Anatomy

Question 1

Weakness of finger flexion would be the result of a spinal lesion at the level of:

Answer 1

C8

Question 2

Brachioradialis reflex (suppinator reflex), mediated by:

Answer 2

C5/6

Question 3

Deltoid is supplied by spinal level:

Answer 3

C5/6.

Question 4

Sensory supply lateral aspect of arm, spinal root: .

Answer 4

C5

Question 5

Winging of the scapula is caused by paralysis of the long thoracic nerve to serratus anterior with roots at:

Answer 5

C5, 6, 7

Question 6

A 48-year-old female patient develops an acute, severe, and isolated right C6 radiculopathy affecting both the motor and sensory roots. She is examined in an EMG clinic three weeks after the onset of symptoms. Which of the following statements is true? 1. A repeat examination 12 months later is likely to reveal rapidly recruited low amplitude short duration motor units in the clinically involved muscle on EMG 2. Absent sensory nerve potentials would be expected on examination of the thumb and index finger on the right This is the correct answer 3. Fibrillation potentials would be expected in the right extensor carpi ulnaris and extensor pollicis brevis 4. Triceps tendon jerk is likely to be depressed or absent 5. Voluntary motor unit activity may be absent in the right biceps

Answer 6

Thumb and index finger are within the C6 dermatome. A pattern of rapidly recruited low amplitude short duration motor units on the electromyogram (EMG) would be considered to represent myopathic changes rather than de-innervation.

Question 7

Extensor pollicis brevis and extensor carpi ulnaris are supplied by roots at:

Answer 7

C7/C8

Question 8

Fibers from __ are also responsible for the triceps reflex, with some contribution from C6.

Answer 8

C7

Question 9

Right bundle branch block in acute anterior myocardial infarction suggests obstruction prior to the __ of the left anterior descending coronary artery

Answer 9

first septal branch

Question 10

The posterior descending coronary artery is most often (85%) a branch of the __ coronary artery.

Answer 10

right

Question 11

The sinus node artery is a branch of the __ coronary artery in 60% of cases.

Answer 11

right

Question 12

The AV node is supplied from the __ coronary artery.

Answer 12

right

Question 13

The left main stem is about _ mm long.

Answer 13

10 to 25 mm bifurcates into the LAD and LCx

Question 14

The combination of diplopia, crossed hemiparesis, and a lower motor neurone facial nerve lesion

Answer 14

pontine stroke

Question 15

Weber syndrome

Answer 15

Stroke in the brainstem Ipsilateral IIIrd nerve lesion and a contralateral hemiplegia Explanation: The cranial nerve lesions arise because of a stroke in the brainstem. Example of ‘crossed signs’.

Question 16

Lateral pontine syndrome

Answer 16

involves the cranial nerve nuclei of the pons and lateral spinothalamic tracts

Question 17

Contralateral loss of pain and temperature sensation in the trunk and extremities; lesion is in

Answer 17

lateral spinothalamic tract

Question 18

Ipsilateral paralysis of the upper and lower face (LMN lesion), ipsilateral loss of lacrimation and reduced salivation, ipsilateral loss of taste from the anterior two thirds of the tongue, loss of the corneal reflex (efferent limb). Lesion involves:

Answer 18

facial nucleus and nerve (VII)

Question 19

Lateral pontine syndrome: Ipsilateral loss of pain and temperature sensation of the face implies lesion in

Answer 19

spinal trigeminal nucleus and tract

Question 20

Lateral pontine syndrome: Nystagmus, nausea, vomiting, vertigo implies lesion involves

Answer 20

vestibular nuclei

Question 21

Lateral pontine syndrome: Ipsilateral central deafness - __ nuclei Ipsilateral limb and gait apraxia - middle and inferior __ peduncle Ipsilateral Horner’s syndrome - descending __ tract.

Answer 21

Ipsilateral central deafness - cochlear nuclei Ipsilateral limb and gait apraxia - middle and inferior cerebellar peduncle Ipsilateral Horner’s syndrome - descending sympathetic tract.

Question 22

An 80-year-old woman has a three month history of progressive numbness and unsteadiness of her gait. She has a history of hypertension and diet controlled diabetes, but is otherwise well. There is a mild spastic paraparesis, with brisk knee reflexes, ankle reflexes are present with reinforcement, extensor plantars, sensory loss in the legs with a sensory level at T10, impaired joint position sense in the toes, and loss of vibration sense below the iliac crests. Investigations were as follows: Haemoglobin 122 g/L (120-160) MCV 95 fL (80-96) Which of the following is the most likely diagnosis? 1. Anterior spinal artery occlusion 2. Dorsal meningioma 3. Multiple sclerosis 4. Subacute combined degeneration of the cord Incorrect answer selected 5. Tabes dorsalis

Answer 22

Dorsal meningioma Sensory loss at T10 indicates a thoracic myelopathy. Sub-acute combined degeneration of the cord is unlikely as there is no macrocytic anemia. Anterior spinal artery occlusion is unlikely as the history is progressive and chronic, whereas weakness related to anterior spinal artery occlusion occurs over a period of approximately 6-12 hours. Tabes dorsalis is also associated with cognitive impairment and global degeneration, rather than the sensory level seen here.

