Physician Assistant Written Examination Question Pool - Back and Upper Limb

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Lecture 27: Superficial Back and Suboccipital Triangle (Dr. Evey)

Lecture Handouts

Essay - Handwritten Prose. 10 Points.

  • Essay Question 1: Discuss the anatomy of abducting the upper limb from 0 to 180 degrees. Include nerves, muscles, ranges of movement, and anatomical relationships.
  • Essay Question 2: Define the boundaries, contents, and relationships of the suboccipital triangle. Include an account of movements at the atlantooccipital and atlantoaxial joint.

True/False. 1 Point Each.

  • The obliquus capitis inferior muscle is biarticulate and flexes the head at the atlantooccipital joint.
  • The vertebral artery, within the suboccipital triangle, is located on the inferior surface of the arch of the axis.
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Lecture 28: Vertebral Column (L. Urbanik)

Essay - Handwritten Prose. 10 Points.

  • Essay Question 1. A 31-year-old patient is suspected of having bacterial meningitis. A lumbar puncture is performed. The patient is placed flat on their side with their lumbar spine in full flexion. Discuss at what vertebral level and body position the needle is to be inserted and why. List the structures and spaces penetrated by the needle and describe the anatomy and functions for each of these layers.
  • Essay Question 2. A 15-year-old girl presents with uneven shoulders, a unilateral protruding scapula, as well as protruding ribs on her right side. She is now experiencing some mild chest pain and altered breathing while participating in sports. Radiographic imaging reveals a moderate lateral curvature of the thoracic spine accompanied with vertebral rotation. Discus the anatomy of the vertebral column and vertebral canal including bones, joints, ligaments, movements, spaces and contents. Address what vertebral region(s) and movements are affected in this case study and the diagnosis you would determine.

True/False. 1 Point Each.

  • The filum terminale internum is derived from pia mater.
  • Both the anterior and posterior spinal arteries arise from the right and left vertebral arteries.
  • The posterior internal vertebral venous plexus is contained within the epidural space.
  • In a pair of thoracic vertebrae, a single rib has two points of articulation with the inferior vertebra and one point of articulation with the superior vertebra.
  • The anterior longitudinal ligament limits extension.
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Lecture 29: Spinal Cord (A. Ricci)

Essay - Handwritten Prose. 10 Points.

  • Essay Question 1. A 34-year-old pregnant woman presents with severe lower back pain, motor and sensory deficits in the lower limb, saddle anesthesia, and sudden onset of incontinence. Radiographic examination indicates a herniated disc between L5 and S1 vertebrae. You diagnose her with cauda equina syndrome (CES). Discuss the anatomy of the conus medullaris and cauda equina. Briefly account for each of the patient’s symptoms.
  • Essay Question 2. A 60-year-old patient comes to your office with lower back pain and sensory deficits in the lower limbs. Radiographic examination indicates a herniated disc between T12 and L1 vertebrae, resulting in compression of the posterior column of the spinal cord. Discuss the white matter tract that is present in the posterior column of the spinal cord at the level of the injury. Include the name of the tract, the sensory system it carries, the regions of the spinal cord in which it is present, and if the fibers travel in the ipsilateral or contralateral tract of the spinal cord. Discuss the impact of this injury on gait and limb position.
  • Essay Question 3. A 75-year-old patient reports to the clinic with sudden, severe back and abdominal pain, shortness of breath, and difficulty walking. A CT scan revealed that the patient has an abdominal aortic dissection, causing ischemia of the anterior spinal artery. What portions of the spinal cord are supplied by the anterior spinal artery? Describe the pathway and function of the lateral corticospinal tract.

True/False. 1 Point Each.

  • The dorsal roots and rootlets carry sensory input into the dorsal gray horn of the spinal cord.
  • The spinal cord ends between vertebral levels L1 and L2.
  • The gracile tract is present at all spinal levels, while the cuneate tract is only present at spinal levels T6 and above.
  • The gracile tract is an ascending sensory tract that carries proprioception, vibration, and discriminative/fine touch from the upper limb.
  • The anterolateral system carries pain, temperature, and light touch from the entire body to the primary somatosensory cortex.
  • Injury to the lateral corticospinal tract in the spinal cord would result in motor deficits in the contralateral limb.
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Lecture 30: Scapular Region (R. Saint-Fort)

Essay - Handwritten Prose. 10 Points.

