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  • Question 1 - A mother brings her 6-year-old daughter into hospital worried that she is slower...

    Incorrect

    • A mother brings her 6-year-old daughter into hospital worried that she is slower than the other girls when standing up. Upon further inquiry, the mother discloses that her daughter walks in an unusual manner and that her grandmother passed away when she was very young. What is the probable cause of the young girl's condition?

      Your Answer: Lack of enzymatic breakdown of phenylalanine

      Correct Answer: Mutation in the gene coding for dystrophin

      Explanation:

      Duchenne muscular dystrophy (DMD) is characterised by a waddling gait and Gower’s sign, and follows an X-linked recessive pattern of inheritance. Cystic fibrosis is caused by improper chloride ion channel formation, myasthenia gravis by an autoimmune process against acetylcholine receptors, phenylketonuria by a lack of phenylalanine breakdown, and sickle cell anaemia by a mutation in the gene coding for haemoglobin.

      Dystrophinopathies are a group of genetic disorders that are inherited in an X-linked recessive manner. These disorders are caused by mutations in the dystrophin gene located on the X chromosome at position Xp21. Dystrophin is a protein that is part of a larger membrane-associated complex in muscle cells. It connects the muscle membrane to actin, which is a component of the muscle cytoskeleton.

      Duchenne muscular dystrophy is a severe form of dystrophinopathy that is caused by a frameshift mutation in the dystrophin gene. This mutation results in the loss of one or both binding sites, leading to progressive proximal muscle weakness that typically begins around the age of 5 years. Children with Duchenne muscular dystrophy may also exhibit calf pseudohypertrophy and Gower’s sign, which is when they use their arms to stand up from a squatted position. Approximately 30% of patients with Duchenne muscular dystrophy also have intellectual impairment.

      In contrast, Becker muscular dystrophy is a milder form of dystrophinopathy that typically develops after the age of 10 years. It is caused by a non-frameshift insertion in the dystrophin gene, which preserves both binding sites. Intellectual impairment is much less common in individuals with Becker muscular dystrophy.

    • This question is part of the following fields:

      • Neurological System
      22
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  • Question 2 - A 27-year-old male with a history of paraplegia, due to C5 spinal cord...

    Incorrect

    • A 27-year-old male with a history of paraplegia, due to C5 spinal cord injury sustained 8 weeks prior, is currently admitted to an orthopaedic and spinal ward. One night, he wakes up in distress with a headache and diaphoresis above the level of his spinal cord injury. His blood pressure is currently 160/110 mmHg. It was recorded 2 hours ago as 110/70mmHg. His pulse rate is 50. The patient also has an indwelling catheter which was changed earlier today.

      The healthcare provider on-call suspects that autonomic dysreflexia might be the cause of the patient's symptoms.

      What is the most common life-threatening outcome associated with this condition?

      Your Answer: Pulmonary embolism

      Correct Answer: Haemorrhagic stroke

      Explanation:

      Autonomic dysreflexia is a condition that occurs in patients who have suffered a spinal cord injury at or above the T6 spinal level. It is caused by a reflex response triggered by various stimuli, such as faecal impaction or urinary retention, which sends signals through the thoracolumbar outflow. However, due to the spinal cord lesion, the usual parasympathetic response is prevented, leading to an unbalanced physiological response. This response is characterized by extreme hypertension, flushing, and sweating above the level of the cord lesion, as well as agitation. If left untreated, severe consequences such as haemorrhagic stroke can occur. The management of autonomic dysreflexia involves removing or controlling the stimulus and treating any life-threatening hypertension and/or bradycardia.

    • 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
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  • Question 4 - You are a final year medical student working in the emergency department. You...

    Incorrect

    • You are a final year medical student working in the emergency department. You have been asked to see a 25-year-old male presenting with a red, painful eye. He reports a gritty discomfort in his right eye which has been increasing in severity throughout the last day. He has no significant past medical history, although reports having a recent upper respiratory tract infection. He works as a plumber and has been on an active construction site for much of the day without eye protection.

      On examination, the right eyelid appears swollen and mildly erythematous. There is a watery discharge from the eye. The conjunctiva is widely injected. The eye has a full range of movements and the pupil is equal and reactive to light. There is no reduction in visual acuity. There is a small dark corneal lesion with an orange halo at the 3-o'clock position with minor fluorescein uptake around its periphery.

      What is the most likely cause for the presenting symptoms?

      Your Answer: Viral conjunctivitis

      Correct Answer: Iron-containing corneal foreign body

      Explanation:

      When someone presents with a red eye, it is often due to an ocular foreign body. If the foreign body contains iron, it may have a distinctive orange halo. Dendritic corneal ulcers, which have a characteristic shape visible with fluorescein staining, are caused by HSV-1 viruses from the herpesviridae family. It is important to avoid using topical steroids in these cases. Plant-based foreign bodies are more likely to cause infection than inert foreign bodies like plastic or glass, or oxidizing foreign bodies like iron. Viral conjunctivitis typically presents with bilateral, itchy, painful red eyes with watery discharge and small follicles on the tarsal conjunctiva. Acute angle closure crisis is a serious emergency that causes a painful, red eye with a poorly responsive pupil that is mid-dilated. Iron-containing foreign bodies begin to oxidize within six hours of contact with the corneal surface, leading to an orange ring of ferrous material that disperses into the superficial corneal layers and tear film surrounding the foreign body.

      Corneal foreign body is a condition characterized by eye pain, foreign body sensation, photophobia, watering eye, and red eye. It is important to refer patients to ophthalmology if there is a suspected penetrating eye injury due to high-velocity injuries or sharp objects, significant orbital or peri-ocular trauma, or a chemical injury has occurred. Foreign bodies composed of organic material should also be referred to ophthalmology as they are associated with a higher risk of infection and complications. Additionally, foreign bodies in or near the centre of the cornea and any red flags such as severe pain, irregular pupils, or significant reduction in visual acuity should be referred to ophthalmology. For further information on management, please refer to Clinical Knowledge Summaries.

