Are You Patient Person

1. The 10 YO boy had been teased cruelly by the other children in his class, the mother told you, because his head had been tilted to one side since birth. You respond by telling her that the lad has congenital torticollis and that it can be corrected rather easily by a surgical procedure. The condition resulted from fibrosis of the ...

Splenius musculature, unilaterally

Levator scapulae muscle

Sternocleidomastoid

Omohyoid

Ipsilateral strap muscles

The correct answer is sternocleidomastoid. Congenital torticollis is a condition characterized by the tilting of the head to one side due to the shortening or fibrosis of the sternocleidomastoid muscle. This muscle is located in the neck and is responsible for the rotation and flexion of the head. Surgical correction of congenital torticollis often involves lengthening or releasing the sternocleidomastoid muscle to restore normal head positioning.

Explanation

The correct answer is sternocleidomastoid. Congenital torticollis is a condition characterized by the tilting of the head to one side due to the shortening or fibrosis of the sternocleidomastoid muscle. This muscle is located in the neck and is responsible for the rotation and flexion of the head. Surgical correction of congenital torticollis often involves lengthening or releasing the sternocleidomastoid muscle to restore normal head positioning.

2. Unilateral clefts of the upper lip are common, occurring about once in 1000 births. The underlying cause for this congenital defect is known to be the lack of fusion....

Between palatine shelves

Between the primary and secondary palate and distorsion of the lateral palatine processes, preventing their migration

Of the maxillary processes

Between maxillary and mandibular processes

Between a maxillary prominence and the medial nasal prominence

Unilateral clefts of the upper lip occur due to the lack of fusion between a maxillary prominence and the medial nasal prominence. This fusion failure during embryonic development leads to a separation or gap in the upper lip. This defect is a common congenital abnormality, happening in approximately one out of every 1000 births.

Explanation

Unilateral clefts of the upper lip occur due to the lack of fusion between a maxillary prominence and the medial nasal prominence. This fusion failure during embryonic development leads to a separation or gap in the upper lip. This defect is a common congenital abnormality, happening in approximately one out of every 1000 births.

3. The patient responds properly as you check the blink reflex (corneal reflex) in both eyes, closing and opening both eyes. But, as you examine the patient's right eye with a small, bright flashlight, the right pupil does not constrict in response to the light, although the contralateral pupil does. You would be CORRECT in thinking that ...

The patient obviously suffers from glaucoma in the right eye.

The left oculomotor nerve is not functioning properly

The parasympathetic fibers in the right oculomotor nerve are not functional

The patient is blind in the right eye

The right oculomotor nerve is paralyzed

light reflex is mediated by parasympathetics

Explanation

light reflex is mediated by parasympathetics

4. Imaging studies demonstrated that the patient's prostatic cancer had spread upward through the vertebral canal by way of the venous plexus of Batson in the epidural space. A metastatic tumor had grown in the posterior cranial fossa, there affecting cranial nerves leaving the skull. The patient's left shoulder drooped lower than the right shoulder. When protruded, his tongue deviates to the left. He has weakness in turning his head to the right. From this evidence, one can easily deduce which nerves have been affected:

Right cranial nerves IX, X, XI and XII

Left cranial nerves X, XII and right XI, together with cervical nerves C3 and C4

Right cranial nerves X, XI, XII

Left cranial nerves XI and XII

Right cranial nerve XI, left cranial nerve XII

XI does trapezius and SCM, XII does hypoglossal, tongue deviates toward lesion, (uvula away from lesion)

Explanation

XI does trapezius and SCM, XII does hypoglossal, tongue deviates toward lesion, (uvula away from lesion)

5. Magnetic resonance imaging can provide excellent visualization of soft tissues of the body. With such imaging methodology, for instance, it could be demonstrated that one of the following DOES NOT pass through the superior orbital fissure:

Trochlear nerve

Abducens nerve

Ophthalmic artery

Oculomotor nerve

Superior ophthalmic vein

Opthathamic artery travels in optic canal with the optic nerve. (artery in-nerve out)
V1 also travels in Superior orbital fissure.

