A 15-year-old boy comes for evaluation because of right knee pain that began gradually 6

months ago. He plays basketball for his high school team and says the pain worsens with activity
and subsides with rest. He has no other medical conditions and his family history is
unremarkable. The patient’s vital signs are within normal limits.  Physical examination shows
swelling, tenderness, and erythema of the anterior proximal leg. Pain is elicited with direct
pressure on the tibial tubercle and with forced resisted extension of the knee.

Which of the following is the most likely diagnosis?

A.Baker cyst
B.Osgood-Schlatter disease
C.Patellar tendon rupture
D.Patellofemoral syndrome
E.Pes anserine bursitis
F.Prepatellar bursitis

A 15-year-old boy comes to the emergency department with a three-hour history of acute scrotal
swelling and pain. He has had several episodes of emesis and significant nausea. The patient has
no fever, chills, lower urinary tract symptoms, or urethral discharge and is not sexually active.
He is otherwise healthy. On physical examination, the scrotum is swollen and tender to
palpation. Light stroking of the proximal and medial thigh does not elicit a reflex response.

The muscle involved in this patient’s absent reflex is derived from which of the following
abdominal wall layers?

External oblique
check
B.Internal oblique
C.Pyramidalis
D.Rectus abdominis
E.Transverse abdominal

A young man presents to the emergency department with severe head trauma following a fight.
He is admitted and evaluated. A day later, he reports that he is feeling better but complains that
he is having difficulty eating, particularly with opening his mouth and chewing. He has no
difficulty sipping fluids with a straw and has a symmetric smile and tongue movement. The
patient is able to speak normally.

Damage to which of the following cranial nerves would best explain his condition?

A.CN V1
B.CN V2
C.CN V3
D.CN VII
E.CN X
F.CN XII

A 74-year-old man involved in a motor vehicle accident is brought to the emergency department
via ambulance. He is in stable condition on arrival and reports persistent and worsening left
shoulder pain. Passive movement of the shoulder elicits severe pain. The patient demonstrates
good hand grip with active motion. Examination reveals difficulty abducting the left shoulder.
There are mild sensory deficits over the inferior aspect of the deltoid muscle. X-ray of the left
shoulder discloses a fracture of the surgical neck of the humerus.

Which of the following locations shows where the injury most likely responsible for this
patient’s physical findings can be found?

A.A
B.B
C.C
D.D
E.E
A 17-year-old man comes to his physician with what he describes as “shooting pain” in his right
hand. He says the problem started 2 months ago, after he had a snowboarding accident in which
he directly struck a tree with his arms raised. On examination, he is noted to have decreased
sensation over the medial aspect of his right palm, as well as atrophy of the hypothenar
eminence. He is also unable to maintain finger abduction against resistance.

Which part of the brachial plexus is most likely injured in this patient?

A.Lateral cord
B.Lower trunk
C.Middle trunk
D.Posterior cord
E.Upper trunk

A 50-year-old woman who works as a secretary comes to the physician because of numbness and
tingling in her hands. She has no significant medical history. Physical examination reveals
decreased sensation in all of her fingers except the small finger and thenar eminence of each
hand. Muscle strength is intact and range of motion is normal. Reflexes are 2+ throughout.
Flexion of the palm at the wrist reproduces the symptoms in her hands.

Which of the following muscles is most commonly weakened in patients with this condition in
the long term?

A.Adductor pollicis
B.Dorsal interossei
C.Lumbricals (3rd/4th)
D.Opponens digiti minimi
E.Opponens pollicis

A 16-year-old boy is brought to the emergency department after injuring his left arm when he
fell out of a tree. He rates the pain as a 7 out of 10. Pulse is 80/min, respirations are 15/min, and
blood pressure is 115/80 mm Hg. Physical examination reveals tenderness to palpation over the
left shoulder, and limited range of motion at the shoulder including loss of abduction and
decreased flexion. His arm dangles at his side, with the forearm pronated and extended at the
elbow. Sensation is absent along his left lateral forearm.

Which of the following structures is most likely injured?

