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  • Question 1 - An 80-year-old man arrives at the emergency department with his daughter. They were...

    Incorrect

    • An 80-year-old man arrives at the emergency department with his daughter. They were having a conversation when she noticed he was having difficulty understanding her. He has a history of high blood pressure and has smoked for 40 years.

      During your assessment, you observe that he is able to speak fluently but makes some errors. However, his comprehension appears to be intact and he can correctly identify his daughter and name objects in the room. When asked to repeat certain words, he struggles and appears frustrated by his mistakes.

      Based on these symptoms, what is the likely diagnosis?

      Your Answer: Wernicke's aphasia

      Correct Answer: Conduction aphasia

      Explanation:

      The patient is experiencing conduction aphasia, which is characterized by fluent speech but poor repetition ability. However, their comprehension remains intact. This type of aphasia is typically caused by a stroke that affects the arcuate fasciculus, the part of the parietal lobe that connects Broca’s and Wernicke’s areas. Given the sudden onset of symptoms, it is likely an acute cause. The patient’s medical history and smoking habit put them at risk for stroke.

      Anomic aphasia, which causes difficulty in naming objects, is less likely as the patient was able to name some bedside objects correctly. This type of aphasia can be caused by damage to various areas, including Broca’s and Wernicke’s areas, the parietal lobe, and the temporal lobe, due to trauma or neurodegenerative disease.

      Broca’s aphasia, which results in non-fluent speech but intact comprehension, can be ruled out as the patient is fluent but struggles with repeating sentences. Broca’s area is located in the dominant hemisphere’s frontal lobe and can be damaged by a stroke or trauma.

      Global aphasia, which involves a lack of fluency and comprehension, is not the diagnosis as the patient has both. This type of aphasia is caused by extensive damage to multiple language centers in the dominant hemisphere, often due to a stroke, but can also be caused by a tumor, trauma, or infection.

      Types of Aphasia: Understanding the Different Forms of Language Impairment

      Aphasia is a language disorder that affects a person’s ability to communicate effectively. There are different types of aphasia, each with its own set of symptoms and underlying causes. Wernicke’s aphasia, also known as receptive aphasia, is caused by a lesion in the superior temporal gyrus. This area is responsible for forming speech before sending it to Broca’s area. People with Wernicke’s aphasia may speak fluently, but their sentences often make no sense, and they may use word substitutions and neologisms. Comprehension is impaired.

      Broca’s aphasia, also known as expressive aphasia, is caused by a lesion in the inferior frontal gyrus. This area is responsible for speech production. People with Broca’s aphasia may speak in a non-fluent, labored, and halting manner. Repetition is impaired, but comprehension is normal.

      Conduction aphasia is caused by a stroke affecting the arcuate fasciculus, the connection between Wernicke’s and Broca’s area. People with conduction aphasia may speak fluently, but their repetition is poor. They are aware of the errors they are making, but comprehension is normal.

      Global aphasia is caused by a large lesion affecting all three areas mentioned above, resulting in severe expressive and receptive aphasia. People with global aphasia may still be able to communicate using gestures. Understanding the different types of aphasia is important for proper diagnosis and treatment.

    • This question is part of the following fields:

      • Neurological System
      15.2
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  • Question 2 - Which one of the following structures is not closely related to the carotid...

    Correct

    • Which one of the following structures is not closely related to the carotid sheath?

      Your Answer: Anterior belly of digastric muscle

      Explanation:

      The carotid sheath is connected to sternohyoid and sternothyroid at its lower end. The superior belly of omohyoid crosses the sheath at the cricoid cartilage level. The sternocleidomastoid muscle covers the sheath above this level. The vessels pass beneath the posterior belly of digastric and stylohyoid above the hyoid bone. The hypoglossal nerve crosses the sheath diagonally at the hyoid bone level.

      The common carotid artery is a major blood vessel that supplies the head and neck with oxygenated blood. It has two branches, the left and right common carotid arteries, which arise from different locations. The left common carotid artery originates from the arch of the aorta, while the right common carotid artery arises from the brachiocephalic trunk. Both arteries terminate at the upper border of the thyroid cartilage by dividing into the internal and external carotid arteries.

      The left common carotid artery runs superolaterally to the sternoclavicular joint and is in contact with various structures in the thorax, including the trachea, left recurrent laryngeal nerve, and left margin of the esophagus. In the neck, it passes deep to the sternocleidomastoid muscle and enters the carotid sheath with the vagus nerve and internal jugular vein. The right common carotid artery has a similar path to the cervical portion of the left common carotid artery, but with fewer closely related structures.

      Overall, the common carotid artery is an important blood vessel with complex anatomical relationships in both the thorax and neck. Understanding its path and relations is crucial for medical professionals to diagnose and treat various conditions related to this artery.

    • This question is part of the following fields:

      • Neurological System
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  • Question 3 - A teenage boy is brought in with clinical indications of Herpes Simplex Virus...

    Incorrect

    • A teenage boy is brought in with clinical indications of Herpes Simplex Virus (HSV) encephalitis. In an MRI, where would the lesions be typically observed?

      Your Answer: Cerebellum

      Correct Answer: Temporal lobes

      Explanation:

      HSV encephalitis is commonly linked with damage to the bitemporal lobes, but it can also affect the inferior frontal lobe. However, the parietal lobes, occipital lobes, and cerebellum are not typically affected by this condition.

      Herpes Simplex Encephalitis: Symptoms, Diagnosis, and Treatment

      Herpes simplex encephalitis is a common topic in medical exams. This viral infection affects the temporal lobes of the brain, causing symptoms such as fever, headache, seizures, and vomiting. Focal features like aphasia may also be present. It is important to note that peripheral lesions, such as cold sores, are not related to the presence of HSV encephalitis.

      HSV-1 is responsible for 95% of cases in adults and typically affects the temporal and inferior frontal lobes. Diagnosis is made through CSF analysis, PCR for HSV, and imaging studies like CT or MRI. EEG patterns may also show lateralized periodic discharges at 2 Hz.