Explanation

Opthathamic artery travels in optic canal with the optic nerve. (artery in-nerve out)
V1 also travels in Superior orbital fissure.

6. A 14 YO female patient from Calibishe, Dominica is seen in the Portsmouth hospital by the small group of nervous 4th semester students (nervous, but highly self‑confident). It is immediately apparent that the girl has a bad case of acne. She complains of severe headache, pain superficially and deeply in her midface, and loss of all voluntary movement of her right eye. She has an elevated temperature. Physical and ophthalmoscopic examination reveal ipsilateral ptosis, a swollen palpebra and engorged retinal veins. Which of the following combinations of structures possibly involved in this case of coronary sinus thrombosis might BEST explain the ocular findings?

CN VII and CN VI

CN III, CN IV and CN VI

CNV1, CNV2 and CN III

CN I, CN VI, CNV, and CNV2

CN III, CN IV, CN VI and CN V3

The ocular findings in this case suggest that there is involvement of the cranial nerves responsible for eye movement and control. CN III (oculomotor nerve) controls the movement of the eye, CN IV (trochlear nerve) controls the superior oblique muscle, and CN VI (abducens nerve) controls the lateral rectus muscle. Dysfunction or involvement of these nerves can result in ptosis (drooping of the eyelid), loss of voluntary eye movement, and swollen palpebra (eyelid). Therefore, the combination of CN III, CN IV, and CN VI being involved best explains the ocular findings in this case.

Explanation

The ocular findings in this case suggest that there is involvement of the cranial nerves responsible for eye movement and control. CN III (oculomotor nerve) controls the movement of the eye, CN IV (trochlear nerve) controls the superior oblique muscle, and CN VI (abducens nerve) controls the lateral rectus muscle. Dysfunction or involvement of these nerves can result in ptosis (drooping of the eyelid), loss of voluntary eye movement, and swollen palpebra (eyelid). Therefore, the combination of CN III, CN IV, and CN VI being involved best explains the ocular findings in this case.

7. The recurring infections in the young boy seemed to indicate a need for removal of his palatine tonsils. These lymphoid organs are found in the...

Oropharynx

Oral vestibule

Pharyngeal recess

Laryngopharynx

Oral cavity propber

The correct answer is oropharynx. The passage mentions that the boy's recurring infections indicate a need for removal of his palatine tonsils. The palatine tonsils are a part of the lymphoid tissue located in the oropharynx. Therefore, the oropharynx is the most appropriate location for the palatine tonsils. The other options, such as the oral vestibule, pharyngeal recess, laryngopharynx, and oral cavity proper, do not specifically mention the location of the palatine tonsils.

Explanation

The correct answer is oropharynx. The passage mentions that the boy's recurring infections indicate a need for removal of his palatine tonsils. The palatine tonsils are a part of the lymphoid tissue located in the oropharynx. Therefore, the oropharynx is the most appropriate location for the palatine tonsils. The other options, such as the oral vestibule, pharyngeal recess, laryngopharynx, and oral cavity proper, do not specifically mention the location of the palatine tonsils.

8. The little girl was obviously small for her age and her eyes were so far apart that you include hypertelorism as one of your observations during the physical exam. In response to your cautious questioning, the mother tells you that the child suffers from recurring colds. Laboratory studies reveal that the little patient also has a condition of hypocalcemia, leading you to decide on a diagnosis of DiGeorge Syndrome. Which of the following might BEST explain the chronic colds the little girl is suffering?

Internal branchial fistula

Ectopic parathyroid glands

Hypoplastic thymus gland

Persistent thyroglossal duct

Cervical cysts

DiGeorge Syndrome is from a dysfunction of thymus.

Explanation

DiGeorge Syndrome is from a dysfunction of thymus.

