A patient displays the following constellation of symptoms ...



NAME __________________________________

BRAIN & BEHAVIOR I

SECOND Exam

May 14, 2001

For the following questions, indicate the letter that corresponds to the SINGLE MOST APPROPRIATE ANSWER.

1. Corticospinal fibers could be injured in a tumor involving the

A. tissue normally supplied by the posterior inferior cerebellar artery.

B. tegmentum of the rostral midbrain.

C. anterior limb of the internal capsule.

* D. base of the medulla.

E. dorsal columns of the spinal cord.

2. Hyperkinetic movement disorders associated with lesions of the basal

ganglia include all of the following EXCEPT

A. chorea.

B. athetosis.

C. tics.

D. dystonia.

* E. bradykinesia.

3. Which one of the following motor skills would normally be seen in a 24-month-old girl?

A. Alternates feet when going up steps

B. Hops

C. Copies a circle

D. Catches a ball

* E. Turns pages, one at a time

4. Separation anxiety

A. normally develops at age two.

B. resolves when children enter kindergarten.

* C. is pathological when a child refuses to go to school.

D. does not occur in children who have been in day care.

E. occurs more often in boys than girls.

5. The lesion at “A” most likely resulted from an occlusion of the

A. basilar artery.

* B. superior cerebellar artery.

C. anterior inferior cerebellar artery.

D. vertebral artery.

E. posterior inferior cerebellar artery.

6. A mentally handicapped child has had medically uncontrollable seizures

since birth. It may be possible to surgically remove the cortical seizure

focus and achieve seizure control. Which type of neuroimaging technique,

performed during a seizure, might delineate the area where the seizures

begin?

A. CT scan

B. MRI scan

C. MR angiograph

* D. PET scan

E. Plain skull radiograph

7. At age five

A. cognitive development features the emergence of formal perational thinking.

B. imaginary friends are signs of separation anxiety.

* C. symbolic play increases.

D. the Eriksonian stage of trust vs. mistrust is initiated.

E. the pincer grasp is achieved by 75% of children.

The following figure shows the circuitry of the DIRECT and INDIRECT

pathways of the motor (skeletomotor) loop through the basal ganglia. The

projections of the pathways are labeled with a number.

8. Which inhibitory pathway would show INCREASED activity as a result of a striatal lesion and lead to hyperkinesia characteristic of Huntington’s disease?

A. 1

B. 2

C. 3

D. 4

* E. 5

9. Brainstem Auditory Evoked Response (BAER) / Brainstem Auditory Response

Test (ABR) would not be a useful diagnostic test to determine whether a patient’s

hearing difficulty is the result of

A. presbycusis.

B. Meniere’s disease.

* C. otosclerosis.

D. an acoustic schwannoma.

E. exposure to aminoglycoside antibiotics.

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10. As shown in the graph above, the uptake of L-dopa across the blood-brain barrier (BBB) is different than predicted from its lipid solubility. This can BEST be explained by the fact that L-dopa

A. does not bind to plasma proteins.

B. is capable of diffusion across the BBB.

C. has a molecular charge distribution that increases its lipophilicity.

* D. is transported by a specific carrier protein.

E. lacks steric hindrance.

Question #11 and 12:

A 48-year-old right-handed woman complains of headaches and weakness of her

right upper extremity and drooping of the right side of her face. On examination

she is alert, with moderate weakness of the right lower facial muscles. She also

has sensory loss of the right face and right upper extremity and loss of vision in

the right visual field of both eyes.

11. The signs and symptoms contained in the history are MOST LIKELY the manifestations of disease at which of the following levels of the nervous system?

* A. Supratentorial

B. Posterior fossa

C. Spinal canal and/or vertebral column

D. Peripheral neuromuscular system

E. More than one level

12. Within the level you have selected, the responsible lesion is MOST

LIKELY

A. focal - on the right side of the nervous system.

* B. focal - on the left side of the nervous system.

C. focal - but involving midline structures and/or both sides of the nervous system.

D. non-focal and diffusely located.

E. diffuse - on the right side of the nervous system.

13. An unstable trauma patient in the emergency department has abdominal

bleeding with a severe headache and lethargy. Which of the following is

the most appropriate neuroimaging technique to use on this patient?

