QUESTION: 13

A 62-year-old patient diagnosed with prostate carcinoma complains of a right-sided headache worsening over 4 days and displays a drooping right upper eyelid. Examination reveals a right third nerve palsy. An MRI reveals a single metastasis of the prostatic carcinoma in the right side of the midbrain, causing Benedikt's syndrome. Which of the following signs would also be seen in this patient?

complete paralysis of facial expression musculature on the left side
deviation of the tongue to the right
intention tremor in the left upper and lower extremity
ipsilateral hemiplegia
vertical gaze palsy

Answer(s): C

Explanation:

Benedikt's syndrome results from a lesion situated in the tegmentum of the midbrain, at the level of the third cranial nerve (oculomotor) nucleus and its associated tracts, as exemplified by ptosis and third nerve palsy in this patient. The red nucleus is also affected at this level giving rise to motor impairment displayed by the intention tremor. Since the rubrospinal tract crosses at the level of the midbrain to project to the opposite side of the body, the tremor will manifest itself contralateral to the side to the lesion. The seventh cranial nerve (facial) nucleus is located in the pons, and the facial musculature (choice A) in this patient would not be affected. Likewise, the twelfth cranial nerve (hypoglossal) nucleus is located in the medulla, and the innervation of the tongue (choice B) would be spared in this patient. A lesion causing a pure Benedikt's syndrome would be confined to the midbrain tegmentum and not affect the corticospinal tract.
Ipsilateral hemiplegia (choice D) would not be present in this patient. Finally, vertical gaze palsy (choice E) results from a lesion or compression of the midbrain tectum and not of the tegmentum.

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QUESTION: 14

During a routine physical examination, you notice that your patient, a 35-year-old avid surfer, has spots of abnormal pigmentation on two of her fingers. You explain to your patient that long-term exposure to the sun increases the risk of neoplastic changes and that you would like to perform biopsies to verify the nature of the abnormal pigmentation. Referring to following figure, cells from which layer of the epidermis are most vulnerable to neoplastic changes due to long-term exposure to the sun?

Answer(s): D

Explanation:

Long-term exposure to the sun increases the risk of alteration of the DNA structure by cleavage, ionizing radiation, or recombination of DNA with highly reactive free radicals. These changes can result in neoplastic changes or death in skin cells. In the skin, mitosis occurs only in the malpighian layer formed by the stratum basale and the stratum spinosum of the epidermis. The DNA of dividing cells is more vulnerable to the harmful effects of the sun, and neoplastic changes are usually observed in the Malpighian layer. They are not seen in the stratum corneum (choice A), stratum lucidum (choice B), or stratum granulosum (choice C). Choice E represents the dermis located below the epidermis, which is the only skin layer considered in this question.

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QUESTION: 15

A female 44-year-old patient suffers from acute bacterial sinusitis localized to the frontal sinus. The patient displays a mucopurulent greenish discharge from the nose bilaterally, with associated fever and malaise. The patient also complains of pain over the forehead with headache.
Which of the following innervates the frontal sinus?

anterior ethmoidal nerve
lacrimal nerve
nasociliary nerve
posterior ethmoidal nerve
supraorbital nerve

Answer(s): E

Explanation:

The frontal sinus is innervated by the supraorbital and supratrochlear branches of the frontal nerve. All nerves mentioned in this question are branches of ophthalmic division (V1) of the trigeminal (fifth cranial) nerve. The anterior (choice A) and the posterior (choice D) ethmoidal nerves arise from the nasociliary nerve (choice C). They innervate the ethmoid and sphenopalatine sinuses. The lacrimal nerve (choice B) carries in its terminal segment the parasympathetic innervations to the lacrimal gland and provides sensory innervation to the upper eyelid.

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QUESTION: 16

In a medial medullary syndrome that involves a left-sided branch of the anterior spinal artery, which of the following deficits is seen?

deviation of the tongue to the left, hemiplegia of arm and leg on the left
deviation of the tongue to the right, hemiplegia of arm and leg on the right
loss of conscious proprioception and precise tactile discrimination over the right side of the body exclusive of the face
only deviation of the tongue to the left
only hemiplegia on the right

Answer(s): C

Explanation:

A vascular lesion affecting the left caudal medulla involves the left medial lemniscus, left hypoglossal nerve fibers, and the left medullary pyramid. Involvement of the left medial lemniscus produces somatosensory deficits involving the right side of the body. Damage to the left hypoglossal nerve would result in deviation of the protruded tongue to the left (and other lower motoneuron signs), and damage to the left pyramid results in right hemiplegia (choices A and B involve incorrect combinations) along with other upper motoneuron signs. Choices D and E are incorrect because they fail to combine involvement of the tongue and contralateral hemiplegia.

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