9. The second semester student had gone to Roseau because pain from a bad molar tooth was distracting him from his preparations for the second Mini exam at Ross. The dentist who treated the student injected a bolus of anesthetic into the region just anterior to the mandibular lingula. In a few minutes, the student observed that he had lost all sensations on the anterior parts of the tongue ipsilateral to the injection. He realized that the loss of tongue sensation was due to the fact that the anesthetic had directly affected the ...

Inferior alveolar nerve

Auriculotemporal nerve

Lingual nerve

Buccal nerve

Chorda tympani nerve

The correct answer is the lingual nerve. The lingual nerve is a branch of the mandibular division of the trigeminal nerve (V3). It provides sensory innervation to the anterior two-thirds of the tongue, as well as the floor of the mouth. In this case, the injection of anesthetic into the region just anterior to the mandibular lingula would have directly affected the lingual nerve, leading to the loss of sensation on the anterior parts of the tongue ipsilateral to the injection.

Explanation

The correct answer is the lingual nerve. The lingual nerve is a branch of the mandibular division of the trigeminal nerve (V3). It provides sensory innervation to the anterior two-thirds of the tongue, as well as the floor of the mouth. In this case, the injection of anesthetic into the region just anterior to the mandibular lingula would have directly affected the lingual nerve, leading to the loss of sensation on the anterior parts of the tongue ipsilateral to the injection.

10. The knowledge that important nerves often accompany named arteries (so‑called "neurovascular pairs") can be of great assistance to the clinician when looking for a particular nerve. An example of such an association is that of the ...

Angular artery and the buccal branch of the facial nerve

The external laryngeal nerve with the superior laryngeal artery

The inferior thyroid artery and the recurrent laryngeal nerve

Superficial temporal artery and the facial nerve

The lingual artery and the buccal nerve

The correct answer is the inferior thyroid artery and the recurrent laryngeal nerve. This is because the inferior thyroid artery and the recurrent laryngeal nerve often travel together in close proximity. This knowledge can be helpful for clinicians who are looking for the recurrent laryngeal nerve during surgical procedures involving the thyroid gland.

Explanation

The correct answer is the inferior thyroid artery and the recurrent laryngeal nerve. This is because the inferior thyroid artery and the recurrent laryngeal nerve often travel together in close proximity. This knowledge can be helpful for clinicians who are looking for the recurrent laryngeal nerve during surgical procedures involving the thyroid gland.

11. During the Saturday morning Morbidity and Mortality Conference in the Staten Island Hospital, the conclusion was offered that the patient under discussion had almost died as a result of asphyxiation (suffocation) because both recurrent laryngeal nerves had been injured during the removal of the patient's diseased thyroid glands. The young resident, a graduate of Ross Medical School, left no doubt in the minds of those attending the conference that one pair of laryngeal muscles would still be innervated after bilateral injuries to the recurrent laryngeal nerves. The continuing contraction of this muscle brought the vocal cords together in the heavily sedated patient, thereby blocking the airway. The financial loss to the hospital in a lawsuit would have been great if she had not observed the problem and ordered respiratory intubation for the patient. The muscle that was still functioning was the ...

Cricothyroid

Posterior cricoarytenoid

Arytenoideus

Lateral cricoarytenoid

Thyroarytenoid

cricothyroid is innervated by EXTERNAL LN. which is a branch of the Superior LN.

Explanation

cricothyroid is innervated by EXTERNAL LN. which is a branch of the Superior LN.

12. The 28 YO female has come to you complaining hoarsely of difficulty swallowing (especially liquids) and in speaking. As you performed the physical examination, you observe that touching the posterior 1/3 of her tongue or pharyngeal wall on the right side produced no noticeable result. When the contralateral areas were stimulated, however, there was a distinct gag reflex and the uvula moved distinctly toward the left side of the pharynx. Use of a laryngoscope in examination of the true vocal folds would confirm that the patient had paralysis of the ...

