H1. Coronary artery disease is a frequent cause of myocardial infarction in the United States. If an echocardiogram suggests reduced posterior ventricular wall movement, there will be reduced blood flow within which of the following coronary arteries and veins?

A. Circumflex branch of the left artery; great cardiac vein

B. Anterior interventricular artery; great cardiac vein

C. Anterior interventricular artery; middle cardiac vein

D. Right marginal branch of the right artery; small cardiac vein

E. Posterior interventricular artery; middle cardiac vein

H2. A middle-aged male is diagnosed with a rare form of encephalopathy, which mainly causes demyelination of cerebral cortical neurons that project to the cerebellum. Which of the following best describes the distribution of these fibers?

A. Somatotopically distributed only to the anterior lobe

B. Somatotopically distributed only to the vermal region of the anterior and posterior lobes

C. Somatotopically distributed to the cerebellar hemispheres

D. Not somatotopically organized but do project to the hemispheres of the anterior and posterior lobes

E. Distributed mainly to the interposed and dentate nuclei

H3. In a presurgical patient, the great saphenous vein was cannulated in the vicinity of the ankle. During the procedure, the patient experienced severe pain that radiated along the medial border of the foot. Which of the following nerves was accidentally included in a ligature during this procedure?

A. Medial femoral cutaneous nerve

B. Saphenous nerve

C. Superficial fibular nerve

D. Sural cutaneous nerve

E. Tibial nerve

H4. Muscle relaxants are used routinely during anesthesia with resultant closure of the vocal folds. Laryngeal intubation by the anesthesiologist is necessary because which one of the following muscle(s) is/are unable to keep the glottis open?

A. Cricothyroid muscles

B. Lateral cricoarytenoid muscles

C. Posterior cricoarytenoid muscles

D. Thyroarytenoid muscle

E. Transverse arytenoid muscles

H5. A 64-year-old woman who has had heart disease for many years. While carrying chemicals down the stairs of the dry-cleaning shop where she works, she suddenly lost control of her right leg and arm. She fell down the stairs and was able to stand up with some assistance from a coworker. When attempting to walk on her own, she had a very unsteady gait, with a tendency to fall to the right side. Her supervisor asked her if she was all right, and noticed that her speech was very slurred when she tried to answer. He called an ambulance to take her to the nearest hospital. Upon admission, her face appears symmetric, but when asked to protrude her tongue, it deviates toward the left. She is unable to tell if her right toe is moved up or down by the physician when she closes her eyes, and she can not feel the buzz of a tuning fork on her right arm and leg. In addition, her right arm and leg are markedly weak. The physician can find no other abnormalities in the remainder of the patient's general medical examination. Where in the nervous system could a lesion occur that would cause her arm and leg weakness but spare her face?

A. Right corticospinal tract in the cervical spinal cord

B. Left inferior frontal lobe

C. Right medullary pyramids

D. Occipital lobe

E. Right side of basilar pons

H6. A pituitary adenoma is likely to result in which one of the following?

A. Cushing syndrome

B. Deficiency in T3 and T4

C. Diabetes insipidus

D. Osteoporosis

E. Stunted growth or dwarfism

H7. A physician examines a patient who complains of pain and paresthesia in the left leg. The distribution of the pain, running down the lateral aspect of the leg and the dorsal surface of the foot, is suggestive of a herniated intervertebral disk. The physician links the distribution of symptoms with nerve L5 and concludes that herniation has occurred at which location?

A. L3 to L4 intervertebral disk

B. L4 to L5 intervertebral disk

C. L5 to S1 intervertebral disk

D. S1 to S2 intervertebral disk

E. Insufficient data to determine

H8. A 43-year-old male was recovering from an infectious disease and experienced a marked instability in his blood pressure, with episodes of spiking of blood pressure. After a series of extensive examinations, it was concluded that this disorder was due to the effects of the infectious agent upon a component of the peripheral nervous system. Which of the following constitute logical sites where an infectious agent could produce such an effect?

A. Superior ganglia of cranial nerves IX and X

B. Geniculate and trigeminal ganglia

C. Otic and superior salivatory ganglia

D. Carotid sinus and aortic arch

E. Carotid and aortic bodies

H9. A 17-year-old adolescent arrives at the ED with her jaw wide open and an apple core in her left hand. She is in obvious pain from dislocating her jaw, displacing the articular disk beyond the articular tubercle of the temporomandibular joint while eating the apple. The dislocation was the result of excessive contraction of which one of the following muscles?

A. Buccinator

B. Lateral pterygoid

C. Medial pterygoid

D. Masseter

E. Temporalis

H10. An elderly female patient suffered a stroke resulting in weakness of her left limbs, reduced reflexes in those limbs, inability to gaze to the left and loss of facial expression on the left side, and failure to verbally acknowledge that anything was wrong with the left arm or leg. In this patient, which of the following was most likely occluded?

A. Right anterior cerebral artery

B. Left anterior cerebral artery

C. Right posterior cerebral artery

D. Right middle cerebral artery

E. Left middle cerebral artery

H11. A carcinoma in the medial portion of the lower lip is most likely to first metastasize via which of the following lymph nodes?