* A. CT scan

B. MRI scan

C. MR angiograph

D. PET scan

E. Plain skull radiograph

14. At age eight

* A. reading skills exceed writing ability.

B. attention deficit disorder occurs in 10 percent of children.

C. play with the opposite sex commonly occurs.

D. formal cognitive operations are developed.

E. the Eriksonian stage is characterized by generativity versus stagnation.

Question # 15 and 16:

A 59-year-old right-handed woman complains of difficulty getting in and out of a

chair. Over the last year, she has also noted some difficulty with handwriting.

She complains that she has difficulty writing a full sentence because the words

tend to get smaller. On examination, she has increased tone in her right

upper extremity as well as a tremor that is most prominent when her hands are

resting on her lap.

15. A deficit in which of the following areas is MOST LIKELY the source of this patient's signs and symptoms?

A. Motor cortex

B. Posterior limb of the internal capsule

* C. Substantia nigra

D. Lateral hemispheres of the cerebellum

E. Red nuclei

16. What is the blood supply of the main structure damaged?

A. Middle cerebral artery

B. Basilar artery

C. Anterior choroidal artery

* D. Posterior cerebral artery

E. Anterior cerebral artery

17. A 12 month-old boy is brought to the pediatrician because of concern about possible developmental delay. The pediatrician observes that the boy drinks from a cup and builds a tower of only two cubes. The boy stands but needs to hold onto furniture. He takes a couple of steps, but cannot walk well. He calls for his "mama" and "dada" but otherwise jabbers. The most appropriate assessment is

A. normal motor development, but delayed speech development.

B. delayed motor development, but normal speech development.

* C. normal motor and language development.

D. delayed personal and gross motor development.

E. delayed personal and speech development.

18. A boy's development by age nine is most likely to be characterized by

A. the ability to understand abstract ideas.

B. the presence of a growth spurt

C. developmental regression.

D. a lack of sexual exploration.

* E. an ability to grasp game rules.

19. An occlusion of the anterior choroidal artery at its origin could result in all the

following neurologic signs or symptoms EXCEPT

A. visual deficits.

B. movement disorders.

C. difficulty localizing sound.

D. hemianesthesia.

* E. a loss of pain perception.

The following diagram represents the synaptic circuitry in the superior olivary

nucleus.

20. The letter of the neuron that would be most sensitive to a sound source located

45 degrees to the right of the listener is

A.

* B.

C.

D.

E.

21. The initial sign of puberty in males is

A. nocturnal emissions.

B. pubic hair.

C. roughening of scrotum.

* D. enlargement of testicles.

E. facial hair.

22. During adolescence

* A. the leading cause of death is accidents.

B. psychiatric disorders are common.

C. cognitive development is characterized by tertiary circular reactions.

D. the Eriksonian stage is characterized by autonomy versus doubt.

E. boys typically mature earlier than girls.

23. A stroke involving the genu of the left internal capsule

would MOST LIKELY have long-term effects on

A. the jaw jerk reflex.

B. chewing food.

C. running.

* D. smiling symmetrically.

E. turning the head while walking to see the person behind.

24. The middle ear

* A. increases the pressure exerted on the oval window.

B. increases the total force of the sound wave at the stapes.

C. reduces the acoustic impedance of the cochlear perilymph.

D. is filled with endolymph containing high levels of K+.

E. plays no role in protection against acoustic trauma.

25. Attributing one's own unacknowledged impulses to others is described as

A. isolation.

* B. projection.

C. rationalization.

D. acting-out.

E. regression.

26. A 65-year-old man with a history of chronic alcoholism has an ataxic gait and

difficulty with the “heel-to-shin” test. He most likely is suffering from

A. flocculonodular lobe syndrome.

B. dysdiadokokinesia.

* C. anterior lobe syndrome.

D. dystonia.

E. posterior lobe syndrome.

27. Returning to earlier levels of adaptation is described as

A. isolation.

B. projection.

C. rationalization.

D. acting-out.

* E. regression.

