USMLE Step 1 Review Questions Dr. Bennett-Clarke 1) A48-year old woman has loss of pain and temperature sensation in the left upper and lower limbs. Which of the following labeled areas in the medulla is the most likely site of the causal lesion? 2) Accollege student received an injury as a result of being tackled in a football game, After the game, the student was treated at a local hospital and was found to be unable to abduct and rotate the left arm at the shoulder, flex the elbow, and extend the wrist of the left side. Upon further examination, testing revealed depression of the biceps reflex of this limb, but the reflex activity involving the other limbs was normal. The most likely site of the injury is: . Precentral gyrus . Basilar pons . Ventral hom cells at C1 |. Nerve roots of C5-C6 . Trleeps muscle go gee3) A.38 year old woman is referred to a neurologist because she complained of visual loss and muscle weakness. Subsequent examination revealed additional signs: impairment of other sensations, which included tingling and burning sensations; weakness of the lower limbs: paralysis of the upper limbs; progressive impairment of gait; signs of UMN involvement (i.e., spasticity and increased tendon reflexes); and bladder disturbances. No signs of infection were detected as ‘measured by blood analysis, cultures, and chest x-ray. However, elevations in CSF protein were noted as well as abnormal IgG synthesis. Consequently, the heurologist's diagnosis of the patient was that she was suffering from: a. Diffuse cerebellar degeneration b. ALS . Multiple sclerosis MS d. A peripheral neuropathy @. A prefrontal cortical brain tumor Questions 4&5 An individual experiences an ipsilateral paralysis of the soft palate and pharynx, producing hoarseness and dysphagia (inability to swallow) and, in addition, displays a loss of the carotid sinus refiex. 4) The nerve group most likely affected is the: a. Cranial nerve Xil b. Cranial nerve XI ¢. Cranial nerve X d. Cranial nerve Vil e. Ventral hom cells of the cervical cord 5) The most probable nuclei damaged in this case include the: a. Solitary and lateral reticular nuclei b. Deep pontine and facial nuclei c. Dorsal motor nucleus and nucleus ambiguus 4. Ventral hom of the cervical segment of the spinal cord e. Inferior salivatory and medial vestibular nucleiQuestions 6-8 Julie is a 29-year-old office worker with diabetes, who awoke one moming with the inability to close her left eye and a left facial droop. Her left eye felt a bit dry, as well. She had run out of sick days and, hoping that the problem would go away, went fo work, After several coworkers noticed that her face was drooping and that she was especially sensitive to loud noises on her left side, they convinced her to go to the nearest emergency room in order to make sure that she did not have a stroke. She was examined right away in the emergency room because of her age. The doctor noted right away that her mouth drooped on the left side. Her left eye was slightly closed. He tested her speech and mental status, which were normal, other than some slight slurring of her speech. Her vision and eye movements were also Normal. Sensation and jaw movements were also normal, but when she was asked to wiggle her eyebrows, only the right side of her forehead moved. When asked to close her eyes tightly, and not allow him to open her eyes, her right eye would not open, but her left eye could not oppose the force. She was not able to hold air in her cheeks when asked to hold her breath, and when asked to smile, only the right side of her mouth elevated. She was very sensitive to noise on her left side. When asked to protrude her tongue, it did not deviate to either side, but if she closed her eyes and sugar water was placed on the left side of the anterior portion of her tongue, she could not identify it. The remainder of her examination was normal. A nurse asked if a head CT should be ordered in order to look for a stroke or tumor, but the doctor said that it wasn't necessary. He told Julie that he would draw some blood and give her a medication to take for a while. 6) Assuming that the doctor is correct, and that this isn't a stroke, where is the nervous system has the damage occurred? a. Buccinator muscle b. Trigeminal nerve ©. Facial nerve 4d. Glossopharyngeal nerve @. Hypoglossal nerve 7) Julie's facial weakness is characteristic of a. A muscle lesion b. Alesion of the internal capsule c. A superior brainstem lesion d. A UMN seventh-nerve lesion @. ALMN seventh-nerve lesion8} If Julie did not have loss of taste and noise sensitivity, but did have the inability to move her left eye to the left, which area would now be damaged? a. The trigeminal and abducens nerves b. The facial and trigeminal nerves, distal to their point of exit from the brainstem ¢. The facial and abducens nerve nuclei in the pons 4d. The facial nerve distal