  1. Submandibular
  2. Parotid
  3. Superficial cervical
  4. Submental
  5. Buccal

H12. A 40-year-old man presents to the emergency department barely able to walk. He finds it painful to sit down. He was waterskiing and was trying to learn to water ski backwards when his left ski caught the water "wrong" and he fell. He has intense pain in the left gluteal region. Examining him in the prone position, a bulging of the left hamstring muscles is noted with significant pain upon palpation of the left ischial tuberosity. An avulsion of the hamstring muscles from their origin on the ischial tuberosity is suspected. Which three muscle origins most likely avulsed a piece of bone from the ischial tuberosity when his ski caught the water?

  1. Adductor longus, adductor magnus, and biceps femoris
  2. Adductor longus, adductor magnus, and gracilis
  3. Semitendinosus, semimembranosus, and adductor magnus
  4. Semitendinosus, semimembranosus, and biceps femoris
  5. Semitendinosus, semimembranosus, and gracilis

H13. A newborn female infant cannot swallow, exhibits persistent drooling, and aspiration or regurgitation of food after attempted feedings. When the infant strains, coughs, or cries, the stomach inflates, elevating the diaphragm and making respiration more difficult. The patient is diagnosed with congenital esophageal atresia at the cervical levels, necessitating surgical repair. During the surgery, the blood supply of the esophagus must be carefully isolated to protect from injury. Which of the following arteries supplies the esophagus at cervical levels?

  1. bronchial artery
  2. inferior thyroid artery
  3. internal thoracic artery
  4. left inferior gastric artery
  5. left inferior phrenic artery

H14. A 55-year-old male had been complaining about having difficulty in coordinating the use of his arms in meaningful ways. For example, when examined by a neurologist, the patient was unable to move his finger accurately to his nose from his side when requested to do so but instead would undershoot or overshoot the target. He also had difficulty in making rapid alternating rotational movements of the hand. The neurologist believed that the patient was suffering from a disorder that resulted in a lesion of a region of the cerebellum or structures related to it. Which of the following regions most likely contained this lesion?

  1. Fastigial nucleus
  2. Vermal region
  3. Cerebellar hemispheres
  4. In ferior cerebellar peduncle
  5. Vestibular nuclei

H15. A 53-year-old male patient has developed an abnormal hypersensitivity in the face area. He complains that he feels pain when he drives with the window down and from the wind blowing on his face. The pain is exacerbated by direct touch to the left side of his lower jaw. The patient is diagnosed with trigeminal neuralgia (tic douloureux). Where do pain fibers from the left side of his mandible project to?

  1. mesencephalic trigeminal nucleus
  2. motor trigeminal nucleus
  3. principal sensory trigeminal nucleus
  4. spinal (descending) trigeminal nucleus
  5. trigeminal (gasserian) ganglion

H16. An otherwise healthy married 25-year-old female medical student is referred to the cardiology clinic by her primary care physician for consultation and evaluation. She has told her primary care physician that she is thinking of starting a family. She has an atrial septal defect (ASD), diagnosed at age 5, but it was not repaired because of parental concerns about their healthy daughter undergoing open-heart surgery. Why should her cardiologist recommend that she at least consider getting her ASD surgically repaired prior to her planned pregnancy?

  1. The pregnancy adds significant additional resistance to the peripheral venous system because of the size of the placenta. This will cause a left to right atrial shunt, leading to hypertrophy of the left ventricle. In addition, there are clamshell devices that may be inserted intravenously to repair the ASD that do not require open-heart surgery.
  2. The pregnancy adds significant additional resistance to the peripheral venous system because of the size of the fetal circulatory system. This will cause a right to left shunt, leading to hypertrophy of the left atrium. In addition, there are clamshell devices that may be inserted intravenously to repair the ASD that do not require open-heart surgery.
  3. No treatment is recommended because living with an ASD carries no risk if you have lived with it for 25 years.
  4. Pregnancy increases the chances of venous emboli, which may lead to stroke because emboli can bypass the lung by traversing the ASD. In addition, there are clamshell devices that may be inserted intravenously to repair the ASD that do not require open-heart surgery.
  5. The pregnancy adds significant additional resistance to the peripheral venous system because of the size of the fetal circulatory system. This will cause a left to right shunt, leading to hypertrophy of the right atrium. In addition, now that she is older the risks of open-heart surgery are significantly reduced compared to surgery as a child because the heart is much larger.

H17. A 72-year-old grandmother is watching her grandson play baseball on one field, when a foul ball from another baseball diamond strikes the right side of her face, knocking her unconscious. She regains consciousness in the ambulance on the way to the hospital. Skull films reveal fractures of both her right zygomatic arch and the coronoid process on the right side of the mandible. Which two of the following muscles either originate from or insert onto the fractured structures, thus weakening the woman's ability to chew?

