Case-based MCQ

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A 72-year-old male with past medical history of pulmonary embolism presented with fever 5-days post-chemotherapy for Hodgkin’s lymphoma. His neutrophil count is zero. He is given on intravenous antibiotics and isolation maintained to prevent any infection. His current medications include warfarin, cefepime, candesartan and omeprazole. After a few days of admission, platelets count decreased to 22000/microlitre (150,000-450,000 platelets per microliter). What will you do next? A. Cease omeprazole B. Cease warfarin C. Cease candesartan D. Cease cefepime E. No action needed

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Correct Answer Is E A herniation of the disc between the L5 and S1 vertebrae will impinge on the S1 spinal nerve, which exits between the S1 and S2 vertebrae.In L5-S1 disc prolapse, ankle reflex is lost. A brief description of signs and symptoms of nerve root involvement at each level in the lumbar region is given below. 1.T12-L1-Pain in inguinal region and medial thigh. 2.L1-2- Pain in anterior and medial aspect of upper thigh- slight weakness in quadriceps 3.L2-3-Pain in anterolateral thigh and weakness of quadriceps leading to weak of knee reflex. 4.L3-4-Pain in the posterolateral thigh and anterior tibial area with diminished knee reflex. 5.L4-5-Pain dorsum of the foot with weak dorsiflexion of big toe and foot. 6.L5-S1-Pain in the lateral aspect of the foot with absent ankle jerk.

A 45-year-old male presented with sharp,burning, stabbing pain in the lateral aspect of the right foot.You suspect L5-S1 radiculopathy. Which of the following is lost in L5-S1 disc prolapse? A. Knee jerk B. Dorsiflexion of big toe and foot C. Inversion of foot D. Eversion of foot E. Ankle jerk

Correct Answer Is C The clinical presentation is suggestive of right anterior interosseous nerve injury {AIN). AIN is a purely motor branch of the median nerve that innervates all deep muscles of the anterior compartment of forearm except the ulnar part of the muscle flexor digitorum profundus. AIN branches from median nerve 4cm distal to medial epicondyle and runs along the front of the interosseous membrane of the forearm in the space between the flexor pollicis longus and flexor digitorum profundus. AIN ends distally In the pronator quadratus and wrist joint. Muscles innervated by AIN Include: Flexor pollicis longus (the long flexor of thumb) The radial part of flexor digitorum profundus (flexor of the index and (sometimes)middle fingers) Pronator quadratus (forearm pronation resulting in palm of the hand facing down) Radial nerve supplies thumb and fingers extensors and forearm supinator muscles. Radial nerve injuries or neuropathies do not cause weakness of fingers flexion or forearm pronation. Median nerve injuries distal to where AIN branches off cause weakness of thenar muscles including flexor pollicis brevis, abductor pollicis brevis and opponens pollicis. With compensatory action of flexor pollicis longus (supplied by the AIN) and abductor pollicis longus(supplied by the radial nerve) flexion and abduction remain almost unaffected; however, thumb opposition becomes impaired. Median nerve injuries proximal to AIN origin result in dysfunction of all median-innervated muscles in the forearm and hand. Posterior interosseous nerve innervates the common and deep extensors of the fingers. It branches off from the radian nerve at the radiohumeral joint line and travels down in the posterior compartment of the forearm. Injuries or neuropathies of this nerve do not result in the presentation in the case scenario. With ulnar nerve involvement, there would be weak flexion of the 4th and 5th fingers, weak flexion of wrist, and sensory disturbances in the territory of the ulnar nerve

After a left elbow injury, a 55-year-old man develops weakness of the long flexors of the right thumb and index finger. He is also unable to do forearm pronation on the same side. Which one of the nerves is involved? A. Radial nerve B. Median nerve C. Anterior interosseous nerve D. Posterior interosseous nerve E. Ulnar nerve

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