      Early treatment with intravenous acyclovir is crucial for a good prognosis. Mortality rates can range from 10-20% with prompt treatment, but can approach 80% if left untreated. MRI is a better imaging modality for detecting changes in the medial temporal and inferior frontal lobes.

      In summary, herpes simplex encephalitis is a serious viral infection that affects the brain. It is important to recognize the symptoms and seek prompt medical attention for early diagnosis and treatment.

    • This question is part of the following fields:

      • Neurological System
      34.6
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  • Question 4 - A 67-year-old man is rushed to the operating room for suspected ruptured abdominal...

    Incorrect

    • A 67-year-old man is rushed to the operating room for suspected ruptured abdominal aortic aneurysm without prior fasting. To perform rapid sequence intubation, the anaesthetists administer thiopental sodium, a barbiturate. What is the mechanism of action of this medication?

      Your Answer: Blocks acetylcholine release at the neuromuscular junction

      Correct Answer: Increase duration of chloride channel opening

      Explanation:

      Barbiturates increase the duration of chloride channel opening, while sodium valproate and phenytoin work by blocking voltage-gated sodium channels. SNRIs like duloxetine function by inhibiting serotonin-norepinephrine reuptake, and memantine is a glutamate receptor antagonist used for treating moderate to severe Alzheimer’s disease. Botulinum toxin, on the other hand, blocks acetylcholine release at the neuromuscular junction and is used to treat muscle disorders like spasticity and excessive sweating.

      Barbiturates are commonly used in the treatment of anxiety and seizures, as well as for inducing anesthesia. They work by enhancing the action of GABAA, a neurotransmitter that helps to calm the brain. Specifically, barbiturates increase the duration of chloride channel opening, which allows more chloride ions to enter the neuron and further inhibit its activity. This is in contrast to benzodiazepines, which increase the frequency of chloride channel opening. A helpful mnemonic to remember this difference is Frequently Bend – During Barbeque or Barbiturates increase duration & Benzodiazepines increase frequency. Overall, barbiturates are an important class of drugs that can help to manage a variety of conditions by modulating the activity of GABAA in the brain.

    • This question is part of the following fields:

      • Neurological System
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  • Question 5 - A 55-year-old woman complains of discomfort and pain in her hand. She is...

    Correct

    • A 55-year-old woman complains of discomfort and pain in her hand. She is employed as a typist and experiences the most pain while working. She also experiences symptoms during the night. The pain is less severe in her little finger. Which nerve is most likely to be affected?

      Your Answer: Median

      Explanation:

      EIWRTREY

      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 6 - A 32-year-old overweight woman comes to you complaining of a severe headache that...

    Incorrect

    • A 32-year-old overweight woman comes to you complaining of a severe headache that is affecting both sides of her head. She also reports blurred vision in her left eye. Upon examination, you notice papilloedema and a CNVI palsy in her left eye. Her blood pressure is 160/100 mmHg, and she is currently taking the combined oral contraceptive pill (COCP). What is the probable diagnosis?

      Your Answer: Berry aneurysm

      Correct Answer: Idiopathic intracranial hypertension

      Explanation:

      The correct answer is: Headache, blurred vision, papilloedema, and CNVI palsy in a young, obese female on COCP are highly indicative of idiopathic intracranial hypertension. PKD may lead to hypertension and rupture of a berry aneurysm, but it would present with stroke-like symptoms. The presence of a berry aneurysm on its own would not cause any symptoms. Acute-angle closure glaucoma would present with a painful acute red eye and vomiting.

      Understanding Idiopathic Intracranial Hypertension

      Idiopathic intracranial hypertension, also known as pseudotumour cerebri, is a medical condition that is commonly observed in young, overweight females. The condition is characterized by a range of symptoms, including headache, blurred vision, and papilloedema, which is usually present. Other symptoms may include an enlarged blind spot and sixth nerve palsy.

      There are several risk factors associated with idiopathic intracranial hypertension, including obesity, female sex, pregnancy, and certain drugs such as the combined oral contraceptive pill, steroids, tetracyclines, vitamin A, and lithium.

      Management of idiopathic intracranial hypertension may involve weight loss, diuretics such as acetazolamide, and topiramate, which can also cause weight loss in most patients. Repeated lumbar puncture may also be necessary, and surgery may be required to prevent damage to the optic nerve. This may involve optic nerve sheath decompression and fenestration, or a lumboperitoneal or ventriculoperitoneal shunt to reduce intracranial pressure.

      It is important to note that if intracranial hypertension is thought to occur secondary to a known cause, such as medication, it is not considered idiopathic. Understanding the risk factors and symptoms associated with idiopathic intracranial hypertension can help individuals seek appropriate medical attention and management.

    • This question is part of the following fields:

      • Neurological System
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  • Question 7 - A young intravenous drug user suffers from a false aneurysm and needs immediate...

    Correct

    • A young intravenous drug user suffers from a false aneurysm and needs immediate surgery. During the procedure, the femoral nerve is accidentally cut, making the surgery more challenging. Which muscle is the least likely to be impacted by this injury?

      Your Answer: Adductor magnus

      Explanation:

      R emember E very W ord I n T his E xercise

      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 8 - A 60-year-old man visits his physician with a complaint of double vision. During...

    Incorrect

    • A 60-year-old man visits his physician with a complaint of double vision. During the examination, the physician observes that the left eye is in a 'down and out' position and the pupil is dilated. The physician suspects a cranial nerve palsy.

      What is the probable reason for his nerve palsy?

      Your Answer: Diabetes

      Correct Answer: Posterior communicating artery aneurysm

      Explanation:

      Consider compression as the likely cause of surgical third nerve palsy.

      When the dilation of the pupil is involved, it is referred to as surgical third nerve palsy. This condition is caused by a lesion that compresses the pupillary fibers located on the outer part of the third nerve. Unlike vascular causes of third nerve palsy, which only affect the nerve and not the pupillary fibers.

      Out of the given options, only answer 4 is a compressive cause of third nerve palsy. The other options are risk factors for vascular causes.

