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M208 MSK+CNS summative (12 Nov 2010)

OBA

1) Which muscle is attached to medial meniscus of the knee joint?


Popliteus
2) 70 year old female, chronic asthma patient, presented with fracture
Osteoporotic fracture
3) Osteochondroma
Normal cortical bone with cartilage cap
4) 66 years old, tibial tumour, high calcium
Ostitis fibrosa cystica
5) Unable to dorsiflex
Injury to common peroneal nerve at neck of fibula
6) Axoplasmic transport
From cell bodies to terminal
7) Botulinum toxin
Prevent exocytosis of NT
8) COX-2 selective NSAID
Meloxicam
9) Mentally handicapped child, hyperactive and violent. Which is most suitable for him?
Behaviour modification
10) Stab injury to axillary area, unable to punch
Long thoracic nerve
11) Undergone gastrectomy surgery, anterior bowing of tibia
Saber shin
12) Nod ‘yes’
Atlanto-occipital joint (the description)
13) Weak upon flexing knee joint and extending hip joint
Adductor longus
14) Irregular anaesthetic macules, thickened nerves
Leprosy
15) Most abundant fibres in osteoid
Collagen type I
16) Best description about adjustment process in handicapped
Mourning
17) HyperPTH, main PTH function
Increase plasma Ca by withdrawing Ca from bone
18) Autosomal dominant, cortical thinning and attenuation of trabeculae
Osteogenesis imperfecta
19) Best description about lumbar puncture
Landmark is iliac crest
20) Medial epicondyle of humerus
Flexor carpi ulnaris

21) External ear from?


1st branchial cleft
22) Chronic hypertension, aneurysm. Which statement is true about blood supply of the brain?
Anterior communicating artery connects two anterior cerebral artery
23) Motor and sensory fibres
Posterior limb of internal capsule
24) Fracture of sella turcica. Which bone might have been fractured?
Sphenoid
25) False about neourotransmitter
Must have at least one amine and one –COOH group (something like this)
26) Headcahe will occur in the followings EXCEPT:
Epilepsy
27) Couldn’t remember
28) Couldn’t remember
29) Unable to abduct R eye
Infection in cavernous sinus
30) Which artery supplies caudate nucleus?
Anterior cerebral artery
31) Which is true?
Loss of intrastriatal cholinergic fibers - Huntington’s disease (given answer)
Cerebellar lesion – Intentional tremor (also true, was debated)
32) Which one is spinal cord reflex?
Positive supporting reflex
33) UMNL
Corticospinal tract
34) Sewage worker
Leptospira interrogans
35) Stage III astrocytoma
SINGLE mitosis
36) Non-declarative learning
Simple classic conditoning
37) Unable to stop taking alcohol
Alcohol dependence
38) Why MAOI is better than SSRI
Less weight gain (given answer, but totally not true!)
39) Couldn’t remember
40) Which GA cause hallucination?
Ketamine

EMQ

A. Brachial plexus
1) Chronic presentation : Rotator cuff muscles tear (not frozen shoulder because frozen
shoulder is not chronic in presentation)
2) Baby – Weak upper limbs, presented with flexed fingers (DIP) : Klumpke’s
3) Painful, restricted passive extension of fingers, absent rasial pulse : Volkmann’s
ischaemic contracture
4) Thumb and index finger glass injury : Tenosynovititis
5) Frequent Dislocation : Axillary nerve injury

B. Ascending and descending tracts


1) Dorsal column affected : Rhomberg’s test positive
2) Amyotrophic lateral sclerosis, degeneration of anterior horn cells : fasciculation of
proximal muscles (bcoz LMNL)
3) R side spinal cord lesion at T9 level : L side paraesthesia at T10 level
4) Something about UMNL : Exaggerated knee jerks (bcoz UMNL)
5) Prolapsed Intervertebral disc : Paraesthesia of lower limbs

C. Muscles of the face and nerve supply


1) When going downstairs : Superior oblique
2) Drainage of lacrimal secretion : Orbicularis oculi
3) Prevent food from entering vestibule during chewing : Buccinator?
4) Having problem with lateral gaze : Abducens
5) Side to side chewing : Medial pterygoid

OSPE

A.

Case 1 : a picture of an x-ray of a bone

Case 2 : Bence Jones protein, M spike + a picture of an x-ray of patient’s skull

Case 3 : Patient with Paget’s disease + gross dissected skull

1)
Description of diagram Provisional diagnosis
Case 1 Sunburst appearance Osteogenic sarcoma
Case 2 Punched out (multiple) lesions in the Multiple myeloma
skull
Case 3 Skull with large mass Osteosarcoma

2) Name the structures according to the label.

The picture (to me) was non-coloured, hence it was not clear. (Sorry as I couldn’t find the
exact picture to include it here.)

A : Flexor retinaculum

B : Thenar muscle

C : Median nerve

D : Ulnar bursae

E:

3) How would infection travels here? (if I’m not mistaken, do correct me)
TENOSYNOVITIS - infection of RADIAL, ULNAR BURSA & Fibrous flexor Sheath of
Digits-by PENETRATING WOUND. PUS may enter FASCIAL SPACE IN FOREARM
through underneath flexor retinaculum– into SPACE OF PERONA

B. The visual pathway and lesions


X

Name X, Y and Z.
W : Optic radiation
X : Optic nerve
Y : Optic tract
Z : Visual cortex

Name the exact location for Z in the brain.


- Area 17 in occipital cortex

Name the abnormality caused by lesion A. B and D.


