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Question 1
Incorrect
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A 67-year-old man presents to his doctor with a one month history of speech difficulty. He reports experiencing pronunciation difficulties which he has never had before. However, his reading ability remains intact.
During the consultation, the doctor observes occasional pronunciation errors when the patient is asked to repeat certain words. Despite this, the patient is able to construct meaningful sentences with minimal grammatical errors. He also demonstrates the ability to comprehend questions and respond appropriately.
The doctor performs a cranial nerve examination which yields normal results.
Which area of the brain may be affected by a lesion to cause this presentation?Your Answer: Broca's area
Correct Answer: Arcuate fasciculus
Explanation:Conduction dysphasia is characterized by fluent speech but poor repetition ability, with relatively intact comprehension. This is a typical manifestation of conduction aphasia, which is caused by damage to the arcuate fasciculus connecting Broca’s and Wernicke’s areas. Patients with this condition may be aware of their pronunciation difficulties and may become frustrated when attempting to correct themselves.
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.
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This question is part of the following fields:
- Neurological System
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Question 2
Incorrect
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A 55-year-old man comes in with hyperacousia on one side. What is the most probable location of the nerve lesion?
Your Answer: Vestibulocochlear
Correct Answer: Facial
Explanation:If the nerve in the bony canal is damaged, it can lead to a loss of innervation to the stapedius muscle, which can result in sounds not being properly muted.
The Facial Nerve: Functions and Pathways
The facial nerve is a crucial nerve that supplies the structures of the second embryonic branchial arch. It is primarily responsible for controlling the muscles of facial expression, the digastric muscle, and various glandular structures. Additionally, it contains a few afferent fibers that originate in the cells of its genicular ganglion and are involved in taste sensation.
The facial nerve has four main functions, which can be remembered by the mnemonic face, ear, taste, tear. It supplies the muscles of facial expression, the nerve to the stapedius muscle in the ear, taste sensation to the anterior two-thirds of the tongue, and parasympathetic fibers to the lacrimal and salivary glands.
The facial nerve’s path begins in the pons, where its motor and sensory components originate. It then passes through the petrous temporal bone into the internal auditory meatus, where it combines with the vestibulocochlear nerve. From there, it enters the facial canal, which passes superior to the vestibule of the inner ear and contains the geniculate ganglion. The canal then widens at the medial aspect of the middle ear and gives rise to three branches: the greater petrosal nerve, the nerve to the stapedius, and the chorda tympani.
Finally, the facial nerve exits the skull through the stylomastoid foramen, passing through the tympanic cavity anteriorly and the mastoid antrum posteriorly. It then enters the parotid gland and divides into five branches: the temporal, zygomatic, buccal, marginal mandibular, and cervical branches. Understanding the functions and pathways of the facial nerve is essential for diagnosing and treating various neurological and otolaryngological conditions.
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This question is part of the following fields:
- Neurological System
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Question 3
Incorrect
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A 47-year-old woman is experiencing muscle spasticity due to relapsing-remitting multiple sclerosis. Baclofen is prescribed to alleviate the pain associated with spasticity.
What is the mechanism of action of Baclofen?Your Answer: N-methyl-D-aspartate receptor (NMDA) receptor agonist
Correct Answer: Gamma-aminobutyric acid (GABA) receptor agonist
Explanation:Baclofen is a medication that acts as an agonist at GABA receptors in the central nervous system. It is primarily used as a muscle relaxant to treat spasticity conditions such as multiple sclerosis and cerebral palsy. It should be noted that baclofen is not a GABA antagonist like flumazenil, nor does it act as an NMDA agonist like the toxin responsible for Amanita muscaria poisoning. Additionally, baclofen does not exert its effects at muscarinic receptors like buscopan, which is commonly used to treat pain associated with bowel wall spasm and respiratory secretions during end-of-life care. Instead, baclofen specifically targets GABA receptors.