    • This question is part of the following fields:

      • Neurological System
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  • Question 5 - A 68-year-old male presents to the emergency department with a sudden onset headache...

    Correct

    • A 68-year-old male presents to the emergency department with a sudden onset headache that he describes as the worst he has ever experienced. He has a history of a coiled brain aneurysm four years ago. There are no changes in his mental status, vision, or movement. A CT scan reveals a subarachnoid hemorrhage. What tissue will be immediately deep to the blood in this case?

      Your Answer: Pia mater

      Explanation:

      The pia mater is the innermost layer of the meninges, which is directly adhered to the surface of the brain and connected to the arachnoid mater by trabeculae. It lies immediately deep to the blood in a subarachnoid haemorrhage.

      The arachnoid mater is the middle layer of the meninges, which is superficial to the subarachnoid space and deep to blood following a subdural haemorrhage or haematoma but not following a subarachnoid haemorrhage.

      The dura mater is the outermost layer of the meninges, which is formed from two layers – the inner, meningeal, layer and the outer, endosteal, layer. It is a thick fibrous layer that protects the brain from trauma and is superficial to the subarachnoid space.

      The cerebrum is the largest portion of the brain tissue, comprised of four main lobes. It is deep to the subarachnoid space, but it is not the tissue immediately deep to it.

      The corpus callosum is a band of nerve fibres that connects the two hemispheres of the brain. It is not immediately deep to the subarachnoid space, but it may be compressed and shifted away from its normal position following a subarachnoid haemorrhage, which can be seen on imaging.

      The Three Layers of Meninges

      The meninges are a group of membranes that cover the brain and spinal cord, providing support to the central nervous system and the blood vessels that supply it. These membranes can be divided into three distinct layers: the dura mater, arachnoid mater, and pia mater.

      The outermost layer, the dura mater, is a thick fibrous double layer that is fused with the inner layer of the periosteum of the skull. It has four areas of infolding and is pierced by small areas of the underlying arachnoid to form structures called arachnoid granulations. The arachnoid mater forms a meshwork layer over the surface of the brain and spinal cord, containing both cerebrospinal fluid and vessels supplying the nervous system. The final layer, the pia mater, is a thin layer attached directly to the surface of the brain and spinal cord.

      The meninges play a crucial role in protecting the brain and spinal cord from injury and disease. However, they can also be the site of serious medical conditions such as subdural and subarachnoid haemorrhages. Understanding the structure and function of the meninges is essential for diagnosing and treating these conditions.

    • This question is part of the following fields:

      • Neurological System
      15.9
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  • Question 6 - A 50-year-old motorcyclist is seeking treatment at your clinic after a bike accident...

    Correct

    • A 50-year-old motorcyclist is seeking treatment at your clinic after a bike accident that occurred 10 months ago. The patient suffered a significant pelvic fracture, which has since healed. However, he is worried about the persistent numbness in his right leg. During the examination, he experiences difficulty in adducting his right hip against resistance and has reduced sensation around the medial aspect of his right thigh. Which nerve is most likely to have been affected?

      Your Answer: Obturator

      Explanation:

      The patient is experiencing decreased sensation in the inner thigh and weakened adductor muscles, which are both controlled by the obturator nerve.

      Meanwhile, the femoral nerve is responsible for providing sensation to the front of the thigh, while the sciatic nerve is responsible for sensation in the back of the thigh.

      Additionally, the ilio-inguinal nerve is responsible for sensation in certain areas of the genital region, and the tibial nerve controls the movement of ankle muscles.

      Anatomy of the Obturator Nerve

      The obturator nerve is formed by branches from the ventral divisions of L2, L3, and L4 nerve roots, with L3 being the main contributor. It descends vertically in the posterior part of the psoas major muscle and emerges from its medial border at the lateral margin of the sacrum. After crossing the sacroiliac joint, it enters the lesser pelvis and descends on the obturator internus muscle to enter the obturator groove. The nerve lies lateral to the internal iliac vessels and ureter in the lesser pelvis and is joined by the obturator vessels lateral to the ovary or ductus deferens.

      The obturator nerve supplies the muscles of the medial compartment of the thigh, including the external obturator, adductor longus, adductor brevis, adductor magnus (except for the lower part supplied by the sciatic nerve), and gracilis. The cutaneous branch, which is often absent, supplies the skin and fascia of the distal two-thirds of the medial aspect of the thigh when present.

      The obturator canal connects the pelvis and thigh and contains the obturator artery, vein, and nerve, which divides into anterior and posterior branches. Understanding the anatomy of the obturator nerve is important in diagnosing and treating conditions that affect the medial thigh and pelvic region.

    • This question is part of the following fields:

      • Neurological System
      19.9
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  • Question 7 - A 68-year-old male comes to the emergency department with a sudden onset of...

    Correct

    • A 68-year-old male comes to the emergency department with a sudden onset of numbness in his right arm and leg. During the examination, you observe that he has left-sided facial numbness. There are no alterations in his speech or hearing, and he has no weakness in any of his limbs.

      What is the probable diagnosis?

      Your Answer: Lateral medullary syndrome

      Explanation:

      Understanding Lateral Medullary Syndrome

      Lateral medullary syndrome, also referred to as Wallenberg’s syndrome, is a condition that arises when the posterior inferior cerebellar artery becomes blocked. This condition is characterized by a range of symptoms that affect both the cerebellum and brainstem. Cerebellar features of the syndrome include ataxia and nystagmus, while brainstem features include dysphagia, facial numbness, and cranial nerve palsy such as Horner’s. Additionally, patients may experience contralateral limb sensory loss. Understanding the symptoms of lateral medullary syndrome is crucial for prompt diagnosis and treatment.

    • This question is part of the following fields:

      • Neurological System
      12.7
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  • Question 8 - A 75-year-old man is brought to his family doctor by his wife, who...

    Correct

    • A 75-year-old man is brought to his family doctor by his wife, who reports that her husband has been misplacing items around the house, such as putting his wallet in the fridge. She also mentions that he has gotten lost on two occasions while trying to find his way home. The man has difficulty remembering recent events but can recall his childhood and early adulthood with clarity. He denies experiencing any visual or auditory hallucinations or issues with his mobility. The wife notes that her husband's behavioral changes have been gradual rather than sudden. A CT scan reveals significant widening of the brain sulci. What is the most likely diagnosis for this man, and what is the underlying pathology?

