(MCQS 280 –282):A 75-year-old farmer presents with pain in his right thigh and left upper arm

Question:280
Correct Answer: F
Explanation:
This is an example of referred pain. After the perforation, the gastric contents passed to the underside of the diaphragm on the upper surface of the liver in the right anterior subphrenic space. The phrenic nerve supplies the parietal peritoneum here. The phrenic nerve is derived from the C3 C4 and C5 segments of the spinal cord. The supraclavicular nerves, which supply the skin over the shoulder, are also derived from the same segments of the spinal cord.
 
Question:281
Correct Answer: F
Explanation:
Clinically, herpes encephalitis is characterized by rapid onset of fever, chills, restlessness, and signs of increased intracranial pressure. The mortality rate of herpes encephalitis is at least 25%. The characteristic gross appearance of herpes encephalitis include edema, hemorrhages and necrosis confined primarily to the temporal lobes. The degree of edema is evidenced by the medial displacement of the uncal gyri. The involvement may be bilateral or may be unilateral. In the acute stages, microscopic examination reveals vascular destruction with infiltrates of neutrophils and lymphocytes as shown on this slide In the later stages, glial proliferation becomes the prominent feature. The histological feature which characterizes herpes simplex encephalitis is the finding of eosinophilic intranuclear inclusion bodies (Cawdry type A). The inclusions may be seen in neurons, astrocytes, and oligodendroglia. At the ultrastructural level, the nuclear inclusions of herpes simplex are found to contain viral particles with a characteristic bull's eye appearance. Herpes simplex, a DNA virus, is carried by a majority of the human population. The virus is harbored in the trigeminal ganglia, and produces lesions in the oral mucosa when activated by stress. Herpes simplex encephalitis arises sporadically and does not necessarily occur in people with a history of oral lesions.
 
Question:282
Correct Answer: H
Explanation:
These features are suggestive of Paget's disease of bone. The combination of a bony abnormality in the leg and arm and nerve deafness with a high alkaline phosphatase suggest that this patient has Paget's disease [osteitis deformans]. This disease occurs mainly in the elderly and is characterized by excessive and disorganized resorption and formation of bone. Bone pain occurs due to distention of the periosteum, or from deformity causing arthritis. Affected bones are enlarged, deformed and warm. It can affect any bone, but commonly affects the pelvis and spine. The skull is often enlarged and compression of the VIIIth cranial nerve can cause deafness. Rarer complications are high-output cardiac failure secondary to high blood flow through the abnormal bone and osteosarcoma in the affected bone. The major biochemical change is an elevated plasma alkaline phosphatase released by osteoblasts in overactive bone. Serum calcium is usually normal unless the patient is immobilized. The X-ray appearances are of enlarged bone, a resorbing front, thickened and deformed bone and multiple microfractures. Osteomalacia is a possible differential diagnosis, however the serum calcium will be low together with a low phosphate despite a raised alkaline phosphatase level unlike in Paget's disease where both the calcium and phosphate levels are within the normal range. Similarly, in osteoporosis, yet another differential in this case, the calcium, phosphate and alkaline phosphatase levels will all be within the normal range. In sarcoidosis, on the other hand, calcium will be elevated with phosphate and alkaline phosphatase levels within the normal range.


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