Essay - Handwritten Prose. 10 Points.

• Essay Question #1: A 55-year-old male has complaints of numbness, burning, and tingling of the superolateral thigh. The history and physical examination reports that the patient gained 40 pounds during the past year. A pendulous abdomen is observed. Meralgia paresthetica is diagnosed. Discuss the anatomy of the lateral femoral cutaneous nerve. Explain the difference between peripheral nerve entrapment and spinal nerve entrapment with regard to sensory deficits. How might the patient’s recent weight gain contribute to his condition?
• Essay Question #2: A 70-year-old woman is having knee surgery and the anesthesiologist is looking to anesthetize the saphenous nerve. Upon post-operative recovery the patient has a difficult time walking, even though the surgeon says there were no surgical complications. Discuss the anatomy of the adductor canal and the clinical ramifications if the anesthesiologist were to anesthetize too proximal within the adductor canal.
• Essay Questions #3: A 58-year-old female enters the emergency room, describing pain upon hip extension in the region of her inguinal ligament. Upon further examination, clinicians determine that she has a severe femoral hernia. Discuss the anatomy of the femoral canal and the saphenous opening within the context of a femoral hernia.

True/False. 1 Point Each.

• Question.

Essay - Handwritten Prose. 10 Points.

• Essay Question #1: A clinician administers an intragluteal injection on a 72-year-old patient and two weeks later, this individual develops Trendelenburg gait. Discuss why the superior lateral gluteal quadrant is preferable for an injection site relative to each of the remaining 3 quadrants. Describe the anatomical pathway of the superior gluteal nerve, including musculature, and the functional deficits and compensation(s) resulting from injury to this nerve.
• Essay Question #2: Strain of the hamstring muscles is common in runners, and alteration of hamstrings is important in disease such as spastic cerebral palsy. Discuss the anatomy of the hamstring muscles including criteria for inclusion, innervation, vascularization, and function.

True/False. 1 Point Each.

• In regard to the gluteal region: the pudendal nerve passes through the greater sciatic foramen to enter the gluteal region from the pelvis.
• In regard to the gluteal region: the gluteus maximus inserts onto the gluteal tuberosity and the iliotibial tract.
• In regard to the posterior thigh: the biceps femoris, semitendinosis, and semimembranosus are all considered true hamstring muscles.

Essay - Handwritten Prose. 10 Points.

• Essay Question #1: A 42-year-old female comes to your clinic reporting of knee pain that is heightened with knee extension. Upon examination you observe a swelling in the popliteal fossa. Radiographic imaging indicates a Baker’s (popliteal) cyst. Describe the boundaries and contents of the popliteal fossa including vasculature and lymphatics, nerves, ligaments, muscles and cutaneous innervation.
• Essay Question #2: A 30-year-old stepped into a hole and tripped, tearing their calcaneal (Achilles) tendon. Upon examination and radiographic imaging, you determine there is a partial tear in the calcaneal tendon. Discuss the anatomy of the muscles that form the calcaneal tendon, including location, function, innervation, vasculature, and lymphatic drainage.

True/False. 1 Point Each.

• Biceps femoris creates the superomedial boundary of the popliteal fossa.
• The middle genicular artery pierces the oblique popliteal ligament.
• The tibial nerve innervates all muscles in the posterior compartment of the leg.

Essay - Handwritten Prose. 10 Points.

• Essay Question #1: A 16-year-old hockey player reports that a hockey puck struck him in the region of the fibular neck. His chief complaint is an inability to dorsiflex his ankle. Cutaneous sensation to most of the dorsum of the foot is intact, but he has diminished sensation at the web between first and second toes. Discuss the anatomy of the common fibular nerve. What is your diagnosis? What is the expected resting position of the foot? Discuss gait compensation. Account for sensory deficits.
• Essay Question #2: A 33-year-old female is referred to your clinic after recently having completed a marathon with minimal training (i.e. “weekend warrior”). She presents with sharp pain, tingling, and paresthesia in the web between the first and second digit. You detect an absent dorsalis pedis pulse and diagnose the patient with anterior compartment syndrome. Discuss the anatomy of the anterior compartment of the leg, including why the anterior compartment is particularly prone to compartment syndrome. In your response, explain the significance of the physical examination described above, as well as potential surgical intervention.

True/False. 1 Point Each.

