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nd 2 year neurology Q&A By Chean Chung Shen EMQ 1: Cranial nerve anatomy A. B. C. D. E. F. G. H. I. J. K. L. Abducent nerve Accessory nerve Facial nerve Glossopharyngeal nerve Hypoglossal nerve Occulomotor nerve Trigeminal nerve Trochlear nerve Vagus nerve Vestibulocochlear nerve Olfactory nerve Optic nerve For each of the statements below, select the most appropriate cranial nerve from the above list. 1. Forms the afferent pathway of gag reflex D 2. Innervates the levator palpebrae superioris F 3. Required for a normal cough I 4. Innervates the stapedius muscle C 5. Required to look downwards and outwards H 6. Associated with herpes zoster ophthalmicus G EMQ 2: Cranial nerve anatomy & lesion A. B. C. D. E. F. G. H. I. J. K. L. Abducent nerve Accessory nerve Facial nerve Glossopharyngeal nerve Hypoglossal nerve Occulomotor nerve Trigeminal nerve Trochlear nerve Vagus nerve Vestibulocochlear nerve Olfactory nerve Optic nerve 1. 2. 3. 4. 5. 6. Damage is accompanied by the inability to whistle C Innervates the orbicularis oculi C Associated with false localising sign A Associated with posterior communicating artery aneurysm F Only cranial nerve that exits from the dorsal part of the brainstem H Longest cranial nerve H SBA question 1 A previously fit and well 34-year-old man presents with a 10-day history of flu-like illness and weakness in his lower limbs. Neurological examination of his cranial nerves and upper limbs is normal but his lower limbs have grade 4/5 distal weakness, diminished reflexes and equivocal plantar responses. Vibration and joint position sense and light touch are also reduced distally. Which of the following is the most likely diagnosis? A. Gullain-Barre syndrome B. Multiple sclerosis C. Poliomyelitis D. Spinal cord compression E. Motor neurone disease SBA question 2 Which of the following is the BEST explanation of ‘forehead sparing’ in upper motor neuron lesion? A. Bilateral innervation in the brainstem B. Partial stroke C. Occulomotor nerve is usually not affected D. Weakness of levator palpebrae superioris E. Weakness of Muller muscle causing partial ptosis SBA Question 3 A previously fit and well 75-year-old man presents to his GP with a 3month history of insidious worsening of his right hand tremor. On examination, his gait is slow and has poor ‘swing through’. There is an associated ‘cog-wheeling’ of the right upper limb. Which of the following is the most likely diagnosis? A. Alzheimer’s disease B. Multisystem atrophy C. Post-encephalitic parkinsonism D. Idiopathic Parkinson disease E. Progressive supranuclear palsy SBA question 4 Which of the following neurotransmitters are excitatory? A. Glutamate B. GABA C. Dopamine D. Serotonin E. Glycine Neurotransmitter Foramen of the skull Foramen rotundum- Maxillary nerve (V2) Foramen lacerum- artery of pterygoid canal, Meningeal branch of ascending pharyngeal artery, Occipital arteryemissary vein Foramen ovale- Mandibular nerve (V3) Foramen magnum- anterior and posterior spinal arteries, vertebral arteries, accessory nerve Foramen cecum- emissary veins to superior sagittal sinus from the upper part of the nose Foramen spinosum- Middle meningeal artery and meningeal branch of the mandibular nerve EMQ 3: Memory loss A. B. C. D. E. F. G. H. Implicit memory Explicit memory Episodic memory Semantic memory Short-term memory Anterograde memory Retrograde memory Transient global amnesia 1. Associated with driving a car and other complex motor skills, which are learned motor responses, not available to conscious access A 2. Recalling autobiographic details C 3. General store of world knowledge D 4. Acquisition of new material F 5. Recall of previously learnt information G 6. Working memory responsible for immediate recall of small amounts of material E Dementia types: - Alzheimer’s disease - Vascular dementia - Lewy body dementia - Frontotemporal dementia/ Picks dementia/ ‘semantic dementia’ - Alcoholic dementia - Pseudodementia - Normal pressure hydrocephalus (gait dyspraxia, urinary incontinence, cognitive impairment) Hydrocephalus • Communicating: - More common - Due to blockage outside the ventricular system - Most commonly occur in the arachnoid villi - Example: post-meningitic • Non-communicating - Obstruction with the ventricular system - Example: aqueductal stenosis, pineal tumour EMQ 4: Neurological terms A. B. C. D. E. F. G. H. I. J. K. L. Dyspraxia Dyscalculia Dysarthria Dysgraphia Agnosia Prosopagnosia Aphasia Dysphasia Dystonia Dyskinesia Dyslexia Dysnomia 1. 