Baclofen is a medication that is commonly prescribed to alleviate muscle spasticity in individuals with conditions like multiple sclerosis, cerebral palsy, and spinal cord injuries. It works by acting as an agonist of GABA receptors in the central nervous system, which includes both the brain and spinal cord. Essentially, this means that baclofen helps to enhance the effects of a neurotransmitter called GABA, which can help to reduce the activity of certain neurons and ultimately lead to a reduction in muscle spasticity. Overall, baclofen is an important medication for individuals with these conditions, as it can help to improve their quality of life and reduce the impact of muscle spasticity on their daily activities.
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This question is part of the following fields:
- Neurological System
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Question 4
Incorrect
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A 55-year-old male arrives at the emergency department complaining of a painful red eye. He has vomited once since the onset of pain and reports seeing haloes around lights.
What is the mechanism of action of pilocarpine?
Immediate management involves administering latanoprost and pilocarpine, and an urgent referral to ophthalmology is necessary.Your Answer: Adrenergic receptor agonist
Correct Answer: Muscarinic receptor agonist
Explanation:Pilocarpine stimulates muscarinic receptors, leading to constriction of the pupil and increased uveoscleral outflow. However, muscarinic receptor antagonists like atropine and hyoscine are not used in treating glaucoma. Nicotine and acetylcholine are examples of nicotinic receptor agonists, while succinylcholine, atracurium, vecuronium, and bupropion are nicotinic receptor antagonists.
Acute angle closure glaucoma (AACG) is a type of glaucoma where there is a rise in intraocular pressure (IOP) due to a blockage in the outflow of aqueous humor. This condition is more likely to occur in individuals with hypermetropia, pupillary dilation, and lens growth associated with aging. Symptoms of AACG include severe pain, decreased visual acuity, a hard and red eye, haloes around lights, and a semi-dilated non-reacting pupil. AACG is an emergency and requires urgent referral to an ophthalmologist. The initial medical treatment involves a combination of eye drops, such as a direct parasympathomimetic, a beta-blocker, and an alpha-2 agonist, as well as intravenous acetazolamide to reduce aqueous secretions. Definitive management involves laser peripheral iridotomy, which creates a tiny hole in the peripheral iris to allow aqueous humor to flow to the angle.
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This question is part of the following fields:
- Neurological System
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Question 5
Incorrect
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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: Vestibulocochlear nerve
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.
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This question is part of the following fields:
- Neurological System
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Question 6
Correct
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A pregnant woman at 32 weeks gestation comes to you worried that her baby boy may have Duchenne muscular dystrophy (DMD) after reading about it in a magazine. She is a nursing student who has taken a break for a year. You educate her on the likelihood of her child having DMD and the genetic mutation that causes it.
Which gene is impacted by a deletion mutation in DMD?Your Answer: Dystrophin gene
Explanation:The cause of Duchenne muscular dystrophy is a mutation in the dystrophin gene. While mutations in the myostatin gene can lead to myostatin-induced muscle hypertrophy, there is no known association with DMD. The dysferlin gene is involved in skeletal muscle repair and mutations can result in various muscular myopathies, but there is no known association with DMD. It should be noted that the myodystrophin gene is fictitious and does not exist.
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.
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This question is part of the following fields:
- Neurological System
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Question 7
Incorrect
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A 25-year-old man is struck with a hammer on the right side of his head. He passes away upon arrival at the emergency department. What is the most probable finding during the post mortem examination?
Your Answer: Subdural haematoma
Correct Answer: Laceration of the middle meningeal artery
Explanation:The given scenario involves a short delay before death, which is not likely to result in a supratentorial herniation. The other options are also less severe.