Question 23

Which organs are in direct contact with the anterior surface of the left kidney, without being separated from it by peritoneum?

Answer 23

Pancreas Adrenal Colon

Question 24

Ptosis, miosis, and anhidrosis.

Answer 24

Horner’s

Question 25

Three separate forms of Horner’s syndrome, depending on:

Answer 25

Level the sympathetic fibres are affected at:

Question 26

First-order sympathetic fibers originate in the _ and descend to synapse with the preganglionic sympathetic fibres at _. First-order lesions can be caused by strokes, multiple sclerosis, and basal _.

Answer 26

First-order sympathetic fibers originate in the hypothalamus and descend to synapse with the preganglionic sympathetic fibres at C8-T2. First-order lesions can be caused by strokes, multiple sclerosis, and basal meningitis.

Question 27

Second-order (preganglionic) fibres leave the cord at T1 and ascend in the sympathetic chain over the __ __. They synapse in the superior cervical ganglion at the level of C3-C4, at the bifurcation of the __ __ __. Lesions affecting these fibres can be caused by apical lung tumours, lymphadenopathy, and lower __ __ trauma. Third-order (___) fibres pass along the internal carotid artery, with branches passing to the blood vessels and sweat glands of the face. They pass through the cavernous sinus and superior orbital fissure, where they joint the long ___ nerves to supply the iris dilator. Because the sympathetic plexus accompanying the internal carotid artery innervates sweat glands __ ___ __ __ __, facial anhydrosis is only partial when Horner’s syndrome is caused postganglionic lesions. These lesions can be caused by _ _ _ dissection or __ __ infection.

Answer 27

Second-order (preganglionic) fibres leave the cord at T1 and ascend in the sympathetic chain over the lung apex. They synapse in the superior cervical ganglion at the level of C3-C4, at the bifurcation of the common carotid artery. Lesions affecting these fibres can be caused by apical lung tumours, lymphadenopathy, and lower brachial plexus trauma. Third-order (postganglionic) fibres pass along the internal carotid artery, with branches passing to the blood vessels and sweat glands of the face. They pass through the cavernous sinus and superior orbital fissure, where they joint the long ciliary nerves to supply the iris dilator. Because the sympathetic plexus accompanying the internal carotid artery innervates sweat glands only to the medial forehead, facial anhydrosis is only partial when Horner’s syndrome is caused postganglionic lesions. These lesions can be caused by internal carotid artery dissection or herpes zoster infection.

Question 28

An 80-year-old male presented with acute right-sided weakness. Minimal right facial weakness, impaired elevation of the right shoulder, with relatively preserved right hand strength. There was global weakness in the right leg which appeared to be maximal in the foot. Which of the following arteries is most likely to have been affected? (Please select 1 option) 1. Anterior cerebral artery 2. Lenticulostriate artery 3. Middle cerebral artery 4. Posterior cerebral artery 5. Posterior communicating artery

Answer 28

Anterior cerebral artery Occlusion (distal to ant. comm. origin) of anterior cerebral artery produces contralateral sensorimotor deficits mainly involving the lower extremity with relative sparing of face and hands.

Question 29

The lateral lenticulostriate artery is a branch of the __ __ artery. Occlusion causes damage to the internal capsule resulting in __ __ and sensory deficit. __ may be affected (medial temporal lobe) as well as __ function (Meyer’s loop: optic radiations affected).

Answer 29

The lateral lenticulostriate artery is a branch of the MCA. Occlusion causes damage to the internal capsule resulting in contralateral hemiparesis and sensory deficit. Speech may be affected (medial temporal lobe) as well as visual function (Meyer’s loop: optic radiations affected).

Question 30

Contralateral hemiplegia Homonymous hemianopia ipsilateral head/eye deviation If on left: global aphasia. Territory?

Answer 30

MCA

Question 31

Posterior cerebral artery stroke can cause

Answer 31

Multiple syndromes: Pure hemisensory loss Visual field loss Agnosia alexia, dyslexia

Question 32

A 40-year old male: two week history numbness and a burning sensation on the lateral aspect of the left upper thigh. Examination reveals sensory loss over the anterolateral thigh.

Answer 32

Meralgia paraesthetica Damage to the lateral cutaneous nerve of the thigh. It is usually a consequence of entrapment at the lateral inguinal ligament or less likely, trauma, ischaemia, or a retroperitoneal lesion.

Question 33

contralateral hemihypesthesia mild hemiparesis homonymous hemianiopia inferior quadrantanopia, and unilateral impairment of optokinetic nystagmus

Answer 33

Unilateral parietal lobe lesion,

Question 34

Hemihypesthesia

Answer 34

reduction in sensitivity on one side of the body.