2. 3. 4. 5. 6. 7. G/L Inability to recognise things E Inability to recognise familiar faces F Impairment of language function H Impairment of articulation C Impairment in writing D Inability to perform complex motor acts despite normal power, sensation, coordination and good comprehension A General inability to produce words for things a person want to take about EMQ 5: Weakness A. B. C. D. E. F. G. H. I. J. Transient ischaemic attack Stroke Bell’s Palsy Bulbar palsy Pseudobulbar palsy Quadriplegia Paraplegia Hemiplegia Hemiparesis Paraparesis Please select the most appropriate term that best represents the statement below: 1. 2. 3. 4. 5. An idiopathic condition that gives lower motor neuron signs of facial nerve palsy C Paralysis of both lower limbs G Paralysis of all four limbs F Episodes of neurological dysfunction caused by ischaemia which usually resolve within 24 hours A Usually associated with amaurosis fugax A EMQ 6: Nerve roots and dermatomes A. B. C. D. E. F. G. H. I. J. K. L. M. C5/6 C7/8 C8/T1 T12/L1 L1/2 L2/3 L3/4 L5/S1 S1/2 S3/4 T4 T10 T12 1. Nerve root for knee jerk reflex G 2. Innervates the levator ani J 3. Common location for lumbar puncture G 4. Dermatomes for umbilicus L 5. Nerve root reflex for brachioradialis reflex A 6. Nerve root for cremasteric reflex D EMQ 7: Upper limb innervation A. Musculocutaneous nerve B. Median nerve C. Ulnar nerve D. Radial nerve E. Axillary nerve F. Subscapular nerve G. Long thoracic nerve Please select the most appropriate nerves associated with the following statement: 1. Damage of the nerve causes winging of scapula G 2. Sensory supply to the regimental badge E 3. Nerve roots are mainly C8-T1 C 4. Innervates the brachialis, coracobrachialis, and biceps brachii A 5. Damage of the nerve causes ‘Saturday night palsy’ D EMQ 7: Upper limb innervation (2) A. Musculocutaneous nerve B. Median nerve C. Ulnar nerve D. Radial nerve E. Axillary nerve F. Subscapular nerve G. Long thoracic nerve 1. Damage of the nerve causes wrist drop D 2. This nerve is compressed in carpal tunnel syndrome B 3. Nerve damage associated with humeral shaft fracture D 4. Nerve damage associated with supracondylar fracture B/C 5. Most commonly damaged due to fracture of surgical neck of humerus E EMQ 8: Spinal tracts A. Dorsal column B. Dorsal spinocerebellar tract C. Dorsolateral tract D. Gracile fasciculus E. Cuneate fasciculus F. Fasciculus proprius G. Lateral corticospinal tract H. Anterior corticospinal tract I. Substantia gelatinosa J. Anterior spinothalamic tract K. Lateral spinothalamic tract L. Anterior spinocerebellar tract M. Ventral grey column (Medial reticulopsinal and lateral reticulospinal) Please identify the most appropriate pathway from the list to match the following descriptions. 1. Carries fibres that synapse in the upper medulla and decussate to form the medial lemniscus D 2. Carries fibres that decussate in the medullary pyramid G 3. Carries ascending neurones responding to cutaneous pain and temperature J 4. Carries predominantly ipsilateral ascending proprioceptive fibres from the thoracic nucleus B 5. Lies between the dorsal root and dorsal grey matter C EMQ9: Visual defects A. Amaurosis fugax B. Bitemporal hemianopia C. Metamorphopsia D. Central scotoma E. Cortical blindness F. Diplopia to left gaze G. Diplopia to right gaze H. Myopia I. Hypermetropia J. Nyctalopia K. Right homonymous hemianopia L. Retrobulbar neuritis M. Tunnel vision N. Altitudinal visual loss O. Right homonymous superior quadrantanopia Please select the most appropriate visual defect that is most