Patients with head injuries should be managed according to ATLS principles and extracranial injuries should be managed alongside cranial trauma. Different types of traumatic brain injury include extradural hematoma, subdural hematoma, and subarachnoid hemorrhage. Primary brain injury may be focal or diffuse, while secondary brain injury occurs when cerebral edema, ischemia, infection, tonsillar or tentorial herniation exacerbates the original injury. Management may include IV mannitol/furosemide, decompressive craniotomy, and ICP monitoring. Pupillary findings can provide information on the location and severity of the injury.
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This question is part of the following fields:
- Neurological System
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Question 8
Incorrect
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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: Abducens nerve palsy
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.
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This question is part of the following fields:
- Neurological System
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Question 9
Incorrect
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A 6-year-old girl is brought to you by her father who complains that his daughter has been vomiting for the past few weeks, especially in the morning, and has complained of double vision for the past week. You suspect the child may have increased intracranial pressure, and order a CT brain to rule out an intracranial mass.
If the underlying cause of her symptoms turned out to a medulloblastoma, what histological finding would be most characteristic?Your Answer: Spindle cells in concentric whorls and calcified psammoma bodies
Correct Answer: Small, blue cells with rosette patterns
Explanation:The histological appearance of a medulloblastoma is small, blue cells with rosette patterns, which is the most common malignant primary tumour in the paediatric population and frequently found in the infratentorial region.
Brain tumours can be classified into different types based on their location, histology, and clinical features. Metastatic brain cancer is the most common form of brain tumours, which often cannot be treated with surgical intervention. Glioblastoma multiforme is the most common primary tumour in adults and is associated with a poor prognosis. Meningioma is the second most common primary brain tumour in adults, which is typically benign and arises from the arachnoid cap cells of the meninges. Vestibular schwannoma is a benign tumour arising from the eighth cranial nerve, while pilocytic astrocytoma is the most common primary brain tumour in children. Medulloblastoma is an aggressive paediatric brain tumour that arises within the infratentorial compartment, while ependymoma is commonly seen in the 4th ventricle and may cause hydrocephalus. Oligodendroma is a benign, slow-growing tumour common in the frontal lobes, while haemangioblastoma is a vascular tumour of the cerebellum. Pituitary adenoma is a benign tumour of the pituitary gland that can be either secretory or non-secretory, while craniopharyngioma is a solid/cystic tumour of the sellar region that is derived from the remnants of Rathke’s pouch.
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This question is part of the following fields:
- Neurological System
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Question 10
Incorrect
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A 55-year-old male has been suffering from chronic pain for many years due to an industrial accident he had in his thirties. The WHO defines chronic pain as pain that persists for how long?
Your Answer: 1 year
Correct Answer: 12 weeks
Explanation:Chronic pain is defined by the WHO as pain that lasts for more than 12 weeks. Therefore, the correct answer is 12 weeks, and all other options are incorrect.
Guidelines for Managing Chronic Pain
Chronic pain is defined as pain that lasts for more than 12 weeks and can include conditions such as musculoskeletal pain, neuropathic pain, vascular insufficiency, and degenerative disorders. In 2013, the Scottish Intercollegiate Guidelines Network (SIGN) produced guidelines for the management of chronic, non-cancer related pain.
Non-pharmacological interventions are recommended by SIGN, including self-management information, exercise, manual therapy, and transcutaneous electrical nerve stimulation (TENS). Exercise has been shown to be effective in improving chronic pain, and specific support such as referral to an exercise program is recommended. Manual therapy is particularly effective for spinal pain, while TENS can also be helpful.
Pharmacological interventions may be necessary, but if medications are not effective after 2-4 weeks, they are unlikely to be effective. For neuropathic pain, SIGN recommends gabapentin or amitriptyline as first-line treatments. NICE also recommends pregabalin or duloxetine as first-line treatments. For fibromyalgia, duloxetine or fluoxetine are recommended.
If patients are using more than 180 mg/day morphine equivalent, experiencing significant distress, or rapidly escalating their dose without pain relief, SIGN recommends referring them to specialist pain management services.
