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1. The internal carotid artery:
a. lies in the floor of the middle ear
b. lies medial to the abducent nerve
c. enters the skull and divides into the anterior and middle cerebral arteries
d. is separated from the external carotid artery by the styloglossus
e. grooves the greater wing of the sphenoid bone
2. The internal jugular vein:
a. is separated from the sympathetic chain by the prevertebral fascia
b. lies anteromedial to the sympathetic chain.
c. is a continuation of the sigmoid sinus
d. receives the anterior jugular vein
e. is separated from the inferior petrosal sinus by the 9th, 10th and 11th cranial nerves
3. The following are true about the trigeminal nerve:
a. it supplies the muscle of mastication
b. its ganglion lies on the apex of the petrous bone
c. emerges from the brain stem between the pons and the medulla
d. emerges from the brain stem as separate sensory and motor roots
e. innervates all the teeth of the upper jaw
4. The following nerves are transmitted through the temporal bone:
a. vagus nerve
b. facial nerve
c. vestibulocohclear nerve
d. mandibular branch of the trigeminal nerve
e. olfactory nerve
5. The following are true about the circulation of the cerebrospinal fluid (CSF):
a. is produced by the modified ependymal cells of the choroid plexus
b. is absorbed mainly through the arachnoid granulations in the superior sagittal sinus
c. the ventricular system communicates with the subarachnoid space through the roof of the third ventricle
d. the arachnoid granulation is in contact with the endothelium of the venous sinuses
e. blockage of the arachnoid granulation causes communicating hydrocephalus
6. True statements about the medulla include:
a. contains the spinal nucleus of the trigeminal nerve which extends throughout the length of the medulla
b. the vagus nerve emerge between the medulla and the inferior cerebellar peduncle
c. contains gracile nucleus which lies medial to the cuneate nucleus
d. the vagal nucleus lies medial to the hypoglossal nucleus
e. the pyramids decussate in the lower part of the medulla
7. The pterygopalatine ganglion:
a. supplies parasympathetic fibres to the lacrimal gland
b. sympathetic nerves from the superior cervical ganglion passes through it
c. is suspended from the maxillary nerve
d. supplies the iris
e. supplies secretomotor fibres to the glands of the nose
8. The parathyroid glands:
a. are found on the anterior surface of the thyroid glands
b. develops from the 3rd and 4th pharyngeal pouch endoderm
c. may be confused with fat globules
d. receives blood supply from the middle thyroid arteries
e. contain chief cells which have dark staining nuclei
9. True statements about the boundary of the nasal cavity include:
a. cribriform plate forms part of the roof
b. maxilla forms the floor of the cavity
c. vomer forms the lateral wall of the cavity
d. palatine forms part of the roof
e. the vertical plate of the ethmoid bone forms the medial wall
10. The following are true about the relations of the cavernous sinus:
a. it lies on the body of the sphenoid bone
b. it is situated above the pituitary gland 
c. it is posterior to the superior orbital fissure
d. the maxillary branch of the trigeminal nerve passes through it
e. the trochlear nerve passes through it
ANSWERS:- the following options are true for the above questions.
1. a,b,c,d = T.
2. a,c,e = T .
3. a,b,d,e = T
4. bce = T
5. abde = T
6. abce = T
7. abce = T
8. bce = T
9. abe = T
10. acde =T
1. Supination of the hand and forearm would be diminished by loss of radial nerve function. But one very powerful supinator would remain intact and unaffected, namely:
Biceps brachii
Flexor carpi radialis

2. A worker doing repetitive lifting develops an inflammation in the tendon of origin of the extensor carpi radialis brevis muscle, commonly called "tennis elbow". The focal point of pain would most likely be near which palpable bony landmark?

Coronoid process of ulna
Lateral epicondyle of humerus
Lateral supracondylar ridge of humerus
Medial epicondyle of humerus
Medial supracondylar ridge of humerus
Posterior (subcutaneous) border of ulna

3. The anterior interosseous is a branch of which nerve?

4. In an attempt to commit suicide by slashing the ventral side of the wrist, the two tendons of the flexor digitorum superficialis located most superficially were completely severed. What movement would be affected?

