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  • Question 1 - 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: Strokes will present with a significant troponin rise

      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 2 - A 75-year-old man presents to the ophthalmology clinic with complaints of gradually worsening...

    Incorrect

    • A 75-year-old man presents to the ophthalmology clinic with complaints of gradually worsening peripheral vision and a progressive headache that is worse at night. During the cranial nerve exam, a superior homonymous quadrantanopia is observed, but eye movements are intact. The rest of the cranial nerve and neurological examinations are unremarkable.

      Which region of the brain is likely affected by the lesion causing these symptoms?

      Your Answer: Superior optic chiasm

      Correct Answer: Temporal lobe

      Explanation:

      Superior homonymous quadrantanopias occur when there are lesions in the inferior optic radiations located in the temporal lobe. The location of the lesion can be determined by analyzing the pattern of the visual field defect. Lesions in front of the optic chiasm cause incongruous defects, while lesions at the optic chiasm cause bitemporal/binasal hemianopias. Lesions behind the optic chiasm result in homonymous hemianopias, such as the superior homonymous quadrantanopia in this case. The optic radiations carry nerve signals from the optic chiasm to the occipital lobe. Lesions in the inferior aspect of the optic radiation cause superior visual field defects, while lesions in the superior aspect of the optic radiation cause inferior visual field defects. Therefore, the lesion causing the superior homonymous quadrantanopia in this woman must be located in the inferior aspect of the optic radiation in the temporal lobe. Lesions compressing the lateral aspect of the optic chiasm cause nasal/binasal visual field defects, while lesions to the optic nerve before the optic chiasm result in an incongruous homonymous hemianopia affecting the same eye. Parietal lobe lesions can cause inferior homonymous quadrantanopias, but not superior homonymous quadrantanopias. Compression of the superior optic chiasm causes bitemporal hemianopias, not homonymous hemianopias.

      Understanding Visual Field Defects

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

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

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

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

    • This question is part of the following fields:

      • Neurological System
      68
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  • Question 3 - A 45-year-old woman had an attempted central line placement in her internal jugular...

    Incorrect

    • A 45-year-old woman had an attempted central line placement in her internal jugular vein, but the doctor accidentally damaged her carotid artery, requiring surgical exploration. During the procedure, a nerve was found between the carotid artery and internal jugular vein. What is the most likely identity of this nerve?

      Your Answer: Recurrent laryngeal nerve

      Correct Answer: Vagus

      Explanation:

      The carotid sheath contains the vagus nerve, while the hypoglossal nerve passes through it but is not situated inside it.

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

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

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

    • This question is part of the following fields:

      • Neurological System
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  • Question 4 - A 61-year-old man is being evaluated during the ward round in the ICU....

    Incorrect

    • A 61-year-old man is being evaluated during the ward round in the ICU. The patient was admitted through the emergency department with his wife who reported that he had lost consciousness.

      During the examination, the patient is able to move his eyes spontaneously and can perform different eye movements as instructed. However, the patient seems incapable of responding verbally and has 0/5 power in all four limbs.

      Which artery occlusion is probable to result in this clinical presentation?

      Your Answer: Anterior cerebral artery

      Correct Answer: Basilar artery

      Explanation:

      Locked-in syndrome is a rare condition that can be caused by a stroke, particularly of the basilar artery. This can result in quadriplegia and bulbar palsy, while cognition and eye movements may remain intact. Other potential causes of locked-in syndrome include trauma, brain tumours, infection, and demyelination.

      If the anterior cerebral artery is affected by a stroke, the patient may experience contralateral hemiparesis and sensory loss, with the lower extremity being more severely affected than the upper extremity. Additional symptoms may include behavioural abnormalities and incontinence.

      A stroke affecting the middle cerebral artery can cause contralateral hemiparesis and sensory loss, with the face and arm being more severely affected than the lower extremity. Speech and visual deficits are also common.

      Strokes affecting the posterior cerebral artery often result in visual deficits, as the occipital lobe is responsible for vision. This can manifest as contralateral homonymous hemianopia.

      Cerebellar infarcts, such as those affecting the superior cerebellar artery, can be difficult to diagnose as they often present with non-specific symptoms like nausea/vomiting, headache, and dizziness.

      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 5 - An 81-year-old patient has presented to their physician with episodes of syncope and...

    Incorrect

    • An 81-year-old patient has presented to their physician with episodes of syncope and lightheadedness triggered by activities such as shaving or wearing a shirt with a collar. The patient also reports a change in their sense of taste. During the examination, the physician feels the patient's carotid pulse, which triggers another lightheaded episode. The patient's vital signs are taken immediately, revealing a heart rate of 36 bpm, blood pressure of 60/42 mmHg, sats of 96%, and a temperature of 36.7ºC. The physician suspects carotid sinus syndrome and wonders which cranial nerve is responsible for the hypersensitive response in this scenario.

