A professional musician visits his physician after a morning concert. He complains of painless swelling in his right cheek when he plays his tuba. Physical examination of the patient reveals slight facial asymmetry due to minor swelling on the right side of the face. The skin over the swelling is smooth without any secondary changes. Palpation reveals a soft and non-tender swelling. The oral opening is normal without any trismus. Further examination reveals swelling of the left buccal mucosa extending from the first to the third molar. Bedside ultrasound shows small areas of high echogenicity consistent with pneumoparotid. Which nerve is associated with motor function to prevent air from entering the affected duct in this patient?
A. V2 – Maxillary nerve
B. V3 – Mandibular nerve
C. CN VII – Zygomatic branch
D. CN VII – Buccal branch
E. CN VII – Marginal mandibular branch
A 59-year-old truck driver presents to the emergency department after returning from his usual week-long trucking trip with excruciating pain around his anus. The patient admits to drinking beer when not working and notes that his meals usually consist of fast food. He has no allergies, takes no medications, and his vital signs are normal. On examination, he was found to have a tender lump on the right side of his anus that measures 1 cm in diameter. The lump is bluish and surrounded by edema. It is visible without the aid of an anoscope. It is soft and tender with palpation. The rest of the man’s history and physical examination are unremarkable. Which vein drains the vessels responsible for the formation of this lump?
A. Internal hemorrhoids
B. Internal pudenal
C. Inferior mesenteric
D. Superior rectal
E. Middle rectal
A 31-year-old woman presents to the clinic with shortness of breath, palpitations, and fatigue. She has had these symptoms over the last several weeks. She had been tolerating these symptoms until last night when she could not fall asleep due to palpitations. She has a past medical history of infective endocarditis 6 months ago that was successfully treated with antibiotics. She does not smoke or drink alcohol. Her blood pressure is 138/89 mm Hg and her pulse is 76/min and regular. The cardiac exam reveals a soft S1, S3 gallop, a hyperdynamic apex beat, and a pansystolic murmur that radiates to the axilla on auscultation. Echocardiography reveals incompetence of one of the valves. Which of the following sites is the best position to auscultate this defect?
A. Right lower end of the body of the sternum
B. 4th intercostal space at the midclavicular line on the left side
C. Medial end of the 2nd intercostal space on the right side
D. 5th intercostal space at the midclavicular line on the left side
E. Medial end of the 2nd intercostal space on the left side
A 72-year-old woman presents with left lower limb swelling. She first noticed her left leg was swollen about 2 weeks ago. She denies any pain and initially thought the swelling would subside on its own. Past medical history is significant for hypertension and hyperlipidemia. She is a smoker with a 35 pack-year history and an occasional drinker. She takes chlorthalidone, lisinopril, atorvastatin, and a multivitamin. On physical examination, her left leg appears larger than her right with 2+ pitting edema up to her knee. She also has a few distended superficial veins along the posterior aspect of her left leg. Lower extremities have 2+ pulses bilaterally. The ultrasound of her left lower thigh and leg shows an obstructing thrombosis of the distal portion of the femoral vein. Which of the following veins help to prevent this patient’s condition from happening?
A. Giacomini vein
B. Perforator veins
C. Accessory saphenous vein
D. Deep femoral vein
E. Fibular vein
An 86-year-old woman is brought to the emergency department by her niece because the patient felt like she was spinning and about to topple over. This occurred around 4 hours ago, and although symptoms have improved, she still feels like she is being pulled to the right side. Her vital signs include: blood pressure 116/75 mm Hg, pulse 90/min, and SpO2 99% on room air. Physical examination reveals right-sided limb ataxia along with hypoalgesia and decreased temperature sensation on the right side of the face and left side of the body. An urgent noncontrast CT scan of the head shows no evidence of hemorrhage. What other finding is most likely to be present in this patient?