Flexion of the MP and IP joints of the thumb
Flexion of the PIP joints of digits 2 and 5
Flexion of the PIP joints of digits 3 and 4
Flexion of the DIP joints of digits 2 and 5
Flexion of the DIP joints of digits 3 and 4

5. What muscle is innervated by branches of both the median and ulnar nerves?

Flexor carpi ulnaris
Flexor digitorum profundus
Flexor digitorum superficialis
Flexor pollicis longus
Pronator quadratus

6. Interruption of the median nerve in the cubital fossa affects what movement(s) of the thumb?


7. Compression of the median nerve in the carpal tunnel affects which hand muscle(s)?

Dorsal interossei
Flexor pollicis brevis
Flexor pollicis longus
Opponens digiti minimi
Palmar interossei

8. Structures within the carpal tunnel include the:

Radial bursa
Ulnar bursa

9. A patient is severely limited in extension at the wrist joint after several months in a cast following a Colles fracture. Which joint would be especially important in therapy to regain full extension?

distal radioulnar

10. The victim of multiple shrapnel wounds to the upper limb must have his forearm amputated at midlength. Because of concomitant damage in the patient's arm, the surgeon must ligate the main artery at some point. The best chance of saving collateral circulation to the stump of the forearm would be when the ligature is placed just below which of the following?

Beginning of brachial artery
Origin of the deep brachial artery
Origin of the superior ulnar collateral artery
Origin of the inferior ulnar collateral artery
Bifurcation of the brachial artery

11. During an industrial accident, a sheet metal worker lacerates the anterior surface of his wrist at the junction of his wrist and hand. Examination reveals no loss of hand function, but the skin on the thumb side of his palm is numb. Branches of which nerve must have been severed?

Lateral antebrachial cutaneous
Medial antebrachial cutaneous

12. A middle-aged woman comes to you complaining of pain on the lateral side of her right elbow, so severe that she holds her eating utensils in her left hand to eat. She says that she spent the weekend putting in a new garden plot and that it involved loosening and turning over a large area of grass sods with a garden fork. You find that the region just proximal to the lateral epicondyle of her humerus is painful to the touch. There is no sensory loss in her forearm or hand. You suspect a localized tearing of the origin of a muscle producing the equivalent of "tennis elbow." The muscle most likely involved is the:

common flexor tendon
extensor carpi radialis brevis
extensor digitorum
pronator teres

13. A boy fell onto a sharp object and cut his deep radial nerve as it emerged from the supinator muscle. The artery joining it at this point was also injured. The injured artery is the:

anterior interosseous
common interosseous
posterior interosseous

14. While going up for a rebound, a basketball player jams her middle finger against the ball. She experiences severe pain and the trainer notes that she can no longer extend the distal phalanx of the finger. The injury has avulsed (torn away from the bone) which structure from her distal phalanx to produce this condition?

extensor carpi radialis brevis tendon
extensor carpi radialis longus tendon
extensor digiti minimi tendon
extensor expansion
extensor indicis tendon

15. The tendons on the dorsal side of the wrist are held in place by a thickening of the antebrachial fascia called the:

bicipital aponeurosis
extensor expansion
extensor retinaculum
interosseous membrane
palmar carpal ligament

16. The function of the posterior interosseous nerve is:

motor to the brachioradialis
motor to the extensor carpi ulnaris
parasympathetic to the dorsum of the forearm
sensory from the wrist joint
sensory from the dorsum of the forearm

17. Development of "tennis elbow" (lateral epicondylitis) involves the origin of which muscle?

Abductor pollicis longus
Extensor carpi radialis brevis
Triceps brachii

18. In an industrial accident, the artery passing lateral to the pisiform bone is cut. This artery is the :

Deep palmar arch
Superficial palmar arch
Superficial palmar branch of the radial artery

19. After suffering a gunshot wound to the forearm, it was determined that the posterior interosseous nerve was severed. What function was lost?

Sensory from the wrist joint
Motor to brachioradialis
Motor to the extensor carpi radialis longus
Parasympathetic to the dorsum of the forearm
Motor to the flexor digitorum superficialis

20. When falling on an outstretched hand, the most commonly dislocated carpal bone is the:


21. If the musculocutaneous nerve is severed at its origin from the brachial plexus, flexion at the elbow is greatly weakened but not abolished. What muscle remains operative and can contribute to flexion?

Long head of biceps brachii
Short head of biceps brachii

22. After falling on the ice, it was determined that a patient had a Colles' fracture. Care must be taken to relieve tension on the broken distal end of the radius created by the pull of which muscle?

Extensor carpi ulnaris
Extensor carpi radialis longus
Pronator quadratus
Extensor carpi radialis brevis

23. If the tendon of palmaris longus were transected, what movement would be affected?

Flexion of the MP and IP joints of the thumb
Flexion of the proximal IP joints of digits 2 and 5
Flexion of the proximal IP joints of digits 3 and 4
Flexion of the wrist
Extension of the wrist

24. What muscle is supplied by both the median and ulnar nerves?

Flexor carpi ulnaris
Flexor digitorum profundus
Flexor digitorum superficialis
Flexor pollicis longus
Pronator quadratus

25. The pulse of the radial artery at the wrist is felt immediately lateral to which tendon?

Abductor pollicis longus
Extensor pollicis longus
Flexor carpi radialis
Flexor digitorum profundus
Palmaris longus

26. If the medial epicondyle of the humerus is fractured and the nerve passing dorsal to it is injured, which muscle would be most affected?