  • Essay Question 1. A 22-year-old pitcher presents with an anteroinferior dislocated shoulder. The shoulder joint has extreme mobility at the sacrifice for stability. Much of the support for the glenohumeral joint is derived from soft tissues. Discuss the supportive structures that reinforce the stability of the glenohumeral joint.
  • Essay Question 2. A 30-year-old male presents with suprascapular nerve (SSN) entrapment at the suprascapular notch. Recall that the suprascapular artery accompanies the nerve and travels over the superior transverse scapular ligament. Discuss the scapular anastomosis. Include the arterial branches that contribute to the shoulder anastomosis and explain how the blood flow is altered when the axillary artery is ligated proximal to the subscapular artery.

True/False. 1 Point Each.

  • The coracoacromial ligament is considered a false ligament and forms the superior boundary of the supraspinatus canal.
  • Under non-pathological conditions, the subscapular bursa is a diverticulum of the synovial membrane and communicates with the glenohumeral joint.
  • Rotator cuff injury of the subscapularis m. can cause the inability to initially abduct the arm from 0-15 degrees.
  • The profunda brachii a. and radial n. pass through the triangular space to traverse into the posterior compartment of the arm.
  • If the axillary a. is ligated proximal to the subscapular artery there will be retrograde flow in the circumflex scapular artery.
  • Improper use of crutches can lead to axillary n. injury due to the nerve’s relationship to the surgical neck of the humerus.
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Lecture 31: Breast, Pectoral Region, and Axilla (M. Olsen, C. Werner)

Essay - Handwritten Prose. 10 Points.

  • Essay Question 1. A professional baseball player is clocked throwing a 92mph fastball during practice. The rapid arm movement, however, causes an axillary artery aneurysm. Recall that the axillary artery is one of several contents of the axilla. Discuss the anatomy of the axilla, including boundaries and contents. Be sure to describe the axillary artery and its branches.
  • Essay Question 2. A thirty one year old female was diagnosed with breast cancer. Account for the spread of breast cancer by way of contiguity (spread to adjacent tissue) to the lung and lymphogenous spread. Include in your answer how internal structures of the breast tissue could be impacted due to the cancerous mass.

True/False. 1 Point Each.

  • The following muscles attach to the lateral lip, floor, and medial lip of the intertubercular sulcus, respectively: pectoralis minor, latissimus dorsi, and teres major.
  • The pectoralis major muscle is innervated by the medial and lateral pectoral nerves, while the pectoralis minor muscle is only innervated by the lateral pectoral nerve.
  • Clavipectoral fascia invests the subclavius and pectoralis minor muscles.
  • Axillary fascia, which is formed by contributions from the pectoral and clavipectoral fascia, is the base of the axilla.
  • The anterior axillary fold is formed by the inferolateral border of the pectoralis major muscle, while the posterior axillary fold is formed by the lateral borders of latissimus dorsi and teres minor.
  • The axillary artery extends from the lateral border of rib 1 to the inferior border of the teres major muscle.
  • The second part of the axillary artery is located deep to the pectoralis minor muscle.
  • The anterior and posterior circumflex humeral arteries form an anastomotic ring around the anatomical neck of the humerus.
  • The clavicular branch of the thoracoacromial artery contributes to the shoulder anastomosis.
  • The basilic vein passes through the deltopectoral triangle to drain into the axillary vein.
  • The tendon of the long head of the biceps brachii muscle is a content of the axilla.
  • The long thoracic artery branches from the second part of the axillary artery.
  • The axillary tail of spence is located in the superolateral quadrant of the breast.
  • The right and left breast have lymphatic drainage communication by way of the parasternal lymph nodes.
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Lecture 32: Brachial Plexus (D. Rasicci)

Essay - Handwritten Prose. 10 Points.

