Case 20 questions 1-20

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Question 1

What is presbyopia?

  1. Short-sightedness
  2. Long-sightedness
  3. Difficulty with near vision (age related)
  4. Blurry vision (age related)
  5. Double vision

The correct answer is option c, Difficulty with near vision (age related)

Question 2

What eye muscle is responsible for lateral movement of the right eye?

  1. Medial rectus
  2. Lateral rectus
  3. Superior rectus
  4. Inferior rectus
  5. Superior oblique

The correct answer is option b, Lateral rectus

The lateral rectus is responsible for lateral movement of the eye
Medial rectus is responsible for medial movement of the eye
Superior rectus is responsible for elevation of the eye and some abduction
Inferior rectus is responsible for depression of the eye and some abduction
Superior oblique is responsible for adduction of the eye in a donwards direction

Question 3

The lesion of which cranial nerve would cause a down and out position?

  1. CN I
  2. CN III
  3. CN IV
  4. CN VI
  5. CN II

The correct answer is option b, CNIII

Question 4

What is the innervation of the extraocular muscle which chiefly acts to the adduct the eyeball?

  1. Optic Nerve
  2. Abducens
  3. Ophthalmic
  4. Oculomotor
  5. Trigeminal

The correct answer is option d, Oculomotor

The main action of the medial rectus is the adduct the eyeball. It is innervated by the oculomotor nerve

Question 5

What type of lens is used to correct myopia?

  1. Concave
  2. Convex
  3. Trifocal
  4. Bifocal
  5. Cavex

The correct answer is option a, concave (for myopia, aka short sightedness)

Question 6

Which of the following is NOT a typical feature of Horner’s syndrome?

  1. Partial ptosis
  2. Diplopia
  3. Miosis
  4. Ipsilateral anhidrosis
  5. Ipsilateral facial flushing

The correct answer is option b, diolopia

The classical triad of horners sundrome is partial ptosis, miosis and anhydrosis on the side which the sympathetic chain is affected. Although rare, facial flushing can occur due to sympathetic dysfunction. Diplopia does not occur.

Question 7

What is Broca’s area responsible for?

  1. Understanding of spoken and written language
  2. Receives impulses and converts to motor commands
  3. Initiating movement
  4. Vision processing
  5. Processing sensory stimuli such as touch, taste and temperature

The correct answer is option b

Receives impulses and converts to motor commands -> Broca’s
Understanding of spoken and written language -> Wernicke’s
Initiating movement -> primary motor complex
Vision processing -> occipital lobe
Processing sensory stimuli such as touch, taste and temperature -> parietal lobe

Question 8

Where is Wernicke’s area located in the brain?

  1. Temporal lobe
  2. Frontal lobe
  3. Parietal lobe
  4. Occipital lobe
  5. Brain stem

The correct answer is option a, temporal lobe

Question 9

Which sensory receptor is responsible for detecting vibration?

  1. Pacinian
  2. Ruffini
  3. Meissner’s corpuscle
  4. Merkle’s disc
  5. Nociceptor

The correct answer is option a, Pacinian receptor

Question 10

Which type of fibre is the golgi tendon organ?

  1. Ia
  2. Ib
  3. II
  4. III
  5. IV

The correct answer is option b, Ib

Question 11

This is a question about the areas of the brain that are involved in the interpretation and production of speech and language.

Select the answer that is most correct.

  1. Damage to the arcuate fasciculus will result solely in a receptive dysphasia
  2. Broca’s area is most commonly in the left posterior superior temporal gyrus
  3. Wernicke’s dysphasia involves the production of normal sounding words but in sentences that have no meaning
  4. Expressive dysphasia can be recognised by a patient using random words.
  5. Damage to the medullary reigon of the brain stem results in respiratory depression

The correct answer is option d, Wernicke’s dysphasia involves the production of normal sounding words but in sentences that have no meaning

Wernicke’s dysphasia is also known as a receptive aphasia and is characterised by normal sounding, properly articulated, fluent speech but the use of random words, forming grammatical sentences with no meaning.

