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  • Question 1 - A 36-year-old woman is referred to neurology clinic by her GP due to...

    Incorrect

    • A 36-year-old woman is referred to neurology clinic by her GP due to a 2-month history of gradual onset numbness in both feet. She has a medical history of well-controlled Crohn's disease on a vegan diet.

      During examination, the patient's gait is ataxic and Romberg's test is positive. There is a loss of proprioception and vibration sense to the mid shin bilaterally. Bilateral plantars are upgoing with absent ankle jerks.

      Based on these findings, you suspect the patient has subacute combined degeneration of the spinal cord. Which part of the nervous system is affected?

      Your Answer: The cerebellum

      Correct Answer: The dorsal column and lateral corticospinal tracts of the spinal cord

      Explanation:

      Subacute combined degeneration of the spinal cord is caused by a deficiency in vitamin B12, which is absorbed in the terminal ileum along with intrinsic factor. Individuals at high risk of vitamin B12 deficiency include those with a history of gastric or intestinal surgery, pernicious anemia, malabsorption (especially in Crohn’s disease), and vegans due to decreased dietary intake. Medications such as proton-pump inhibitors and metformin can also reduce absorption of vitamin B12.

      SACD primarily affects the dorsal columns and lateral corticospinal tracts of the spinal cord, resulting in the loss of proprioception and vibration sense, followed by distal paraesthesia. The condition typically presents with a combination of upper and lower motor neuron signs, including extensor plantars, brisk knee reflexes, and absent ankle jerks. Treatment with vitamin B12 can result in partial to full recovery, depending on the extent and duration of neurodegeneration.

      If a patient has both vitamin B12 and folic acid deficiency, it is important to treat the vitamin B12 deficiency first to prevent the onset of subacute combined degeneration of the cord.

      Subacute Combined Degeneration of Spinal Cord

      Subacute combined degeneration of spinal cord is a condition that occurs due to a deficiency of vitamin B12. The dorsal columns and lateral corticospinal tracts are affected, leading to the loss of joint position and vibration sense. The first symptoms are usually distal paraesthesia, followed by the development of upper motor neuron signs in the legs, such as extensor plantars, brisk knee reflexes, and absent ankle jerks. If left untreated, stiffness and weakness may persist.

      This condition is a serious concern and requires prompt medical attention. It is important to maintain a healthy diet that includes sufficient amounts of vitamin B12 to prevent the development of subacute combined degeneration of spinal cord.

    • This question is part of the following fields:

      • Neurological System
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  • Question 2 - Samantha is a 65-year-old alcoholic who has come to her doctor with worries...

    Incorrect

    • Samantha is a 65-year-old alcoholic who has come to her doctor with worries about the feeling in her legs. She is experiencing decreased light-touch sensation and proprioception in both legs. Her blood work reveals a deficiency in vitamin B12.

      What signs are most probable for you to observe in Samantha?

      Your Answer: Reduced temperature sensation bilaterally

      Correct Answer: Positive Babinski sign

      Explanation:

      The presence of a positive Babinski sign may indicate subacute degeneration of the spinal cord, which is typically caused by a deficiency in vitamin B12. This condition primarily affects the dorsal columns of the spinal cord, which are responsible for fine-touch, proprioception, and vibration sensation. In addition to the Babinski sign, patients may also experience spastic paresis. However, hypotonia is not typically observed, as this is a characteristic of lower motor neuron lesions. It is also important to note that temperature sensation is not affected by subacute degeneration of the spinal cord, as this function is mediated by the spinothalamic tract.

      Subacute Combined Degeneration of Spinal Cord

      Subacute combined degeneration of spinal cord is a condition that occurs due to a deficiency of vitamin B12. The dorsal columns and lateral corticospinal tracts are affected, leading to the loss of joint position and vibration sense. The first symptoms are usually distal paraesthesia, followed by the development of upper motor neuron signs in the legs, such as extensor plantars, brisk knee reflexes, and absent ankle jerks. If left untreated, stiffness and weakness may persist.

      This condition is a serious concern and requires prompt medical attention. It is important to maintain a healthy diet that includes sufficient amounts of vitamin B12 to prevent the development of subacute combined degeneration of spinal cord.

    • This question is part of the following fields:

      • Neurological System
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  • Question 3 - A 38-year-old male comes to his GP complaining of recurring episodes of abdominal...

    Incorrect

    • A 38-year-old male comes to his GP complaining of recurring episodes of abdominal pain. He characterizes the pain as dull, affecting his entire abdomen, and accompanied by intermittent diarrhea and constipation. He has observed that his symptoms have intensified since his wife departed, and he has been under work-related stress. The physician suspects that he has irritable bowel syndrome.

      What are the nerve fibers that are stimulated to produce his pain?