A.Axillary nerve
B.C5-C6 nerve roots
C.C8-T1 roots
D.Long thoracic nerve
E.Lower trunk
F.Radial nerve
G.Ulnar nerve

A 45-year-old woman who is a pianist comes to the physician because of pain and a tingling
sensation in both of her hands that started 3 weeks ago. These symptoms worsen at night and are
sometimes relieved by shaking her hands vigorously. On examination, her thenar muscles appear
atrophied and there is loss of sensation on the palmar aspect of the second digit of both hands.
She reveals that her colleague at work also had similar symptoms that required her to be
medicated with NSAIDs. What additional information would help confirm the suspected
diagnosis?

A.Atrophied hypothenar eminence

B.Loss of sensation in the ventral aspect of the medial wrist
C.Loss of sensation of skin overlying the anatomic snuffbox
D.Loss of sensation of the medial aspect of the fourth digit
E.Loss of wrist extension
F.Tingling that feels like pins and needles

A 12-year-old boy is brought to the emergency department because of left hand pain. He fell on
his outstretched left hand while rollerblading and extended his wrist to break his fall. On physical
examination, wrist movements are painful; tenderness is noted on palpation of the anatomic
snuffbox. X-ray of the hand showed no obvious fracture, and the patient was discharged with a
splint. He returns 2 weeks later because the pain has not improved.

Which of the following is most likely to be observed on a repeat radiograph?

A.A dislocation of the lunate

B.A focal increase in opacity of the scaphoid
C.A fracture of the distal end of the radius with a distal fracture fragment displaced dorsally
D.A fracture of the distal end of the radius with a distal fracture fragment displaced ventrally
E.A fracture of the hook of the hamate

A 70-year-old woman sustains a fracture to the left femoral head after a fall.

Injury to which of the following arteries increases the risk of osteonecrosis in this patient?

A.Deep femoral artery

B.Inferior gluteal artery

C.Lateral femoral circumflex artery

D.Medial femoral circumflex artery

E.Obturator artery

A 22-year-old man presents to his physician because he is unable to raise his left arm. The
physician notes that the patient's arm is hanging at his side, with his forearm pronated. Upon
questioning, the patient states that he is an avid horseback rider and was recently thrown off his
horse. He landed on the lateral aspect of his left shoulder. On physical examination, the patient
has 1/5 strength in shoulder abduction.

In addition to the abductors at the shoulder, which of the following muscles are likely to be
affected by this injury?
A.Biceps brachii
B.Diaphragm
C.Extensor carpii radialis
D.Interossei
E.Pronator teres

A 21-year-old football player comes to the emergency department with significant pain in his left
shoulder and numbness in the lateral aspect of the joint. The patient is a quarterback and states
that the pain began after he was tackled from behind mid-throw. His medical history is
unremarkable. An x-ray film of his shoulder is shown in the image. No fractures are identified.

After he has received an appropriate intervention, the patient is found to have a nerve injury.
Which of the following motor deficits would he most likely experience?

A.Weakness in abducting his arm at the shoulder

B.Weakness in extending his wrist
C.Weakness in flexing his wrist
D.Weakness in horizontal flexion of his arm at the shoulder
E.Weakness in pronating his forearm

A 16-year-old gymnast is brought to the emergency department after landing awkwardly on her
ankle during dismounting from the uneven bars. She reports that she felt the sole of her foot roll
inward (overinverting her ankle as a result of a misaligned axial load). Since the injury, she is
able to invert her feet equally on both sides, and on physical examination of the injured ankle,
there appears to be swelling and erythema with bluish discoloration over the lateral aspect of the
joint. Sensation is intact, and dorsalis pedis and posterior tibial pulses are 2+ bilaterally. There is
tenderness to palpation at the anterolateral aspect of the ankle joint.

Which of the following ligaments has she most likely injured?