Right vagus and right glossopharyngeal nerves

Right glossopharyngeal and left vagus nerves

Left vagus nerve only

Right glossopharyngeal nerve only

Left vagus and left glossopharyngeal nerves

IX is afferent pathway of gag reflex, X is efferent. Uvula deviates away from lesion becuase it is being "pulled" whereas the tongue deviates away from deficit because it is being "pushed"

Explanation

IX is afferent pathway of gag reflex, X is efferent. Uvula deviates away from lesion becuase it is being "pulled" whereas the tongue deviates away from deficit because it is being "pushed"

13. The fourth semester student was asked by the examining clinician in the ICM program to check the functions of the masticatory muscles in an elderly woman from Portsmouth. After the student asked the woman to clench her jaws together tightly he could feel on palpation that there was a lack of symmetry in size and strength of the muscles from one side of the jaw to the other, as noted both by the lack of fullness under his examining fingertips and the unequal strength of the jaws as the patient closed her mouth against resistance. When the patient was asked to "stick out your chin," (in other words, protrude her mandible directly forward) the mandible deviated to the right. This would MOST LIKELY occur as a direct result of paralysis to the ...

Posterior segment of her left temporalis

Right medial pterygoid

Left masseter

Right lateral pterygoid

Left lateral pterygoid

remember tongue. When pushing the Jaw, as in protusion, the jaw will deviate toward the weaker side.

Explanation

remember tongue. When pushing the Jaw, as in protusion, the jaw will deviate toward the weaker side.

14. Tumors or infections that develop in the middle ear cavity can affect structures associated with the various walls of the chamber. An infectious process that invades the promontory of the medial wall would MOST LIKELY involve the ...

Internal carotid artery in the carotid canal

Pyramid of the stapedius muscle

Temporal lobe of the brain

Jugular bulb

Cochlea

The promontory of the tympanic cavity, better known as the cochlear promontory is a rounded hollow prominence, formed by the projection outward of the first turn of the cochlea.

It is placed between the fenestrae, and is furrowed on its surface by small grooves, for the lodgement of branches of the tympanic plexus.
A minute spicule of bone frequently connects the promontory to the pyramidal eminence.

Explanation

The promontory of the tympanic cavity, better known as the cochlear promontory is a rounded hollow prominence, formed by the projection outward of the first turn of the cochlea.

It is placed between the fenestrae, and is furrowed on its surface by small grooves, for the lodgement of branches of the tympanic plexus.
A minute spicule of bone frequently connects the promontory to the pyramidal eminence.

15. The 30 YO male medical student enters the campus clinic following one of the Embryology lectures, seeking confirmation of his self‑diagnosis. The student has a small, soft lump on the anterior border of his left sternocleidomastoid muscle and he has decided to ask the opinion of the campus physician about it. A mucoid secretion can be seen oozing from the soft mass of tissue. The clinician's classic training leads him to agree with the medical student that the proper diagnosis is ...

Branchial or pharyngeal fistula

Aberrant thymic tissue

Persistent 2nd pharyngeal pouch

Inflamed and severely infected deep cervical lymph nodes

Ectopic palatine tonsil

The correct answer is branchial or pharyngeal fistula. This is because the description of a small, soft lump on the anterior border of the left sternocleidomastoid muscle with mucoid secretion oozing from it is consistent with a branchial or pharyngeal fistula. These fistulas are congenital anomalies that result from incomplete closure of the branchial arches during embryonic development. They can present as cysts or sinuses and are commonly found in the neck area. The classic training of the clinician would lead them to recognize and agree with the medical student's self-diagnosis.

Explanation

The correct answer is branchial or pharyngeal fistula. This is because the description of a small, soft lump on the anterior border of the left sternocleidomastoid muscle with mucoid secretion oozing from it is consistent with a branchial or pharyngeal fistula. These fistulas are congenital anomalies that result from incomplete closure of the branchial arches during embryonic development. They can present as cysts or sinuses and are commonly found in the neck area. The classic training of the clinician would lead them to recognize and agree with the medical student's self-diagnosis.

