Postsynaptic sympathetic neurons typically release the neurotransmitter
norepinephrine/noradrenaline from their endings,
so the sympathetic division is described as a noradrenergic
system. Blocking the release of norepinephrine would disrupt
normal neurotransmission at these terminal sites. An
important exception to this rule is that the postsynaptic sympathetic
neurons supplying sweat glands typically release
acetylcholine from their endings. Choice A (Somatic neuron
motor end plates) is incorrect. The somatic motor neurons
that supply skeletal muscle fi bers utilize acetylcholine as their
neurotransmitter at motor end plates. Choice B (Postsynaptic
parasympathetic nerve terminals) is incorrect. Postsynaptic
parasympathetic neurons typically release acetylcholine as
the neurotransmitter at their endings, so the parasympathetic
division is described as a cholinergic system. Choice D (Synapses
between presynaptic and postsynaptic parasympathetic
neurons) is incorrect. Both sympathetic and parasympathetic
divisions utilize acetylcholine as the neurotransmitter between
their presynaptic and postsynaptic cells. Choice E (Synapses
between presynaptic and postsynaptic sympathetic neurons)
is incorrect. Both sympathetic and parasympathetic divisions
utilize acetylcholine as the neurotransmitter between their
presynaptic and postsynaptic cells.

13. A 2-year-old male patient develops progressive
generalized weakness and muscle atrophy.
The impairment first began with the muscles of
the hips, and then progressed to the pelvic area,
thigh, and shoulder muscles. The patient is
diagnosed with Duchenne’s muscular dystrophy,
a congenital disorder where the protein
dystrophin is deficient. Which of the following
describes the role of dystrophin in muscle
tissue?

Dystrophin anchors actin to the sarcolemma,
reinforcing and stabilizing the latter
during muscle contraction. Titin is a large protein
which associates with myosin filaments
and endows them with elastic recoil properties
(choice B). Desmin filaments form a supportive
network extending from Z disk to Zdisk
(choice C). Troponin I inhibits the binding of
myosin to actin (choice D). AlphaB-crystallin
protects desmin filaments from stress-induced
damage (choice E).

14)A 55-year-old man with severe coughing is admitted to the hospital. Radiographic examination reveals tuberculosis of the right lung, with extension to
the thoracic vertebral bodies of T6 and T7, producing
a “gibbus deformity.” Which of the following conditions is most likely also to be confi rmed by radiographic examination?

B Kyphosis is characterized by a “hunchback”
due to an abnormal increase in curvature of the thoracic region of the vertebral column. Lordosis, or
“swayback,” is an increase in lumbar curvature of the
spine. Lordosis can be physiologic, such as seen in a
pregnant woman. Scoliosis is a lateral curvature of
the spine with rotation of the vertebrae. Spina bifida is a neural tube defect characterized by failure of closure of the vertebral arch. Osteoarthritis is a degen-
erative disorder that affects the articular cartilage of
joints and is not specifi cally related to the thoracic
region of the spine.

15) 30-year-old female patient cones to OPDcomplains of increasing muscle weakness andfatigue during the day, requiring her to takefrequent rests. She also reports that she cannotenjoy her meals any more because her musclesof mastication quickly weaken and she has tostop chewing. When she watches television atnight for a long period of time, her visionbecomes blurry and she sees double. Her neurologistmakes a preliminary diagnosis ofmyasthenia gravis. Which of the following isthe cause of myasthenia gravis?

(C) Myasthenia gravis is an autoimmune disorder
where autoantibodies target the postsynaptic
cholinergic receptors and destroy them.
Acetylcholine released from motor neurons is
thus unable to bind and the muscle contraction
weakens due to decreased neurotransmitter
communication. Acetylcholine synthesis in
motor neurons (choice A) remains normal.
Acetylcholinesterase (choice B) is the enzyme
which degrades acetylcholine and its synthesis
is not affected in myasthenia gravis. The cholinergic
neurotransmitter release mechanism
(choice D) at the presynaptic membrane, as
well as the signal transduction mechanism
within the muscle, remain normal.

15) 67 A 65-year-old patient complains of severe, chronic
pain from the region of her right hip. The patient is
admitted to the hospital and a decision is made to per￾form surgery to avoid prescribing excessive pain medi￾cation. In such a case, which would the surgeon most
likely choose to perform?
⃣ A. Division of the ventral primary rami of nerves
supplying the affected region
⃣ B. Transection of all dorsal primary rami of
nerves from the hip area
⃣ C. Removal of abdominal sympathetic chain gan￾glia on the right side
⃣ D. Transection of the dorsal rootlets of spinal
nerves supplying the right hip
⃣ E. Division of lower lumbar and sacral ventral
rootlets

The lower border of the lung is usually located two intercostal spaces above the respective pleural border. Thoracentesis, therefore, should be performed between 5- and 7- ribs along the midclavicular line, the 7 and 9 ribs along the midaxillary line, and 9 and 11 ribs along the paravertebral line. If the needle is inserted higher, there is a risk of lung injury. Insertion of the needle below the 9 rib at the middle axillary line on the right may cause liver injury (Choice B).

(Choice A) The lower border of the right lung is located two intercostal spaces

above the pleural border. The lung is not likely to be injured by insertion of a needle
into the 10* intercostal space at the midaxillary line as described.

(Choices C and D) The intercostal vein, artery, and nerve lie in the subcostal groove on the lower border of the rib. Thoracentesis should be performed along the upper border of the rib to prevent injury to these structures.

(Choice E) Hepatic veins are not likely to be injured during thoracocentesis.

Educational tip:

Thoracocentesis should be performed above the 7- rib in midclavicular line, the 9 rib along midaxillary line and the 11 rib along posterior scapular line. Insertion of a needle lower than these points increases the risk of penetrating abdominal structures, and insertion of the needle on the inferior margin of the rib risks striking the subcostal neurovascular bundle.

A 23-year-old woman is brought to the emergency department unconscious after a motor vehicle accident. The patient was texting on her cell phone and was not wearing a seatbelt during the incident. She has no known medical problems and takes no medications. Her temperature is 36.7 C (98 F), blood pressure is 155/90 mm Hg, pulse is 62/min, and respirations are 10/min. A linear skull fracture at the junction of the frontal, parietal, temporal, and sphenoid bones is seen on head CT scan.
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The following statements concerning the trachea are true except:
a) It lies anterior to the esophagus in the superior mediastinum
b) In deep inspiration the carina may descend as far as the level of the sixth thoracic vertebra
c)The left principal bronchus is wider than the right principal bronchus
d) The arch of the aorta lies on its anterior and left sides in the superior mediastinum
e) The sensory innervation of the mucous membrane lining the trachea is derived from branches of the vagi, ad the recurrent laryngeal nerves

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