A : Left monocular blindness
B : Bitemporal hemianopia
D : Right homonymous hemianopia with macula sparing

C. Blood supply of the brain :

 A picture of blood supply of the brain


1) Label A and B and give two functional areas supplied by B.
A : Anterior cerebral artery
B : Middle cerebral artery;
B supplies primary motor area, primary sensory area, Broca’s area etc

2) How is E and F connected?


RIGHT internal carotid artery ………

3) Name C and D
C : Anterior choroidal artery
D : Choroid plexus

4) Another question which I don’t remember

 Another picture of cerebral haemorrhage (not sure of the questions and answers, the lecturer
was too fast)

5) Which artery is damaged?


Basilar artery?

6) What might be the cause?


Berry aneurysm?

MEQ

A. Part 1
A case of osteoarthritis (basically know all about arthritis), old woman, presented with painful knee

1) Give four clinical presentations of an old woman with painful knee


- Septic arthritis
- Gouty arthritis
- Traumatic arthritis/bursitis?
- Osteoarhtritis
2) State four nerves that supply the knee joint.
- Femoral nerve
- Obturator nerve
- Common peroneal nerve
- Tibial nerve

3) How do you exclude your differential diagnosis with clinical findings?


- Gouty arthritis : usually involves toes, presented with swelling and tenderness
- Rheumathoid arthritis : weight bearing, tender joint usually at night time,
positive rheumatoid factor

Part 2
Radiography shows intra-articular effusion.

4) Non-arthritic causes of effusion.


- Meniscal injury
- Loose body
- Traumatic bursitis
-

5) State the expected findings in radiography


- Non-uniform joint space loss
- Ankylosing/deformity
- Subchondral sclerosis
- Cyst formation
- Callus formation
- Osteophytes

6) State a structure in the knee joint and give TWO of its function.
- Medial and lateral meniscus (menisci) : shock absorber, weight-bearing.
- Cruciate ligaments (anterior and posterior) : provide rotational stability,
prevent hyperextension and hyperflexion of the knee joint.

Part 3
Patient was treated with NSAIDs.

7) What are the treatment modalities for this patient besides NSAIDs?
- Exercise
- Reduce weight
- Intra-articular injection of steroid
- Joint lavage
- Arthroplasty
- Surgery

8) What symptoms might develop in this patient after taking NSAIDs?


- Increase bleeding time
- Epigastric pain
9) What are the areas you need to discuss with the patient during counseling? (Give four I
guess)
- Treatment options for OA
- The nature of OA
- Weight loss
-

B. Part 1
A case of a lady presented A&E after serious vomiting for past one hour.
1) What might be the cause of her vomiting? Give four (if I’m not mistaken)
- Hyperemesis gravidarum
- Increase intracranial pressure
- Food poisoning
- Ear infection
- Drug intoxication
- Metabolic acidosis
- Migrain

2) What further history should be obtained to narrow down the differential diagnosis? Give four.
- Menstrual history
- Past medical history (drug Hx)
- Hx of food poisoning
- Any associated symptoms such as headache, tinnitus, loss of balance
- Precipitated with aura?

3) Is the vomiting centre located inside the blood brain barrier? Where is the vomiting centre?
No. Area of postrema.
Part 2

Her period was normal. There’s no history of drug intake.

4) Give 2 structures in both respective middle wall and anterior wall of the middle ear cavity.
- Medial wall : Oval window (with foot of stapes) and round window
- Anterior wall : Eustachian tube and Internal carotid artery

5) How can infection of the middle ear cause vertigo and vomiting?
- Infection spreads through oval window into vestibules…..
-
- Hence cause vertigo and vomiting

Part 3

Pseudomonas aeruginosa was isolated.

6) What are the symptoms of increased intracranial pressure?


- Headache
- Vomiting
- Altered mental status
- Bradycardia

7) The bacteria are sensitive against what kind of drug?


- Penicillin
- Aminoglycoside (Gentamycin)
- Cephalosporins
- Quinolones

8) Describe CSF circulation.


- Starts in lateral ventricles, into third ventricle, cerebral aqueduct and fourth
ventricle
- Enter subarachnoid space in the cranial cravity
- Some flow downwards into subarachnoid space surrounding the spinal cord
C. Part 1
A case of osteoporosis with fracture : old woman, complain of back pain for two weeks.

1) The risk factors


- Old age (the answer was the age specifically)
- Female
- Post-menopausal

2) What are the fractures that might develop after a fall like this? Where does the fracture in
femur most probably occur in this patient)
- Vertebrae/
- Neck of femur (rasanya)

3) How to manage the fracture? Give two.


- POP cast
- Continuous traction
- Functional bracing
- External fixation

4) Treatment for osteoporosis :


- Bisphosphonates
- Calcium supplement
- Raloxifene
- HRT

Part 2

Diabetic. Upon pre-surgical procedure, the anesthetist was vigilant to found out that the patient’s
blood pressure was 195/…Hg (very high BP) and her cholesterol level was high.
5) Why was the anaesthetist vigilant?
- High BP high risk of anaesthesia or something (not so sure)
- High cholesterol is a risk for atheroma

6) Something about pre-disposing factors

Part 3

Patient remained unconscious after the surgery. She couldn’t be woken up. The doctor suggested that
she has stroke.

7) Why did the patient remain unconscious?


- Used to hypertension
- Slight drop in BP cause hypotension in watershed area
- Poor perfusion to cerebral cortex
- Leading to ischaemia

8) What type of brain infarction?


- Water-shed infarction

9) Explain how this happens based on the anatomical location.


- ACA, MCA, PCA are major artery branches supplying the brain.
- Water-shed are in between ACA and MCA, MCA and PCA, PCA and ACA

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