      Your Answer: Extracellular amyloid plaques and intracellular fibrillary tangles

      Explanation:

      Alzheimer’s disease is caused by the deposition of insoluble beta-amyloid protein, leading to the formation of cortical plaques, and abnormal aggregation of the tau protein, resulting in intraneuronal neurofibrillary tangles. This disease is characterized by a gradual onset of memory and behavioral problems, as well as brain atrophy visible on CT scans. Vascular dementia, on the other hand, is caused by multiple ischemic insults to the brain, resulting in a stepwise decline in cognition. Prion disease, such as Creutzfeldt-Jakob disease, is characterized by the presence of insoluble beta-pleated protein sheets. Lacunar infarcts, caused by obstruction of small penetrating arteries in the brain, can be detected by MRI or CT scans. Lewy body dementia is characterized by the presence of intracellular Lewy bodies, along with symptoms of dementia and Parkinson’s disease.

      Alzheimer’s disease is a type of dementia that gradually worsens over time and is caused by the degeneration of the brain. There are several risk factors associated with Alzheimer’s disease, including increasing age, family history, and certain genetic mutations. The disease is also more common in individuals of Caucasian ethnicity and those with Down’s syndrome.

      The pathological changes associated with Alzheimer’s disease include widespread cerebral atrophy, particularly in the cortex and hippocampus. Microscopically, there are cortical plaques caused by the deposition of type A-Beta-amyloid protein and intraneuronal neurofibrillary tangles caused by abnormal aggregation of the tau protein. The hyperphosphorylation of the tau protein has been linked to Alzheimer’s disease. Additionally, there is a deficit of acetylcholine due to damage to an ascending forebrain projection.

      Neurofibrillary tangles are a hallmark of Alzheimer’s disease and are partly made from a protein called tau. Tau is a protein that interacts with tubulin to stabilize microtubules and promote tubulin assembly into microtubules. In Alzheimer’s disease, tau proteins are excessively phosphorylated, impairing their function.

    • This question is part of the following fields:

      • Neurological System
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  • Question 9 - A 65-year-old hypertensive woman comes to the clinic complaining of a sudden decline...

    Correct

    • A 65-year-old hypertensive woman comes to the clinic complaining of a sudden decline in her memory. She had a similar episode a few months ago. Apart from that, she is in good health but has a history of a STEMI three years ago and peripheral arterial disease in her legs. What type of dementia is most probable?

      Your Answer: Vascular dementia

      Explanation:

      Dementia comes in various forms, with Alzheimer’s dementia (AD) being the most prevalent. AD is characterized by a gradual onset that is difficult to pinpoint, and there are no other indications of any other cause. Vascular Dementia, on the other hand, has a sudden onset and progresses in a stepwise manner. Patients may remain stable for a while before suddenly progressing to the next level, resulting in a fluctuating course. They also have uneven impairment and neurological signs, and typically have vascular risk factors such as cardiovascular disease or peripheral vascular disease. Lewy body dementia is characterized by fluctuating levels of consciousness, visual hallucinations, parkinsonian-like symptoms, falls, and neuroleptic sensitivity.

      Vascular dementia is a group of syndromes of cognitive impairment caused by different mechanisms resulting from cerebrovascular disease. It is the second most common form of dementia after Alzheimer’s disease and accounts for around 17% of dementia in the UK. The main subtypes of VD are stroke-related VD, subcortical VD, and mixed dementia. Risk factors include a history of stroke or TIA, atrial fibrillation, hypertension, diabetes mellitus, hyperlipidaemia, smoking, obesity, and coronary heart disease. Diagnosis is made based on a comprehensive history and physical examination, formal screen for cognitive impairment, and MRI scan. Treatment is mainly symptomatic, and non-pharmacological management includes tailored cognitive stimulation programs, multisensory stimulation, music and art therapy, and animal-assisted therapy. There is no specific pharmacological treatment approved for cognitive symptoms, and AChE inhibitors or memantine should only be considered for people with suspected comorbid Alzheimer’s disease, Parkinson’s disease dementia, or dementia with Lewy bodies.

    • This question is part of the following fields:

      • Neurological System
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  • Question 10 - A 67-year-old man visits the clinic with a concern about a lump he...

    Incorrect

    • A 67-year-old man visits the clinic with a concern about a lump he has noticed at the corner of his jaw. Apart from this, he reports feeling well. During the examination, there is no visible swelling, but on palpation, you detect a hard, immovable mass located about 2 cm above the angle of the mandible. Based on your assessment, you suspect that the patient may have a parotid gland tumor. If this is the case, the tumor may cause additional symptoms if it affects the cranial nerve that passes through the parotid gland. Which cranial nerve has a path that runs through the substance of the parotid gland?

      Your Answer: Maxillary nerve

      Correct Answer: Facial nerve

      Explanation:

      The parotid gland contains the facial nerve, which divides into five branches: the temporal, zygomatic, buccal, marginal mandibular, and cervical branches. The mandibular nerve, a division of the trigeminal nerve, carries both sensory and motor fibers, providing sensation to the lower lip, lower teeth and gums, chin, and jaw, and motor innervation to muscles involved in chewing and other functions. The glossopharyngeal nerve, the ninth cranial nerve, has various functions, including carrying taste and sensation from the back of the tongue, pharyngeal wall, tonsils, middle ear, external auditory canal, and auricle, as well as supplying the parotid gland with parasympathetic fibers. The maxillary nerve, another division of the trigeminal nerve, carries only sensory fibers, providing sensation to the lower eyelid and cheeks, upper teeth and gums, palate, nasal cavity, and certain paranasal sinuses. The hypoglossal nerve, the twelfth cranial nerve, supplies the intrinsic muscles of the tongue and most of the extrinsic muscles, except for the palatoglossus. A parotid tumor, which is usually benign, can cause symptoms such as a mass, tenderness of the gland, facial nerve palsy, or lymphatic infiltration.