Comprehension is not preserved. Broca’s dysphasia is an expressive speech problem meaning that the words spoken are relevant, make sense and comprehension is mostly intact, however speech is effortful, disjointed and agrammatical.

Question 12

Which muscle of the larynx is the only abductor of the vocal cords?

  1. Posterior cricoarytenoid muscle
  2. Lateral cricoarytenoid muscle
  3. Cricothyroid muscle
  4. Thyroarytenoid muscle
  5. Vocalis muscle

The correct answer is option a, Posterior cricoarytenoid muscle

There is only one abductor, the rest either adduct or tense or relax the vocal cords. Other than cricothyroid, they are innervated by the recurrent laryngeal nerve.

Question 13

Order the following to describe the processing of speech:

  1. Vagus nerve, Precentral gyrus, Wernicke’s area, Broca’s area, Premotor cortex
  2. Precentral gyrus, Wernicke’s area, Broca’s area, Vagus nerve, Premotor cortex
  3. Premotor cortex, Precentral gyrus, Wernicke’s area, Broca’s area, Vagus nerve
  4. Broca’s area, Precentral gyrus, Wernicke’s area, Premotor cortex,Vagus nerve
  5. Wernicke’s area, Precentral gyrus, Broca’s area, Premotor cortex, Vagus nerve

The correct answer is option c, Premotor cortex, Precentral gyrus, Wernicke’s area, Broca’s area, Vagus nerve

Premotor cortex is anterior to the primary motor cortex (precentral gyrus). Although wernicke’s and broca’s areas don’t work strictly sequentially, it is thought that wernicke’s area is involved in continuous monitoring of the speech production. The recurrent and superior laryngeal nerves are branches of the vagus nerve.

Question 14

Describe the stages involved in the production of speech

  1. Exhalation, phonation and articulation
  2. Phonation, exhalation and articulation
  3. Articulation, phonation and exhalation
  4. Exhalation, articulation and phonation
  5. Inhalation, articulation and phonation

The correct answer is option a, Exhalation, phonation and articulation

This is a fairly simple question that requires thought of what is happening to produce sound. Air is expelled through the vocal cords which is modulated by the shapes formed by the lips mouth and pharynx.

Question 15

Which of the following statements is true?

  1. The trigeminal nerve is a solely sensory cranial nerve
  2. The trigeminal nerve originates from four brainstem nuclei
  3. The ophthalmic branch of the trigeminal nerve exits through the foramen rotundum
  4. The lingual nerve is also known as V3, the third branch of the trigeminal nerve
  5. The trigeminal nerve mainly serves a motor function

The correct answer is option b, The trigeminal nerve originates from four brainstem nuclei

The trigeminal nerve has a motor nuclei in addition to its three sensory branch nuclei.

Question 16

A young and usually healthy patient presents to you, the GP, having noticed a change in her appearance and is upset to report that she has begun to drool. Upon carrying out a cranial nerve examination, you report the following abnormal findings. You notice that the patient’s smile is asymmetrical with little movement on the left and when raising her eyebrows, her left eyebrow doesn’t move.

  1. This is likely to be Bell’s palsy affecting CNV
  2. This is likely an ischaemic stroke affecting the muscles of facial expression
  3. This is likely a haemorrhagic stroke causing unilateral facial paresis
  4. This is likely to be caused by very bad trigeminal neuralgia
  5. This is likely to be varicella-zoster virus affecting CNVII

The correct answer is option e, This is likely to be varicella-zoster virus affecting CNVII

Varicella-zoster virus also known as chickenpox is known to be a cause of Bell’s palsy, Ramsey Hunt syndrome is the specific disease of a reactivation of VZV with a vesicular rash and the symptoms described in the question.

Question 17

What is currently the biggest barrier to using stem cells as treatment for spinal cord transection?