A section through the CNS of a patient with a tumor (labeled “T”) is shown below.

28. As a result of this tumor, this patient would probably have symptoms that include

all the following EXCEPT

A. contralateral spastic paralysis.

B. diplopia.

C. impaired ability to localize sound.

* D. ipsilateral hemianesthesia.

E. ipsilateral facial paralysis.

29. A 70-year-old retired gross anatomy professor had a stroke that involved

the vascular territory supplied by the left lenticulostriate arteries. As the

attending physician you need to explain to the family the possible long term

symptoms. These include all the following EXCEPT

A. chorea of the right upper extremity.

B. decreased vibratory sensation of the right hand.

C. spastic paralysis of the right lower limb.

* D. right hemiballism.

E. a right Babinski sign.

30. During performance of a knee jerk reflex, you would normally expect, within milliseconds after tapping the tendon of the quadriceps femoris muscle, an

INCREASE in all of the following EXCEPT

A. opening of ion channels in afferent fibers from dynamic bag fibers in the

quadriceps muscle.

B. the firing rate of Ia afferent fibers from the quadriceps femoris muscle.

C. the firing rate of alpha motor neurons to the quadriceps femoris muscle.

* D. alpha-gamma coactivation.

E. the length of intrafusal fibers in the quadriceps femoris muscle.

31. A 64-year-old engineer work up one morning feeling “funny,” but decided to go to

work. While driving to her office, she got lost. This had never happened in the

23 years at that office, but she rationalized that she was very distracted over a

new project at work. Three days later, she could not find her way home from a

shopping mall. This woman might have had a stroke located in the

A. cerebrocerebellum.

B. head of the caudate nucleus.

C. premotor and/or supplementary motor area

* D. posterior parietal cortex.

E. paracentral lobule.

32. A 19-year-old college student made a surprise visit to his home in Mother’s Day

with a bouquet of flowers (in addition to a bag of laundry). As he entered the

house, his mother recognized him instantly as the result of increased activity in

A. Broca’s area of the brain.

B. Wernicke’s area of the brain.

* C. the inferior temporal cortex.

D. the primary somatosensory cortex.

E. the superior parietal lobule.

Questions #33 and 34:

A section through the CNS of a patient with an area of infarct (labeled “X”)

resulting from a stroke is shown below.

Left

Right

33. This patient would probably have clinical signs and/or symptoms that include all

the following EXCEPT

A. a loss of pain and temperature sensation on the right side of the

body.

B. paralysis of the muscles of facial expression on the left side of the

face.

C. dysmetria.

D. limb and gait ataxia on the left side of the body.

* E. spastic paralysis on the right side of the body.

34. The area of infarct was most likely due to an occlusion of

* A. the anterior inferior cerebellar artery.

B. the superior cerebellar artery.

C. paramedian branches of the basilar artery.

D. posterior inferior cerebellar artery.

E. long circumferential branches of the posterior cerebral artery.

QUESTIONS #35 and #36.

35. A 57-year-old man had a stroke that affected the area marked by hatching in the

drawing above. The MOST SEVERE long-term (enduring) effects of this stroke

would probably be difficulty in

A. walking to the bus.

B. holding his grandson on his lap.

* C. playing the piano.

D. putting his elbows on the table while he ate.

E. getting out of bed in the morning.

36. The patient with the lesion shown above was examined six months after his

stroke. At that time, he probably had

A. a Babinski sign on the left side.

B. hypotonia of the muscles of mastication on the right side.

C. fasciculations of the left deltoid muscle.

D. atrophy of the muscles of the right lower limb.

* E. hyperreflexia of the muscles of the left upper limb.

37. A good way to gather information about a possible sacral spinal cord tumor

would include clinical testing of

* A. the ankle jerk reflex.

B. the knee jerk reflex.

C. abdominal reflex.

D. the cremaster reflex.

E. strength of flexion of the thigh at the hip.

38. A 19-year-old man was stabbed in the back during an argument in a bar. The wound caused an injury to the area marked by hatching below. Six months after the injury, this patient probably has

A. hypotonia of the right hamstring (posterior thigh) muscles.

B. spasticity (hypertonia) of the left hamstring (posterior thigh) muscles.

* C. a Babinski sign on the right.