      Your Answer: A delta fibres

      Correct Answer: C fibres

      Explanation:

      Neurons and Synaptic Signalling

      Neurons are the building blocks of the nervous system and are made up of dendrites, a cell body, and axons. They can be classified by their anatomical structure, axon width, and function. Neurons communicate with each other at synapses, which consist of a presynaptic membrane, synaptic gap, and postsynaptic membrane. Neurotransmitters are small chemical messengers that diffuse across the synaptic gap and activate receptors on the postsynaptic membrane. Different neurotransmitters have different effects, with some causing excitation and others causing inhibition. The deactivation of neurotransmitters varies, with some being degraded by enzymes and others being reuptaken by cells. Understanding the mechanisms of neuronal communication is crucial for understanding the functioning of the nervous system.

    • This question is part of the following fields:

      • Neurological System
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  • Question 4 - A 29-year-old man is stabbed outside a nightclub in the upper arm. The...

    Incorrect

    • A 29-year-old man is stabbed outside a nightclub in the upper arm. The median nerve is transected. Which one of the following muscles will demonstrate impaired function as a result?

      Your Answer:

      Correct Answer: Abductor pollicis brevis

      Explanation:

      Palmaris brevis is innervated by the ulnar nerve, as are the palmar interossei and adductor pollicis. The abductor pollicis longus, on the other hand, is innervated by the posterior interosseous nerve.

      Anatomy and Function of the Median Nerve

      The median nerve is a nerve that originates from the lateral and medial cords of the brachial plexus. It descends lateral to the brachial artery and passes deep to the bicipital aponeurosis and the median cubital vein at the elbow. The nerve then passes between the two heads of the pronator teres muscle and runs on the deep surface of flexor digitorum superficialis. Near the wrist, it becomes superficial between the tendons of flexor digitorum superficialis and flexor carpi radialis, passing deep to the flexor retinaculum to enter the palm.

      The median nerve has several branches that supply the upper arm, forearm, and hand. These branches include the pronator teres, flexor carpi radialis, palmaris longus, flexor digitorum superficialis, flexor pollicis longus, and palmar cutaneous branch. The nerve also provides motor supply to the lateral two lumbricals, opponens pollicis, abductor pollicis brevis, and flexor pollicis brevis muscles, as well as sensory supply to the palmar aspect of the lateral 2 ½ fingers.

      Damage to the median nerve can occur at the wrist or elbow, resulting in various symptoms such as paralysis and wasting of thenar eminence muscles, weakness of wrist flexion, and sensory loss to the palmar aspect of the fingers. Additionally, damage to the anterior interosseous nerve, a branch of the median nerve, can result in loss of pronation of the forearm and weakness of long flexors of the thumb and index finger. Understanding the anatomy and function of the median nerve is important in diagnosing and treating conditions that affect this nerve.

    • This question is part of the following fields:

      • Neurological System
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  • Question 5 - A 73-year-old female is seen by an ophthalmologist for a follow-up after being...

    Incorrect

    • A 73-year-old female is seen by an ophthalmologist for a follow-up after being diagnosed with primary open-angle glaucoma. The patient is asymptomatic and has 20/20 vision with glasses. During the examination, it is noted that the patient's intraocular pressure remains significantly elevated despite consistent use of a prostaglandin analogue. The decision is made to initiate treatment with timolol eye drops.

      What is the main mode of action of timolol eye drops?

      Your Answer:

      Correct Answer: Reduces aqueous production

      Explanation:

      Timolol, a beta-blocker, is commonly used as a second-line treatment for primary open-angle glaucoma. It works by reducing the production of aqueous humor, which in turn lowers intraocular pressure. Mitotic agents like pilocarpine can cause pupil constriction and may be used in acute closed-angle glaucoma to increase space for aqueous drainage. However, this mechanism is not routinely used in open-angle glaucoma. Carbonic anhydrase inhibitors like acetazolamide can also reduce aqueous production but are taken orally and can cause systemic side effects. Increasing trabecular meshwork drainage is a mechanism used by drugs like pilocarpine, while increasing uveoscleral drainage is achieved by drugs like latanoprost, a prostaglandin analogue.

      Primary open-angle glaucoma is a type of optic neuropathy that is associated with increased intraocular pressure (IOP). It is classified based on whether the peripheral iris is covering the trabecular meshwork, which is important in the drainage of aqueous humour from the anterior chamber of the eye. In open-angle glaucoma, the iris is clear of the meshwork, but the trabecular network offers increased resistance to aqueous outflow, causing increased IOP. This condition affects 0.5% of people over the age of 40 and its prevalence increases with age up to 10% over the age of 80 years. Both males and females are equally affected. The main causes of primary open-angle glaucoma are increasing age and genetics, with first-degree relatives of an open-angle glaucoma patient having a 16% chance of developing the disease.