• The common fibular nerve splits as it courses around the fibular neck.
• The deep fibular nerve innervates the lateral compartment of the leg, and the superficial fibular nerve innervates the anterior compartment of the leg.
• The deep fibular nerve courses adjacent to the anterior tibial artery in the anterior compartment of the leg.
• Fibularis brevis is superficial to fibularis longus in the lateral compartment of the leg.
• Fibularis longus courses posterior to the lateral malleolus and inferior to the cuboid bone before coursing medially on the plantar aspect of the foot.
• The anterior compartment is subject to compartment syndrome due to its rigid borders of the tibia, the interosseus membrane, the anterior intermuscular septum, and the crural fascia.
• Injury to the deep fibular nerve may cause foot drop, a condition in which the inability to concentrically or eccentrically activate the anterior compartment musculature results in gait deficits.
• To overcome foot drop, patients often employ a “high steppage gait” in which they exhibit excessive flexion at the hip and knee.
• Fibularis tertius is the third muscle of the lateral compartment of the leg.
• With regard to compartment syndrome, diminished or absent dorsalis pedis pulse usually suggests vascular insufficiency of the anterior compartment.
• In the dorsum of the foot, the extensor expansion is a specialized connective tissue by which the extensor tendons insert into the phalanges.
• Regarding cutaneous distributions, the deep fibular nerve is associated with the web between the 2nd and 3rd digits.

Essay - Handwritten Prose. 10 Points.

• Essay Question #1: A 46 year old carpenter stepped on a nail that penetrated the medial sole of the foot and pierced the spring ligament. Discuss the fascia, muscles, tendons, nerves, bones, and vasculature at risk with this injury. Discuss the support of the medial longitudinal arch.
• Essay Question #2: Forced inversion at the ankle joint may injure structures that support the lateral side of the ankle joint. Discuss the associated damaged structures, including discussion on the malleolar anastomosis.

True/False. 1 Point Each.

• The cutaneous sensation to nail beds of the foot is supplied by proper plantar digital nerves.
• The main blood supply to the dorsalis pedis artery is always the anterior tibial artery.
• The dorsalis pedis artery can be palpated between the tendons of extensor digitorum longus and extensor hallucis longus, proximal to the talocrural joint.
• The medial and lateral plantar arteries anastomose deep to adductor hallucis to form the deep plantar arch.
• The medial plantar nerve supplies the majority of cutaneous sensation and muscular innervation in the plantar aspect of the sole of the foot.

Essay - Handwritten Prose. 10 Points.

• Essay Question: A 22 year old male unexpectedly falls 15 feet because of a rock climbing accident. The patient reports landing on his feet with straightened legs before falling over to his left side. No laceration or abrasion is observed, but there is marked deformity of the left ankle joint. Discuss the anatomy of the ankle joint including bones, muscles, and ligaments. Compare and contrast inversion and eversion injuries with regards to anatomy, as well as their relative prevalance. Discuss neurovasculature that is at risk during either inversion or eversion fracture-dislocations.

True/False. 1 Point Each.

• The only major movements that occur at the talocrural joint are plantarflexion and dorsiflexion.
• To obtain a mortise view radiograph of the talocrural joint, the patient's lower extremity must be externally rotated 15-20 degrees.
• Standing on a slope with the left foot uphill, the right foot is in inversion and the left foot is in eversion.
• The anterior talofibular ligament is part of the deltoid ligament.
• During an inversion injury, the deltoid ligament is primarily at risk for sprain.
• The stance phase of gait begins with heel strike and ends with toe off.
• To achieve a greater speed of locomotion, humans shift their pattern of gate from plantigrade to digitigrade, running on only the distal phalanges of each foot.

Essay - Handwritten Prose. 10 Points.

Essay Question #1: An 18 year old football player is tackled during a football game. He falls to the ground holding his left knee. When reviewing the video replay of the tackle, it is noted that he was struck on the posterior lateral aspect of the knee. On exam, he has "a positive anterior drawer sign" (forward sliding of tibia) and tenderness and laxity (relaxation/looseness) of the medial joint space of the knee when valgus (bending/twisting) stress is placed on it. Discuss the anatomy of the knee joint. Include bones, cartilage, ligaments, muscles, bursa, vascular supply, innervation, stabilization, center of gravity, and locking/unlocking of the knee joint.

• • Answer Guide
• Essay Question #2: The passenger of a sports car was thrown forward during an acute decelleration. A posterior dislocation of the hip joint was confirmed by a radiologic study. Discuss the anatomy of the hip joint. Include an account of the innervation, vascular supply, muscles, ligaments, bones and articulations, movements and limitations of movements, and stability.
  • Answer Guide

True/False. 1 Point Each.

• The hip joint is most stable in extension.
• The popliteus muscle, when the leg is fixed, laterally rotates the femur.

Essay - Handwritten Prose. 10 Points.

• Essay Question #1: A 45-year-old male has a compound fracture of the leg after involvement in a serious car accident. As a result, a blood clot travels through the heart and obstructs the pulmonary artery (pulmonary embolism). Recall that the pulmonary artery is one of several root of the lung structures that enter the lung at the hilum. Discuss the anatomy of the hilum. Be sure to describe structures that are entering/exiting both the right and left lungs at the hilum.
• Essay Question #2: A 30-year-old female with a history of smoking presents to the E.R. with sudden onset of sharp chest pain and shortness of breath. Upon physical exam, tracheal deviation is observed and decreased breath sounds noted upon auscultation of the right hemithorax. Pneumothorax is confirmed by radiographic imaging, and thoracocentesis is performed. Describe the layers of the thoracic wall punctured during thoracocentesis. Discuss pertinent anatomical relationships in your answer.