  1. Stem cells are hard to use experimentally as we are unable to replicate real conditions in vitro.
  2. Stem cells are fraught with ethical issues making them a completely unfeasible option.
  3. Stem-cells once transplanted are affected by the spinal cord scar microenvironment which inhibits regeneration
  4. Stem-cells are not the wonder-cure that people think they are
  5. Spinal cord injuries are like peripheral nerve injuries, they often are able to regenerate and would not need stem cells to promote repair.

The correct answer is option c, Stem-cells once transplanted are affected by the spinal cord scar microenvironment which inhibits regeneration

Glial scarring is specific to the central nervous system and involves the permanent ending of neuronal connection. Molecular inducers include TGFbeta, IL-1, IFNgamma, FGF2, nestin and the formation of dense network of gap junctions.

Question 18

A patient presents with acute stroke that started 2 hours ago. You decide not to give alteplase but immediately give intravenous vitamin K. What led you to make this decision?

  1. Ultrasound doppler of the carotids detected bruits and found severe stenosis
  2. An MRI head showed normal brain morphology with multiple discreet, highly enhancing white matter lesions.
  3. Non-contrast CT head showed an irregularly shaped white region in the occipital lobe with midline shift.
  4. You found the patient to be looking grey with a weak, irregularly irregular pulse.
  5. The patient had weakness in his left arm and leg, was talking but not making any sense and had seemingly ignored half his lunch.

The correct answer is option c, Non-contrast CT head showed an irregularly shaped white region in the occipital lobe with midline shift.

In acute stroke, a haemorrhagic stroke should always be excluded first. A CT head is the gold standard, any evidence of increased intra-cranial pressure or blood out of place or midline shift would suggest haemorrhage. In the acute phase, ischaemic stroke is not always visible on imaging. Most of the answers are referring to ischemic stroke.

Question 19

An 85-year-old female patient presents to A&E after falling out of bed. She has known high blood pressure but no other past medical, family or social history. Upon checking her pulse, you find it to be 75bpm but weak and irregular. After a full neurological examination, you find her left arm and left leg to have power scores of 3/5 for each test and notice that her smile is asymmetrical.

You, the acute stroke doctor, having excluded haemorrhagic stroke will make the following decision about her treatment:

  1. Refer her straight to the cath lab for immediate thrombectomy to treat her acute ischaemic stroke
  2. Call the on-call neurosurgery reg as you believe she requires a decompressive hemicraniectomy for acute ischaemic stroke
  3. Start the patient on aspirin 300mg orally to treat an acute ischaemic stroke
  4. Administer immediate clot-busting drug alteplase to treat her acute ischaemic stroke
  5. Start the anticoagulant therapy warfarin in order to treat her acute ischaemic stroke

The correct answer is option c, Start the patient on aspirin 300mg orally to treat an acute ischaemic stroke

One might instinctively choose the clot-buster in a confirmed ischaemic stroke however this can strictly only be given when it is known that the patient has had a stroke int the last 4.5 hours. Interventional radiology is also unlikely to intervene without a known onset. Anticoagulants are not given to treat ischaemic stroke but may be given as secondary prevention.

Question 20

You, the FY1, are asked to assess a patient’s GCS. The patient is a 21-year-old man who has been blue lighted to A&E after a road traffic accident. The patient has no known medical, drug, family or social history. Upon meeting the patient, you clearly and loudly ask him his name and for him to open his eyes to which he does not respond. In order to elicit a response, you give his shoulder a firm shake followed by a squeeze to his trapezius muscle. The patient makes no noise nor opens his eyes to this action however you notice that both his arms begin to flex and his legs internally rotate.

What is the patients Glasgow Coma Scale?

  1. E1, V1, M1 GCS of three
  2. E1, V1, M2 GCS of four
  3. E1, V2, M2 GCS of five
  4. E1, V1, M3 GCS of five
  5. E2, V1, M3 GCS of six

The correct answer is option 4, E1, V1, M3 GCS of five

This is the flexor, decorticate reflex. The way I remember is that decerebrate and extensor have more ‘E’s in.

Credits

  • 1-10 (Thomas Welford, 5th year),
  • 11-20 (Bertie Harrington, intercalating),