16. While treating young children from the local public school, you examine the swollen, and angry‑red eardrum of Carolon, a 7 YO girl with a middle ear infection. Which of the following statements do you remember as being TRUE, as you review the clinical anatomy of the area?

The "cone of light" is due to reflection of the otoscope light toward the posterior inferior quadrant of the eardrum.

The vagus nerve, auriculotemporal nerve and glossopharyngeal nerve are all involved in the sensory supply of the eardrum.

The statement that the vagus nerve, auriculotemporal nerve, and glossopharyngeal nerve are all involved in the sensory supply of the eardrum is true. The vagus nerve provides sensory innervation to the posterior part of the external acoustic meatus and the eardrum. The auriculotemporal nerve, a branch of the trigeminal nerve, provides sensory innervation to the anterior part of the external acoustic meatus. The glossopharyngeal nerve provides sensory innervation to the posterior part of the eardrum.

Explanation

The statement that the vagus nerve, auriculotemporal nerve, and glossopharyngeal nerve are all involved in the sensory supply of the eardrum is true. The vagus nerve provides sensory innervation to the posterior part of the external acoustic meatus and the eardrum. The auriculotemporal nerve, a branch of the trigeminal nerve, provides sensory innervation to the anterior part of the external acoustic meatus. The glossopharyngeal nerve provides sensory innervation to the posterior part of the eardrum.

17. A staphylococcal infection that spreads from a region of abscess of a mandibular tooth into the soft tissues of the floor of the mouth and neck can result in suffocation, if antibiotic therapy is not instituted promptly. This clinical problem is referred to as ...

Ranula

Torus mandibularis

Submaxillary cellulitis (Ludwig's angina)

Quinsy

Ankyloglossia

Ludwig's angina is a serious, potentially life-threatening cellulitis, or connective tissue infection, of the floor of the mouth, usually occurring in adults with concomitant dental infections and if left untreated, may obstruct the airways, necessitating tracheotomy.

Explanation

Ludwig's angina is a serious, potentially life-threatening cellulitis, or connective tissue infection, of the floor of the mouth, usually occurring in adults with concomitant dental infections and if left untreated, may obstruct the airways, necessitating tracheotomy.

18. The 72 YO woman had a lesion in the middle of her right vocal cord which biopsy revealed to be carcinoma. Further treatment would be dictated by the position of the tumor and by the location of the lymph nodes draining the area. The lymph nodes which receive lymph directly from this part of the vocal cord are the ...

Juguloomohyoid node

Sentinal node

Submental nodes

Jugulodigastric node

None of the above is a correct response

The glottis or true vocal cords are not rich in lymphatics and drain to pretracheal or paralaryngeal lymph nodes.

Explanation

The glottis or true vocal cords are not rich in lymphatics and drain to pretracheal or paralaryngeal lymph nodes.

19. The patient had suffered a hemisection of the lower part of the cervical portion of the spinal cord (approximately C6, 7, 8). As a result, one would expect to see ...

Complete ptosis of the ipsilateral superior palpebra

Decrease in sweating on the ipsilateral side of the face

Paralysis of the ipsilateral hemidiaphragm

Loss of the contralateral abdominal reflex

A Babinski sign in the contralateral foot

decreased sympathetic innervation would lead to decreased sweating.
not complete ptosis due to innervation by CN III opens the eye. (VII closes it)
C345 keeps the diaphram alive.

Explanation

decreased sympathetic innervation would lead to decreased sweating.
not complete ptosis due to innervation by CN III opens the eye. (VII closes it)
C345 keeps the diaphram alive.

20. The left side of the face of the 60 YO fruit salesman in the clinic appears to be strangely smooth, with absence of the nasolabial furrow and less wrinkling of the skin of his forehead than on the contralateral side. The corner of his mouth on the left side droops noticeably. He complains that he had to stuff a little piece of cloth into his left ear because sounds heard with that ear seemed so loud (hyperacusis). Physical examination reveals absence of the sense of taste on the left side of his tongue anteriorly. Function of his lacrimal gland on that side seems to be normal. With these facts in mind, you can conclude that the lesion of the involved nerve is probably located ...