to the geniculate ganglion €. The facial nerve distal to the chorda tympani 9) Vasopressin is released from the posterior pituitary. However, it is synthesized in ‘the: a. Mammillary bodies b. Lateral hypothalamus ¢. Supraoptic hypothalamic nucleus . Ventromedial hypothalamic nucleus @. Posterior hypothalamus 10) Lesions of the lateral hypothalamus will likely produce: a, Feeding behaviors b. Drinking behaviors ©. Sexual behaviors d. Aphagia @. Hypertension 11) An 18-year-old male high school baseball player gets hit in the head with a fastball in the temporal area. He does not lose consciousness, but afterward develops a slight headache. He is not taken to the emergency room. By evening he develops severe headache with vomiting and confusion. At that time he is take to the emergency room, where, after being examined by a neurosurgeon, he is taken to the operating room for immediate surgery for an epidural hematoma. Which one of the following is most likely present in this individual? Transection of a branch of the middle meningeal artery . Bleeding from torn bridging veins . Rupture of a preexisting berry aneurysm Rupture of an arteriovenous malformation . Cortical bleeding occurring opposite the point of a traumatic injury 2aecm12} A68 year old man goes to a sleep clinic after he has repeated episodes of loud snoring during sleep coupled with sudden periods of restlessness and cessation of breathing. After extensive analysis, the physicians concluded that the patient's problem was not a result of obstructive sleep. Instead, it was judged that this condition reflected central sleep apnea due to loss of chemoreceptor sensitivity of the neuronal control mechanisms governing respiration. The most likely site within the CNS that is most closely associated with these effects is the: a. Dorsal hom of the thoracic spinal cord b. Reticular formation of the medulla ¢. Midbrain periaqueductal gray d. Hippocampal formation e. Border of occipital and parietal lobes 13) A patient presents in her fifth pregnancy with a history of numbness and tingling in her right thumb and index finger during each of her previous four pregnancies. Currently, the same symptoms are constant although generally worse in the early morning. ' Symptoms could be somewhat relieved by vigorous shaking of the wrist. Neurologic examination revealed atrophy and weakness of the abductor pollicis brevis, the opponens pollicis, and the first two lumbrical muscles. Sensation was decreased over the lateral palm and the volar aspect of the first three digits. Numbness and tingling were markedly increased over the first three digits and the lateral palm when the wrist was held in flexion for 30 s. The symptoms suggest damage to: a. The radial artery b. The median nerve ¢, The ulnar nerve 4. Proper digital nerves e. The radial nerve 14) The MRI scan in the figure below reveals a large chromophobe adenoma {T) of the pituitary that impinges on the adjacent brain tissue. This tumor caused a: Binasal hemianopsia 9. Bitemporal hemianopsia Loss of the accommodation reflex Loss of the pupillary light reflex . Loss of conjugate gaze gaecpQuestions 15-17 Herb, a 62 year old man who has smoked two packs of cigarettes per day for 35, years, was suffering from a chronic cough that was attributed to smoking habit by is physician. One day, Herb noticed that his right eyelid drooped slightly and that his right pupil was smaller than the left. He also noticed that the inner side of his right hand was numb and that he had begun to drop things from his right hand. He had No other symptoms. Herb consulted his physician who directed him to a neurologist. The neurologist noted that although the right pupil was smaller than the left, it was stil reactive to light. Although Herb’s right eyelid drooped slightly, he could close his eyes tightly when asked to do so. The neurologist noted that Herb did not sweat on the right side of his face. He was unable to feel a pinprick on the inner surface of his right hand, and his right triceps and hand muscles were weak. 15) Where in the nervous system has damage occurred? a. Left oculomotor nerve b. Right oculomotor nerve ¢. Edinger-Westphal nucleus d. ‘Sympathetic fibers coursing from the hypothalamus to the intermediolateral cell column e. Parasympathetic fibers coursing from the Edinger-Westphal nucleus 16) Herb's small pupil is due to: a. Unopposed action of the muscles with parasympathetic innervation b. Unopposed action of the muscles with sympathetic innervation ¢, Both sympathetic and parasympathetic damage 4. Alesion in the nucleus of the third nerve e. Alesion distal branches of the trochlear nerve 17) Damage to fibers in which area caused numbness and weakness of his hands? a. Ipsilateral cerebral peduncle b. Corticospinal tract ¢. Cervical spinai roots enter in the brachial plexus d. Precentral gyrus 8. Median nerveQuestions 18 & 19 Joe