D. a loss of the cremaster reflex on the left.

E. an inability to recognize a key in his left pocket.

39. Which of the following clinical tests mainly involves stimulation of static receptors

in muscle spindle organs of the biceps brachii muscle of the upper limb?

A. The joint jerk (stretch) test

B. The Romberg test

* C. Testing muscle tone

D. Observation of arm swing during walking

E. Withdrawal from pain as the result of nail-bed mashing

40. A 59-year-old woman visited her physician with complaints that she was having

difficulties that have increased over the past year in “seeing and doing things with

her hands.” On examination, she had numerous clinical signs, including:

hyperreflexia, hypertonia, and weakness of many muscles of the right upper limb,

especially those of the hand; a left eyeball that was deviated laterally and

inferiorly at rest; a droopy left eyelid; and a decreased pupillary light reflex on the

right side after shining a light into either the right or left eyeball. There were no

sensory signs. Of the following, the MOST LIKELY cause of these findings is

A. a stroke involving branches of the posterior cerebral artery.

B. an anterior spinal artery syndrome.

* C. a tumor in the base of the left side of the rostral midbrain.

D. multiple sclerosis lesions in the subcortical white matter of the left cerebral

hemisphere.

E. multiple sclerosis lesions in the subcortical white matter of the right

cerebral hemisphere.

41. A 27-year-old builder fell two stories while working on a roof. He was comatose

upon arrival at the entrance to an Emergency Department. During a clinical

exam of this patient, a second year medical student provided severely painful

stimuli to his nail beds. The response of the patient was flexion of the upper

limbs and extension of the lower limbs. This finding was probably caused by a

lesion at the level of the

* A. cerebral cortex.

B. midbrain.

C. pons.

D. medulla.

E. spinal cord.

42. A general principle to keep in mind during the neurologic exam is that if the

patient has dizziness, dysarthria, diplopia and dysmetria they most likely have a

A. mononeuropathy.

B. lesion in the spinal cord.

C. hemispheric lesion.

D. lesion involving the basal ganglia.

* E. brainstem lesion.

43. A 21-year-old woman had a complete transection of the upper thoracic spinal

cord as the result of a motorcycle accident. One year after the injury, she had

clinical signs and symptoms that included all of the following EXCEPT

A. bilateral Babinski signs.

B. hypertonia of the lower limb muscles.

* C. fasciculations of the lower limbs.

D. paraplegia.

E. increased responses of the knee jerk reflexes.

44. On clinical testing of a comatose accident victim seen in the Emergency

Department, a physician noticed that on stimulation of either the left or right

cornea with a Q tip, there was a brisk left corneal reflex but a sluggish right

corneal reflex. These findings suggest a lesion in

A. the tegmentum of the rostral midbrain.

B. the base of the pons.

C. fibers of the left trigeminal nerve.

D. fibers of the right trigeminal nerve.

* E. fibers of the right facial nerve.

45. Choose the visual field defect that usually results from an aneurysm of the right

internal carotid artery.

*

46. A 43-year-old woman who developed numerous “difficulties in doing things” over

a two-year period visited her physician. An MR scan revealed a tumor of the left

pyramid of the medulla. The clinical symptoms and signs in this patient would

probably include

A. a decrease in magnitude of abdominal reflex responses on the right side.

B. an increase in the jaw jerk reflex response on the left side.

C. asymmetric movement of the lips on attempts to smile.

* D. clumsiness of the right hand while attempting to hold a pen.

E. a fine tremor of the right hand while writing.

47. During examination of a comatose patient in the Emergency Department, you

were concerned about a possible compression of the midbrain by a herniation of

the temporal lobes (uncal herniation) through the tentorial notch into the posterior

cranial fossa. A good and quick way to test for intact processing in the midbrain

would be to test for

A. jaw jerk reflex on both sides.

B. ability of the patient to sit up.

C. the vestibuloocular reflex.

D. awareness of pain and temperature sensation of the upper limbs.

* E. the pupillary light reflexes on both sides.