A.Anterior talofibular ligament

B.Calcaneofibular ligament
C.Talonavicular ligament
D.Tibiocalcaneal ligament
E.Tibiotalar ligament

A 20-year-old man is brought to the student health clinic after sustaining a knee injury during
rugby practice. He says he landed with a planted knee and was kicked by another player on the
lateral side of the knee. On examination of the injured knee, the tibia is displaced anteriorly from
the femur in the flexed position; there is laxity of the knee with valgus stress at 0 degrees of
flexion; and a click is heard when the patient’s knee is externally rotated and passively extended
from 90 degrees to 0 degree.

Which of the following structures are most likely injured?

A.Lateral collateral ligament, anterior cruciate ligament, medial meniscus

B.Lateral collateral ligament, posterior cruciate ligament, lateral meniscus
C.Medial collateral ligament, anterior cruciate ligament, medial meniscus
D.Medial collateral ligament, posterior cruciate ligament, lateral meniscus
E.Medial collateral ligament, posterior cruciate ligament, medial meniscus

A 49-year-old man comes for evaluation because of right shoulder pain that has lasted for several
days. He was lifting a heavy box onto a shelf when he experienced a sudden tearing sensation in
his shoulder. He reports continued pain with movement of the right arm. Physical examination
discloses weakness on internal rotation of the arm on the affected side. The shoulder is diffusely
tender to palpation. He is able to lift his right arm away from the body but grimaces in pain when
bringing it back down to his side.

Which of the following muscles is most likely injured?

A.Infraspinatus
B.Middle fibers of the deltoid
C.Subscapularis
D.Supraspinatus
E.Teres minor

A 25-year-old man who is a track and field athlete visits his physician because of right lower
extremity weakness and an unsteady gait for the past 2 months. His symptoms worsen markedly
with exercise. In addition, he has had intermittent groin pain since he started doing squats to try
to improve his sprint times approximately 3 months ago. On examination, the physician notes
atrophy of the medial portion of the right thigh and weakness to adduction.

Which of the following nerves is most likely involved?

A.Femoral nerve
B.Inferior gluteal nerve
C.Nerve to obturator internus
D.Obturator nerve
E.Sciatic nerve

A 24-year-old man comes to the emergency department after experiencing hand pain for 1 week
after injuring the hand while skiing. Physical examination reveals tenderness over the scaphoid
tubercle, significant bruising, and absent radial pulse. However, the hand is warm and color
returns to the hand within 10 seconds after release of compression of the artery on the medial
side of the wrist while the lateral side remains compressed. Ultrasonography confirms complete
clotting in the radial artery.

Which of the following arteries have ensured adequate collateral arterial flow in this patient’s
hand despite his injury?

A.Anterior and posterior interosseous arteries

B.Arcuate artery
C.Arteries of deep and superficial palmar arch
D.Common and proper palmar digital arteries
E.Radial collateral and recurrent radial arteries

A 19-year-old man presents to the emergency department with a severely dislocated left elbow
after a snowboarding accident. He is sedated and undergoes manual reduction by the orthopedic
resident on call. Two weeks after he is discharged, the patient reports difficulty making a fist
with his left hand. Neurologic examination indicates that he has difficulty flexing the
metacarpophalangeal joints of the second and third digits of the left hand. Sensation to pinprick
is intact on the dorsal hand but is lost over the palmar aspect of the first three digits.

This patient most likely sustained an injury to which nerve?

A.Axillary nerve
B.Median nerve
C.Musculocutaneous nerve
D.Radial nerve
E.Ulnar nerve

A 14-year-old boy with an uncomplicated medical history presents with acute-onset testicular
pain, nausea, and vomiting. Earlier in the day, he was kicked in the groin during a soccer match
but was able to finish the game without further difficulty. However, a few hours later, he started
experiencing pain and scrotal swelling. He denies having a fever or painful or frequent urination.
He is up-to-date with immunizations and is not sexually active. On clinical examination, the right
testicle is high-riding in appearance, but stroking the right inner-thigh does not cause the right
testes to elevate. Furthermore, the cord is not tender to palpation. Which of the following is the
abdominal muscle that gives rise to the muscle tested in this reflex?