      Primary open-angle glaucoma is characterised by a slow rise in intraocular pressure, which is symptomless for a long period. It is typically detected following an ocular pressure measurement during a routine examination by an optometrist. Signs of the condition include increased intraocular pressure, visual field defect, and pathological cupping of the optic disc. Case finding and provisional diagnosis are done by an optometrist, and referral to an ophthalmologist is done via the GP. Final diagnosis is made through investigations such as automated perimetry to assess visual field, slit lamp examination with pupil dilatation to assess optic nerve and fundus for a baseline, applanation tonometry to measure IOP, central corneal thickness measurement, and gonioscopy to assess peripheral anterior chamber configuration and depth. The risk of future visual impairment is assessed using risk factors such as IOP, central corneal thickness (CCT), family history, and life expectancy.

      The majority of patients with primary open-angle glaucoma are managed with eye drops that aim to lower intraocular pressure and prevent progressive loss of visual field. According to NICE guidelines, the first line of treatment is a prostaglandin analogue (PGA) eyedrop, followed by a beta-blocker, carbonic anhydrase inhibitor, or sympathomimetic eyedrop as a second line of treatment. Surgery or laser treatment can be tried in more advanced cases. Reassessment is important to exclude progression and visual field loss and needs to be done more frequently if IOP is uncontrolled, the patient is high risk, or there

    • This question is part of the following fields:

      • Neurological System
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  • Question 6 - At what age does the Moro reflex usually disappear? ...

    Incorrect

    • At what age does the Moro reflex usually disappear?

      Your Answer:

      Correct Answer: 4-6 months

      Explanation:

      The Moro reflex vanishes by the time the baby reaches 4 months of age.

      Primitive Reflexes in Infants

      Primitive reflexes are automatic movements that are present in infants from birth to a certain age. These reflexes are important for survival and development in the early stages of life. One of the most well-known primitive reflexes is the Moro reflex, which is triggered by head extension and causes the arms to first spread out and then come back together. This reflex is present from birth to around 3-4 months of age.

      Another primitive reflex is the grasp reflex, which causes the fingers to flex when an object is placed in the infant’s palm. This reflex is present from birth to around 4-5 months of age and is important for the infant’s ability to grasp and hold objects.

      The rooting reflex is another important primitive reflex that assists in breastfeeding. When the infant’s cheek is touched, they will turn their head towards the touch and open their mouth to suck. This reflex is present from birth to around 4 months of age.

      Finally, the stepping reflex, also known as the walking reflex, is present from birth to around 2 months of age. When the infant’s feet touch a flat surface, they will make stepping movements as if they are walking. This reflex is important for the development of the infant’s leg muscles and coordination.

      Overall, primitive reflexes are an important part of infant development and can provide insight into the health and functioning of the nervous system.

    • This question is part of the following fields:

      • Neurological System
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  • Question 7 - A 14-month-old infant is undergoing investigation by community paediatrics for developmental delay. The...

    Incorrect

    • A 14-month-old infant is undergoing investigation by community paediatrics for developmental delay. The mother has observed that the child has poor balance, cannot take steps alone, and walks on tiptoes with support. The infant was delivered via c-section at 28 weeks gestation and weighed 1400 grams at birth.

      During the assessment, the infant exhibits hyperreflexia, increased tone in the lower limbs, and sustained clonus in both ankles. The suspected diagnosis is cerebral palsy.

      What type of cerebral palsy is likely to be present in this infant based on the observed symptoms?

      Your Answer:

      Correct Answer: Spastic cerebral palsy

      Explanation:

      Understanding Cerebral Palsy

      Cerebral palsy is a condition that affects movement and posture due to damage to the motor pathways in the developing brain. It is the most common cause of major motor impairment and affects 2 in 1,000 live births. The causes of cerebral palsy can be antenatal, intrapartum, or postnatal. Antenatal causes include cerebral malformation and congenital infections such as rubella, toxoplasmosis, and CMV. Intrapartum causes include birth asphyxia or trauma, while postnatal causes include intraventricular hemorrhage, meningitis, and head trauma.

      Children with cerebral palsy may exhibit abnormal tone in early infancy, delayed motor milestones, abnormal gait, and feeding difficulties. They may also have associated non-motor problems such as learning difficulties, epilepsy, squints, and hearing impairment. Cerebral palsy can be classified into spastic, dyskinetic, ataxic, or mixed types.

      Managing cerebral palsy requires a multidisciplinary approach. Treatments for spasticity include oral diazepam, oral and intrathecal baclofen, botulinum toxin type A, orthopedic surgery, and selective dorsal rhizotomy. Anticonvulsants and analgesia may also be required. Understanding cerebral palsy and its management is crucial in providing appropriate care and support for individuals with this condition.