      The facial nerve is responsible for supplying the muscles of facial expression, the digastric muscle, and various glandular structures. It also contains a few afferent fibers that originate in the genicular ganglion and are involved in taste. Bilateral facial nerve palsy can be caused by conditions such as sarcoidosis, Guillain-Barre syndrome, Lyme disease, and bilateral acoustic neuromas. Unilateral facial nerve palsy can be caused by these conditions as well as lower motor neuron issues like Bell’s palsy and upper motor neuron issues like stroke.

      The upper motor neuron lesion typically spares the upper face, specifically the forehead, while a lower motor neuron lesion affects all facial muscles. The facial nerve’s path includes the subarachnoid path, where it originates in the pons and passes through the petrous temporal bone into the internal auditory meatus with the vestibulocochlear nerve. The facial canal path passes superior to the vestibule of the inner ear and contains the geniculate ganglion at the medial aspect of the middle ear. The stylomastoid foramen is where the nerve passes through the tympanic cavity anteriorly and the mastoid antrum posteriorly, and it also includes the posterior auricular nerve and branch to the posterior belly of the digastric and stylohyoid muscle.

    • This question is part of the following fields:

      • Neurological System
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  • Question 11 - A 52-year-old woman arrives at the emergency department with a complaint of the...

    Incorrect

    • A 52-year-old woman arrives at the emergency department with a complaint of the most intense headache she has ever experienced. The pain came on suddenly, and there is no history of trauma. She is feeling nauseated, sensitive to light, and extremely anxious. Based on her symptoms, you suspect a subarachnoid hemorrhage. You order an urgent CT scan, but it shows no abnormalities. To obtain a sample of cerebrospinal fluid (CSF), you perform a lumbar puncture. What is the primary structure responsible for producing CSF?

      Your Answer: Pineal gland

      Correct Answer: Choroid plexus

      Explanation:

      The choroid plexus is a branching structure resembling sea coral that contains specialized ependymal cells responsible for producing and releasing cerebrospinal fluid (CSF). It is present in all four ventricles of the brain, with the largest portion located in the lateral ventricles. The choroid plexus plays a role in removing waste products from the CSF.

      The inferior colliculus is a nucleus in the midbrain involved in the auditory pathway. There are two inferior colliculi, one on each side of the midbrain, and they are part of the corpora quadrigemina along with the two superior colliculi (involved in the visual pathway).

      Arachnoid villi are microscopic projections of the arachnoid membrane that allow for the absorption of cerebrospinal fluid into the venous system. This is important as the amount of CSF produced each day is four times the total volume of the ventricular system.

      The corpus callosum is a bundle of nerve fibers that connects the left and right hemispheres of the brain, allowing for communication between them.

      The pineal gland is a small protrusion on the brain that produces melatonin and regulates the sleep cycle.

      A sudden-onset severe headache, described as the worst ever experienced, may indicate a subarachnoid hemorrhage. This can occur with or without trauma and is characterized by a thunderclap headache. If a CT scan is normal, CSF should be examined for xanthochromia, which is a yellow coloration that occurs several hours after a subarachnoid hemorrhage due to the breakdown of red blood cells and the release of bilirubin into the CSF.

      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.

    • This question is part of the following fields:

      • Neurological System
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  • Question 12 - A 25-year-old male presents for a follow-up appointment. He sustained a crush injury...

    Incorrect

    • A 25-year-old male presents for a follow-up appointment. He sustained a crush injury to his arm at work six weeks ago and was diagnosed with axonotmesis. The patient is eager to return to work and asks when he can expect the numbness in his arm to go away.

      What guidance should you provide to the patient?

      Your Answer: In most patients, this type of injury will recover in around 2 months

      Correct Answer: This type of injury usually recovers fully but can take up to a year

      Explanation:

      When a nerve is crushed, it can result in axonotmesis, which is a type of injury where both the axon and myelin sheath are damaged, but the nerve remains intact. Fortunately, axonotmesis injuries usually heal completely, although the process can be slow. The amount of time it takes for the nerve to heal depends on the severity and location of the injury, but typically, axons regenerate at a rate of 1mm per day and can take anywhere from three months to a year to fully recover. It’s not uncommon to experience residual numbness up to four weeks after the injury, but there’s usually no need for further testing at this point. While amitriptyline can help with pain relief, it doesn’t speed up the healing process. In contrast, neurotmesis injuries are more severe and can result in permanent nerve damage. However, in most cases of axonotmesis, full recovery is possible with time. Neuropraxia is a less severe type of nerve injury where the axon is not damaged, and healing typically occurs within six to eight weeks.

      Nerve injuries can be classified into three types: neuropraxia, axonotmesis, and neurotmesis. Neuropraxia occurs when the nerve is intact but its electrical conduction is affected. However, full recovery is possible, and autonomic function is preserved. Wallerian degeneration, which is the degeneration of axons distal to the site of injury, does not occur. Axonotmesis, on the other hand, happens when the axon is damaged, but the myelin sheath is preserved, and the connective tissue framework is not affected. Wallerian degeneration occurs in this type of injury. Lastly, neurotmesis is the most severe type of nerve injury, where there is a disruption of the axon, myelin sheath, and surrounding connective tissue. Wallerian degeneration also occurs in this type of injury.

      Wallerian degeneration typically begins 24-36 hours following the injury. Axons are excitable before degeneration occurs, and the myelin sheath degenerates and is phagocytosed by tissue macrophages. Neuronal repair may only occur physiologically where nerves are in direct contact. However, nerve regeneration may be hampered when a large defect is present, and it may not occur at all or result in the formation of a neuroma. If nerve regrowth occurs, it typically happens at a rate of 1mm per day.

    • This question is part of the following fields:

      • Neurological System
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  • Question 13 - Which statement is false about the foramina of the skull? ...

    Incorrect

    • Which statement is false about the foramina of the skull?

      Your Answer: The jugular foramen transmits the accessory nerve

      Correct Answer: The foramen spinosum is at the base of the medial pterygoid plate.

      Explanation:

      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 abducens nerve.

