Question 1
A 26 year old male with a recent history of a respiratory tract infection presents with pain behind the left ear and increased sensitivity to loud noises. He has also noticed that his forehead and left face appear to be drooping, and that there is saliva drooling out from the left side of the patients mouth. No rash or vesicles are noted. With regards to the most likely diagnosis, which of the following is a poor prognostic factor?
(A) Hyperacuisis
(B) Age younger than 40
(C) Symptom acuity
(D) Hypotension
(E) Left sided presentation
A: Hyperacuisis occurs because of the role of the facial nerve in innervating the stapedius muscle. Poor prognostic factors include older age, hypertension, impairment of taste, pain other than in the ear, and complete facial weakness. Ramsey hunt syndrome is herpes oticus caused by varicella zoster virus. Lesions proximal to the geniculate ganglion can cause loss of taste sensation to the anterior two thirds of the tongue. They are also unable to produce tears because of facial parasympathetic innervation to the lacrimal glands. 71% of untreated patients recover completely and 84% achieve near normal facial function. Initiating glucocorticoids within 7 days of symptom onset improves the chance of symptom recovery by 17% when compared to placebo. HSV-1 is probably the cause of most cases of idiopathic bell's palsy. Acyclovir added to placebo also has some evidence in one randomised control trial - summarised in N Engl J Med 2004; 351:1323-1331
Question 2
A 42 year old male who is on warfarin for atrial fibrillation develops sudden onset pain, numbness and tingling on his right anterior thigh which extends to her medial leg. She has decreased hip flexion and knee extension, with reduced knee jerk reflexes. Which structure is involved?
(A) obturator nerve
(B) nerve of the piriformis
(C) left femoral nerve
(D) left common perineal nerve
(E) L3 radiculopathy
C: Can be caused by retroperitoneal haematoma. Anterior thigh sensation occurs through the anterior femoral cutaneous nerve and the medial distal leg sensation occurs through the saphenous nerve. Muscle Nerve. 1993;16(9):891
Question 3
A 67 year old male wearing tight jeans, who is overweight and has diabetes presents with burning sensation and paraesthesias over the lateral portion of his right thigh. This sensation radiates to the knee. At which level does compression of the lateral femoral cutaneous nerve of the thigh occur to give the syndrome of meralgia paraesthesia?
(A) inguinal ligament
(B) crossing of the iliac artery over the lateral femoral cutaneous nerve
(C) obturator canal
(D) popliteal fossa
(E) femoral ligament
A: inguinal ligament, very common entrapment neuropathy. Managed with conservative measures
Question 4 - 8
(A) femoral nerve
(B) common peroneal nerve
(C) posterior tibial nerve
(D) sciatic nerve
(E) L5 radiculopathy
(F) obturator nerve
Question 4
Weakness in hip adduction and sensory loss in the medial aspect of the thigh
F: can be the sole presentation of pelvic cancer, especially transitional bladder cancer
Question 5
Patient wearing a cast following a fibular fracture, as cast is removed there is a foot drop with weakness of foot eversion. Foot inversion is spared. There is sensory disturbance to the webbed space of digits 1 and 2, as well as the lateral surface of the shin.
B: Common compression neuropathy as the common peroneal nerve wraps around the neck of the fibula just below the knee. Unlike an L5 radiculopathy, inversion is spared (posterior tibial muscle innervated by the posterior tibial nerve)
Question 6
Patient has back pain radiating down the legs, presents with foot drop, weakness in inversion, eversion and dorsiflexion.
E: The most common lumbosacral radiculopathy.
A 26 year old male with a recent history of a respiratory tract infection presents with pain behind the left ear and increased sensitivity to loud noises. He has also noticed that his forehead and left face appear to be drooping, and that there is saliva drooling out from the left side of the patients mouth. No rash or vesicles are noted. With regards to the most likely diagnosis, which of the following is a poor prognostic factor?
(A) Hyperacuisis
(B) Age younger than 40
(C) Symptom acuity
(D) Hypotension
(E) Left sided presentation
A: Hyperacuisis occurs because of the role of the facial nerve in innervating the stapedius muscle. Poor prognostic factors include older age, hypertension, impairment of taste, pain other than in the ear, and complete facial weakness. Ramsey hunt syndrome is herpes oticus caused by varicella zoster virus. Lesions proximal to the geniculate ganglion can cause loss of taste sensation to the anterior two thirds of the tongue. They are also unable to produce tears because of facial parasympathetic innervation to the lacrimal glands. 71% of untreated patients recover completely and 84% achieve near normal facial function. Initiating glucocorticoids within 7 days of symptom onset improves the chance of symptom recovery by 17% when compared to placebo. HSV-1 is probably the cause of most cases of idiopathic bell's palsy. Acyclovir added to placebo also has some evidence in one randomised control trial - summarised in N Engl J Med 2004; 351:1323-1331
Question 2
A 42 year old male who is on warfarin for atrial fibrillation develops sudden onset pain, numbness and tingling on his right anterior thigh which extends to her medial leg. She has decreased hip flexion and knee extension, with reduced knee jerk reflexes. Which structure is involved?
(A) obturator nerve
(B) nerve of the piriformis
(C) left femoral nerve
(D) left common perineal nerve
(E) L3 radiculopathy
C: Can be caused by retroperitoneal haematoma. Anterior thigh sensation occurs through the anterior femoral cutaneous nerve and the medial distal leg sensation occurs through the saphenous nerve. Muscle Nerve. 1993;16(9):891
Question 3
A 67 year old male wearing tight jeans, who is overweight and has diabetes presents with burning sensation and paraesthesias over the lateral portion of his right thigh. This sensation radiates to the knee. At which level does compression of the lateral femoral cutaneous nerve of the thigh occur to give the syndrome of meralgia paraesthesia?
(A) inguinal ligament
(B) crossing of the iliac artery over the lateral femoral cutaneous nerve
(C) obturator canal
(D) popliteal fossa
(E) femoral ligament
A: inguinal ligament, very common entrapment neuropathy. Managed with conservative measures
Question 4 - 8
(A) femoral nerve
(B) common peroneal nerve
(C) posterior tibial nerve
(D) sciatic nerve
(E) L5 radiculopathy
(F) obturator nerve
Question 4
Weakness in hip adduction and sensory loss in the medial aspect of the thigh
F: can be the sole presentation of pelvic cancer, especially transitional bladder cancer
Question 5
Patient wearing a cast following a fibular fracture, as cast is removed there is a foot drop with weakness of foot eversion. Foot inversion is spared. There is sensory disturbance to the webbed space of digits 1 and 2, as well as the lateral surface of the shin.
B: Common compression neuropathy as the common peroneal nerve wraps around the neck of the fibula just below the knee. Unlike an L5 radiculopathy, inversion is spared (posterior tibial muscle innervated by the posterior tibial nerve)
Question 6
Patient has back pain radiating down the legs, presents with foot drop, weakness in inversion, eversion and dorsiflexion.
E: The most common lumbosacral radiculopathy.