Extensor carpi ulnaris
Extensor digitorum
Flexor carpi ulnaris
Flexor digitorum profundus
Flexor digitorum superficialis
1.The second costal cartilage can be located by palpating the:

A. costal margin
B. sternal angle
C. sternal notch
D. sternoclavicular joint
E. xiphoid process

2.The thoracic wall is innervated by:

A. Dorsal primary rami
B. Intercostal nerves
C. Lateral pectoral nerves
D. Medial pectoral nerves
E. Thoracodorsal nerves

3.The sternocostal surface of the heart is formed primarily by the anterior wall of which heart chamber?

A. Left atrium
B. Left ventricle
C. Right atrium
D.Right ventricle

4.A patient involved in an automobile accident presents with a sharp object puncture of the middle of the sternum at about the level of the 4th or 5th costal cartilage. If the object also penetrated pericardium and heart wall, which heart chamber would most likely be damaged?

A. Left atrium
B. Left ventricle
C. Right atrium
D. Right ventricle

5.You are caring for a 68-year-old male who has copious amounts of fluid in the left pleural cavity due to acute pleurisy. When you examine him as he sits up in bed (trunk upright), where would the fluid tend to accumulate?

A. costodiaphragmatic recess
B. costomediastinal recess
C. cupola
D. hilar reflection
E. middle mediastinum

6.A 23-year-old male injured in an industrial explosion was found to have multiple small metal fragments in his thoracic cavity. Since the pericardium was torn inferiorly, the surgeon began to explore for fragments in the pericardial sac. Slipping her hand under the heart apex, she slid her fingers upward and to the right within the sac until they were stopped by the cul-de-sac formed by the pericardial reflection near the base of the heart. Her fingertips were then in the:

A. coronary sinus
B. coronary sulcus
C. costomediastinal recess
D. oblique sinus
E. transverse sinus

7.When inserting a chest tube, intercostal vessels and nerves are avoided by placing the tube immediately:

A. above the margin of a rib
B. below the margin of a rib

8.A hand slipped behind the heart at its apex can be extended upwards until stopped by a line of pericardial reflection that forms the:

A. Cardiac notch
B. Costomediastinal recess
B. Hilar reflection
C. Oblique pericardial sinus
D. Transverse pericardial sinus

9.The first rib articulates with the sternum in close proximity to the:

A. Nipple
B. Root of the lung
C. Sternal angle
D. Sternoclavicular joint
C. Xiphoid process

10.The portion of the parietal pleura that extends above the first rib is called the :

A. costodiaphragmatic recess
B. costomediastinal recess
C. costocervical recess
D. cupola
E. endothoracic fascia

11.You are attending an operation to remove a thymic tumor from the superior mediastinum. The surgeon asks, "What important nerve lying on and partly curving posteriorly around the arch of the aorta should we be careful of as we remove this mass?" You quickly answer, "The--

A. left phrenic
B. left sympathetic trunk
C. left vagus
D. right phrenic
E. right sympathetic trunk

12.In cardiac surgery it is sometimes necessary to clamp off all arterial flow out of the heart. This could be done within the pericardial sac by inserting the index finger immediately behind the two great arteries and compressing them with the thumb of the same hand. The index finger would have to be inserted into which space?

A. Cardiac notch
B. Coronary sinus
C. Oblique pericardial sinus
D. Coronary sulcus
E. Transverse pericardial sinus

13.A needle inserted into the 9th intercostal space along the midaxillary line would enter which space?

A. Cardiac notch
B. Costodiaphragmatic recess
C. Costomediastinal recess
D. Cupola
E. Oblique pericardial sinus

14.During a heart transplant procedure, the surgeon inserted his left index finger through the transverse pericardial sinus, and then pulled forward on the two large vessels lying ventral to his finger. Which vessels were these?