Overall, the management of chronic pain requires a comprehensive approach that includes both non-pharmacological and pharmacological interventions, as well as referral to specialist services when necessary.
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This question is part of the following fields:
- Neurological System
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Question 11
Correct
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A 75-year-old male arrives at the Emergency Department with sudden onset facial weakness and concerns of a stroke. However, upon further questioning, the patient denies any risk factors for cardiovascular disease. During the examination, the patient displays unilateral weakness on the right side of their face and reports experiencing pain in their right ear. Further investigation reveals a widespread vesicular rash on the patient's right ear.
What is the causative organism responsible for this syndrome?Your Answer: Varicella zoster virus
Explanation:Ramsey-Hunt syndrome (VII nerve palsy) is caused by the varicella zoster virus.
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.
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This question is part of the following fields:
- Neurological System
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Question 12
Incorrect
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A 40-year-old male comes to the emergency department complaining of a severe headache that started today. He reports that the pain is situated at the back of his head and worsens when he coughs and bends forward. He has vomited twice and is experiencing some blurred vision. An MRI scan is ordered, which reveals a downward herniation of the cerebellar tonsils.
What brain structure has the cerebellar tonsils herniated into, based on the most probable diagnosis?Your Answer: Fourth ventricle
Correct Answer: Foramen magnum
Explanation:Arnold-Chiari malformation refers to the cerebellar tonsils herniating downwards through the foramen magnum. This condition has four types, with type one being the most prevalent.
The fourth ventricle is situated in front of the cerebellum and serves as a pathway for cerebrospinal fluid (CSF) from the cerebral aqueduct.
The thalamus is a central structure located between the midbrain and cerebral cortex. It comprises various nuclei that transmit sensory and motor signals to the cerebral cortex.
The cerebral aqueduct is positioned between the third and fourth ventricle and facilitates the flow of CSF.
The hypothalamus is a subdivision of the diencephalon that primarily regulates homeostasis.
Understanding Arnold-Chiari Malformation
Arnold-Chiari malformation is a condition where the cerebellar tonsils are pushed downwards through the foramen magnum. This can occur either due to a congenital defect or as a result of trauma. The condition can lead to non-communicating hydrocephalus, which is caused by the obstruction of cerebrospinal fluid outflow. Patients with Arnold-Chiari malformation may experience headaches and syringomyelia, which is a condition where fluid-filled cysts form in the spinal cord.
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This question is part of the following fields:
- Neurological System
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Question 13
Incorrect
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A 28-year-old woman is receiving chemotherapy for ovarian cancer. She experiences severe nausea and vomiting in the initial days after each chemotherapy session.
To alleviate her symptoms, she is prescribed ondansetron to be taken after chemotherapy.
What is the mode of action of ondansetron?Your Answer: Dopamine antagonist
Correct Answer: Serotonin antagonist
Explanation:Ondansetron belongs to the class of drugs known as serotonin antagonists, which are commonly used as antiemetics to treat nausea caused by chemotoxic agents. These drugs act on the chemoreceptor trigger zone (CTZ) in the medulla oblongata, where serotonin (5-HT3) is an agonist. Antihistamines, antimuscarinics, and dopamine antagonists are other classes of antiemetics that act on different pathways and are used for different causes of nausea. Glucocorticoids, such as dexamethasone, can also be used as antiemetics due to their anti-inflammatory properties and effectiveness in treating nausea caused by intracerebral factors.
Understanding 5-HT3 Antagonists
5-HT3 antagonists are a type of medication used to treat nausea, particularly in patients undergoing chemotherapy. These drugs work by targeting the chemoreceptor trigger zone in the medulla oblongata, which is responsible for triggering nausea and vomiting. Examples of 5-HT3 antagonists include ondansetron and palonosetron, with the latter being a second-generation drug that has the advantage of having a reduced effect on the QT interval.