      Understanding Third Nerve Palsy: Causes and Features

      Third nerve palsy is a neurological condition that affects the third cranial nerve, which controls the movement of the eye and eyelid. The condition is characterized by the eye being deviated ‘down and out’, ptosis, and a dilated pupil. In some cases, it may be referred to as a ‘surgical’ third nerve palsy due to the dilation of the pupil.

      There are several possible causes of third nerve palsy, including diabetes mellitus, vasculitis (such as temporal arteritis or SLE), uncal herniation through tentorium if raised ICP, posterior communicating artery aneurysm, and cavernous sinus thrombosis. In some cases, it may also be a false localizing sign. Weber’s syndrome, which is characterized by an ipsilateral third nerve palsy with contralateral hemiplegia, is caused by midbrain strokes. Other possible causes include amyloid and multiple sclerosis.

    • This question is part of the following fields:

      • Neurological System
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  • Question 9 - A builder in his 40s falls off a ladder while laying roof tiles...

    Incorrect

    • A builder in his 40s falls off a ladder while laying roof tiles and suffers a burst fracture of L3. The MRI scan reveals complete nerve transection at this level due to the injury. What clinical sign will be absent in the beginning?

      Your Answer: Flaccid paralysis of the legs

      Correct Answer: Extensor plantar response

      Explanation:

      In cases of lower motor neuron lesions, there is a reduction in various features such as muscle strength, muscle size, reflexes, and the occurrence of muscle fasciculation.

      The spinal cord is a central structure located within the vertebral column that provides it with structural support. It extends rostrally to the medulla oblongata of the brain and tapers caudally at the L1-2 level, where it is anchored to the first coccygeal vertebrae by the filum terminale. The cord is characterised by cervico-lumbar enlargements that correspond to the brachial and lumbar plexuses. It is incompletely divided into two symmetrical halves by a dorsal median sulcus and ventral median fissure, with grey matter surrounding a central canal that is continuous with the ventricular system of the CNS. Afferent fibres entering through the dorsal roots usually terminate near their point of entry but may travel for varying distances in Lissauer’s tract. The key point to remember is that the anatomy of the cord will dictate the clinical presentation in cases of injury, which can be caused by trauma, neoplasia, inflammatory diseases, vascular issues, or infection.

      One important condition to remember is Brown-Sequard syndrome, which is caused by hemisection of the cord and produces ipsilateral loss of proprioception and upper motor neuron signs, as well as contralateral loss of pain and temperature sensation. Lesions below L1 tend to present with lower motor neuron signs. It is important to keep a clinical perspective in mind when revising CNS anatomy and to understand the ways in which the spinal cord can become injured, as this will help in diagnosing and treating patients with spinal cord injuries.

    • This question is part of the following fields:

      • Neurological System
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  • Question 10 - 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 11 - A 43-year-old male visits his doctor complaining of headaches, nausea, and vomiting that...

    Incorrect

    • A 43-year-old male visits his doctor complaining of headaches, nausea, and vomiting that have been worsening when lying down or leaning forwards for the past 3 months. He has no significant medical history and is not taking any medications. Upon undergoing an MRI, multiple suspicious lesions are found along his spinal cord. A biopsy confirms the presence of ependymal cells that have undergone malignant transformation. What is the typical role of these cells?

      Your Answer:

      Correct Answer: Cerebrospinal fluid (CSF) production

      Explanation:

      The nervous system is composed of various types of cells, each with their own unique functions. Oligodendroglia cells are responsible for producing myelin in the central nervous system (CNS) and are affected in multiple sclerosis. Schwann cells, on the other hand, produce myelin in the peripheral nervous system (PNS) and are affected in Guillain-Barre syndrome. Astrocytes provide physical support, remove excess potassium ions, help form the blood-brain barrier, and aid in physical repair. Microglia are specialised CNS phagocytes, while ependymal cells provide the inner lining of the ventricles.

      In summary, the nervous system is made up of different types of cells, each with their own specific roles. Oligodendroglia and Schwann cells produce myelin in the CNS and PNS, respectively, and are affected in certain diseases. Astrocytes provide physical support and aid in repair, while microglia are specialised phagocytes in the CNS. Ependymal cells line the ventricles. Understanding the functions of these cells is crucial in understanding the complex workings of the nervous system.

    • This question is part of the following fields:

      • Neurological System
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  • Question 12 - John is a 35-year-old man who was discharged 3 days ago from hospital,...

    Incorrect

    • John is a 35-year-old man who was discharged 3 days ago from hospital, after sustaining an injury to his head. Observations and imaging were all normal and there was no neurological deficit on examination. Since then he has noticed difficulty in going upstairs. He says that he can't see where he is going and becomes very unsteady. His wife also told him that he has started to tilt his head to the right, which he was unaware of.

      On examination, his visual acuity is 6/6 but he has difficulty looking up and out with his right eye, no other abnormality is revealed.

      What is the most likely diagnosis?

      Your Answer:

      Correct Answer: Trochlear nerve palsy

      Explanation:

      Consider 4th nerve palsy if your vision deteriorates while descending stairs.

      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.

    • This question is part of the following fields:

      • Neurological System
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  • Question 13 - A 30-year-old woman presents with an absent corneal reflex on cranial nerve examination....

    Incorrect

    • A 30-year-old woman presents with an absent corneal reflex on cranial nerve examination. The examining neurologist suspects a lesion affecting either the afferent or efferent limb of this reflex. Which two cranial nerves should be considered as potential culprits?

      Your Answer:

      Correct Answer: Trigeminal and facial nerve

      Explanation:

      The trigeminal nerve’s ophthalmic branch serves as the input or arriving limb in the corneal reflex, while the facial nerve acts as the output or exiting limb.

      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 14 - An 80-year-old man arrives at the emergency department with abrupt vertigo, accompanied by...

    Incorrect

    • An 80-year-old man arrives at the emergency department with abrupt vertigo, accompanied by right-sided facial paralysis and hearing loss. All four limbs' motor function and vision are intact. You suspect a stroke diagnosis. Which vessel's stroke would best account for his symptoms?