    • This question is part of the following fields:

      • Neurological System
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  • Question 8 - A 51-year-old man is admitted to a neuro-rehabilitation ward following a road traffic...

    Incorrect

    • A 51-year-old man is admitted to a neuro-rehabilitation ward following a road traffic accident. Upon examination of his cranial nerves, it is found that he has anosmia with the scents used for CN I testing, but all other CNs appear intact. However, when speaking, he exhibits poor grammar and long pauses between words. What brain region is likely to be damaged in this patient?

      Your Answer:

      Correct Answer: Frontal lobe

      Explanation:

      Anosmia may be caused by lesions in the frontal lobe. This is supported by the presence of expressive dysphasia and anosmia in the case described. Other symptoms of frontal lobe damage include changes in personality and motor deficits on one or both sides of the body.

      The cerebellum is not the correct answer as damage to this region may cause a range of symptoms such as dysdiadochokinesia, ataxia, nystagmus, intention tremor, scanning dysarthria, and positive heel-shin test (poor coordination).

      Similarly, the occipital lobe is not the correct answer as damage to this region may cause visual disturbances.

      The parietal lobe is also not the correct answer as damage to this region may cause loss of sensations like touch, apraxias, alexia, agraphia, acalculia, hemi-spatial neglect, astereognosis (inability to identify things placed in the hand), or homonymous inferior quadrantanopia.

      Brain lesions can be localized based on the neurological disorders or features that are present. The gross anatomy of the brain can provide clues to the location of the lesion. For example, lesions in the parietal lobe can result in sensory inattention, apraxias, astereognosis, inferior homonymous quadrantanopia, and Gerstmann’s syndrome. Lesions in the occipital lobe can cause homonymous hemianopia, cortical blindness, and visual agnosia. Temporal lobe lesions can result in Wernicke’s aphasia, superior homonymous quadrantanopia, auditory agnosia, and prosopagnosia. Lesions in the frontal lobes can cause expressive aphasia, disinhibition, perseveration, anosmia, and an inability to generate a list. Lesions in the cerebellum can result in gait and truncal ataxia, intention tremor, past pointing, dysdiadokinesis, and nystagmus.

      In addition to the gross anatomy, specific areas of the brain can also provide clues to the location of a lesion. For example, lesions in the medial thalamus and mammillary bodies of the hypothalamus can result in Wernicke and Korsakoff syndrome. Lesions in the subthalamic nucleus of the basal ganglia can cause hemiballism, while lesions in the striatum (caudate nucleus) can result in Huntington chorea. Parkinson’s disease is associated with lesions in the substantia nigra of the basal ganglia, while lesions in the amygdala can cause Kluver-Bucy syndrome, which is characterized by hypersexuality, hyperorality, hyperphagia, and visual agnosia. By identifying these specific conditions, doctors can better localize brain lesions and provide appropriate treatment.

    • This question is part of the following fields:

      • Neurological System
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  • Question 9 - Which one of the following structures lies posterior to the femoral nerve in...

    Incorrect

    • Which one of the following structures lies posterior to the femoral nerve in the femoral triangle?

      Your Answer:

      Correct Answer: Iliacus

      Explanation:

      The femoral nerve is located in front of the iliacus muscle within the femoral triangle. Meanwhile, the iliacus and pectineus muscles are situated behind the femoral sheath.

      The femoral nerve is a nerve that originates from the spinal roots L2, L3, and L4. It provides innervation to several muscles in the thigh, including the pectineus, sartorius, quadriceps femoris, and vastus lateralis, medialis, and intermedius. Additionally, it branches off into the medial cutaneous nerve of the thigh, saphenous nerve, and intermediate cutaneous nerve of the thigh. The femoral nerve passes through the psoas major muscle and exits the pelvis by going under the inguinal ligament. It then enters the femoral triangle, which is located lateral to the femoral artery and vein.

      To remember the femoral nerve’s supply, a helpful mnemonic is don’t MISVQ scan for PE. This stands for the medial cutaneous nerve of the thigh, intermediate cutaneous nerve of the thigh, saphenous nerve, vastus, quadriceps femoris, and sartorius, with the addition of the pectineus muscle. Overall, the femoral nerve plays an important role in the motor and sensory functions of the thigh.

    • This question is part of the following fields:

      • Neurological System
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  • Question 10 - As you help the FY1 draft discharge summaries for the care of the...

    Incorrect

    • As you help the FY1 draft discharge summaries for the care of the elderly ward, you come across a patient who is reported to have profound apraxia. This individual is 89 years old and has significant dementia. Can you explain what apraxia is?

      Your Answer:

      Correct Answer: Inability to perform voluntary movements

      Explanation:

      Apraxia refers to the incapacity to execute deliberate movements even when the motor and sensory systems are functioning properly. This condition impacts activities like dressing, eating, artistic endeavors (such as drawing), and ideomotor actions (like waving goodbye).