  • Essay Question 1. A 42-year-old cowboy reports to your clinic after being thrown from his horse. His chief concerns are weakness of his upper limb, accompanied by numbness in his posterolateral arm and forearm. At rest, his affected side assumes a “waiter’s tip position,” in which his arm is adducted and medially rotated, with an extended elbow and flexed wrist. Discuss the anatomy of the brachial plexus. Describe the likely mechanism of injury. Account for the patient’s symptoms, citing nerves involved, their innervations, and the actions of these muscles.
  • Essay Question 2. An 81-year-old woman with osteoporosis is rushed to the ED after suffering a fall. Radiography reveals a fracture of the surgical neck of her humerus. Describe the terminal branch of the brachial plexus that is at highest risk of nerve damage with this fracture, including expected motor and sensory deficits. Compare deficits associated with this injury with fractures at both a) the humeral shaft and b) the medial epicondyle of the humerus.

True/False. 1 Point Each.

  • A pre-fixed brachial plexus is formed from roots C6-T2.
  • The suprascapular nerve is a side branch of the upper trunk that will innervate the supraspinatus and infraspinatus muscles.
  • Divisions of the brachial plexus are named based upon their relationship to the axillary artery.
  • Injury to the long thoracic nerve may present clinically as ”winging” of the scapula.
  • Inferior dislocation of the glenohumeral joint may result in injury to the axillary nerve.
  • The lateral and medial pectoral nn. communicate via the ansa cervicalis.
  • With regard to fractures of the humerus, radial nerve injury is associated with a surgical neck fracture, whereas axillary nerve injury is associated with the humeral shaft.
  • A patient with ”Saturday night palsy” may present with wrist drop and paresthesia of the posterior arm and forearm due to compression of the radial nerve.
  • The teres major muscle is innervated by both the upper and lower subscapular nerves.
  • Erb-Duchenne palsy is associated with upper brachial plexus injury, whereas Klumpke’s palsy is associated with lower brachial plexus injury.
  • Prolonged compression of the median nerve in the carpal tunnel may result in ape hand deformity, as well as the hand of benediction when a patient is instructed to make a fist.
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Lecture 33: Arm and Cubital Fossa (A. Ricci)

Essay - Handwritten Prose. 10 Points.

  • Essay Question 1. A 21-year-old college pitcher presents to the clinic with shoulder pain. Upon examination, you diagnose the patient with biceps tendinitis in the long head of the biceps brachii as it courses through the intertubercular groove/sulcus. Discuss the anatomy of the biceps brachii and other muscles in the anterior compartment of the arm, including attachments, innervation, and vasculature.
  • Essay Question 2. You are drawing blood from a 24-year-old for a blood test. You puncture the median cubital vein as it overlies the cubital fossa to draw blood. Discuss the contents of the cubital fossa, including tendons, nerves, and blood vessels.

True/False. 1 Point Each.

  • The cephalic vein courses through the deltopectoral groove.
  • The musculocutaneous nerve pierces the coracobrachialis muscle and innervates the muscles of the anterior compartment of the arm.
  • The brachialis muscle functions to flex the shoulder.
  • All three heads of the triceps brachii muscle cross the shoulder joint.
  • The ulnar nerve is a content within the cubital fossa.
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Lecture 34: Forearm (G. Kincheloe)

Essay - Handwritten Prose. 10 Points.

  • Essay Question 1. A patient enters the Emergency Department with a knife wound superior to the cubital fossa. The median nerve is lacerated. Describe the effects of this injury. Include muscles of the forearm and hand, potential weakened actions, sensory deficits, and position of the fingers after the patient is asked to make a fist.
  • Essay Question 2. A patient enters the Emergency Department after landing on their arm in a bicycle accident. The radial nerve has been damaged by a fracture at the radial groove of the humerus. What affects would this have on the muscles and movements of the forearm? Be sure to include resting position of the hand and potential sensory deficits in your answer.

True/False. 1 Point Each.

  • The median nerve pierces the supinator muscle during its course in the forearm.
  • The ulnar nerve will travel between the two heads of the extensor carpi ulnaris during its course in the forearm.
  • Damage to the median nerve proximal to its innervation to the flexor carpi radialis will result in ulnar deviation upon flexion of the wrist.
  • The medial half of the flexor digitorum profundus muscle is innervated by the median nerve.
  • The brachioradialis muscle is a strong flexor of the forearm.
  • Extensor digitorum muscle is innervated by the deep branch of the radial nerve.
  • The anterior interosseus artery provides the distal part of the posterior forearm with blood.
  • The common interosseus artery is a branch of the radial artery.
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Lecture 35: Hand (C. Werner)

Essay - Handwritten Prose. 10 Points.