Question 35

Dysgraphia, dyscalculia, finger agnosia, left-right disorientation

Answer 35

Gerstmann syndrome contralateral hemihypesthesia mild hemiparesis homonymous hemianiopia inferior quadrantanopia, and unilateral impairment of optokinetic nystagmus A left (dominant) parietal lesion causes the above signs in addition to sensory aphasia + Gerstmann syndrome (dysgraphia, dyscalculia, finger agnosia, left-right disorientation), bilateral apraxia, and tactile agnosia.

Question 36

A 75-year-old female presents partial left homonymous hemianopia, a mild left hemiparesis and left hemisensory inattention. Where on the right is the most likely area of infarction? 1. Frontal lobe 2. Medial temporal lobe 3. Occipital lobe 4. Parietal lobe 5. Thalamus

Answer 36

Parietal lobe

Question 37

A 50-year-old man presented with paraesthesia in the ring and little fingers of his right hand. On examination there was wasting of the hypothenar eminence of his right hand. Which one of the following movements would you expect to be weak in this patient? (Please select 1 option) Abduction of the thumb Adduction of the thumb Extension of the little finger Flexion of the index finger Opposition of the thumb

Answer 37

Adduction of the thumb The clinical features suggest an ulnar neuropathy. The ulnar nerve supplies the hypothenar muscles (opponens digiti minimi, abductor digiti minimi, flexor digiti minimi), the third and fourth lumbricals, dorsal and palmar interossei and adductor pollicis. It also provides sensory innervation to the fifth digit and medial half of the fourth digit.

Question 38

Abduction and opposition of the thumb and flexion of the index finger are via the.

Answer 38

median nerve

Question 39

Extension of the little finger is via the __ nerve.

Answer 39

Radial nerve

Question 40

The __ nerve supplies the hypothenar muscles (opponens digiti minimi, abductor digiti minimi, flexor digiti minimi), the third and fourth lumbricals, dorsal and palmar interossei and adductor pollicis.

Answer 40

Ulnar

Question 41

_ nerve: sensory innervation to the fifth digit and medial half of the fourth digit.

Answer 41

Ulnar

Question 42

A 69-year-old man is admitted with pain and numbness in his right foot following a right hip replacement. In his past medical history he had been treated for lower backache by his GP. On examination there was weakness of all movements at the right ankle, with absent right ankle jerk, and sensory impairment on the lateral aspect and sole of the foot. Which is the most likely site of the lesion? (Please select 1 option) 1. Femoral nerve 2. Lumbosacral plexus 3. Obturator nerve 4. Sciatic nerve

Answer 42

S1 spinal root Sciatic nerve palsy is a known complication of a total hip replacement (femoral nerve palsy can occur but is much less common). The right ankle jerk is absent due to tibial nerve involvement.

Question 43

Why does sciatic nerve palsy cause global weakness of the ankle?

Answer 43

It causes global weakness of the ankle due to the involvement of both of its branches: tibial nerve (plantaflexion and inversion) and common peroneal nerve (dorsiflexion and eversion).

Question 44

An 18-year-old male presents with blurring of vision in his right eye. Examination reveals visual acuity in the right eye of 6/18 and in the left eye 6/6. Visual fields to confrontation reveal a right temporal visual field defect and partial loss of superior part of the temporal field of the left eye. Where is the most likely position of the lesion responsible for this defect? (Please select 1 option) Occipital lobe Optic chiasm Optic nerve Optic tract Temporal lobe

Answer 44

The most likely localisation of the lesion is around the optic chiasm spreading up the right optic nerve. The signs indicate a bitemporal visual field defect with involvement of the right optic nerve (decreased visual acuity).

Question 45

Occipital lobe lesion causes a congruous __ __ whereas an optic tract lesion causes an incongruous __ __. Temporal lobe lesion causes an upper homonymous __.

Answer 45

Occipital lobe lesion causes a congruous homonymous hemianopia whereas an optic tract lesion causes an incongruous homonymous hemianopia. Temporal lobe lesion causes an upper homonymous quantranopia.

Question 46

Quadrantopia

Answer 46

Temporal lobe lesion causes an upper homonymous quantranopia.

Question 47

The more posterior the cerebral lesion, the more symmetric (___) the homonymous hemianopsia will be.

Answer 47

The more posterior the cerebral lesion, the more symmetric (congrous) the homonymous hemianopsia will be.

Question 48

Only nerve to pass through carpal tunnel

Answer 48

Median nerve

Question 50

Nerve supply of the hand

Answer 50

The cutaneous innervation of the right hand. Areas supplied by the median nerve are colored green, the radial nerve red and the ulnar nerve blue. It appears that the borderline has been mistakenly drawn through the middle finger, rather than through the ring finger on the dorsal side of the hand!