      Brain lesions can be localized based on the neurological disorders or features that are present. The gross anatomy of the brain can provide clues to the location of the lesion. For example, lesions in the parietal lobe can result in sensory inattention, apraxias, astereognosis, inferior homonymous quadrantanopia, and Gerstmann’s syndrome. Lesions in the occipital lobe can cause homonymous hemianopia, cortical blindness, and visual agnosia. Temporal lobe lesions can result in Wernicke’s aphasia, superior homonymous quadrantanopia, auditory agnosia, and prosopagnosia. Lesions in the frontal lobes can cause expressive aphasia, disinhibition, perseveration, anosmia, and an inability to generate a list. Lesions in the cerebellum can result in gait and truncal ataxia, intention tremor, past pointing, dysdiadokinesis, and nystagmus.

      In addition to the gross anatomy, specific areas of the brain can also provide clues to the location of a lesion. For example, lesions in the medial thalamus and mammillary bodies of the hypothalamus can result in Wernicke and Korsakoff syndrome. Lesions in the subthalamic nucleus of the basal ganglia can cause hemiballism, while lesions in the striatum (caudate nucleus) can result in Huntington chorea. Parkinson’s disease is associated with lesions in the substantia nigra of the basal ganglia, while lesions in the amygdala can cause Kluver-Bucy syndrome, which is characterized by hypersexuality, hyperorality, hyperphagia, and visual agnosia. By identifying these specific conditions, doctors can better localize brain lesions and provide appropriate treatment.

    • This question is part of the following fields:

      • Neurological System
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  • Question 11 - Eve, a 67-year-old female, is undergoing endovascular surgery to repair an abdominal aortic...

    Incorrect

    • Eve, a 67-year-old female, is undergoing endovascular surgery to repair an abdominal aortic aneurysm. The surgeon places the stent in the aorta and common iliac arteries, as the aneurysm is located just above the aortic bifurcation. What is the level of the bifurcation?

      Your Answer:

      Correct Answer: L4

      Explanation:

      The point at which the aorta divides into the common iliac arteries is located at the level of the fourth lumbar vertebrae (L4). The renal arteries originate at the level of the second lumbar vertebrae (L2), while the inferior mesenteric artery originates at the level of the third lumbar vertebrae (L3). The posterior superior iliac spines are located at the level of the second sacral vertebrae (S2).

      Anatomical Planes and Levels in the Human Body

      The human body can be divided into different planes and levels to aid in anatomical study and medical procedures. One such plane is the transpyloric plane, which runs horizontally through the body of L1 and intersects with various organs such as the pylorus of the stomach, left kidney hilum, and duodenojejunal flexure. Another way to identify planes is by using common level landmarks, such as the inferior mesenteric artery at L3 or the formation of the IVC at L5.

      In addition to planes and levels, there are also diaphragm apertures located at specific levels in the body. These include the vena cava at T8, the esophagus at T10, and the aortic hiatus at T12. By understanding these planes, levels, and apertures, medical professionals can better navigate the human body during procedures and accurately diagnose and treat various conditions.

    • This question is part of the following fields:

      • Neurological System
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  • Question 12 - A 61-year-old woman comes to the Emergency Department with slurred speech and left-sided...

    Incorrect

    • A 61-year-old woman comes to the Emergency Department with slurred speech and left-sided facial drooping. You perform a cranial nerves examination and find that her vagus nerve has been impacted. What sign would you anticipate observing in this patient?

      Your Answer:

      Correct Answer: Uvula deviated to the left

      Explanation:

      The uvula is deviated to the left, indicating a right-sided stroke affecting the vagus nerve (CN X). This can cause a loss of gag reflex and uvula deviation away from the site of the lesion. Loss of taste (anterior 2/3) is a symptom of facial nerve (CN VII) lesions, while tongue deviation to the right is a symptom of hypoglossal nerve (CN XII) lesions. Vertigo is a symptom of vestibulocochlear nerve (CN VIII) lesions.

      Cranial nerves are a set of 12 nerves that emerge from the brain and control various functions of the head and neck. Each nerve has a specific function, such as smell, sight, eye movement, facial sensation, and tongue movement. Some nerves are sensory, some are motor, and some are both. A useful mnemonic to remember the order of the nerves is Some Say Marry Money But My Brother Says Big Brains Matter Most, with S representing sensory, M representing motor, and B representing both.

      In addition to their specific functions, cranial nerves also play a role in various reflexes. These reflexes involve an afferent limb, which carries sensory information to the brain, and an efferent limb, which carries motor information from the brain to the muscles. Examples of cranial nerve reflexes include the corneal reflex, jaw jerk, gag reflex, carotid sinus reflex, pupillary light reflex, and lacrimation reflex. Understanding the functions and reflexes of the cranial nerves is important in diagnosing and treating neurological disorders.