A.External oblique
B.Internal oblique
C.Pyramidalis
D.Rectus abdominis
E.Superficial fascia
F.Transversus abdominis

A 47-year-old man comes to his physician because of a painless “bulge” in his groin that first
appeared several months ago. It becomes visible when he lifts heavy boxes at work and
spontaneously "disappears." Physical examination demonstrates a swelling in the lower
abdomen. The swelling protrudes through the superficial inguinal ring but does not descend into
the scrotum. The swelling becomes prominent when the patient is asked to cough and recedes
once straining ceases. What is the location of the patient’s most likely pathology in relation to
normal anatomic landmarks?

A.Inferior and lateral to the pubic tubercle

B.Inferior to the inguinal ligament  and medial to the common femoral vein
C.Lateral to the femoral artery and inferior to the anterior superior iliac spine
D.Lateral to the inferior epigastric artery and superior to the inguinal ligament
E.Medial to the inferior epigastric artery and superior to the inguinal ligament

A 45-year-old woman presents to her physician reporting that she feels like her left shoulder
blade sticks out sometimes. She denies any pain or recent trauma. She recently underwent a left
mastectomy and axillary dissection for breast cancer. Her vital signs are within normal limits. No
skin lesions or rashes are identified. Her left shoulder is nontender to palpation, and she has full
range of motion of both her arms and shoulders. There is a notable protrusion of the posterior left
shoulder blade when she is asked to push up against the wall. There is no loss of sensation to the
affected area. The nerve that is most likely injured in this patient would originate at which of the
following spinal levels?

A.C3, C4, and C5

B.C5 and C6
C.C5, C6, and C7
D.C7 and C8
E.C7, C8, and T1

A 28-year-old man presents for a follow-up appointment after undergoing surgical fixation of
multiple facial fractures sustained during a motor vehicle accident 1 month ago. The patient
states he is unable to fully open his mouth. Initially, the symptoms were very subtle, but they
have gradually progressed to the point at which he has significant difficulty opening his mouth
during meals. He denies pain, and the review of systems is otherwise negative. Physical
examination reveals a maximum opening of 10 mm without any abnormal jaw protrusions or
horizontal mandibular movements. CT imaging reveals significant calcification of one of the jaw
muscles.

Which of the following muscles likely has significant calcification revealed on imaging?

A.Buccinator
B.Lateral pterygoids
C.Masseter
D.Medial pterygoids
E.Temporalis

A 15-year-old boy comes to the emergency department after falling off his skateboard. Physical
examination reveals a swollen knee with bruising and erythema. Popliteal and pedal pulses are
2+, but he is unable to dorsiflex or evert at the ankle. In addition, the patient reports pain and
numbness in the lateral leg and dorsum of the foot. When asked to walk, he raises his affected
leg high off the ground, and his foot slaps the ground when walking. He is diagnosed with a
fracture.
Which of the following nerves is most likely to be compromised by the fracture?

A.Common fibular (peroneal) nerve

B.Deep peroneal nerve
C.Femoral nerve
D.Superficial peroneal nerve
E.Tibial nerve

A 24-year-old man comes to the emergency department because of a laceration over the anterior
surface of the middle section of his left index finger. The wound has stopped bleeding and
appears clean. Using a subcutaneous local block, the physician numbs only the area to be sutured
with lidocaine.

The nerve the physician is targeting also most likely provides cutaneous innervation to which of
the following areas?

A.The lateral aspect of the forearm

B.The lateral dorsum of the hand
C.The lateral palmar surface of the hand
D.The medial surface of the forearm
E.The radial aspect of the wrist
F.The ulnar aspect of the wrist

A 50-year-old man comes to the emergency department because of severe pain with even slight
abduction of his arm following a skiing accident. The pain is anterior and superior to the
glenohumeral joint of the injured arm. During the physical examination, the patient is unable to
initiate abduction of the shoulder. However, when assistance is provided for the first 20 degrees
of abduction the patient is able to complete the motion without discomfort.

Which of the following structures is most likely injured in this patient?