  • Essay Question 1. A 40-year-old male assembly line worker presents with carpal tunnel syndrome due to excessive wrist flexion at work. Describe the anatomy of the carpal tunnel and account for the sensory and muscular deficits in the hand due to the nerve compression.
  • Essay Question 2. An excessive bicyclist started having symptoms due to compression of Guyon’s canal. Discuss the anatomy of Guyon’s canal and account for the clinical presentation in the hand (Claw Hand) if there was continuous damage to the nerve at this location.

True/False. 1 Point Each.

  • The anatomical snuffbox contains the radial artery, extensor carpi radialis longus tendon, dorsal carpal branch of radial artery, and superficial branch of radial nerve.
  • If there is ulnar nerve damage and the individual presents with Claw Hand, the individual will have more severe clawing if the injury to the ulnar nerve occurs at the elbow compared to injury at the wrist.
  • The superficial palmar arch is located distal to the deep palmar arch in the hand.
  • The opponens pollicis muscle has no compensation for its loss.
  • The adductor pollicis muscle contributes to the thenar eminence of the hand.
  • The interossei and lumbrical muscles are synergistic.
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Lecture 36: Joints of the Upper Limb (N. Yoshioka)

Essay - Handwritten Prose. 10 Points.

  • Essay Question 1. A 35 year old male patient arrives at your clinic with an anterior shoulder dislocation following a car accident. Discuss the anatomy and support of the glenohumeral joint to explain how the injury may have occured. Include in your response relevant bones, tendons, ligaments, and musculature. Before performing the joint reduction, explain why you would test the skin superficial to the deltoid for cutaneous sensation.
  • Essay Question 2. A 27 year old pitcher arrives at your clinic with medial elbow pain due to repetitive and forceful throwing motions. Describe the anatomy and stability of the elbow, including joints, bony articulations, and ligamentous support.

True/False. 1 Point Each.

  • The coracoid process is the site of attachment for 3 muscles and 4 ligamentous structures in total.
  • The coracoacromial ligament supports the acromioclavicular joint against superior displacement and can be compromised with shoulder separations.
  • Testing the posterior cutaneous nerve of the arm assesses the integrity of the radial nerve, which can be compromised with inferior GH dislocations.
  • “SLAP” lesion stands for Superior Lateral Anterior to Posterior tear of the long head of the biceps tendon at the supraglenoid tubercle.
  • The subacromial bursa is continuous with the synovial cavity of the glenohumeral joint, deep to the tendon of supraspinatus.
  • The proximal radioulnar joint is a hinge joint which allows for flexion/ extension at the elbow.
  • The radial collateral ligament limits adduction of the elbow.
  • The annular ligament inserts onto the head of the radius.
  • The radius is the only bone of the forearm which articulates with the scaphoid bone.
  • The articular disc of the TFCC limits wrist adduction and sits between distal ulna and the triquetrum.
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About the Written Examination and the Question Pool

  • Laboratory Examination: Monday, September 21, 2020: 1:00 - 2:15 (1 hr 15 min = 75 Min, 90 Sec per Identification)
  • The laboratory examination will be worth 100 points.
    • 50 Identifications
    • 90 Seconds per Identification
    • Clipboards and answer sheet will be provided (bring pencil)
    • Touching is acceptable pending instructions on the answer answer card.
    • Dissection is not allowed. We want the question to be the same for everyone.
  • Written Examination: Monday, September 21, 2020: 2:30 - 5:30 (3 hrs = 180 Min, 18 min per question for 10 questions)
  • The written examination will be worth 100 points.
    • 10 pts of radiography identification (Dr. French). Radiographs are on website.
    • 10 pts True/False (Dr. Evey and Teaching Assistants). True/False examples are on website.
    • 80 pts of written essay. (Dr. Evey and Teaching Assistants). Essay question pool is on website.
    • Essay answers shall be handwritten in prose.
  • Grading
    • The written examination will not be graded according to keywords. A demonstration of understanding is requested.
    • Your essay answers should be written, not as recall of rote memorization, but as a stand-alone communication to a colleague or patient.
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Topic revision: r3 - 09 Nov 2020, LorenEvey
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