      Your Answer: Vagus nerve (CN X)

      Correct Answer: Glossopharyngeal nerve (CN IX)

      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
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  • Question 6 - Which muscle is not innervated by the trigeminal nerve? ...

    Incorrect

    • Which muscle is not innervated by the trigeminal nerve?

      Your Answer: Mylohyoid

      Correct Answer: Stylohyoid

      Explanation:

      The facial nerve provides innervation to the stylohyoid.

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

    • This question is part of the following fields:

      • Neurological System
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  • Question 7 - Sarah is a 28-year-old teacher who has presented to the emergency department with...

    Incorrect

    • Sarah is a 28-year-old teacher who has presented to the emergency department with a sudden onset of a severe headache and visual disturbances. Her medical history is significant only for asthma. She does not take any medications, does not smoke nor drink alcohol.

      Upon examination, Sarah is alert and oriented but in obvious pain. Neurological examination reveals a fixed, dilated, non-reactive left pupil that is hypersensitive to light. All extra ocular movements are intact and there is no relative afferent pupillary defect. Systematic enquiry reveals no other abnormalities.

      What is the most likely cause of Sarah's symptoms?

      Your Answer: Horner's syndrome

      Correct Answer: Posterior communicating artery aneurysm

      Explanation:

      Understanding Third Nerve Palsy: Causes and Features

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

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

    • This question is part of the following fields:

      • Neurological System
      21.3
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  • Question 8 - A neurologist evaluates a stroke patient who is experiencing difficulty with word finding...

    Incorrect

    • A neurologist evaluates a stroke patient who is experiencing difficulty with word finding and reduced fluency of speech, but with intact comprehension. Based on these symptoms, the neurologist diagnoses the patient with a particular type of aphasia.

      Can you identify the location of the brain lesion in this patient, given the probable diagnosis?

      Your Answer: Superior temporal gyrus

      Correct Answer: Inferior frontal gyrus

      Explanation:

      The cause of Broca’s aphasia is a lesion in the inferior frontal gyrus, resulting in non-fluent speech but preserved comprehension. The arcuate fasciculus connects Broca’s and Wernicke’s areas, and a lesion here causes conduction aphasia with fluent speech but errors. The cerebellar peduncles connect the cerebellum to the brainstem and midbrain. The hypoglossal trigone contains the hypoglossal nerve ganglion responsible for tongue motor activity, not language deficits. Wernicke’s aphasia, characterized by fluent but disconnected speech, is caused by a lesion in the superior temporal gyrus.

      Types of Aphasia: Understanding the Different Forms of Language Impairment

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

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

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

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

    • This question is part of the following fields:

      • Neurological System
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  • Question 9 - Which one of the following is not a typical feature of neuropraxia? ...

    Incorrect

    • Which one of the following is not a typical feature of neuropraxia?

      Your Answer: Absence of neuroma formation

      Correct Answer: Axonal degeneration distal to the site of injury

      Explanation:

      Neuropraxia typically results in full recovery within 6-8 weeks after nerve injury, and Wallerian degeneration is not a common occurrence. Additionally, autonomic function is typically maintained.

      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 10 - A woman in her 50s with lung cancer and bone metastasis in the...

    Incorrect

    • A woman in her 50s with lung cancer and bone metastasis in the thoracic spinal vertebral bodies experiences a pathological fracture at the level of T4. The fracture is unstable and the spinal cord is severely compressed at this level. Which of the following findings will not be present six weeks after the injury?

      Your Answer: Spasticity of the lower limbs

      Correct Answer: Diminished patellar tendon reflex

      Explanation:

      When there is a lesion in the thoracic cord, it can lead to spastic paraparesis, hyperreflexia, and extensor plantar responses, which are all signs of an upper motor neuron (UMN) lesion. In addition, there may be incontinence, loss of sensation below the lesion, and a type of ataxia known as sensory ataxia. These symptoms usually appear a few weeks after the initial injury, once the spinal shock phase (characterized by areflexia) has passed.

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

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

    • This question is part of the following fields:

      • Neurological System
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  • Question 11 - During a clinical examination of a 26-year-old woman with a history of relapsing-remitting...

    Incorrect

    • During a clinical examination of a 26-year-old woman with a history of relapsing-remitting multiple sclerosis, you observe nystagmus of the left eye and significant weakness in adduction of the right eye when she looks to the left. What is the location of the lesion responsible for these findings?

      Your Answer: Abducens nerve

      Correct Answer: Midbrain

      Explanation:

      The medial longitudinal fasciculus is situated in the paramedian region of the midbrain and pons.