A.Deltoid tendon
B.Infraspinatus tendon
C.Serratus anterior
D.Subacromial bursa
E.Supraspinatus tendon
F.Teres minor tendon

A 16-year-old boy is brought to the emergency department after sustaining an injury during a
football game. He was tackled from behind by another player, making contact with the back of
his knee. The patient’s leg is extended on the bed, but the EMT reports that the patient’s knee
was bent on the field. The patient is in severe pain, saying that the pain is 9 out of 10 on the pain
scale. His temperature is 98.6°F (37°C), blood pressure is 116/83 mmHg, and heart rate is
110/min. Physical examination is limited due to pain. The patella is more movable than normal.
No pulses can be palpated at the dorsalis pedis or posterior tibial artery. Toes look dusky red and
leg is swollen. There are no open wounds to the leg. There is decreased sensation over the lower
leg. Which of the following structures was most likely injured in this patient?

A.Anterior tibial artery

B.Common femoral artery
C.Deep femoral artery
D.Fibular artery
E.Popliteal artery
F.Posterior tibial artery
A 17-year-old boy comes to the emergency department with pain and swelling in his foot after
landing awkwardly on his teammate’s foot while playing basketball. The patient has no
significant medical or surgical history and describes himself as being quite athletic and "good at
his sport." He has never had an injury like this before. On physical examination, in addition to
pain and swelling, the patient has a limited range of motion. X-ray of the foot reveals no fracture
of the bone. The patient is treated appropriately and discharged. Which of the following
ligaments is most likely injured in this patient?
A.Anterior inferior tibiofibular ligament
B.Anterior talofibular ligament
C.Calcaneofibular ligament
D.Deltoid ligament
E.Posterior talofibular ligament
A 45-year-old man comes to the dermatologist because of dry, thick, and rough skin on his foot.
He has a previous history of allergy to pollen grains but is otherwise healthy and takes no
medications. His temperature is 98.5° F (36.9° C), blood pressure is 126/70 mm Hg, pulse is
66/min, and respirations are 16/min. Physical examination findings of the right foot are shown in
the image.

Courtesy of Wikimedia Commons user Emilio J. Rodríguez Posada.

Which of the following skin layers is responsible for the patient's presentation?

A.Basement membrane
B.Stratum basale
C.Stratum corneum
D.Stratum granulosum
E.Stratum lucidum
F.Stratum spinosum

A 20-year-old woman presents to the emergency department after an attempt to commit suicide
by cutting her wrists. She has never tried to cut herself in the past and currently denies active
suicidal or homicidal ideation. All of her vital signs are within normal limits. Physical
examination reveals several superficial lacerations on the medial side of the ventral left wrist.
She has some sensory loss over the left fifth digit. After obtaining relevant laboratory test results,
the resident places calls for psychiatric and orthopedic consults.The function of which of the
following muscles is most likely affected by this patient's injuries?

A.Abductor pollicis brevis

B.Adductor pollicis
C.Extensor pollicis brevis
D.Lumbricals (1 and 2)
E.Opponens pollicis
A 5-year-old boy is brought to the physician for a routine check-up. The patient’s mother states
that she has noticed a dark mole on his abdomen, which first appeared about 6 months ago. Other
than the mole, she states that the patient has been in good health, aside from an episode of otitis
media 1 year ago. On physical examination, a dark circular lesion on his abdominal region is
observed. The lesion is symmetric and circular with well-defined borders and homogeneous
color. The mother states that it has not seemed to change in shape or size since she first noticed it
6 months ago.

The cell type responsible for this pigmentation is normally found in which of the following skin
layers?

A.Label A
B.Label B
C.Label C
D.Label D
E.Label E
A 10-year-old boy is brought to the pediatrician by his mother because he has been complaining
of difficulty using his right hand. The mother states that her son has had a fever for several days
but that she grew more concerned when he was unable to properly use his fork at the breakfast
table today. On examination, the boy is found to have weakness on extension of the right wrist
and significant difficulty with shoulder abduction. There is diminished sensation to light touch
over the right deltoid and lateral and posterior arm. Biceps reflexes 2+ bilaterally and triceps
reflexes are 1+ on the right and 2+ on the left. A thorough workup reveals a soft-tissue mass in
the right axilla/axillary region. Ultrasonography is suggestive of an abscess.