      Your Answer:

      Correct Answer: Anterior inferior cerebellar artery

      Explanation:

      The correct answer is the anterior inferior cerebellar artery. This artery can cause sudden onset vertigo and vomiting, as well as ipsilateral facial paralysis and deafness, which are all symptoms mentioned in the question. The fact that the patient has right-sided facial paralysis indicates that the right anterior inferior cerebellar artery is affected.

      The anterior cerebral artery is not the correct answer. This artery can cause contralateral hemiparesis and sensory loss, but the patient in the question has intact motor function in all four limbs.

      The basilar artery is also not the correct answer. Strokes affecting this artery can cause ‘locked-in’ syndrome, which is characterized by complete paralysis of voluntary muscles except for those controlling eye movement. However, the patient in the question has intact motor function in all limbs.

      The posterior cerebral artery is also not the correct answer. Strokes affecting this artery can cause contralateral homonymous hemianopia with macular sparing and visual agnosia, but the patient in the question has intact vision.

      Stroke can affect different parts of the brain depending on which artery is affected. If the anterior cerebral artery is affected, the person may experience weakness and loss of sensation on the opposite side of the body, with the lower extremities being more affected than the upper. If the middle cerebral artery is affected, the person may experience weakness and loss of sensation on the opposite side of the body, with the upper extremities being more affected than the lower. They may also experience vision loss and difficulty with language. If the posterior cerebral artery is affected, the person may experience vision loss and difficulty recognizing objects.

      Lacunar strokes are a type of stroke that are strongly associated with hypertension. They typically present with isolated weakness or loss of sensation on one side of the body, or weakness with difficulty coordinating movements. They often occur in the basal ganglia, thalamus, or internal capsule.

    • This question is part of the following fields:

      • Neurological System
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  • Question 15 - Emma, a 31-year-old female, has been in labour for 20 hours. She has...

    Incorrect

    • Emma, a 31-year-old female, has been in labour for 20 hours. She has only received Entonox and pethidine for pain relief and now requests an epidural.

      After examining Emma, the anaesthetist determines that she is suitable for an epidural.

      What is the proper sequence of structures that the needle must pass through to administer epidural analgesia to Emma?

      Your Answer:

      Correct Answer: Skin, subcutaneous fat, supraspinous ligament, interspinous ligament, and ligamentum flavum

      Explanation:

      Lumbar Puncture Procedure

      Lumbar puncture is a medical procedure that involves obtaining cerebrospinal fluid. In adults, the procedure is typically performed at the L3/L4 or L4/5 interspace, which is located below the spinal cord’s termination at L1.

      During the procedure, the needle passes through several layers. First, it penetrates the supraspinous ligament, which connects the tips of spinous processes. Then, it passes through the interspinous ligaments between adjacent borders of spinous processes. Next, the needle penetrates the ligamentum flavum, which may cause a give. Finally, the needle passes through the dura mater into the subarachnoid space, which is marked by a second give. At this point, clear cerebrospinal fluid should be obtained.

      Overall, the lumbar puncture procedure is a complex process that requires careful attention to detail. By following the proper steps and guidelines, medical professionals can obtain cerebrospinal fluid safely and effectively.

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      • Neurological System
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  • Question 16 - A 16-year-old girl is brought to the doctor after a peculiar incident. She...

    Incorrect

    • A 16-year-old girl is brought to the doctor after a peculiar incident. She complained of feeling an intense sense of terror, experiencing nausea, having a rapid heartbeat, and hearing laughter. Her mother observed her turning pale. She did not faint or feel lightheaded. The episode lasted for 90 seconds, and afterward, she felt disoriented and had a strange sense of familiarity.

      What could be the probable reason for this occurrence?

      Your Answer:

      Correct Answer: Focal temporal lobe seizure

      Explanation:

      Temporal lobe seizures can lead to hallucinations. In this case, the boy experienced fear, epigastric discomfort, tachycardia, and heard laughter. His mother also noticed a change in his skin color and he felt confused and experienced deja vu after the seizure. These symptoms are typical of temporal lobe seizures.

      The options of focal frontal lobe seizure, focal parietal lobe seizure, and panic attack are incorrect. Focal frontal lobe seizures usually involve movement, while focal parietal lobe seizures cause a sensation of paraesthesia. A panic attack may cause some of the symptoms, but not the hallucinations or deja vu. It may also lead to dizziness or loss of consciousness.

      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 72-year-old man with a history of a basal skull tumour visits his...

    Incorrect

    • A 72-year-old man with a history of a basal skull tumour visits his GP with a complaint of progressive loss of taste in the posterior third of his tongue over the course of 4 weeks.

      Which cranial nerve is most likely affected in causing this presentation?

      Your Answer:

      Correct Answer: Glossopharyngeal

      Explanation:

      The glossopharyngeal nerve is responsible for taste sensation in the posterior 1/3rd of the tongue. Glossopharyngeal nerve palsy is rare but can be caused by various factors such as tumors or trauma. In this case, the patient’s isolated lower cranial nerve palsy may be due to a basal skull tumor compressing the medullary cranial nerves (IX, X, XI, XII). The patient’s complaint of taste loss towards the anterior portion of the tongue suggests a glossopharyngeal problem rather than a facial, olfactory, or hypoglossal issue.

      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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  • Question 18 - A 55-year-old man with a history of diabetes visits his ophthalmologist for his...

    Incorrect

    • A 55-year-old man with a history of diabetes visits his ophthalmologist for his yearly diabetic retinopathy screening. During the examination, the physician observes venous beading. What other clinical manifestation would be present due to the same underlying pathophysiology?

      Your Answer:

      Correct Answer: Cotton wool spots

      Explanation:

      Cotton wool spots found in diabetic retinopathy are indicative of retinal infarction resulting from ischemic disruption. Venous beading, on the other hand, is characterized by irregular constriction and dilation of venules in the retina due to retinal ischemia. It is important to note that cupping of the optic disc is not associated with diabetic retinopathy but rather with open-angle glaucoma. Similarly, lipid exudates are not a feature of diabetic retinopathy as they occur at the border between thickened and non-thickened retina, resulting in extravasated lipoprotein.