  1. Medial and lateral pterygoid
  2. Masseter and lateral pterygoid
  3. Masseter and medial pterygoid
  4. Stylohyoid and posterior belly of the digastric
  5. Temporalis and masseter

H18. A 13-year-old adolescent is brought to the pediatrician's office by his mother. He has a body mass index (BMI) of 29 and he is limping significantly as he walks due to left knee and hip pain. He does not recall any specific incident; he just woke up early this week in pain. Physical examination reveals that his left leg is shorter than the right and an increase in the gluteal skin fold is noted. He carries his left leg turned slightly outward. Flexion, extension, and rotation of the left leg is limited, with guarding. What is the pediatrician's working diagnosis as she orders a plain film evaluation of the hip joint?

  1. Developmental dysplasia of the hip
  2. Avascular necrosis of the femoral head
  3. Pelvic fracture
  4. Slipped capital femoral epiphysis
  5. Trendelenburg gait

H19. A 45-year-old woman is brought to her local hospital’s emergency room by her husband because of several days of progressive weakness and numbness in her arms and legs. Her symptoms began with tingling in her toes, which she assumed to be her feet “falling asleep.” However, this feeling did not disappear, and she began to feel numb, first in her toes on both feet, then ascending to her calves and knees. Two days later, she began to feel numb in her fingertips and had difficulty lifting her legs. When she finally was unable to climb the stairs of her house because of her leg weakness, had difficulty gripping the banister, and experienced shortness of breath, her husband urged her to go to the emergency room. The neurologist who examined the patient in the emergency room noticed that she was short of breath while sitting in bed. He asked the respiratory therapist to measure her vital capacity (the greatest volume of air that can be exhaled from the lungs after a maximal inspiration), and the value for this was far lower than would be expected for her age and weight. Her neurological examination showed that her arms and legs were very weak, so that she had difficulty lifting them against gravity. She was unable to feel a pin or a vibrating tuning fork at all on her legs and below her elbows, but was able to feel the pin on her upper chest. The neurologist could not elicit any reflexes from her ankles or knees. He subsequently advises the emergency room staff that the patient needed to have a spinal tap and be admitted to the intensive care unit immediately. Where in the nervous system is the damage?

  1. Frontal lobe
  2. Temporal lobe
  3. Peripheral nerves and nerve roots
  4. Spinal cord
  5. Parietal lobe

H20. Since motor dysfunctions associated with disturbances of basal ganglia are expressed on the contralateral side of the body, which of the following is the most appropriate conclusion regarding the projections of the basal ganglia?

  1. Fibers to the spinal cord that are crossed
  2. Fibers to motor nuclei of the brainstem whose axons then project to the contralateral spinal cord
  3. Fibers to structures that ultimately influence motor regions of the ipsilateral cerebral cortex
  4. Axons to the cerebellum, whose outputs are known to modulate the contralateral side of the body
  5. Fibers directly to the contralateral motor cortex

H21. Of the following thalamic nuclei, which nucleus contains neurons that have properties of both “specific” and “nonspecific” thalamus?

  1. CM thalamic nucleus
  2. Medial geniculate thalamic nucleus
  3. Lateral geniculate thalamic nucleus
  4. Dorsomedial thalamic nucleus
  5. VA thalamic nucleus

H22. Which of the following is the smallest active functional unit (including conduction and air exchange) of the lung?

  1. An alveolus
  2. A respiratory bronchiolar unit
  3. A bronchopulmonary segment
  4. Segmental bronchi
  5. An intrapulmonary bronchus

H23. Climbing fibers provide excitation to the deep cerebellar nuclei and the Purkinje neurons. The climbing fibers originate from which of the following structures?

  1. inferior olivary nucleus
  2. pontine nuclei
  3. spinal cord
  4. superior olivary nucleus
  5. vestibular nuclei

H24. A 53-year-old woman has paralysis of the right side of her face that produces an expressionless and drooping appearance. She is unable to close her right eye, has difficulty chewing and drinking, perceives sounds as annoyingly intense in her right ear, and experiences some pain in her right external auditory meatus. Physical examination reveals loss of the blink reflex in the right eye on stimulation of either cornea and loss of taste from the anterior two-thirds of the tongue on the right. The inability to close the right eye is the result of involvement of which one of the following?

  1. Zygomatic branch of the facial nerve
  2. Buccal branch of the trigeminal nerve
  3. Levator palpebrae superioris muscle
  4. Superior tarsal muscle (of Müller)
  5. Orbital portion of the orbicularis oculi muscle

H25. A 46-year-old woman is admitted to a hospital in acute distress. She has experienced severe abdominal pain and vomiting for 2 days. The pain, which is sharp and constant, began in the epigastric region and radiated bilaterally around the chest to just below the scapulae. Subsequently, the pain became localized in the right hypochondrium. The patient, who has a history of similar but milder attacks after hearty meals, is moderately overweight. Palpation reveals marked tenderness in the right hypochondriac region and some rigidity of the abdominal musculature. An x-ray without contrast medium shows numerous calcified stones in the region of the gallbladder. The patient shows no sign of jaundice (icterus). Diffuse pain referred to the epigastric region and radiating circumferentially around the chest is the result of afferent fibers that travel via which of the following nerves?