    • This question is part of the following fields:

      • Neurological System
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  • Question 13 - A 50-year-old woman presents to her primary care physician with complaints of fatigue...

    Incorrect

    • A 50-year-old woman presents to her primary care physician with complaints of fatigue and trouble staying alert while watching TV or reading, particularly in the evenings. Upon examination, she is diagnosed with myasthenia gravis. What is the underlying mechanism for this condition?

      Your Answer:

      Correct Answer: Antibodies are produced against acetylcholine receptors

      Explanation:

      The accurate explanation is that myasthenia gravis involves the production of antibodies against acetylcholine receptors, leading to a decrease in the amount of available acetylcholine for use in the neuromuscular junction.

      Myasthenia gravis is an autoimmune disorder that results in muscle weakness and fatigue, particularly in the eyes, face, neck, and limbs. It is more common in women and is associated with thymomas and other autoimmune disorders. Diagnosis is made through electromyography and testing for antibodies to acetylcholine receptors. Treatment includes acetylcholinesterase inhibitors and immunosuppression, and in severe cases, plasmapheresis or intravenous immunoglobulins may be necessary.

    • This question is part of the following fields:

      • Neurological System
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  • Question 14 - A 13-year-old boy comes to the clinic with his mother complaining of ear...

    Incorrect

    • A 13-year-old boy comes to the clinic with his mother complaining of ear pain. He experienced the pain last night and was unable to sleep. As a result, he stayed home from school today. He reports that sounds are muffled on the affected side. During the examination, he has a fever. Otoscopy reveals a bulging tympanic membrane with visible fluid level, indicating a middle ear infection. The nerve to tensor tympani arises from which nerve?

      Your Answer:

      Correct Answer: Mandibular nerve

      Explanation:

      The mandibular nerve is the correct answer. It is the only division of the trigeminal nerve that carries motor fibers. The vestibulocochlear nerve is the eighth cranial nerve and has two components for balance and hearing. The glossopharyngeal nerve is the ninth cranial nerve and has various functions, including taste and sensation from the tongue, pharyngeal wall, and tonsils. The maxillary nerve carries only sensory fibers. The facial nerve is the seventh cranial nerve and supplies the muscles of facial expression and taste from the anterior two-thirds of the tongue. Tensor tympani is a muscle that dampens loud noises and is innervated through the nerve to tensor tympani, which arises from the mandibular nerve. The patient’s ear pain is likely due to otitis media, which is confirmed on otoscopy.

      The trigeminal nerve is the main sensory nerve of the head and also innervates the muscles of mastication. It has sensory distribution to the scalp, face, oral cavity, nose and sinuses, and dura mater, and motor distribution to the muscles of mastication, mylohyoid, anterior belly of digastric, tensor tympani, and tensor palati. The nerve originates at the pons and has three branches: ophthalmic, maxillary, and mandibular. The ophthalmic and maxillary branches are sensory only, while the mandibular branch is both sensory and motor. The nerve innervates various muscles, including the masseter, temporalis, and pterygoids.

    • This question is part of the following fields:

      • Neurological System
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  • Question 15 - A 30-year-old woman visits the doctor's office complaining of nausea and vomiting. Upon...

    Incorrect

    • A 30-year-old woman visits the doctor's office complaining of nausea and vomiting. Upon taking a pregnancy test, it is discovered that she is indeed pregnant. Can you identify the location of the chemoreceptor trigger zone?

      Your Answer:

      Correct Answer: Area postrema (medulla)

      Explanation:

      The vomiting process is initiated by the chemoreceptor trigger zone, which receives signals from various sources such as the gastrointestinal tract, hormones, and drugs. This zone is located in the area postrema, which is situated on the floor of the 4th ventricle in the medulla. It is noteworthy that the area postrema is located outside the blood-brain barrier. The nucleus of tractus solitarius, which is also located in the medulla, contains autonomic centres that play a role in the vomiting reflex. This nucleus receives signals from the chemoreceptor trigger zone. The vomiting centres in the brain receive inputs from different areas, including the gastrointestinal tract and the vestibular system of the inner ear.

      Vomiting is the involuntary act of expelling the contents of the stomach and sometimes the intestines. This is caused by a reverse peristalsis and abdominal contraction. The vomiting center is located in the medulla oblongata and is activated by receptors in various parts of the body. These include the labyrinthine receptors in the ear, which can cause motion sickness, the over distention receptors in the duodenum and stomach, the trigger zone in the central nervous system, which can be affected by drugs such as opiates, and the touch receptors in the throat. Overall, vomiting is a reflex action that is triggered by various stimuli and is controlled by the vomiting center in the brainstem.