48. A 65-year-old airport engineer complains to his physician of difficulty hearing his

wife when she talks to him. The Rinne and Weber tests were performed with the

following results: bone and air transmission of sound were reduced on the left;

sound lateralized to the right ear. These results indicate

A. a temporal lobe lesion.

* B. a lesion involving cranial nerve VIII or the cochlea.

C. a conduction deficit.

D. normal findings.

E. a lesion of the left lateral lemniscus.

49. Near the apex of the cochlea

A. the basilar membrane is more sensitive to high-frequency sound.

B. hair cells are continuously depolarized by sounds of a certain frequency.

* C. the hair cell voltage oscillates in response to low-frequency sound.

D. the shortest hair cell stereocilia are found.

E. the hair cells fire action potentials at the pure tone frequency.

NAME _____________________________________

GROSS ANATOMY EXAMINATION

May 14, 2001

50. During a baseball game, a 23-year-old player received a severe blow to the right

side of his face, fracturing the ramus of his mandible. The doctor knew that this injury could affect structures contained in the infratemporal fossa. These structures could include all of the following EXCEPT the

A. otic ganglion.

B. inferior alveolar nerve.

C. chorda tympani nerve.

* D. buccinator muscle.

E lateral pterygoid muscle.

51. Little Tommy was brought to the pediatrician with a fever and a purulent

discharge (pus) from the right ear. He was started on antibiotics to eradicate the

infection. The doctor knew that an uncontrolled infection can spread from the

middle ear in all of the following directions EXCEPT

A. superiorly INto the middle cranial fossa.

B. posteriorly into the mastoid air cells.

C. inferiorly into the jugular bulb.

* D. anteriorly into the facial canal.

E. medially into the inner ear.

52. A 35-year-old woman went to see her doctor because she was unable to open

her mouth. Her doctor was concerned that she had damaged her temporomandibular joint. All of the following statements regarding this joint are

correct EXCEPT that it

A. allows protraction and retraction.

* B. is an attachment site for the medial pterygoid muscle.

C. contains an articular disc.

D. involves the articular tubercle of the temporal bone.

E. is a hinge joint.

53. The mandibular division of the trigeminal nerve (V3) provides innervation to all of

the following muscles EXCEPT the

A. tensor tympani.

B. mylohyoid.

C. lateral pterygoid.

D. masseter.

* E. posterior belly of the digastric.

54 While treating a patient with a fractured ramus of the right mandible, the surgeon

remembered that the muscle that inserts on the medial side of the angle of the

mandible

A. is a muscle of facial expression.

B. is supplied by the masseteric branch of the maxillary artery.

C. depresses the mandible.

* D. passes medial to the lingual nerve.

E. is lateral to the maxillary artery.

55. A cut immediately anterior to the auricle could damage the auriculotemporal

nerve. This nerve

A. carries sensory nerve fibers to the inner surface of the tympanic

membrane.

B. accompanies the posterior auricular artery.

* C. usually encircles the middle meningeal artery.

D. is the motor nerve to the temporalis muscle.

E. carries parasympathetic fibers for innervation of the submandibular gland.

56. During surgery of the middle ear, the surgeon accidentally severed a nerve as it

passed between the malleus and incus. After the surgery, the physician

informed his patient that he likely has lost some

A. sensation in the skin over the ramus of the mandible.

B. secretion of saliva from the parotid gland.

* C. taste sensation from the anterior 2/3 of the tongue.

D. sensation of the inner lining of the tympanic membrane.

E. sensation from the semicircular canals.

57. The plexus of nerves that lies deep to the mucus membrane lining the medial

wall of the middle ear contains fibers from which of the following cranial nerves?

A. Trigeminal

B. Facial

* C. Glossopharyngeal

D. Vagus

E. Accessory

58. The right great auricular nerve was removed for pathological examination in a 54-

year-old man who had symptoms of tertiary syphilis. During removal of the right

great auricular nerve, the ENT surgeon was concerned that the spinal accessory

nerve may have been damaged as it emerged from the posterior border of the

sternomastoid muscle. The surgeon knew that if the nerve was damaged, the

patient would have

A. difficulty in turning the chin to the left side.

B. paralysis of some muscles that extend the head.

C. paralysis of the cricothyroid muscle.

* D. difficulty in abducting the right arm above the horizontal plane.

