parietal fibrous

 Fibrous

o Two types of pericardium, fibrous and serous. Fibrous is

outer layer. Serous is parietal and visceral/epicardium

 Serous fibrous

 Serous visceral

 Epicardium

Questions on Transposition of Great Arteries: Aorta goes to the body FROM

the Right Ventricle, so no oxygenated blood is circulated (Same problem

with pulmonary circulation; oxygenated blood keeps going to lungs and back

Micro Review 12/16/2009 6:59:00 AM



ID structure in box

 Bronchus

 Trachea

 Arteriole

 Muscular Artery

 Bronchiole

o No cartilage cap

ID vessel contained within the red box

 Muscular artery

 Capillary

 Arteriole

o <5 layers of smooth muscle, internal elastic lamina visible

 Venule

 Bronchiole

ID the bracketed layer. Be specific!

 Thick Skin

 Dermis

 Reticular Layer

o Deeper layer of the dermis.

 Papillary Layer

 Hypodermis

ID the indicated cells. Be specific!

 Melanocytes

 Keratinocytes

o Darkly stained cells

 Langerhans Cells

 Merkel Cells

 Clara Cells

What sensory modality does the indicated structure respond to?

 Light touch

o Meissner‟s Corpuscle (Horizontal cells)

 Pain

 Temperature

 Moisture

 Deep Touch

ID the structure indicated by the arrows. Be specific

 Valscular Plexus of olfactory epithelium

 Olfactory acini

 Lamina propria

 Bowman’s glands

o Clear lumen, deeper

 Olfactory epithelium

The basic tissue type of the indicated cells is:

 Simple squamous epithelium

 Cardiac muscle

 Endothelium

 Smooth muscle

 Epithelium

o This was the simple squamous epithelium of the

endocardium, and a bullshit question… key word is “basic”

and not “specific”

The features shown in the electron micrograph are diagnostic for which cell?

 Basophils

 Neutrophils

 Eosinophils

o Key in the electron micrograph were the granules (hamburger

looking) which is indicative of eosinophilic granules

 Reticulocytes

ID the structure indicated by the black arrow. Be specific

 Tunica adventitia

 Vaso vasorum

o Blood supply to an artery

 Tunica media

 Elastic lamellae

 Tunica

ID the bracketed layer

 Thin skin

 Tunica granulosum

 Stratum epineurium

 Stratum hallucinum

 Stratum corneum

o Outermost layer, no nuclei, clear

ID the structure indicated by the arrows

 Tracheal cartilage ring

 Lamina propria

 Trachealis muscle

o Muscle tissue in between the cartilage ring

 Hyaline muscle

 Elastic lamina

Of the following choices, what could account for an increase in indicated cell

type?

 Low oxygen tension

 Climbing mount everest

 Fall into a crevasse on Mt. Everest and get injured

o Indicated cells are neutrophils, which I suppose would

respond when bacteria infiltrate a wound if you fell off of a

fucking mountain. Dumb question.

 All of the above

ID the structure enclosed in the brackets

 Alveoli

 Lymph node

 Respiratory bronchiole

 Alveolar sac

 Alveolar Duct

o Respiratory bronchiole will have additional CT. The duct is all

pneumocyte tissue. The sacs are “dead ends.”

Cells in the indicated area are killed by HIV

 True

o This is the T cell region

 False

What happened here?

 Antigen presentation

 Red blood cell formation

 Red cell destruction

 Plasma cell differentiation

o Activated area of white pulp, B cell proliferation, B cells

become PLASMA CELLS!