    • This question is part of the following fields:

      • Neurological System
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  • Question 14 - A 70-year-old male arrives at the emergency department with a complaint of waking...

    Incorrect

    • A 70-year-old male arrives at the emergency department with a complaint of waking up in the morning with a sudden loss of sensation on the left side of his body. He has a medical history of hypertension and reports no pain. There are no changes to his vision or hearing.

      What is the probable diagnosis?

      Your Answer: Lateral pontine syndrome

      Correct Answer: Lacunar infarct

      Explanation:

      Hemisensory loss in this patient, along with a history of hypertension, is highly indicative of a lacunar infarct. Lacunar strokes are closely linked to hypertension.

      Facial pain on the same side and pain in the limbs and torso on the opposite side are typical symptoms of lateral medullary syndrome.

      Contralateral homonymous hemianopia is a common symptom of middle cerebral artery strokes.

      Lateral pontine syndrome is characterized by deafness on the same side as the lesion.

      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 - A 55-year-old man visits his general practitioner complaining of pain in the back...

    Correct

    • A 55-year-old man visits his general practitioner complaining of pain in the back of his leg. The doctor suspects a sciatic nerve injury.

      During the examination, which reflexes are expected to be absent?

      Your Answer: Ankle reflex

      Explanation:

      When the sciatic nerve is damaged, the reflexes in the ankle and plantar areas are lost, but the knee jerk reflex remains intact. This can cause pain and numbness in the back of the leg. If the damage occurs at the pelvic outlet, the ability to flex the knee may be lost, but the knee jerk reflex will still be present. During a neurological examination of the upper limb, the reflexes in the biceps, brachioradialis, and triceps are tested. Additionally, the sural and tibial nerve reflexes are cutaneous reflexes that are activated during walking.

      Understanding Sciatic Nerve Lesion

      The sciatic nerve is a major nerve that is supplied by the L4-5, S1-3 vertebrae and divides into the tibial and common peroneal nerves. It is responsible for supplying the hamstring and adductor muscles. When the sciatic nerve is damaged, it can result in a range of symptoms that affect both motor and sensory functions.

      Motor symptoms of sciatic nerve lesion include paralysis of knee flexion and all movements below the knee. Sensory symptoms include loss of sensation below the knee. Reflexes may also be affected, with ankle and plantar reflexes lost while the knee jerk reflex remains intact.

      There are several causes of sciatic nerve lesion, including fractures of the neck of the femur, posterior hip dislocation, and trauma.

    • This question is part of the following fields:

      • Neurological System
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  • Question 16 - A patient in his mid-50s visits his physician with complaints of difficulty in...

    Incorrect

    • A patient in his mid-50s visits his physician with complaints of difficulty in chewing and tongue movement, leading to eating problems. The patient also reports severe headaches, and the symptoms have been worsening gradually. The doctor decides to conduct an MRI scan to diagnose the condition.

      What is the likely location of the lesion within the skull that the doctor will look for?

      Your Answer: Superior orbital fissure

      Correct Answer: Hypoglossal canal

      Explanation:

      The hypoglossal nerve travels through the hypoglossal canal, which is why damage to this nerve can cause symptoms related to tongue movement and reflexes such as chewing, sucking, and swallowing. The superior orbital fissure is not the correct answer as the nerves that pass through it do not provide motor innervation to the tongue, and the patient in the question does not present with any eye-related symptoms. The jugular foramen and foramen ovale are also incorrect as they do not exclusively house the hypoglossal nerve, and the nerves that pass through them do not provide motor innervation to the tongue. The foramen rotundum is also not the correct answer as only the maxillary branch of the trigeminal nerve passes through it, which does not innervate the tongue.

      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 17 - A 48-year-old woman visits the neurology clinic for a follow-up on her long-standing...

    Correct

    • A 48-year-old woman visits the neurology clinic for a follow-up on her long-standing generalized epilepsy. She has been experiencing seizures since childhood and has tried various medications to manage the condition. Among these medications, she believes that carbamazepine has been the most effective.

      What is the mechanism of action of carbamazepine?

      Your Answer: Inhibits sodium channels

      Explanation:

      Sodium valproate and carbamazepine are both inhibitors of sodium channels, which leads to the suppression of excitation by preventing repetitive and sustained firing of an action potential. Additionally, sodium valproate increases levels of GABA in the brain.

      Tiagabine, on the other hand, blocks the cellular uptake of GABA by inhibiting the GABA transporter, making it a GABA reuptake inhibitor.

      Ethosuximide blocks T-type calcium channels and is primarily used to treat absence seizures, while benzodiazepines elongate the opening time of GABAA receptors. Barbiturates, on the other hand, act as agonists of GABAA receptors and potentiate the effect of GABA.

      Treatment Options for Epilepsy

      Epilepsy is a neurological disorder that affects millions of people worldwide. Treatment for epilepsy typically involves the use of antiepileptic drugs (AEDs) to control seizures. The decision to start AEDs is usually made after a second seizure, but there are certain circumstances where treatment may be initiated after the first seizure. These include the presence of a neurological deficit, structural abnormalities on brain imaging, unequivocal epileptic activity on EEG, or if the patient or their family considers the risk of having another seizure to be unacceptable.

      It is important to note that there are specific drug treatments for different types of seizures. For generalized tonic-clonic seizures, males are typically prescribed sodium valproate, while females may be given lamotrigine or levetiracetam. For focal seizures, first-line treatment options include lamotrigine or levetiracetam, with carbamazepine, oxcarbazepine, or zonisamide used as second-line options. Ethosuximide is the first-line treatment for absence seizures, with sodium valproate or lamotrigine/levetiracetam used as second-line options. For myoclonic seizures, males are usually given sodium valproate, while females may be prescribed levetiracetam. Finally, for tonic or atonic seizures, males are typically given sodium valproate, while females may be prescribed lamotrigine.

      It is important to work closely with a healthcare provider to determine the best treatment plan for each individual with epilepsy. Additionally, it is important to be aware of potential risks associated with certain AEDs, such as the use of sodium valproate during pregnancy, which has been linked to neurodevelopmental delays in children.