appropriate for the following statements: 1. Occur with left sixth nerve palsy, causing blurring of vision F 2. Also called loss of central vision D 3. Causing increased risk of acute close angle glaucoma I 4. Mainly associated with macular degeneration, when patients complain of distorted vision C 5. Associated with retinitis pigmentosa J 6. Associated with multiple sclerosis L 7. Associated with pituitary tumour B 8. Associated with lesion in the optic radiation O 9. Lesion affecting temporal lobe O EMQ 10: Intracranial haemorrhage A. B. C. D. E. F. G. H. I. J. Acute subdural haemorrahage Chronic subdural haemorrhage Extradural haemorrhage Intracerebral haemorrhage: Anterior cerebral artery territory Intracerebral haemorrhage: Middle cerebral artery territory Intracerebral haemorrhage: Posterior cerebral artery territory Intracerebral haemorrhage: Vertebrobasilar artery territory Intracerebellar haemorrhage Intraventricular haemorrhage Subarachnoid haemorrhage Please select the most appropriate diagnosis 1. 2. 3. 4. 5. Most commonly associated with rupture of berry aneurysm J Can cause xanthochromia in CSF J Associated with a lucid interval C Post-head injury syndrome characteristic of frontal brain damage causing behavioural and speech as well as motor abnormalities D A 55-year-old hypertensive man with no previous history of neurological events presents with a sudden onset of right sided hemiparesis (arm>leg) and hemisensory loss. He is also noted to have an expressive aphasia. He is right-handed E EMQ11: Site of stroke A. B. C. D. E. F. G. H. Cerebellar Frontal cortex Medullary Occipital cortex Parietal cortex Pontine Subcortical Temporoparietal cortex The following right-handed patients have presented with a stroke. Please choose the most appropriate anatomical site of their stroke. 1. 70-year-old man with right upper limb weakness, expressive dysphasia, urinary incontinence, and a change in his persona B 2. A 63-year-old diabetic smoker with right hemiparesis and dyspraxia. He is unable to draw a clock face correctly on examination. E 3. 45-year-old with receptive dysphasia, right hemiparesis and a right homonymous hemianopia H 4. 54-year-old woman with nystagmus to the left, past-pointing on the left, and dysdiadochokinesis A 5. 67-year-old man diagnosed with Anton’s syndrome D SBA: Question 5 Which of the following cranial nerves is most probably the first to be affected in cavernous sinus thrombosis? A. Occulomotor nerve B. Trochlear nerve C. Trigeminal nerve D. Abducens nerve E. Facial nerve SBA: Question 6 A 24-year-old student presents in the emergency department with a 6-hour history of severe generalised headache, associated with vomiting. She is noted to be taking oral contraceptive pill. On examination, she is in obvious distress, with mild meningism, but she is apyrexial and has no rash. Ophthalmoscopy shows bilateral papilloedema and a CT scan of her head with contrast confirms the diagnosis. Which of the following is the most likely diagnosis? A. Benign intracranial hypertension B. Meningitis C. Sagittal sinus thrombosis D. Space-occupying lesion E. Temporal arteritis Benign intracranial hypertension vs Sagittal sinus thrombosis Benign intracranial hypertension -Also called idiopathic intracranial hypertension - Young women - Associated with obesity - Associated with visual impairment - Generalised throbbing headache first thing in the morning and last thing at night - Gradual visual field defect Sagittal sinus thrombosis - Hypercoaguability - Young women - Can be associated with sinusitis - Headache similar to subarachnoid haemorrhage - Papilloedema, impaired consciousness, maybe seizures, and possible neurological signs Some of the conditions to go through • • • • • • • • • • • • Stroke TIA Multiple sclerosis Intracranial haemorrhage: Subdural, extradural and subarachnoid haemorrhage Delirium vs dementia (Alzheimer’s disease) Epilepsy Parkinson’s disease Bell’s palsy Myasthenia gravis Mononeuropathies Polyneuropathies Diabetic neuropathy (Autonomic neuropathy) Thank you for listening!