A. Pulmonary trunk and brachiocephalic trunk
B. Pulmonary trunk and aorta
C. Pulmonary trunk and superior vena cava
D. Superior vena cava and aorta
E. Superior vena cava and right pulmonary artery

15.While observing in the OR, you see the resident insert a needle through the body wall just above the ninth rib in the mid-axillary line. She was obviously trying to enter the:

A. Costodiaphragmatic recess
B. Costomediastinal recess
C. Cupola
D. Hilar reflection
E. Pulmonary ligament

16.The pleural cavity near the cardiac notch is known as the:

A. Costodiaphragmatic recess
C. B. Costomediastinal recess
D. Cupola
D. Hilum
E. Pulmonary ligament

17.The tubercle of the 7th rib articulates with which structure?

A. Body of vertebra T6
B. Body of vertebra T7
C. Body of vertebra T8
D. Transverse process of vertebra T6
E. FTransverse process of vertebra T7

18.The ductus arteriosus sometimes remains open after birth requiring surgical closure. When placing a clamp on the ductus, care must be taken to avoid injury to what important structure immediately dorsal to it?

A. Accessory hemiazygos vein
B. Left internal thoracic artery
C. Left phrenic nerve
D. Left recurrent laryngeal nerve
E. Thoracic duct

19.A 16-year-old male suffered a stab wound in which a knife blade entered immediately superior to the upper edge of the right clavicle near its head. He was in extreme pain, which was interpreted by the ER physician as a likely indicator of a collapsed lung following disruption of the pleura. If that was true, what portion of the pleura was most likely cut or torn?

A. costal pleura
B. cupola
C. hilar reflection
D. mediastinal pleura
E.pulmonary ligament

20.During a lung transplant procedure, an observing 4th year attempted to pass his index finger posteriorly inferior to the root of the left lung, but he found passage of the finger blocked. Which structure would most likely be responsible for this?

A. Costodiaphragmatic recess
B. Cupola
C. Inferior vena cava
D. Left pulmonary vein
E. Pulmonary ligament

21.Which of the following layers provides a natural cleavage plane for surgical separation of the costal pleura from the thoracic wall?

A. Deep fascia
B. Endothoracic fascia
C. Parietal pleura
D. Visceral pleura
E. Transversus thoracis muscle fascia

22.The lowest extent of the pleural cavity, into which lung tissue does not extend, is known as the:

A. costodiaphragmatic recess
B. costomediastinal recess
C. cupola
D. inferior mediastinum
E. pulmonary ligament

23.The sternal angle is a landmark for locating the level of the:

A. Costal margin
B. Jugular notch
C. Second costal cartilage
D. Sternoclavicular joint
E. Xiphoid process

24.A 3rd-year medical student was doing her first physical exam. In order to properly place her stethoscope to listen to heart sounds, she palpated bony landmarks. She began at the jugular notch, then slid her fingers down to the sternal angle. At which rib (costal cartilage) level were her fingers?

A. 1
B. 2
C. 3
D. 4
E. Can't be determined
A 33-year-old woman undergoes a lymph node biopsy of her deep cervical nodes on the left side of her neck. Immediately following surgery, she complains of weakness in her left shoulder. On exam, the left shoulder droops, and she is unable to raise the point of her shoulder. She denies numbness in her shoulder, back, and neck.
1. What nerve appears to have been inadvertently cut during the biopsy?
A. Greater occipital n.
B. Spinal n. C3
C. Dorsal scapular n.
D. Accessory n. (Cranial Nerve XI)
E. Cutaneous nn. of the back (dorsal primary rami)
—›The occipital n. innervates posterior neck muscles and the skin of the posterior surface of the scalp. Damage to this nerve does not explain the patient's inability to raise her shoulder and would also manifest itself as numbness in the skin of the posterior surface of the scalp.

The spinal n. C3 is formed by the dorsal and ventral roots of C3. Although branches from the ventral primary rami of both C3 and C4 combine with the accessory n. to form the subtrapezial plexus, C3 and C4 provide only proprioception to the trapezius m. Damage to either spinal n. C3 or C4 would have no effect on raising the shoulder.

The dorsal scapular n. innervates rhomboideus major, rhomoboideus minor, and the lower portion of levator scapulae. Injury to this nerve would weaken the ability of the rhomboids to assist the trapezius in retracting the scapula to the midline on the affected side. Injury to this nerve would not affect the patient's ability to raise her shoulder.

The accessory nerve innervates the trapezius m., the only muscle that can elevate the tip of the shoulder (the acromion). Thus, it appears that this patient's accessory nerve (CN XI) was severed or injured during the biopsy.

The dorsal primary rami provide only motor innervation to deep back mm. and sympathetic and general sensory innervation to the skin of the back. All muscles of the upper and lower limbs (e.g., the one responsible for raising the shoulder) are innervated by nerves that are branches of the ventral primary rami.
A 25-year-old man is brought into the ER with a high fever, lethargy, and a stiff neck. After taking a history and performing a physical exam, you strongly suspect meningitis. In order to find the causative agent, you order a lumbar puncture. Laboratory analysis confirms your suspicion by showing bacterial growth in the cerebrospinal fluid (CSF). You administer the appropriate therapy and the patient recovers without any complications.