      Understanding Diabetic Retinopathy

      Diabetic retinopathy is a leading cause of blindness in adults aged 35-65 years-old. The condition is caused by hyperglycaemia, which leads to abnormal metabolism in the retinal vessel walls, causing damage to endothelial cells and pericytes. This damage leads to increased vascular permeability, which causes exudates seen on fundoscopy. Pericyte dysfunction predisposes to the formation of microaneurysms, while neovascularization is caused by the production of growth factors in response to retinal ischaemia.

      Patients with diabetic retinopathy are typically classified into those with non-proliferative diabetic retinopathy (NPDR), proliferative retinopathy (PDR), and maculopathy. NPDR is further classified into mild, moderate, and severe, depending on the presence of microaneurysms, blot haemorrhages, hard exudates, cotton wool spots, venous beading/looping, and intraretinal microvascular abnormalities. PDR is characterized by retinal neovascularization, which may lead to vitreous haemorrhage, and fibrous tissue forming anterior to the retinal disc. Maculopathy is based on location rather than severity and is more common in Type II DM.

      Management of diabetic retinopathy involves optimizing glycaemic control, blood pressure, and hyperlipidemia, as well as regular review by ophthalmology. For maculopathy, intravitreal vascular endothelial growth factor (VEGF) inhibitors are used if there is a change in visual acuity. Non-proliferative retinopathy is managed through regular observation, while severe/very severe cases may require panretinal laser photocoagulation. Proliferative retinopathy is treated with panretinal laser photocoagulation, intravitreal VEGF inhibitors, and vitreoretinal surgery in severe or vitreous haemorrhage cases. Examples of VEGF inhibitors include ranibizumab, which has a strong evidence base for slowing the progression of proliferative diabetic retinopathy and improving visual acuity.

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      • Neurological System
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  • Question 19 - A 82-year-old man presents to falls clinic with a history of four falls...

    Incorrect

    • A 82-year-old man presents to falls clinic with a history of four falls in the past four months, despite no previous falls. He also complains of a worsening headache at night over the last three months. During the cranial nerve exam, an inferior homonymous quadrantanopia is observed, but eye movements are intact. The rest of the neurological exam is unremarkable. What area of the brain could be responsible for these symptoms?

      Your Answer:

      Correct Answer: Superior optic radiation

      Explanation:

      Superior optic radiation lesions in the parietal lobe are responsible for inferior homonymous quadrantanopias. The location of the lesion can be determined by analyzing the visual field defect pattern. Lesions anterior to the optic chiasm cause incongruous defects, while lesions at the optic chiasm cause bitemporal/binasal hemianopias. Lesions posterior to the optic chiasm result in homonymous hemianopias. The optic radiations carry nerves from the optic chiasm to the occipital lobe. Lesions located inferiorly cause superior visual field defects, and vice versa. Therefore, the woman’s inferior homonymous quadrantanopias indicate a lesion on the superior aspect of the optic radiation in the parietal lobe. Superior homonymous quadrantanopias result from lesions to the inferior aspect of the optic radiations. Compression of the lateral aspects of the optic chiasm causes nasal/binasal visual field defects, while compression of the superior optic chiasm causes bitemporal hemianopias. Lesions to the optic nerve before reaching the optic chiasm cause an incongruous homonymous hemianopia affecting the ipsilateral eye.

      Understanding Visual Field Defects

      Visual field defects can occur due to various reasons, including lesions in the optic tract, optic radiation, or occipital cortex. A left homonymous hemianopia indicates a visual field defect to the left, which is caused by a lesion in the right optic tract. On the other hand, homonymous quadrantanopias can be categorized into PITS (Parietal-Inferior, Temporal-Superior) and can be caused by lesions in the inferior or superior optic radiations in the temporal or parietal lobes.

      When it comes to congruous and incongruous defects, the former refers to complete or symmetrical visual field loss, while the latter indicates incomplete or asymmetric visual field loss. Incongruous defects are caused by optic tract lesions, while congruous defects are caused by optic radiation or occipital cortex lesions. In cases where there is macula sparing, it is indicative of a lesion in the occipital cortex.

      Bitemporal hemianopia, on the other hand, is caused by a lesion in the optic chiasm. The type of defect can indicate the location of the compression, with an upper quadrant defect being more common in inferior chiasmal compression, such as a pituitary tumor, and a lower quadrant defect being more common in superior chiasmal compression, such as a craniopharyngioma.

      Understanding visual field defects is crucial in diagnosing and treating various neurological conditions. By identifying the type and location of the defect, healthcare professionals can provide appropriate interventions to improve the patient’s quality of life.

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  • Question 20 - A 47-year-old woman is being evaluated on the ward 24 hours after a...

    Incorrect

    • A 47-year-old woman is being evaluated on the ward 24 hours after a thyroidectomy. Although she has been feeling fine, she has noticed a hoarseness in her voice. Which nerve may have been affected during the operation?

      Your Answer:

      Correct Answer: Right recurrent laryngeal nerve

      Explanation:

      During neck surgery, the right recurrent laryngeal nerve is at a higher risk of injury compared to the left due to its diagonal path across the neck originating under the subclavian. Both the recurrent and superior laryngeal nerves play a crucial role in the sensory and motor function of the vocal cords. The superior laryngeal nerve is less likely to be damaged during thyroid surgery in the lower neck as it descends from above the vocal cords. The glossopharyngeal nerve is also not commonly affected by this mechanism, but if injured, it can cause difficulty swallowing, changes in taste, and altered sensation in the back of the mouth. Hypoglossal nerve injury is rare and does not align with this mechanism, but if it occurs, it can lead to atrophy of the tongue muscles on the same side.