While 5-HT3 antagonists are generally well-tolerated, they can have some adverse effects. One of the most significant concerns is the potential for a prolonged QT interval, which can increase the risk of arrhythmias and other cardiac complications. Additionally, constipation is a common side effect of these medications. Overall, 5-HT3 antagonists are an important tool in the management of chemotherapy-induced nausea, but their use should be carefully monitored to minimize the risk of adverse effects.
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This question is part of the following fields:
- Neurological System
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Question 14
Correct
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A 49-year-old male presents to the ENT clinic with a 9-month history of constant right-sided deafness and a sensation of feeling off-balance. He has no significant medical history. Upon examination, an audiogram reveals reduced hearing to both bone and air conduction on the right side. A cranial nerve exam shows an absent corneal reflex on the right side and poor balance. Otoscopy of both ears is unremarkable. What is the probable underlying pathology responsible for this patient's symptoms and signs?
Your Answer: Vestibular schwannoma (acoustic neuroma)
Explanation:Vestibular schwannomas, also known as acoustic neuromas, make up about 5% of intracranial tumors and 90% of cerebellopontine angle tumors. These tumors typically present with a combination of vertigo, hearing loss, tinnitus, and an absent corneal reflex. The specific symptoms can be predicted based on which cranial nerves are affected. For example, cranial nerve VIII involvement can cause vertigo, unilateral sensorineural hearing loss, and unilateral tinnitus. Bilateral vestibular schwannomas are associated with neurofibromatosis type 2.
If a vestibular schwannoma is suspected, it is important to refer the patient to an ear, nose, and throat specialist urgently. However, it is worth noting that these tumors are often benign and slow-growing, so observation may be appropriate initially. The diagnosis is typically confirmed with an MRI of the cerebellopontine angle, and audiometry is also important as most patients will have some degree of hearing loss. Treatment options include surgery, radiotherapy, or continued observation.
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This question is part of the following fields:
- Neurological System
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Question 15
Correct
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A 45-year-old woman arrives at the emergency department complaining of a sudden headache. The doctor is evaluating her condition. Her BMI is 33 kgm2.
During the cranial nerve examination, the doctor observes papilloedema on fundoscopy. The patient also reports a loss of taste in the back third of her tongue. Which of the following nerves could be responsible for this loss?Your Answer: Glossopharyngeal nerve
Explanation:The glossopharyngeal nerve mediates taste and sensation from the posterior one-third of the tongue, while the anterior two-thirds of the tongue receive taste input from the chorda tympani branch of the facial nerve and sensation input from the lingual branch of the mandibular division of the trigeminal nerve. The base of the tongue receives taste and sensation input from the internal branch of the superior laryngeal nerve, which is a branch of the vagus nerve.
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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This question is part of the following fields:
- Neurological System
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Question 16
Incorrect
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A 35-year-old man visits the physician's clinic with indications of premature ejaculation, which is believed to be caused by hypersensitivity of the reflex arc.
Can you identify the correct description of this reflex arc?Your Answer: Ejaculation is controlled by the parasympathetic nervous system at the S2-S4 level
Correct Answer: Ejaculation is controlled by the sympathetic nervous system at the L1 level
Explanation:The correct statement is that ejaculation is controlled by the sympathetic nervous system at the L1 level. This is because the preganglionic sympathetic cell bodies responsible for ejaculation are located in the central autonomic region of the T12-L1 segments. It is important to note that erection is controlled by the parasympathetic nervous system at the S2-S4 level, and not by the pudendal nerve, which is responsible for supplying sensation to the penis.
Anatomy of the Sympathetic Nervous System
The sympathetic nervous system is responsible for the fight or flight response in the body. The preganglionic efferent neurons of this system are located in the lateral horn of the grey matter of the spinal cord in the thoraco-lumbar regions. These neurons leave the spinal cord at levels T1-L2 and pass to the sympathetic chain. The sympathetic chain lies on the vertebral column and runs from the base of the skull to the coccyx. It is connected to every spinal nerve through lateral branches, which then pass to structures that receive sympathetic innervation at the periphery.