    • This question is part of the following fields:

      • Neurological System
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  • Question 18 - During a carotid endarterectomy, if the internal carotid artery is cross-clamped without a...

    Correct

    • During a carotid endarterectomy, if the internal carotid artery is cross-clamped without a shunt, which vessels will not experience reduced or absent flow?

      Assuming that no shunt is inserted, which vessels will not have diminished or absent flow as a result during a carotid endarterectomy where the internal carotid artery is cross-clamped?

      Your Answer: Maxillary artery

      Explanation:

      The external carotid artery gives rise to the maxillary artery.

      The internal carotid artery originates from the common carotid artery near the upper border of the thyroid cartilage and travels upwards to enter the skull through the carotid canal. It then passes through the cavernous sinus and divides into the anterior and middle cerebral arteries. In the neck, it is surrounded by various structures such as the longus capitis, pre-vertebral fascia, sympathetic chain, and superior laryngeal nerve. It is also closely related to the external carotid artery, the wall of the pharynx, the ascending pharyngeal artery, the internal jugular vein, the vagus nerve, the sternocleidomastoid muscle, the lingual and facial veins, and the hypoglossal nerve. Inside the cranial cavity, the internal carotid artery bends forwards in the cavernous sinus and is closely related to several nerves such as the oculomotor, trochlear, ophthalmic, and maxillary nerves. It terminates below the anterior perforated substance by dividing into the anterior and middle cerebral arteries and gives off several branches such as the ophthalmic artery, posterior communicating artery, anterior choroid artery, meningeal arteries, and hypophyseal arteries.

    • This question is part of the following fields:

      • Neurological System
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  • Question 19 - A 10-year-old boy is rushed to the emergency department following a seizure. According...

    Incorrect

    • A 10-year-old boy is rushed to the emergency department following a seizure. According to his mother, the twitching started in his right hand while he was having breakfast, then spread to his arm and face, and eventually affected his entire body. The seizure lasted for a few minutes, and afterward, he felt groggy and had no recollection of what happened.

      Which part of the boy's brain was impacted by the seizure?

      Your Answer: Occipital lobe

      Correct Answer: Frontal lobe

      Explanation:

      The correct location for a seizure with progressive clonic movements travelling from a distal site (fingers) proximally, known as a Jacksonian march, is the frontal lobe. Seizures in the occipital lobe present with visual disturbances, while seizures in the parietal lobe result in sensory changes and seizures in the temporal lobe present with hallucinations and automatisms. Absence seizures are associated with the thalamus and are characterized by brief losses of consciousness without postictal fatigue or grogginess.

      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 20 - A 35-year-old woman presents to the Emergency Department with a stab wound to...

    Incorrect

    • A 35-year-old woman presents to the Emergency Department with a stab wound to her forearm following a robbery. Upon examination, there is numbness observed in the thenar eminence and weakness in finger and wrist flexion. Which nerve is the most probable to have been damaged?

      Your Answer: Radial nerve

      Correct Answer: Median nerve

      Explanation:

      The median nerve is responsible for providing sensation to the thenar eminence and controlling finger and wrist flexion. Its palmar cutaneous branch supplies sensation to the skin on the lateral side of the palm, including the thenar eminence. The median nerve directly innervates the flexor carpi radialis and palmaris longus muscles, which are responsible for wrist flexion, as well as the flexor digitorum superficialis and lateral half of the flexor digitorum profundus muscles via the anterior interosseous nerve, which control finger flexion. Damage to the median nerve can result in weakness in these movements.

      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 21 - As a final year medical student in the emergency department, you encounter a...

    Incorrect

    • As a final year medical student in the emergency department, you encounter a 70-year-old woman who presents with a history of falling down the stairs at home. She reports a sudden onset of difficulty with speech and loss of the left side of her field of vision, and is currently experiencing vomiting. The department staff have arranged for a CT scan of her head, with a tentative diagnosis of either a stroke or transient ischaemic attack (TIA).

      What is the distinguishing factor between these two potential diagnoses?

      Your Answer: TIAs do not present with symptoms

      Correct Answer: TIAs do not cause acute infarction

      Explanation:

      The definition of a TIA has been updated to be based on tissue rather than time. It now refers to a temporary episode of neurological dysfunction caused by focal brain, spinal cord, or retinal ischemia, without resulting in acute infarction. Both TIAs and strokes can affect the spinal cord, brain, and retina, and both can cause symptoms that may require hospitalization. However, neither condition typically results in a significant troponin rise, which is more commonly associated with cardiac events.

      A transient ischaemic attack (TIA) is a brief period of neurological deficit caused by a vascular issue, lasting less than an hour. The original definition of a TIA was based on time, but it is now recognized that even short periods of ischaemia can result in pathological changes to the brain. Therefore, a new ’tissue-based’ definition is now used. The clinical features of a TIA are similar to those of a stroke, but the symptoms resolve within an hour. Possible features include unilateral weakness or sensory loss, aphasia or dysarthria, ataxia, vertigo, or loss of balance, visual problems, sudden transient loss of vision in one eye (amaurosis fugax), diplopia, and homonymous hemianopia.

      NICE recommends immediate antithrombotic therapy, giving aspirin 300 mg immediately unless the patient has a bleeding disorder or is taking an anticoagulant. If aspirin is contraindicated, management should be discussed urgently with the specialist team. Specialist review is necessary if the patient has had more than one TIA or has a suspected cardioembolic source or severe carotid stenosis. Urgent assessment within 24 hours by a specialist stroke physician is required if the patient has had a suspected TIA in the last 7 days. Referral for specialist assessment should be made as soon as possible within 7 days if the patient has had a suspected TIA more than a week previously. The person should be advised not to drive until they have been seen by a specialist.

      Neuroimaging should be done on the same day as specialist assessment if possible. MRI is preferred to determine the territory of ischaemia or to detect haemorrhage or alternative pathologies. Carotid imaging is necessary as atherosclerosis in the carotid artery may be a source of emboli in some patients. All patients should have an urgent carotid doppler unless they are not a candidate for carotid endarterectomy.