      The Recurrent Laryngeal Nerve: Anatomy and Function

      The recurrent laryngeal nerve is a branch of the vagus nerve that plays a crucial role in the innervation of the larynx. It has a complex path that differs slightly between the left and right sides of the body. On the right side, it arises anterior to the subclavian artery and ascends obliquely next to the trachea, behind the common carotid artery. It may be located either anterior or posterior to the inferior thyroid artery. On the left side, it arises left to the arch of the aorta, winds below the aorta, and ascends along the side of the trachea.

      Both branches pass in a groove between the trachea and oesophagus before entering the larynx behind the articulation between the thyroid cartilage and cricoid. Once inside the larynx, the recurrent laryngeal nerve is distributed to the intrinsic larynx muscles (excluding cricothyroid). It also branches to the cardiac plexus and the mucous membrane and muscular coat of the oesophagus and trachea.

      Damage to the recurrent laryngeal nerve, such as during thyroid surgery, can result in hoarseness. Therefore, understanding the anatomy and function of this nerve is crucial for medical professionals who perform procedures in the neck and throat area.

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  • Question 21 - Which one of the following is not a branch of the posterior cord...

    Incorrect

    • Which one of the following is not a branch of the posterior cord of the brachial plexus?

      Your Answer:

      Correct Answer: Musculocutaneous nerve

      Explanation:

      The posterior cord gives rise to mnemonic branches, including the subscapular (upper and lower), thoracodorsal, axillary, and radial nerves. On the other hand, the musculocutaneous nerve is a branch originating from the lateral cord.

      Understanding the Brachial Plexus and Cutaneous Sensation of the Upper Limb

      The brachial plexus is a network of nerves that originates from the anterior rami of C5 to T1. It is divided into five sections: roots, trunks, divisions, cords, and branches. To remember these sections, a common mnemonic used is Real Teenagers Drink Cold Beer.

      The roots of the brachial plexus are located in the posterior triangle and pass between the scalenus anterior and medius muscles. The trunks are located posterior to the middle third of the clavicle, with the upper and middle trunks related superiorly to the subclavian artery. The lower trunk passes over the first rib posterior to the subclavian artery. The divisions of the brachial plexus are located at the apex of the axilla, while the cords are related to the axillary artery.

      The branches of the brachial plexus provide cutaneous sensation to the upper limb. This includes the radial nerve, which provides sensation to the posterior arm, forearm, and hand; the median nerve, which provides sensation to the palmar aspect of the thumb, index, middle, and half of the ring finger; and the ulnar nerve, which provides sensation to the palmar and dorsal aspects of the fifth finger and half of the ring finger.

      Understanding the brachial plexus and its branches is important in diagnosing and treating conditions that affect the upper limb, such as nerve injuries and neuropathies. It also helps in understanding the cutaneous sensation of the upper limb and how it relates to the different nerves of the brachial plexus.

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  • Question 22 - Does the external branch of the superior laryngeal nerve innervate the cricothyroid muscle?...

    Incorrect

    • Does the external branch of the superior laryngeal nerve innervate the cricothyroid muscle?

      Your Answer:

      Correct Answer: Cricothyroid

      Explanation:

      The intrinsic muscles of the larynx, with the exception of the cricothyroid muscle, are innervated by the innervation. The cricothyroid muscle is innervated by the external branch of the superior laryngeal nerve.

      The Recurrent Laryngeal Nerve: Anatomy and Function

      The recurrent laryngeal nerve is a branch of the vagus nerve that plays a crucial role in the innervation of the larynx. It has a complex path that differs slightly between the left and right sides of the body. On the right side, it arises anterior to the subclavian artery and ascends obliquely next to the trachea, behind the common carotid artery. It may be located either anterior or posterior to the inferior thyroid artery. On the left side, it arises left to the arch of the aorta, winds below the aorta, and ascends along the side of the trachea.

      Both branches pass in a groove between the trachea and oesophagus before entering the larynx behind the articulation between the thyroid cartilage and cricoid. Once inside the larynx, the recurrent laryngeal nerve is distributed to the intrinsic larynx muscles (excluding cricothyroid). It also branches to the cardiac plexus and the mucous membrane and muscular coat of the oesophagus and trachea.

      Damage to the recurrent laryngeal nerve, such as during thyroid surgery, can result in hoarseness. Therefore, understanding the anatomy and function of this nerve is crucial for medical professionals who perform procedures in the neck and throat area.

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  • Question 23 - A 12-year-old boy comes to the GP after experiencing unusual behavior. His mother...

    Incorrect

    • A 12-year-old boy comes to the GP after experiencing unusual behavior. His mother accompanies him and reports that her son suddenly started smacking his lips together for a brief period. She adds that he then complained of smelling a foul odor that she couldn't detect. Given the family history of epilepsy, you suspect that he may have had a seizure. What type of seizure is typically associated with these symptoms?

      Your Answer:

      Correct Answer: Temporal lobe seizure

      Explanation:

      Temporal lobe seizures can lead to hallucinations, including olfactory hallucinations, which is likely the cause of this patient’s presentation.

      Flashes and floaters are a common symptom of occipital lobe seizures.

      Juvenile myoclonic epilepsy can cause occasional generalized seizures and daytime absences.

      Parietal lobe seizures can result in paraesthesia.

      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.

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  • Question 24 - A 6-year-old boy has been experiencing recurring headaches. During his evaluation, an MRI...

    Incorrect

    • A 6-year-old boy has been experiencing recurring headaches. During his evaluation, an MRI scan of his brain was conducted, revealing an enlargement of the lateral and third ventricles. What is the probable location of the obstruction?

      Your Answer:

      Correct Answer: Aqueduct of Sylvius

      Explanation:

      The Aqueduct of Sylvius is the pathway through which the CSF moves from the 3rd to the 4th ventricle.

      Cerebrospinal Fluid: Circulation and Composition

      Cerebrospinal fluid (CSF) is a clear, colorless liquid that fills the space between the arachnoid mater and pia mater, covering the surface of the brain. The total volume of CSF in the brain is approximately 150ml, and it is produced by the ependymal cells in the choroid plexus or blood vessels. The majority of CSF is produced by the choroid plexus, accounting for 70% of the total volume. The remaining 30% is produced by blood vessels. The CSF is reabsorbed via the arachnoid granulations, which project into the venous sinuses.