E. paralysis of some of the infrahyoid muscles.

59. A 60-year-old woman had continuous and disabling hiccups due to spasms of the

left side of the diaphragm. She agreed to undergo surgical compression of the

nerve to this muscle for temporary relief. At the operating table, the surgeon

looked for this nerve

A. in the carotid sheath.

B. adjacent to the thyroid gland.

* C. anterior to the anterior scalene muscle.

D. medial to the thyrocervical trunk.

E. medial to the vertebral artery.

60. The tip of the tongue of a teenage gang member was pierced as part of the

initiation ceremony into the gang. A ring, bought at the local discount store, was

inserted into the hole. After a few days the tongue was sore and swollen. Which

of the following groups of lymph nodes would be the first to enlarge?

A. Lower deep cervical nodes

B. Submandibular nodes

* C. Submental nodes

D. Preauricular nodes

E. Posterior auricular nodes

61. A 20-year-old man had a large, palpable lymph node medial to the

sternocleidomastoid muscle at the level of the hyoid bone. An MRI scan at this

level of the neck would reveal all of the following structures EXCEPT the

A. internal jugular vein.

B. carotid sinus.

* C. posterior belly of the digastric muscle.

D. third cervical vertebra.

62. Normally, pus from an infection associated with of the sternohyoid muscle will

spread

* A. to the upper border of the manubrium.

B. into the posterior triangle of the neck.

C. into the thoracic cavity anterior to the pericardium.

D. into the retropharyngeal space.

E. into the pretracheal space.

63. In a drunken stupor, a man crashed through a glass door and received numerous

superficial cuts over the right masseter and parotid gland. After the cuts healed,

he noticed that there was no feeling in this region. Most likely the glass cut his

A. transverse cervical nerve.

B. lesser occipital nerve.

* C. great auricular nerve.

D. supraclavicular nerves.

E. ventral rami of C1.

64. A 26-year-old man with Hodgkin’s lymphoma had an enlarged lymph node, which

compressed structures in the area of the junction of the left internal jugular vein

and the left subclavian vein. He could possibly present with edema in all of the

following parts of his body EXCEPT the

A. right ankle.

B. left ankle.

* C. right upper limb.

D. left upper limb.

E. left side of the face.

65. At a family picnic, one of the participants choked on a piece of food. All attempts

to dislodge the food and to re-establish an adequate airway were futile. A first-

year medical student rushed in to perform an emergency cricothyrotomy or

tracheotomy. To his horror, blood started spurting out. He knew he must have cut

through the isthmus of the thyroid gland which is usually found anterior to the

A. cricoid cartilage.

B. cricothyroid muscle.

C. thyroid cartilage.

D. first tracheal cartilage.

* E. second tracheal cartilage.

66. Damaging the nerves which pass through the right internal auditory meatus

would result in all of the following EXCEPT for a/an

A. loss of hearing on the right side.

B. diminished ability to “pucker” the lips.

C. impaired balance.

* D. loss of ability to dampen the vibrations of the right tympanic membrane.

E. diminished ability to lower the mandible.

67. In a futuristic setting, a 34-year-old woman arrives at your clinic, complaining that

she may be pregnant. After consulting with the database containing the

genomes of your patient and her husband, you conclude that it is highly likely

that the developing fetus will be born deaf. Since the fetus is only three weeks

old, you use a highly sophisticated technology to introduce a therapeutic

(transgenic) gene into cells of the otic vesicle of the fetus. When the fetus is

born, the transgenic gene hopefully will be expressed in cells of the

A. ear ossicles.

B. auditory tube.

C. mastoid air cells.

* D. cochlear duct.

E. external auditory meatus.

68. Which of the following is derived from endoderm?

* A. Mastoid air cells

B. Ear ossicles

C. Bony labyrinth

D. External auditory meatus

E. Vestibulocochlear nerve

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FINAL DRAFT

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Left

T

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LEFT

EAR

RIGHT

EAR

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A.

B.

C.

D.

E.

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