True/False. 1 Point Each.

• The costovertebral joint that connects rib 5 to the vertebral column includes the articulation of the superior articular facet and the superior costal facet (of the T5 vertebra) and the articulation of the inferior articular facet and the inferior costal facet (of the T5 vertebra).
• The articulation of a costal cartilage with the sternum is called the sternochondral joint, while the attachment of a rib to its costal cartilage is called the costochondral joint.
• The boundaries of the superior thoracic aperture (thoracic inlet) include: T1 vertebral body, medial margins of both first ribs, and the superior margin of the xiphoid process (of the sternum).
• Along the midaxillary line, the three muscles of the intercostal spaces, from superficial to deep, are: the external intercostal muscle, the internal intercostal muscle, and the tranversus thoracis muscle.
• The intercostal vein is superior to the intercostal artery within the costal groove.
• The tenth anterior intercostal artery is a branch of the internal thoracic artery.
• The lateral cutaneous branch of the third intercostal nerve is called the intercostobrachial nerve.
• Superior to the thoracic inlet, the cupula of the pleura is superficial to the suprapleural membrane (Sibson’s fascia).
• The costodiaphragmatic recess separates the costal and diaphragmatic parietal pleura.
• The cardiac notch is located along the anterior margin of the right lung.
• The left superior lobar bronchus is also known as the eparterial bronchus.
• The bronchopulmonary lymph nodes are located at the hilum of the lung.

Essay - Handwritten Prose. 10 Points.

• Essay Question #1: An eight months pregnant woman comes in to the clinic with concerns regarding shortness of breath. Describe the mechanics of respiration. Be sure to include muscles, bones, joints, and pleura in your answer.

True/False. 1 Point Each.

• The upper ribs perform the bucket handle respiratory movement.
• The lower ribs perform the bucket handle respiratory movement.
• Visceral pleura is attached to the thoracic wall by endothoracic fascia.
• A thoracocentesis will pierce the visceral pleura.
• The diaphragm is contracted during forced expiration.
• Muscle relaxation and lung elastic recoil drives resting expiration.
• In non-pathological conditions, the abdominal muscles aid in resting expiration.
• The pleural cavity should contain nothing but serous fluid.
• The fifth rib will articulate with the fifth vertebra twice and the sixth vertebra once.
• Ribs 8-10 are floating ribs.
• All 12 pairs of ribs articulate with the sternum via costal cartilages.

Essay - Handwritten Prose. 10 Points.

A patient that recently recovered from an open-heart procedure is brought to the hospital after experiencing a sudden onset of chest pain, shortness of breath and pain in the supraclavicular region. An echocardiogram reveals fluid accumulation around the heart and the patient is diagnosed with acute cardiac tamponade.

Essay Question 1: Describe the layers, boundaries and contents of the pericardium including vasculature, nerves and how the layers form the pericardial cavity and sinuses.

Essay Question 2: The above patient undergoes a pericardiocentesis. As the needle is inserted, describe the layers penetrated on its course into the pericardial cavity including relationships, vasculature, nerves and lymphatics.

True/False. 1 Point Each.

• The heart is within the pericardial sac but not within the pericardial cavity.
• The oblique pericardial sinus is bounded laterally by the pulmonary veins.
• The parietal layer of serous pericardium is reflected onto the root of the aorta as arterial mesocardium.
• The fibrous pericardium is continuous inferiorly with the central tendon of the diaphragm as the pericardiacophrenic ligament.
• The superior boundary of the middle mediastinum is the transverse thoracic plane.

Essay - Handwritten Prose. 10 Points.

-Essay Question #1: Heart disease is the leading cause of death, accounting for one in every four deaths. Describe the anatomy of the internal heart. Include descriptions of each heart chamber, and the anatomical specializations found within them that support proper flow of blood.

-Essay Question #2: Blockage of the left coronary artery has been referred to as the “widow maker.” Describe the distribution and relationships of the left coronary artery. What regions of the heart are compromised by left coronary arterial stenosis? What is the clinical significance of a right versus left dominant heart in regards to myocardial infarction involving the left coronary artery?

True/False. 1 Point Each.

• Is it true that this is false.

Essay - Handwritten Prose. 10 Points.

• Essay Question #1: Upon dissection, a group of PA students discover a tumor in the posterior mediastinum. Discuss structures, nerves, viscera, lymphatics, vasculature, relationships and boundaries of the posterior mediastinum.
• Essat Question #2: Ischemia of the myocardium may cause referred pain along the medial side of the left arm. Give a general account of referred pain.* What nervous pathways may link the heart to the medial arm?*

True/False. 1 Point Each.

• In regard to the posterior mediastinum: the anterior border is the pericardial sac and diaphragm
• In regard to the posterior mediastinum: the greater splanchnic nerve and lesser splanchnic nerve are contents, but the least splanchnic nerve is not.

• 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.