is a 75 year old man who is right-handed and was told in the past by his intemist that he had an irregular heartbeat. Unfortunately, Joe decided that he didn't wish to lear anything further about his condition, so he didn't return to this physician, and it remained untreated. One moming he awoke to find that his face drooped on the right side and that he couldn't move his right arm or right leg. When he tried to call an ambulance for help, he had a great deal of difficulty communicating with the operator because his speech was slurred, nonfluent, and missing some pronouns. The call was traced by the police, and an ambulance arrived at his house and brought him to an emergency room. A neurologist was called to see Joe in the emergency room. When he listened to Joe's heart, he detected an irregular heartbeat. It was very difficult to understand Joe's speech because it was halting, with a tendency to repeat the same phrases over and over. He had a great deal of difficulty repeating specific sentences given to him by the neurologist, but he was able to follow simple commands, such as; "Touch your right ear with your left hand.” His mouth drooped on the right when he attempted to smile, but his forehead remained symmetric when he wrinkled it. He couldn't move his right arm at all, but was able to wiggle his right leg a little bit. 18) What kind of language problem does Joe have? a. Dyarthria b. Wemicke's aphasia ¢. Broca's aphasia d. Alexia e. Pure ward deafness 19) Which area of the brain is most likely damaged? a, Intemal capsule b. Right occipital lobe ©. Corpus callosum d. Left precentral gyrus e. Left postcentral gyrus20) An 8 year old male presents with progressive dysarthria, dysphagia, and weakness of tha left side of his body of 2 months' duration. The child has no history of fever, vaccinations, dog bites, or travel outside the United States, Neurological examination reveals normal cranial nerve function with the exception of atrophy of tight side of the tongue, joint position and vibration sense was reduced on left side, there was an indication of spastic left-sided hemiparesis (face spared), deep tendon reflexes brisk on left side, extensor plantar response noted on left side and no cerebellar signs were present. Which of the following labeled areas in the medulla is the most likely site of the causal lesion? Questions 21.25 Mike is a 35 year old man who had optic neuritis (an inflammation of the optic nerve causing blurred vision) several years before. One day, he noticed that he had double vision and felt weak on his right side. Although he noted that the symptoms were becoming steadily worse throughout the day, he attributed this to stress. While driving from work, his vision became steadily worse. As he was about to pull over to the side of the road, he suddenly realized that he was unable to lift his right leg, and his car collided with the tree. A pedestrian on the side of the road called the EMS, and Mike was brought to a nearby emergency room. A neurologist was called to see Mike because the emergency room physicians thought he may have had a stroke, despite his young age. The neurologist found that Mike's left eye was deviated to the left and down. When he attempted to look to his right, his right eye moved normally, but his left eye was unable to move further to the right than the midline. His left pupil was dilated and did not contract to light from a penlight. His left eyelid drooped, and he had difficulty raising it. In addition, the right side of his mouth remained motionless when he attempted to smile and his right arm and leg were markedly weak. The neurologist admitted him to the hospital for observation and tests.21) Alesion in which nerve caused Mike's double vision? a) Optic nerve b) Oculomotor nerve ¢) Cervical sympathetic fibers d) Trochlear nerve e) Abducens nerve 22) Loss of function which eye muscles caused Mike's eye to be deviated toward the left side and down? a) Superior rectus, superior oblique, inferior rectus, inferior oblique b) Superior rectus, inferior rectus, inferior oblique, lateral rectus ) Superior rectus, inferior rectus, inferior oblique, medial rectus 4d) Lateral rectus, superior oblique, medial rectus, inferior rectus e) Lateral rectus, superior oblique, inferior oblique, medial rectus 23) Where in the nervous system did the damage occur? a) Left frontal lobe b) Right frontal lobe c) Left eye 4) Cervical spinal cord ) Midbrain 24) Damage to which fibers caused the enlarged, unreactive pupil on the left? a) Medial longitudinal fasciculus b) Frontal or pontine eye fields ¢) Edinger-Westphal nucleus or preganglionic parasympathetic fibers d) Trochlear nerve e) Cervical sympathetic fibers 25) Damage to which area caused Mike's weakness? a) Left precentral gyrus b) Right precentral gyrus c) Left cervical spinal cord 4d) Right cervical spinal cord @) Left cerebral peduncle