      The patient’s symptoms are indicative of internuclear ophthalmoplegia (INO), a specific gaze abnormality characterized by impaired adduction of the eye on the affected side and nystagmus of the eye on the opposite side of the lesion. Based on the symptoms, the lesion is likely on the right side. INO is caused by damage to the medial longitudinal fasciculus, which coordinates the simultaneous lateral movements of both eyes. Multiple sclerosis is a common cause of this condition, but cerebrovascular disease is also associated with it, especially in older patients.

      Optic neuritis, a common manifestation of multiple sclerosis, is not responsible for the patient’s symptoms. Optic neuritis typically presents with eye pain, visual acuity loss, and worsened pain on eye movement, which are not mentioned in the scenario.

      Distinguishing between internuclear ophthalmoplegia and oculomotor (third) nerve palsy can be challenging. Symptoms that suggest CN III palsy include ptosis, pupil dilation, and weakness of elevation, which causes the eye to rest in a ‘down and out’ position. Clinical examination findings can help differentiate between trochlear or abducens nerve palsy and internuclear ophthalmoplegia. Abducens nerve damage results in unilateral weakness of the lateral rectus muscle and impaired abduction on the affected side, while trochlear nerve damage leads to unilateral weakness of the superior oblique muscle and impaired intorsion and depression when adducted.

      Understanding Internuclear Ophthalmoplegia

      Internuclear ophthalmoplegia is a condition that affects the horizontal movement of the eyes. It is caused by a lesion in the medial longitudinal fasciculus (MLF), which is responsible for interconnecting the IIIrd, IVth, and VIth cranial nuclei. This area is located in the paramedian region of the midbrain and pons. The main feature of this condition is impaired adduction of the eye on the same side as the lesion, along with horizontal nystagmus of the abducting eye on the opposite side.

      The most common causes of internuclear ophthalmoplegia are multiple sclerosis and vascular disease. It is important to note that this condition can also be a sign of other underlying neurological disorders.

    • This question is part of the following fields:

      • Neurological System
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  • Question 12 - A 55-year-old male has been suffering from chronic pain for many years due...

    Correct

    • 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: 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.

    • This question is part of the following fields:

      • Neurological System
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  • Question 13 - A 25-year-old man is struck with a hammer on the right side of...

    Incorrect

    • 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.

    • This question is part of the following fields:

      • Neurological System
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  • Question 14 - A 44-year-old woman with a history of multiple sclerosis (MS) visits her GP...

    Incorrect

    • A 44-year-old woman with a history of multiple sclerosis (MS) visits her GP with a complaint of eating difficulties. During the examination, the GP observes a noticeable elevation of the mandible when striking the base of it. Which cranial nerve provides the afferent limb to this reflex?

      Your Answer: CN VII (marginal mandibular branch)

      Correct Answer: CN V3

      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
      15.1
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  • Question 15 - A 75-year-old man is brought to his family doctor by his wife, who...

    Incorrect

    • 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:

      Correct 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 16 - An 80-year-old man arrives at the emergency department with his daughter. They were...

    Incorrect

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

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

      Based on these symptoms, what is the likely diagnosis?

      Your Answer:

      Correct Answer: Conduction aphasia

      Explanation:

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

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

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

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

      Types of Aphasia: Understanding the Different Forms of Language Impairment

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

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

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

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

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      • Neurological System
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  • Question 17 - A 55-year-old man comes to his doctor complaining of sudden back pain that...

    Incorrect

    • A 55-year-old man comes to his doctor complaining of sudden back pain that causes sharp shooting sensations down his buttocks and the back of his legs. He reports doing some heavy lifting in his garden just before the onset. After conducting a thorough physical examination, you observe a delayed ankle jerk reflex. You suspect that he may have an intervertebral disk prolapse.

      Which level of the spine is most likely affected by this disk prolapse?

      Your Answer:

      Correct Answer: L5-S1

      Explanation:

      L5-S1 disk prolapses often result in a delayed ankle reflex, which can also compress the L5 nerve root and cause sciatic nerve pain in the buttocks and posterior legs. On the other hand, the knee jerk reflex is primarily controlled by the L2-L4 segments.

      The ankle reflex is a test that checks the function of the S1 and S2 nerve roots by tapping the Achilles tendon with a tendon hammer. This reflex is often delayed in individuals with L5 and S1 disk prolapses.

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      • Neurological System
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  • Question 18 - An 80-year-old woman comes in with sudden blurring of vision in one eye....