      Antithrombotic therapy is recommended, with clopidogrel being the first-line treatment. Aspirin + dipyridamole should be given to patients who cannot tolerate clopidogrel. Carotid artery endarterectomy should only be considered if the patient has suffered a stroke or TIA in the carotid territory and is not severely disabled. It should only be recommended if carotid stenosis is greater

    • This question is part of the following fields:

      • Neurological System
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  • Question 22 - A 49-year-old female has a history of B12 deficiency and is now presenting...

    Incorrect

    • A 49-year-old female has a history of B12 deficiency and is now presenting symptoms of subacute combined degeneration of the spinal cord that affects her dorsal columns. Which types of sensation will be impacted by this condition?

      Your Answer: Temperature, fast pain, and proprioception

      Correct Answer: Light touch, vibration and proprioception

      Explanation:

      The spinal cord’s classic metabolic disorder is subacute combined degeneration, which results from a deficiency in vitamin B12. Folate deficiency can also cause this disorder. The damage specifically affects the posterior columns and corticospinal tracts, but peripheral nerve damage often develops early on, making the clinical picture complex. The dorsal columns are responsible for transmitting sensations of light touch, vibration, and proprioception.

      Spinal cord lesions can affect different tracts and result in various clinical symptoms. Motor lesions, such as amyotrophic lateral sclerosis and poliomyelitis, affect either upper or lower motor neurons, resulting in spastic paresis or lower motor neuron signs. Combined motor and sensory lesions, such as Brown-Sequard syndrome, subacute combined degeneration of the spinal cord, Friedrich’s ataxia, anterior spinal artery occlusion, and syringomyelia, affect multiple tracts and result in a combination of spastic paresis, loss of proprioception and vibration sensation, limb ataxia, and loss of pain and temperature sensation. Multiple sclerosis can involve asymmetrical and varying spinal tracts and result in a combination of motor, sensory, and ataxia symptoms. Sensory lesions, such as neurosyphilis, affect the dorsal columns and result in loss of proprioception and vibration sensation.

    • This question is part of the following fields:

      • Neurological System
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  • Question 23 - A 65-year-old man visits his GP complaining of double vision. He reports that...

    Incorrect

    • A 65-year-old man visits his GP complaining of double vision. He reports that the issue started three days ago after he fell off a ladder while doing some home repairs. During the examination, the doctor notices some minor bruising on the patient's head. Upon testing the patient's cranial nerves, the doctor observes vertical diplopia that is exacerbated by looking downwards and inwards.

      Which cranial nerve is most likely to have been affected by the patient's fall?

      Your Answer: Optic (CN II)

      Correct Answer: Trochlear (CN IV)

      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.

    • This question is part of the following fields:

      • Neurological System
      15.4
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  • Question 24 - A 24-year-old dancer undergoes a thyroidectomy due to concerns about the appearance of...

    Incorrect

    • A 24-year-old dancer undergoes a thyroidectomy due to concerns about the appearance of her goitre. Following the surgery, she is informed that there was a laceration of the superior laryngeal nerve, which may affect her ability to produce higher pitches in her voice. She is referred for speech therapy.

      What counseling should be provided to this patient?

      Your Answer: Nerve lacerations usually have a good recovery within a few weeks

      Correct Answer: Nerve lacerations have a poor recovery, even with surgical nerve repair

      Explanation:

      The recovery of nerve lacerations is challenging due to the intricate nature of the neuronal system. However, there is a possibility of a better recovery if the injury is small, does not cause nerve stretching, requires a short nerve graft, and the patient is young and medically fit. It is worth noting that repaired nerves can regain sensory function similar to their pre-injury level.

      Nerve injuries can be classified into three types: neuropraxia, axonotmesis, and neurotmesis. Neuropraxia occurs when the nerve is intact but its electrical conduction is affected. However, full recovery is possible, and autonomic function is preserved. Wallerian degeneration, which is the degeneration of axons distal to the site of injury, does not occur. Axonotmesis, on the other hand, happens when the axon is damaged, but the myelin sheath is preserved, and the connective tissue framework is not affected. Wallerian degeneration occurs in this type of injury. Lastly, neurotmesis is the most severe type of nerve injury, where there is a disruption of the axon, myelin sheath, and surrounding connective tissue. Wallerian degeneration also occurs in this type of injury.

      Wallerian degeneration typically begins 24-36 hours following the injury. Axons are excitable before degeneration occurs, and the myelin sheath degenerates and is phagocytosed by tissue macrophages. Neuronal repair may only occur physiologically where nerves are in direct contact. However, nerve regeneration may be hampered when a large defect is present, and it may not occur at all or result in the formation of a neuroma. If nerve regrowth occurs, it typically happens at a rate of 1mm per day.

    • This question is part of the following fields:

      • Neurological System
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  • Question 25 - A 42-year-old female arrives at the emergency department with sudden onset of drooping...

    Incorrect

    • A 42-year-old female arrives at the emergency department with sudden onset of drooping on the right side of her mouth. She is unable to smile on the right-hand side but can frown and lift her eyebrows. The patient has a medical history of asthma and has experienced four miscarriages in the past. She does not smoke and drinks alcohol moderately on weekends. Based on this information, what is the probable diagnosis?

      Your Answer: Diabetes mellitus

      Correct Answer: Stroke

      Explanation:

      If a facial palsy only affects the lower face and spares the forehead, it is likely caused by an upper motor neuron (UMN) lesion. In this case, stroke is the most probable cause of the UMN lesion. However, the patient’s young age and social history make stroke less likely. The patient’s history of multiple miscarriages suggests antiphospholipid syndrome, which is a significant risk factor for stroke. Bell’s palsy, HIV, diabetes mellitus, and acoustic neuroma would all cause lower motor neuron (LMN) lesions, resulting in LMN signs that involve the forehead.