The sympathetic ganglia are also an important part of this system. The superior cervical ganglion lies anterior to C2 and C3, while the middle cervical ganglion (if present) is located at C6. The stellate ganglion is found anterior to the transverse process of C7 and lies posterior to the subclavian artery, vertebral artery, and cervical pleura. The thoracic ganglia are segmentally arranged, and there are usually four lumbar ganglia.
Interruption of the head and neck supply of the sympathetic nerves can result in an ipsilateral Horners syndrome. For the treatment of hyperhidrosis, sympathetic denervation can be achieved by removing the second and third thoracic ganglia with their rami. However, removal of T1 is not performed as it can cause a Horners syndrome. In patients with vascular disease of the lower limbs, a lumbar sympathetomy may be performed either radiologically or surgically. The ganglia of L2 and below are disrupted, but if L1 is removed, ejaculation may be compromised, and little additional benefit is conferred as the preganglionic fibres do not arise below L2.
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This question is part of the following fields:
- Neurological System
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Question 17
Correct
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A 55-year-old man visits his GP complaining of excessive thirst and urination for the past two weeks. Upon conducting various tests, it was determined that he has diabetes insipidus due to a hormone deficiency. Which gland is responsible for producing and releasing this hormone into the bloodstream?
Your Answer: Posterior pituitary
Explanation:ADH and oxytocin are secreted by the posterior pituitary.
When a person has diabetes insipidus, their kidneys are unable to concentrate urine due to a deficiency of antidiuretic hormone (ADH) or resistance to its action. This results in the production and excretion of a large volume of diluted urine.
The posterior pituitary, also known as the neurohypophysis, is the back part of the pituitary gland and is involved in the endocrine system. Unlike the anterior pituitary, it is not glandular and has a direct neural connection to the hypothalamus. It releases oxytocin and vasopressin/ADH directly into the bloodstream.
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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This question is part of the following fields:
- Neurological System
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Question 18
Incorrect
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A 55-year-old woman is involved in a car accident and is admitted to a neuro-rehabilitation ward for her recovery. During her cranial nerve examination, it is found that she has left-sided homonymous inferior quadrantanopia and difficulty reading. Her family reports that she can no longer read the newspaper or do sudokus, which she used to enjoy before the accident. Based on these symptoms, which area of the brain is likely to be damaged?
Your Answer: Cerebellum
Correct Answer: Parietal lobe
Explanation:Alexia may be caused by lesions in the parietal lobe.
This is because damage to the parietal lobe can result in various symptoms, including alexia, agraphia, acalculia, hemi-spatial neglect, and homonymous inferior quadrantanopia. Other possible symptoms may include loss of sensation, apraxias, or astereognosis.
The cerebellum is not the correct answer, as damage to this region can cause symptoms such as dysdiadochokinesia, ataxia, nystagmus, intention tremor, scanning dysarthria, and positive heel-shin test.
Similarly, the frontal lobe is not the correct answer, as damage to this region can result in anosmia, Broca’s dysphasia, changes in personality, and motor deficits.
The occipital lobe is also not the correct answer, as damage to this region can cause visual disturbances.
Brain lesions can be localized based on the neurological disorders or features that are present. The gross anatomy of the brain can provide clues to the location of the lesion. For example, lesions in the parietal lobe can result in sensory inattention, apraxias, astereognosis, inferior homonymous quadrantanopia, and Gerstmann’s syndrome. Lesions in the occipital lobe can cause homonymous hemianopia, cortical blindness, and visual agnosia. Temporal lobe lesions can result in Wernicke’s aphasia, superior homonymous quadrantanopia, auditory agnosia, and prosopagnosia. Lesions in the frontal lobes can cause expressive aphasia, disinhibition, perseveration, anosmia, and an inability to generate a list. Lesions in the cerebellum can result in gait and truncal ataxia, intention tremor, past pointing, dysdiadokinesis, and nystagmus.