    Incorrect

    • An 80-year-old woman comes in with sudden blurring of vision in one eye. She has a family history of age-related macular degeneration and a smoking history of 50 pack-years. The affected eye has a vision of 20/80, and metamorphopsia is detected during Amsler grid testing. Fundoscopy reveals well-defined red patches. As a result, she is given regular injections of bevacizumab.

      What is the target of this monoclonal antibody, and what does it inhibit?

      Your Answer:

      Correct Answer: Vascular endothelial growth factor (VEGF)

      Explanation:

      Age-related macular degeneration (ARMD) is a common cause of blindness in the UK, characterized by degeneration of the central retina (macula) and the formation of drusen. The risk of ARMD increases with age, smoking, family history, and conditions associated with an increased risk of ischaemic cardiovascular disease. ARMD is classified into dry and wet forms, with the latter carrying the worst prognosis. Clinical features include subacute onset of visual loss, difficulties in dark adaptation, and visual hallucinations. Signs include distortion of line perception, the presence of drusen, and well-demarcated red patches in wet ARMD. Investigations include slit-lamp microscopy, colour fundus photography, fluorescein angiography, indocyanine green angiography, and ocular coherence tomography. Treatment options include a combination of zinc with anti-oxidant vitamins for dry ARMD and anti-VEGF agents for wet ARMD. Laser photocoagulation is also an option, but anti-VEGF therapies are usually preferred.

    • This question is part of the following fields:

      • Neurological System
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  • Question 19 - A 56-year-old woman undergoes a serum calcium test. If her renal function is...

    Incorrect

    • A 56-year-old woman undergoes a serum calcium test. If her renal function is normal, what percentage of calcium filtered by the glomerulus will be reabsorbed by the renal tubules?

      Your Answer:

      Correct Answer: 95%

      Explanation:

      Maintaining Calcium Balance in the Body

      Calcium ions are essential for various physiological processes in the body, and the largest store of calcium is found in the skeleton. The levels of calcium in the body are regulated by three hormones: parathyroid hormone (PTH), vitamin D, and calcitonin.

      PTH increases calcium levels and decreases phosphate levels by increasing bone resorption and activating osteoclasts. It also stimulates osteoblasts to produce a protein signaling molecule that activates osteoclasts, leading to bone resorption. PTH increases renal tubular reabsorption of calcium and the synthesis of 1,25(OH)2D (active form of vitamin D) in the kidney, which increases bowel absorption of calcium. Additionally, PTH decreases renal phosphate reabsorption.

      Vitamin D, specifically the active form 1,25-dihydroxycholecalciferol, increases plasma calcium and plasma phosphate levels. It increases renal tubular reabsorption and gut absorption of calcium, as well as osteoclastic activity. Vitamin D also increases renal phosphate reabsorption in the proximal tubule.

      Calcitonin, secreted by C cells of the thyroid, inhibits osteoclast activity and renal tubular absorption of calcium.

      Although growth hormone and thyroxine play a small role in calcium metabolism, the primary regulation of calcium levels in the body is through PTH, vitamin D, and calcitonin. Maintaining proper calcium balance is crucial for overall health and well-being.

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      • Neurological System
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  • Question 20 - A 25-year-old man has his impacted 3rd molar surgically removed. After the procedure,...

    Incorrect

    • A 25-year-old man has his impacted 3rd molar surgically removed. After the procedure, he experiences numbness on the anterolateral part of his tongue. What is the probable cause of this?

      Your Answer:

      Correct Answer: Injury to the lingual nerve

      Explanation:

      A lingual neuropraxia may occur in some patients after surgical extraction of these teeth, resulting in anesthesia of the front part of the tongue on the same side. The teeth are innervated by the inferior alveolar nerve.

      Lingual Nerve: Sensory Nerve to the Tongue and Mouth

      The lingual nerve is a sensory nerve that provides sensation to the mucosa of the presulcal part of the tongue, floor of the mouth, and mandibular lingual gingivae. It arises from the posterior trunk of the mandibular nerve and runs past the tensor veli palatini and lateral pterygoid muscles. At this point, it is joined by the chorda tympani branch of the facial nerve.

      After emerging from the cover of the lateral pterygoid, the lingual nerve proceeds antero-inferiorly, lying on the surface of the medial pterygoid and close to the medial aspect of the mandibular ramus. At the junction of the vertical and horizontal rami of the mandible, it is anterior to the inferior alveolar nerve. The lingual nerve then passes below the mandibular attachment of the superior pharyngeal constrictor and lies on the periosteum of the root of the third molar tooth.

      Finally, the lingual nerve passes medial to the mandibular origin of mylohyoid and then passes forwards on the inferior surface of this muscle. Overall, the lingual nerve plays an important role in providing sensory information to the tongue and mouth.

    • This question is part of the following fields:

      • Neurological System
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