    • This question is part of the following fields:

      • Neurological System
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  • Question 16 - A 47-year-old woman arrives at the Emergency Department after experiencing a loss of...

    Incorrect

    • A 47-year-old woman arrives at the Emergency Department after experiencing a loss of consciousness. She mentions seeing a man in the corner of the room before this happened. She also describes feeling disconnected from herself and experiencing déjà vu. The diagnosis is a focal seizure.

      Which specific area of the brain is the seizure likely originating from?

      Your Answer:

      Correct Answer: Temporal lobe

      Explanation:

      Temporal lobe seizures can lead to hallucinations, among other focal seizure features such as automatisms and viscerosensory symptoms. Seizures in other areas of the brain, such as the cerebellum, frontal lobe, occipital lobe, and parietal lobe, would present with different symptoms.

      Localising Features of Focal Seizures in Epilepsy

      Focal seizures in epilepsy can be localised based on the specific location of the brain where they occur. Temporal lobe seizures are common and may occur with or without impairment of consciousness or awareness. Most patients experience an aura, which is typically a rising epigastric sensation, along with psychic or experiential phenomena such as déjà vu or jamais vu. Less commonly, hallucinations may occur, such as auditory, gustatory, or olfactory hallucinations. These seizures typically last around one minute and are often accompanied by automatisms, such as lip smacking, grabbing, or plucking.

      On the other hand, frontal lobe seizures are characterised by motor symptoms such as head or leg movements, posturing, postictal weakness, and Jacksonian march. Parietal lobe seizures, on the other hand, are sensory in nature and may cause paraesthesia. Finally, occipital lobe seizures may cause visual symptoms such as floaters or flashes. By identifying the specific location and type of seizure, doctors can better diagnose and treat epilepsy in patients.

    • This question is part of the following fields:

      • Neurological System
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  • Question 17 - A 46-year-old man was in a car accident a week ago and suffered...

    Incorrect

    • A 46-year-old man was in a car accident a week ago and suffered a concussion. He now experiences ongoing diplopia, which is more noticeable when looking down at a book or going downstairs. Upon examination, his right eye is rotated upwards and inwards, with limited movement in depression and adduction. Both pupils are equal and reactive. What is the probable cause of his diplopia?

      Your Answer:

      Correct Answer: 4th nerve palsy

      Explanation:

      If you experience worsened vision while going down stairs, it may be a sign of 4th nerve palsy. This condition is characterized by limited depression and adduction of the eye, as well as persistent diplopia when looking down. It is often caused by head trauma, which can damage the long course of the trochlear nerve.

      People with 4th nerve palsy may tilt their heads away from the affected eye to compensate for the condition. This helps supply the superior oblique nerve, which aids in adduction and intorsion.

      Other conditions that can cause eye movement problems include 3rd nerve palsy, which may be caused by aneurysms or diabetes complications, and 6th nerve palsy, which prevents the affected eye from abducting. Horner syndrome, which is characterized by ptosis, anhidrosis, and miosis, may also affect eye movement and is often associated with Pancoast tumors.

      Understanding Fourth Nerve Palsy

      Fourth nerve palsy is a condition that affects the superior oblique muscle, which is responsible for depressing the eye and moving it inward. One of the main features of this condition is vertical diplopia, which is double vision that occurs when looking straight ahead. This is often noticed when reading a book or going downstairs. Another symptom is subjective tilting of objects, also known as torsional diplopia. Patients may also develop a head tilt, which they may or may not be aware of. When looking straight ahead, the affected eye appears to deviate upwards and is rotated outwards. Understanding the symptoms of fourth nerve palsy can help individuals seek appropriate treatment and management for this condition.

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      • Neurological System
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  • Question 18 - A child with severe hydrocephalus is exhibiting a lack of upward gaze. What...

    Incorrect

    • A child with severe hydrocephalus is exhibiting a lack of upward gaze. What specific area of the brain is responsible for this impairment?

      Your Answer:

      Correct Answer: Superior colliculi

      Explanation:

      The superior colliculi play a crucial role in upward gaze and are located on both sides of the tectal or quadrigeminal plate. Damage or compression of the superior colliculi, such as in severe hydrocephalus, can result in the inability to look up, known as sunsetting of the eyes.

      The optic chiasm serves as the connection between the anterior and posterior optic pathways. The nasal fibers of the optic nerves cross over at the chiasm, leading to monocular visual field deficits with anterior pathway lesions and binocular visual field deficits with posterior pathway lesions.

      The lateral geniculate body in the thalamus is where the optic tract connects with the optic radiations, while the inferior colliculi and medial geniculate bodies are responsible for processing auditory stimuli.