In addition to the gross anatomy, specific areas of the brain can also provide clues to the location of a lesion. For example, lesions in the medial thalamus and mammillary bodies of the hypothalamus can result in Wernicke and Korsakoff syndrome. Lesions in the subthalamic nucleus of the basal ganglia can cause hemiballism, while lesions in the striatum (caudate nucleus) can result in Huntington chorea. Parkinson’s disease is associated with lesions in the substantia nigra of the basal ganglia, while lesions in the amygdala can cause Kluver-Bucy syndrome, which is characterized by hypersexuality, hyperorality, hyperphagia, and visual agnosia. By identifying these specific conditions, doctors can better localize brain lesions and provide appropriate treatment.
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This question is part of the following fields:
- Neurological System
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Question 19
Incorrect
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A 58-year-old woman with a history of lung cancer experiences malignant spinal cord compression, resulting in bilateral compression on the ventral horns of her spinal cord. What are the potential neurological symptoms that may present in this patient?
Your Answer: Proprioception loss below the level of the lesion
Correct Answer: Paresis below the level of the lesion
Explanation:Anterior cord lesions result in motor deficits because the ventral (anterior) horns of the spinal cord contain motor neuron cell bodies. These motor neurons run along the ventral corticospinal tract, which is responsible for voluntary bodily movement. Therefore, compression of the ventral part of the spinal cord by a tumor may cause paresis or paralysis below the level of the lesion. However, pain and temperature loss below the level of the lesion would be from compression of the spinothalamic tract, which runs more laterally in the spinal cord. Proprioception loss below the level of the lesion is also incorrect as it is neurologically tied to the dorsal-column medial-lemniscus tract, which runs dorsally. Additionally, spinal lesions affect sensory experience below the level of the lesion rather than above.
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.
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This question is part of the following fields:
- Neurological System
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Question 20
Correct
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A 25-year-old female comes to the emergency department with complaints of severe pain and tingling sensation in the lower part of her left leg and dorsum of her left foot after twisting her ankle during a football match. The possibility of entrapment of the superficial peroneal nerve is suspected. Which muscle is supplied by this nerve?
Your Answer: Peroneus longus
Explanation:The superficial peroneal nerve is responsible for supplying the peroneus longus and peroneus brevis muscles in the lateral compartment of the leg. These muscles are involved in eversion of the foot and plantar flexion. The peroneus tertius muscle in the anterior compartment of the lower limb is innervated by the deep peroneal nerve and is responsible for dorsiflexion of the ankle and eversion of the foot. The tibialis posterior muscle in the deep posterior compartment of the lower limb is innervated by the tibial nerve and is responsible for plantar flexion and inversion of the foot. The soleus muscle in the superficial posterior compartment of the lower limb is also innervated by the tibial nerve and is responsible for plantar flexion.
Anatomy of the Superficial Peroneal Nerve
The superficial peroneal nerve is responsible for supplying the lateral compartment of the leg, specifically the peroneus longus and peroneus brevis muscles which aid in eversion and plantar flexion. It also provides sensation over the dorsum of the foot, excluding the first web space which is innervated by the deep peroneal nerve.
The nerve passes between the peroneus longus and peroneus brevis muscles along the proximal one-third of the fibula. Approximately 10-12 cm above the tip of the lateral malleolus, the nerve pierces the fascia. It then bifurcates into intermediate and medial dorsal cutaneous nerves about 6-7 cm distal to the fibula.
Understanding the anatomy of the superficial peroneal nerve is important in diagnosing and treating conditions that affect the lateral compartment of the leg and dorsum of the foot. Injuries or compression of the nerve can result in weakness or numbness in the affected areas.
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This question is part of the following fields:
- Neurological System
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