      The circulation of CSF starts from the lateral ventricles, which are connected to the third ventricle via the foramen of Munro. From the third ventricle, the CSF flows through the cerebral aqueduct (aqueduct of Sylvius) to reach the fourth ventricle via the foramina of Magendie and Luschka. The CSF then enters the subarachnoid space, where it circulates around the brain and spinal cord. Finally, the CSF is reabsorbed into the venous system via arachnoid granulations into the superior sagittal sinus.

      The composition of CSF is essential for its proper functioning. The glucose level in CSF is between 50-80 mg/dl, while the protein level is between 15-40 mg/dl. Red blood cells are not present in CSF, and the white blood cell count is usually less than 3 cells/mm3. Understanding the circulation and composition of CSF is crucial for diagnosing and treating various neurological disorders.

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  • Question 25 - A 59-year-old man arrives at the emergency department with a sudden onset of...

    Incorrect

    • A 59-year-old man arrives at the emergency department with a sudden onset of visual disturbance. He has a medical history of hypercholesterolemia and is currently taking atorvastatin. Additionally, he smokes 15 cigarettes daily, drinks half a bottle of wine each night, and works as a bond-trader.

      Upon examination of his eyes, a field defect is observed in the right upper quadrant of both his right and left eye. Other than that, the examination is unremarkable.

      What is the anatomical location of the lesion that is affecting his vision?

      Your Answer:

      Correct Answer: Left inferior optic radiation

      Explanation:

      A right superior homonymous quadrantanopia in the patient is caused by a lesion in the left inferior optic radiation located in the temporal lobe. The sudden onset indicates a possible stroke or vascular event. A superior homonymous quadrantanopia occurs when the contralateral inferior optic radiation is affected.

      A lesion in the left superior optic radiation would result in a right inferior homonymous quadrantanopia, which is not the case here. Similarly, a lesion in the left optic tract would cause contralateral hemianopia, which is also not the diagnosis in this patient.

      Understanding Visual Field Defects

      Visual field defects can occur due to various reasons, including lesions in the optic tract, optic radiation, or occipital cortex. A left homonymous hemianopia indicates a visual field defect to the left, which is caused by a lesion in the right optic tract. On the other hand, homonymous quadrantanopias can be categorized into PITS (Parietal-Inferior, Temporal-Superior) and can be caused by lesions in the inferior or superior optic radiations in the temporal or parietal lobes.

      When it comes to congruous and incongruous defects, the former refers to complete or symmetrical visual field loss, while the latter indicates incomplete or asymmetric visual field loss. Incongruous defects are caused by optic tract lesions, while congruous defects are caused by optic radiation or occipital cortex lesions. In cases where there is macula sparing, it is indicative of a lesion in the occipital cortex.

      Bitemporal hemianopia, on the other hand, is caused by a lesion in the optic chiasm. The type of defect can indicate the location of the compression, with an upper quadrant defect being more common in inferior chiasmal compression, such as a pituitary tumor, and a lower quadrant defect being more common in superior chiasmal compression, such as a craniopharyngioma.

      Understanding visual field defects is crucial in diagnosing and treating various neurological conditions. By identifying the type and location of the defect, healthcare professionals can provide appropriate interventions to improve the patient’s quality of life.

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  • Question 26 - Sophie is a 25-year-old female who has been experiencing trouble fitting into her...

    Incorrect

    • Sophie is a 25-year-old female who has been experiencing trouble fitting into her shoes and wearing her rings. She has a deep voice, stands at a height of 195cm, and her GP observes coarse facial features. Sophie mentions that she suspects her anterior pituitary gland may be producing an excess of hormones. Which hormone is likely being overproduced in Sophie's case?

      Your Answer:

      Correct Answer: Growth hormone

      Explanation:

      The pituitary gland is a small gland located within the sella turcica in the sphenoid bone of the middle cranial fossa. It weighs approximately 0.5g and is covered by a dural fold. The gland is attached to the hypothalamus by the infundibulum and receives hormonal stimuli from the hypothalamus through the hypothalamo-pituitary portal system. The anterior pituitary, which develops from a depression in the wall of the pharynx known as Rathkes pouch, secretes hormones such as ACTH, TSH, FSH, LH, GH, and prolactin. GH and prolactin are secreted by acidophilic cells, while ACTH, TSH, FSH, and LH are secreted by basophilic cells. On the other hand, the posterior pituitary, which is derived from neuroectoderm, secretes ADH and oxytocin. Both hormones are produced in the hypothalamus before being transported by the hypothalamo-hypophyseal portal system.

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  • Question 27 - A 87-year-old woman is brought to the emergency department by ambulance after her...

    Incorrect

    • A 87-year-old woman is brought to the emergency department by ambulance after her husband noticed a facial droop 1 hour ago. She has a medical history of hypertension and dyslipidaemia.

      Upon examination, there is a facial droop on the right side that spares the forehead. There is also a right-sided hemiparesis and loss of fine-touch sensation, with the right arm being more affected than the right leg. The examination of the visual fields reveals right homonymous hemianopia. Although the patient is conscious, she is unable to speak in full sentences.

      Which artery is likely to be occluded?

      Your Answer:

      Correct Answer: Middle cerebral artery

      Explanation:

      The correct answer is the middle cerebral artery, which is associated with contralateral hemiparesis and sensory loss, with the upper extremity being more affected than the lower, contralateral homonymous hemianopia, and aphasia. This type of stroke is also known as a ‘total anterior circulation stroke’ and is characterized by at least three of the following criteria: higher dysfunction, homonymous hemianopia, and motor and sensory deficits.

      The anterior cerebral artery is not the correct answer, as it is associated with contralateral hemiparesis and altered sensation, with the lower limb being more affected than the upper limb.