Questions to consider:

1. Where along the vertebral column is a needle inserted for a lumbar puncture? Which landmark can you use to find this level?

2. During a lumbar puncture, the syringe needle is inserted in the midline and within the median plane. Why? What structures, ligaments and others, does the needle traverse----- before entering the lumbar cistern?

3. What position is the patient placed in during this procedure? Justify this anatomically.

4. Following the procedure, the patient complains of a severe headache. What is the cause of this complication of lumbar punctures?

5. Other than obtaining CSF samples, in what other situations are lumbar punctures performed?
You are called to evaluate a newborn infant in the labor and delivery room. On physical exam you note that the infant has normal vital signs and appearance with the following exception - you note that the patient has a bulging cyst-like structure approximately 4 cm in diameter protruding from his back . You also note that he has limited movement of the lower extremities and that both feet are plantarflexed and inverted at the ankle.

1. What are neural tube defects and how often do they occur?

2. What types of anatomical structures can be involved with a case of spina bifida?

3. How do the various types of neural tube disorders vary in their presentation?

4. What is the cause of spina bifida?

5. What other complications are associated with this condition?

6. What simple prophylactic therapy can be undertaken prenatally to prevent such defects?
Paramedics respond to a report of an 82 year old man unconscious after a fall. They find the patient on the floor in his house in cardiac arrest. His wife said that he fell approximately 18 inches from a lift assist device. The paramedics revive the patient to a normal sinus rhythm using ACLS protocols (Advanced Cardiac Life Support) but the patient remains profoundly unconscious. They fully immobilize his spine and transport him emergently to the hospital.

X-ray, CT, and MRI image studies at the hospital show C1 and C2 fractures with spinal cord injury, resulting in quadriplegia. T2-T4 spinous processes and several left ribs are also fractured. The patient never regains consciousness and dies the next day.


1. What is the function of the dens of C2, and why are fractures in this region so dangerous?

2. What is spinal immobilization, and why is it used?
20-year-old woman whose impacted right lower wisdom tooth was surgically removed. The operation lasted about an hour, and the dental surgeon suspected that some nerves might have been bruised during the operation. The patient presented with loss of sensation in the gums of her lower jaw, and her mouth was slightly dry. You examined taste sensation in the tongue and found that it was diminished in the anterior two-thirds but it was normal in the posterior portion.
1. Which nerve is most likely to have been bruised in this patient?
-> The lingual nerve, which is a branch of the posterior division of the mandibular nerve (CN V3).

2. How would you explain the patient's complaints?
-> The lingual nerve supplies general sensory fibers to the anterior two-thirds of the tongue, the floor of the mouth and the gums of the mandibular teeth. It carries the chorda tympani nerve, which carries taste fibers from the anterior two-thirds of the tongue and parasympathetic innervation to the submandibular and sublingual salivary glands.

3. Which nerve is responsible for sensation in the posterior third of the tongue?
-> The glossopharyngeal (CN IX) supplies taste and general sensation to the posterior third of the tongue.
An 18-year-old woman went to see her dentist for a regular checkup. During the visit, the doctor discovered that her lower third molars ("wisdom teeth"), which had appeared to be erupting fine on her last visit, had begun to cause crowding in the patient's mouth. He was afraid that they might eventually cause her discomfort, and since her teeth were currently straight, he recommended that she have the third molars extracted. She agreed, and returned the following week for the procedure. Before the dentist began to work, the patient told him that she had a low pain tolerance and asked that he make sure that her mouth was fully anesthetized. The dentist promised that he would take care of it , and then proceeded to inject the anesthetic in the mucous membrane on both sides of the patient's mouth.

The teeth were removed without incident; however, when the dentist finished, the patient found that she could not close her mouth. The dentist apologized, saying that he must have dislocated her jaw, but that he could fix it easily and she would suffer no lasting effects. He then reduced the dislocated jaw by pressing downward on the remaining molars until the mandible slipped back into place. He then warned her not to attempt to chew any food until the anesthetic had worn off and she was able to feel her tongue and lower lip again, lest she damage them by chewing on them.
1. What nerve(s) would need to be anesthetized in order to prevent pain during a lower third molar extraction?
2. Why were the patient's lower lip and tongue numb?
3. What joint was dislocated during the tooth extraction and how did this occur?

© 2018 by Partha Sarathi(Director)