Which of the following structures is most likely being compressed by the abscess?

A.Anterior division of the middle trunk of brachial plexus

B.Medial cord
C.Phrenic nerve
D.Posterior cord of brachial plexus
E.Radial nerve

A 12-year-old boy is brought to the emergency department because of pain and weakness along
the left forearm and wrist. The patient was playing soccer when he was tripped and fell forward
onto his left arm 2 days ago. He has no other medical conditions. He has a family history of
hypertension in his father. Temperature is 37.2°C (99.0°F), blood pressure is 118/82 mm Hg,
pulse is 86/min, and respiratory rate is 18/min. Physical examination shows decreased grip
strength, inability to make a fist, and difficulty with pronation of the forearm all on the left.
Sensation is diminished in the left thumb and lateral three fingers of the left hand. X-ray study of
the left arm is shown.

Courtesy of William Scott, MD.

Which of the following nerves is most likely involved with this patient’s condition?
A.Axillary nerve
B.Median nerve
C.Musculocutaneous nerve
D.Radial nerve
E.Recurrent branch of median nerve
F.Ulnar nerve

A 75-year-old man is brought to the emergency department by his daughter after he injured his
left hip during a fall at home. Further examination shows a left hip dislocation. The patient
undergoes hip arthroplasty using a posterior approach, and he is referred for rehabilitation a few
weeks later. During rehabilitation, he has difficulty rising from a seated position and requires
assistance when ascending stairs. While walking, his hips remain level, but he leans back slightly
when his his left heel strikes the ground in front of him.

Which of the following is most likely injured in this patient?

A.Common fibular nerve

B.Deep fibular nerve
C.Femoral nerve
D.Inferior gluteal nerve
E.Superior gluteal nerve

A 60-year-old man visits a new physician for a regular checkup. The physician notes that the
patient has a limp. To examine this further, the physician asks the patient to stand with feet
together. Then the physician asks the patient to stand on his right leg and notes that the patient's
hip drops to the left, and his trunk leans slightly toward the right. No abnormalities are seen
when the patient stands on his left leg. He reports one major illness as a child, after which he
developed this limp.

Which of the following nerves is most likely injured in this patient?

A.Left femoral nerve

B.Left superior gluteal nerve
C.Right obturator nerve
D.Right superior gluteal nerve
E.Ventral rami of L2 and L3
F.Ventral rami of S1 and S2
An 80-year-old woman comes to the emergency department after slipping and falling on ice on
her driveway. The patient landed on her right arm and says that it has been excruciatingly painful
since that time. She also reports right forearm numbness. Her temperature is 98° F (36.7° C),
blood pressure is 125/85 mm Hg, pulse is 120/min, and respiratory rate is 25/min. On physical
examination, she has tenderness over the lateral side of her right arm. She has decreased grip
strength of the right hand and cannot extend her right wrist. An x-ray of her right arm is shown.

Courtesy of RSJ Thompson.

Which of the following structures is most likely injured?

A.Axillary nerve
B.Median nerve
C.Musculocutaneous nerve
D.Radial nerve
E.Recurrent branch of median nerve
F.Ulnar nerve

A 45-year-old obese man who recently emigrated from India comes to the clinic because of
shortness of breath and hoarseness. He reports that the hoarseness started within the past week.
His medical history is significant for a childhood illness that he is unable to name. Physical
examination is normal apart from a body mass index of 33. An electrocardiogram shows
enlarged biphasic P waves in lead II, and cardiac echocardiography shows a stenosed mitral
valve with left atrial enlargement. His hoarseness is believed to be caused by a nerve
impingement.

The impinged nerve is a branch of a larger nerve that controls which of the following muscles?

A.Genioglossus
B.Hyoglossus
C.Mylohyoid
D.Palatoglossus
E.Styloglossus
F.Stylopharyngeus