      The basilar artery is also not the correct answer, as it is associated with locked-in syndrome, which is characterized by paralysis of all voluntary muscles except for those used for vertical eye movements and blinking.

      The posterior cerebral artery is not the correct answer either, as it is associated with contralateral homonymous hemianopia that spares the macula and visual agnosia.

      Finally, the posterior inferior cerebellar artery is not the correct answer, as it is associated with lateral medullary syndrome, which is characterized by ipsilateral facial pain and contralateral limb pain and temperature loss, as well as vertigo, vomiting, ataxia, and dysphagia.

      Stroke can affect different parts of the brain depending on which artery is affected. If the anterior cerebral artery is affected, the person may experience weakness and loss of sensation on the opposite side of the body, with the lower extremities being more affected than the upper. If the middle cerebral artery is affected, the person may experience weakness and loss of sensation on the opposite side of the body, with the upper extremities being more affected than the lower. They may also experience vision loss and difficulty with language. If the posterior cerebral artery is affected, the person may experience vision loss and difficulty recognizing objects.

      Lacunar strokes are a type of stroke that are strongly associated with hypertension. They typically present with isolated weakness or loss of sensation on one side of the body, or weakness with difficulty coordinating movements. They often occur in the basal ganglia, thalamus, or internal capsule.

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  • Question 28 - A patient in his late 40s visits his GP complaining of intense shoulder...

    Incorrect

    • A patient in his late 40s visits his GP complaining of intense shoulder pain that radiates to the scapula area. Despite a thorough shoulder examination revealing no joint issues, the patient is referred for additional tests. Imaging studies reveal a bronchogenic apical lung tumor that has caused lesions in the brachial plexus and extends towards the superior cervical and stellate ganglia. If these two structures are compressed, what signs are most likely to occur?

      Your Answer:

      Correct Answer: Ptosis, miosis, anhydrosis

      Explanation:

      The superior cervical ganglion (SCG) is a component of the sympathetic nervous system that solely innervates the head and neck. Its functions include innervating eye structures, and damage or compression of the SCG can lead to Horner’s syndrome, which is characterized by ptosis, miosis, and anhydrosis. This syndrome occurs due to the unopposed action of the parasympathetic system on the eye, as the sympathetic innervation is impaired.

      Damage to the external laryngeal nerve, a branch of the superior laryngeal nerve, can result in a monotonous voice. However, this nerve does not originate from the SCG, so it is unlikely to affect the voice.

      As the SCG is part of the sympathetic nervous system, its damage impairs sympathetic responses and leads to unopposed parasympathetic innervation. This can cause miosis (constriction) of the eye, not mydriasis (dilation).

      Sweating is caused by the action of the sympathetic nervous system, so damage to the SCG would most likely result in anhydrosis (lack of sweat) of the face, rather than hyperhidrosis (excessive sweating).

      Hoarse voice can result from damage to the recurrent laryngeal nerve, which is not related to the SCG, so it is unlikely to affect the voice.

      Horner’s syndrome is a condition characterized by several features, including a small pupil (miosis), drooping of the upper eyelid (ptosis), a sunken eye (enophthalmos), and loss of sweating on one side of the face (anhidrosis). The cause of Horner’s syndrome can be determined by examining additional symptoms. For example, congenital Horner’s syndrome may be identified by a difference in iris color (heterochromia), while anhidrosis may be present in central or preganglionic lesions. Pharmacologic tests, such as the use of apraclonidine drops, can also be helpful in confirming the diagnosis and identifying the location of the lesion. Central lesions may be caused by conditions such as stroke or multiple sclerosis, while postganglionic lesions may be due to factors like carotid artery dissection or cluster headaches. It is important to note that the appearance of enophthalmos in Horner’s syndrome is actually due to a narrow palpebral aperture rather than true enophthalmos.

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  • Question 29 - A 57-year-old woman is admitted to the orthogeriatric ward for further investigations into...

    Incorrect

    • A 57-year-old woman is admitted to the orthogeriatric ward for further investigations into the underlying cause of her recurrent falls. During a neurological examination, it is found that she has normal power, tone, reflexes, and coordination in both upper and lower limbs bilaterally, but there is a loss of sensation over the medial aspect of her left leg. Based on this information, which nerve is most likely to have been affected?

      Your Answer:

      Correct Answer: Saphenous nerve

      Explanation:

      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.

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  • Question 30 - A 70-year-old man experiences a fall resulting in a fractured neck of femur....

    Incorrect

    • A 70-year-old man experiences a fall resulting in a fractured neck of femur. He undergoes a left hip hemiarthroplasty and two months later presents with an abnormal gait. Upon standing on his left leg, his pelvis dips on the right side, but there is no evidence of foot drop. What could be the underlying cause of this presentation?

      Your Answer:

      Correct Answer: Superior gluteal nerve damage

      Explanation:

      The cause of this patient’s trendelenburg gait is damage to the superior gluteal nerve, resulting in weakened abductor muscles. A common diagnostic test involves asking the patient to stand on one leg, which causes the pelvis to dip on the opposite side. The absence of a foot drop rules out the potential for polio or L5 radiculopathy.

      The gluteal region is composed of various muscles and nerves that play a crucial role in hip movement and stability. The gluteal muscles, including the gluteus maximus, medius, and minimis, extend and abduct the hip joint. Meanwhile, the deep lateral hip rotators, such as the piriformis, gemelli, obturator internus, and quadratus femoris, rotate the hip joint externally.

      The nerves that innervate the gluteal muscles are the superior and inferior gluteal nerves. The superior gluteal nerve controls the gluteus medius, gluteus minimis, and tensor fascia lata muscles, while the inferior gluteal nerve controls the gluteus maximus muscle.

      If the superior gluteal nerve is damaged, it can result in a Trendelenburg gait, where the patient is unable to abduct the thigh at the hip joint. This weakness causes the pelvis to tilt down on the opposite side during the stance phase, leading to compensatory movements such as trunk lurching to maintain a level pelvis throughout the gait cycle. As a result, the pelvis sags on the opposite side of the lesioned superior gluteal nerve.

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