      Understanding the Diencephalon: An Overview of Brain Anatomy

      The diencephalon is a part of the brain that is located between the cerebral hemispheres and the brainstem. It is composed of several structures, including the thalamus, hypothalamus, epithalamus, and subthalamus. Each of these structures plays a unique role in regulating various bodily functions and behaviors.

      The thalamus is responsible for relaying sensory information from the body to the cerebral cortex, which is responsible for processing and interpreting this information. The hypothalamus, on the other hand, is involved in regulating a wide range of bodily functions, including hunger, thirst, body temperature, and sleep. It also plays a role in regulating the release of hormones from the pituitary gland.

      The epithalamus is a small structure that is involved in regulating the sleep-wake cycle and the production of melatonin, a hormone that helps to regulate sleep. The subthalamus is involved in regulating movement and is part of the basal ganglia, a group of structures that are involved in motor control.

      Overall, the diencephalon plays a crucial role in regulating many of the body’s essential functions and behaviors. Understanding its anatomy and function can help us better understand how the brain works and how we can maintain optimal health and well-being.

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      • Neurological System
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  • Question 19 - Which of the cranial nerves listed below is least likely to carry parasympathetic...

    Incorrect

    • Which of the cranial nerves listed below is least likely to carry parasympathetic fibers?

      Your Answer:

      Correct Answer: II

      Explanation:

      Cranial nerves are a set of 12 nerves that emerge from the brain and control various functions of the head and neck. Each nerve has a specific function, such as smell, sight, eye movement, facial sensation, and tongue movement. Some nerves are sensory, some are motor, and some are both. A useful mnemonic to remember the order of the nerves is Some Say Marry Money But My Brother Says Big Brains Matter Most, with S representing sensory, M representing motor, and B representing both.

      In addition to their specific functions, cranial nerves also play a role in various reflexes. These reflexes involve an afferent limb, which carries sensory information to the brain, and an efferent limb, which carries motor information from the brain to the muscles. Examples of cranial nerve reflexes include the corneal reflex, jaw jerk, gag reflex, carotid sinus reflex, pupillary light reflex, and lacrimation reflex. Understanding the functions and reflexes of the cranial nerves is important in diagnosing and treating neurological disorders.

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      • Neurological System
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  • Question 20 - A 78-year-old man comes to the emergency department complaining of double vision. According...

    Incorrect

    • A 78-year-old man comes to the emergency department complaining of double vision. According to his wife, he fell in the garden earlier today and hit his head on a bench. During the examination, you notice that his left eye is fixed in a down and out position. After performing a CT scan, you discover that he has an extradural hematoma on the left side. These types of hematomas are often caused by the middle meningeal artery rupturing. Which foramina does this artery use to enter the cranium?

      Your Answer:

      Correct Answer: Foramen spinosum

      Explanation:

      The correct answer is the foramen spinosum, which is a small opening in the cranial cavity that allows the meningeal artery to pass through.

      The foramen lacerum is covered with cartilage during life and is sometimes described as the passage for the nerve and artery of the pterygoid canal. However, it is more accurate to say that they pass into the cartilage that blocks the foramen before entering the pterygoid canal, which is located in the anterior wall of the foramen.

      The foramen ovale is an oval-shaped opening that allows the mandibular nerve to pass through.

      The foramen magnum is the largest of the foramen and is located in the posterior of the cranial cavity. It allows the brainstem and associated structures to pass through.

      Foramina of the Base of the Skull

      The base of the skull contains several openings called foramina, which allow for the passage of nerves, blood vessels, and other structures. The foramen ovale, located in the sphenoid bone, contains the mandibular nerve, otic ganglion, accessory meningeal artery, and emissary veins. The foramen spinosum, also in the sphenoid bone, contains the middle meningeal artery and meningeal branch of the mandibular nerve. The foramen rotundum, also in the sphenoid bone, contains the maxillary nerve.

      The foramen lacerum, located in the sphenoid bone, is initially occluded by a cartilaginous plug and contains the internal carotid artery, nerve and artery of the pterygoid canal, and the base of the medial pterygoid plate. The jugular foramen, located in the temporal bone, contains the inferior petrosal sinus, glossopharyngeal, vagus, and accessory nerves, sigmoid sinus, and meningeal branches from the occipital and ascending pharyngeal arteries.

      The foramen magnum, located in the occipital bone, contains the anterior and posterior spinal arteries, vertebral arteries, and medulla oblongata. The stylomastoid foramen, located in the temporal bone, contains the stylomastoid artery and facial nerve. Finally, the superior orbital fissure, located in the sphenoid bone, contains the oculomotor nerve, recurrent meningeal artery, trochlear nerve, lacrimal, frontal, and nasociliary branches of the ophthalmic nerve, and abducent nerve.

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      • Neurological System
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