A. Hemiparesis
B. Deviated tongue
C. Hemianopia
D. Intact cough reflex
E. Absent gag reflex
A 50-year-old man presents to his primary care provider complaining of double vision and trouble seeing out of his right eye. His vision started worsening about 2 months ago and has slowly gotten worse. It is now severely affecting his quality of life. His past medical history is significant for poorly controlled hypertension and hyperlipidemia. He takes amlodipine, atorvastatin, and a baby aspirin every day. He smokes 2–3 cigarettes a day and drinks a glass of wine with dinner every night. Today, his blood pressure is 145/85 mm Hg, the heart rate is 90/min, the respiratory rate is 14/min, and the temperature is 37.0°C (98.6°F). On physical exam, he appears pleasant and talkative. His heart has a regular rate and rhythm and his lungs are clear to auscultation bilaterally. Examination of the eyes reveals a dilated left pupil that is positioned inferolateral, with ptosis. An angiogram of the head and neck is performed and he is referred to a neurologist. The angiogram reveals a 1-cm berry aneurysm at the junction of the posterior communicating artery and the posterior cerebral artery that is impinging on and compressing the ocular nerve. Which of the following statements best describes the mechanism behind the oculomotor findings seen in this patient?
A. The parasympathetic nerve fibers of this patient’s eye are activated.
B. The unopposed superior oblique muscle rotates the eye downward.
C. The unopposed inferior oblique muscle rotates the eye downward.
D. The sympathetic nerve fibers of this patient’s eye are inhibited.
E. The unopposed medial rectus muscle rotates the eye in the lateral direction.
The newborn of a mother with poor antenatal care is found to have a larger-than-normal head circumference with bulging fontanelles. Physical examination reveals a predominantly downward gaze with marked eyelid retraction and convergence-retraction nystagmus. Ultrasound examination shows dilated lateral ventricles and a dilated 3rd ventricle. Further imaging studies reveal a solid mass in the pineal region. Which of the following is the most likely finding for this patient?
A. Normal lumbar puncture opening pressure
B. Stenotic intraventricular foramina
C. Dilated cisterna magna
D. Compression of periaqueductal gray matter
E. Hypertrophic arachnoid granulations
A 40-year-old woman is brought to the emergency department by a paramedic team from the scene of a motor vehicle accident. The patient was the vehicle driver at the time of the accident and was restrained by a seat-belt, and was unconscious at the scene. Physical examination reveals multiple injuries involving the trunk and extremities. However, there are no penetrating injuries to the chest. As part of her trauma workup, a CT scan of the chest is ordered. At what vertebral level of the thorax is this image most likely from?
A 55-year-old woman is brought to the emergency department due to a sudden onset of retrosternal chest pain. An ECG shows ST-segment elevation. A diagnosis of myocardial infarction is made and later confirmed by elevated levels of troponin I. The patient is sent to the cardiac catheter laboratory to undergo percutaneous catheterization. She has 2 occluded vessels in the heart. The patient undergoes percutaneous coronary intervention to implant 2 stents in her coronary arteries, and the blood flow is successfully restored in the affected arteries. The patient complains of flank pain during post-procedure evaluation a few hours later. A significant drop in hematocrit is observed, as well as a decline in her blood pressure to 90/60 mm Hg. Physical examination reveals extensive ecchymoses in the flanks and loin as shown in the image. Which of the following conditions is this patient most likely experiencing?
A 67-year-old man presents to the office with complaints of abdominal pain. A trial of proton pump inhibitors that was started 5 weeks ago failed to alleviate the pain, which is described as dull, cramping, and worse during meals. The patient’s medical history is unremarkable. Physical examination is normal except for tenderness in the epigastric region. Endoscopy reveals an eroding gastric ulcer in the proximal part of the greater curvature of the stomach overlying a large pulsating artery. Which of the following arteries is most likely visible?
A. Common hepatic artery
B. Left gastric artery
C. Right gastro-omental artery
D. Left gastro-omental artery
E. Superior pancreaticoduodenal artery
F. Cystic artery
G. Gastroduodenal artery
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