In the petrous part of the temporal bone, proximal to the location of the geniculate ganglioin

At the stylomastoid foramen

In the internal acoustic (auditory) meatus

In the petrous part of the temporal bone, distal to the origin of the greater petrosal nerve

Within the parotid gland

geniculate=taste (mneumonic--cant taste genitals unless they're in your face....face=VII)
great petrosal N = tears (mneumonic--A great proposal makes a woman cry)

The parasympathetic supply of lacrimal G. originates from the lacrimal nucleus of VII in the pons. Just distal to the geniculate ganglion, the facial nerve gives off the greater petrosal nerve. This nerve carries the parasympathetic secretomotor fibers through the pterygoid canal, where it joins the deep petrosal nerve (containing postganglionic sympathetic fibers from the superior cervical ganglion) to form the nerve of the pterygoid canal (vidian nerve). This nerve travels through the pterygoid canal to the pterygopalatine ganglion. Here the fibers synapse and postganglionic fibers join the fibers of the Maxillary Nerve, which travels through the inferior orbital fissure. Once it has traversed this opening, the parasympathetic secretomotor fibers branch off with the zygomatic nerve and then branch off again, joining with the lacrimal branch of the ophthalmic division of CN V, which supplies sensory innervation to the lacrimal gland along with the eyelid and conjunctiva.

Explanation

geniculate=taste (mneumonic--cant taste genitals unless they're in your face....face=VII)
great petrosal N = tears (mneumonic--A great proposal makes a woman cry)

The parasympathetic supply of lacrimal G. originates from the lacrimal nucleus of VII in the pons. Just distal to the geniculate ganglion, the facial nerve gives off the greater petrosal nerve. This nerve carries the parasympathetic secretomotor fibers through the pterygoid canal, where it joins the deep petrosal nerve (containing postganglionic sympathetic fibers from the superior cervical ganglion) to form the nerve of the pterygoid canal (vidian nerve). This nerve travels through the pterygoid canal to the pterygopalatine ganglion. Here the fibers synapse and postganglionic fibers join the fibers of the Maxillary Nerve, which travels through the inferior orbital fissure. Once it has traversed this opening, the parasympathetic secretomotor fibers branch off with the zygomatic nerve and then branch off again, joining with the lacrimal branch of the ophthalmic division of CN V, which supplies sensory innervation to the lacrimal gland along with the eyelid and conjunctiva.

21. He had sustained a sharp blow to his right eye from the soccer ball, kicked with great force by the man facing him, and fell to the ground in pain. At the hospital, the eye was gently checked for injury and the ability to move it. The eye was adducted; the pupil could be turned slightly upward or downward slightly from that position, but he could not abduct the eye. It could therefore be rightly assumed that ...

The trochlea had been torn from its attachment to the upper medial orbital wall.

The lower division of the oculomotor nerve had been injured.

The force had fractured the lamina papyracea, with entrapment of the medial rectus.

The abducens nerve had been severed (cut) at the superior orbital fissure

Based on the given information, the person sustained a sharp blow to his right eye and was unable to abduct the eye. This suggests that there is a problem with the movement of the eye, specifically the inability to move it away from the midline. The option that best explains this is that the force had fractured the lamina papyracea, which is a thin bone in the orbit, and as a result, the medial rectus muscle (which is responsible for adduction) has become trapped or entrapped. This explains the inability to abduct the eye and is the most likely scenario based on the given symptoms.

Explanation

Based on the given information, the person sustained a sharp blow to his right eye and was unable to abduct the eye. This suggests that there is a problem with the movement of the eye, specifically the inability to move it away from the midline. The option that best explains this is that the force had fractured the lamina papyracea, which is a thin bone in the orbit, and as a result, the medial rectus muscle (which is responsible for adduction) has become trapped or entrapped. This explains the inability to abduct the eye and is the most likely scenario based on the given symptoms.