      The facial nerve is responsible for supplying the muscles of facial expression, the digastric muscle, and various glandular structures. It also contains a few afferent fibers that originate in the genicular ganglion and are involved in taste. Bilateral facial nerve palsy can be caused by conditions such as sarcoidosis, Guillain-Barre syndrome, Lyme disease, and bilateral acoustic neuromas. Unilateral facial nerve palsy can be caused by these conditions as well as lower motor neuron disease like Bell’s palsy and upper motor neuron disease like stroke.

      The upper motor neuron lesion typically spares the upper face, specifically the forehead, while a lower motor neuron lesion affects all facial muscles. The facial nerve path includes the subarachnoid path, where it originates in the pons and passes through the petrous temporal bone into the internal auditory meatus with the vestibulocochlear nerve. The facial canal path passes superior to the vestibule of the inner ear and contains the geniculate ganglion at the medial aspect of the middle ear. The stylomastoid foramen is where the nerve passes through the tympanic cavity anteriorly and the mastoid antrum posteriorly, and it also includes the posterior auricular nerve and branch to the posterior belly of the digastric and stylohyoid muscle.

    • This question is part of the following fields:

      • Neurological System
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  • Question 26 - A young intravenous drug user suffers from a false aneurysm and needs immediate...

    Incorrect

    • 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: Pectineus

      Correct 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.

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      • Neurological System
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  • Question 27 - A 75-year-old woman complains of faecal incontinence and displays weakened anal sphincter muscles...

    Incorrect

    • A 75-year-old woman complains of faecal incontinence and displays weakened anal sphincter muscles upon examination. What are the primary nerve root values for the nerves that provide the external anal sphincter?

      Your Answer: S5

      Correct Answer: S2,3,4

      Explanation:

      To prevent fecal matter from reaching the floor, the external anal sphincter receives nerve supply from the pudendal nerve’s inferior rectal branch, which originates from S2, S3, and S4 root values.

      Anatomy of the Anal Sphincter

      The anal sphincter is composed of two muscles: the internal anal sphincter and the external anal sphincter. The internal anal sphincter is made up of smooth muscle and is continuous with the circular muscle of the rectum. It surrounds the upper two-thirds of the anal canal and is supplied by sympathetic nerves. On the other hand, the external anal sphincter is composed of striated muscle and surrounds the internal sphincter but extends more distally. It is supplied by the inferior rectal branch of the pudendal nerve (S2 and S3) and the perineal branch of the S4 nerve roots.

      In summary, the anal sphincter is a complex structure that plays a crucial role in maintaining continence. The internal and external anal sphincters work together to control the passage of feces and gas through the anus. Understanding the anatomy of the anal sphincter is important for diagnosing and treating conditions that affect bowel function.

    • This question is part of the following fields:

      • Neurological System
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  • Question 28 - A 68-year-old man is brought into the emergency department by his wife after...

    Incorrect

    • A 68-year-old man is brought into the emergency department by his wife after she found him complaining of a headache, drowsiness, and difficulty walking. He is currently on warfarin therapy for deep vein thrombosis. The man states that he has had several falls in the past month or so, and has recently become more confused. A magnetic resonance imaging (MRI) scan is ordered for the man.

      Where would you suspect blood to collect in this case?

      Your Answer: Superficial to the dura mater

      Correct Answer: Between the arachnoid mater and the dura mater

      Explanation:

      The arachnoid mater is the middle layer of the meninges. The described condition is a subdural haemorrhage or haematoma, which is a collection of blood between the arachnoid mater and the dura mater. It is often caused by chronic mild trauma and is common in the elderly and those on anticoagulant therapy. MRI scans show a concave pool of blood. There is no potential space between the pia mater and the arachnoid mater for blood to fill.

      The Three Layers of Meninges

      The meninges are a group of membranes that cover the brain and spinal cord, providing support to the central nervous system and the blood vessels that supply it. These membranes can be divided into three distinct layers: the dura mater, arachnoid mater, and pia mater.

      The outermost layer, the dura mater, is a thick fibrous double layer that is fused with the inner layer of the periosteum of the skull. It has four areas of infolding and is pierced by small areas of the underlying arachnoid to form structures called arachnoid granulations. The arachnoid mater forms a meshwork layer over the surface of the brain and spinal cord, containing both cerebrospinal fluid and vessels supplying the nervous system. The final layer, the pia mater, is a thin layer attached directly to the surface of the brain and spinal cord.

      The meninges play a crucial role in protecting the brain and spinal cord from injury and disease. However, they can also be the site of serious medical conditions such as subdural and subarachnoid haemorrhages. Understanding the structure and function of the meninges is essential for diagnosing and treating these conditions.

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      • Neurological System
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  • Question 29 - A patient visiting the neurology outpatient clinic presents with a motor deficit. The...

    Correct

    • A patient visiting the neurology outpatient clinic presents with a motor deficit. The neurologist observes muscle fasciculations, flaccid weakness, and decreased reflexes.

      What is the location of the lesion?

      Your Answer: Peripheral nerve

      Explanation:

      A lower motor neuron lesion can be identified by a decrease in reflex response.

      When a lower motor neuron lesion occurs, it can result in reduced tone, weakness, and muscle fasciculations. These neurons originate in the anterior horn of the spinal cord and connect with the neuromuscular junction.

      On the other hand, if the corticospinal tract is affected in the motor cortex, internal capsule, midbrain, or medulla, it would cause an upper motor neuron pattern of weakness. This would be characterized by hypertonia, brisk reflexes, and an upgoing plantar reflex response.

      Reflexes are automatic responses that our body makes in response to certain stimuli. These responses are controlled by the nervous system and do not require conscious thought. There are several common reflexes that are associated with specific roots in the spinal cord. For example, the ankle reflex is associated with the S1-S2 root, while the knee reflex is associated with the L3-L4 root. Similarly, the biceps reflex is associated with the C5-C6 root, and the triceps reflex is associated with the C7-C8 root. Understanding these reflexes can help healthcare professionals diagnose and treat certain conditions.

    • This question is part of the following fields:

      • Neurological System
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  • Question 30 - Which nerve provides feeling to the nail bed of the middle finger? ...

    Incorrect

    • Which nerve provides feeling to the nail bed of the middle finger?

      Your Answer:

      Correct Answer: Median

      Explanation:

      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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