Clinical Examination Flashcards
A 18-year-old man presents with the bizarre behaviour of picking his clothes and the carpet. He appears agitated and mutters unintelligibly. He has a high temperature on examination. When examining him, it is found that when his knee is extended with flexed hip, he develops a ‘catch’ and flexes the other hip as a reflex. This is called
Select one:
1. Reverse leg raising sign
2. Positive Romberg’s sign
3. Straight leg raising sign
4. Positive Brudzinki’s sign
5. Positive Kernig’s sign
Positive Kernig’s sign
The Kernig’s sign is elicited by flexing one hip and knee and then extending the knee with the hip still
flexed. Hamstring spasm may occur; if severe, opposite knee may flex during the test - this is termed as a positive Kernig’s.
A patient agrees that he has significant problems with the use of alcohol. He takes responsibility and
understands the importance of having a change in his lifestyle. He has not taken any active steps to change his drinking pattern so far and continues heavy alcohol use. Which of the following levels of insight does he have?
Select one:
1. Intellectual insight
2. Complete loss of insight
3. Externalization of cause
4. Emotional insight
5. Awareness of problems but denial of responsibility
Intellectual insight
Intellectual insight: admission that the patient is ill and that symptoms or failures in social adjustment are caused by the patient’s own particular irrational feelings or disturbances without applying this knowledge to future experiences.
Unilateral frontal lobe damage can result in
Select one:
1. Does not cause spastic paresis
2. Contralateral spastic hemiplegia
3. Contralateral hypotonia
4. Ipsilateral spastic hemiplegia
5. Paraplegia
Contralateral spastic hemiplegia
Damage to upper motor neurons originating in frontal motor strip can result in contralateral spastic
hemiparesis.
61-year-old right-handed man presented to the emergency department with an acute onset of right-leg weakness. Soon his weakness progressed to include both arms and legs, and he stopped speaking. On examination, he was alert but produced no spontaneous speech or spontaneous movements. Which artery is most likely to be implicated in this presentation?
Select one:
1. Cerebello Pontine artery
2. Posterior cerebral artery
3. Anterior cerebral artery
4. Middle cerebral artery
5. Basilar artery
Anterior cerebral artery
The syndrome of akinetic mutism is typically the result of bilateral hemispheric injury, usually involving the anterior cingulate gyri. Other lesions producing akinetic mutism include lesions of the thalami, globus pallidus, internal capsule, and frontal white matter. These lesions are thought to disrupt anterior frontal-subcortical circuits that subserve motivation. This is usually a result of anterior cerebral artery occlusion, which in some individuals, can have a predominantly lateralized course due to an anatomical variation on one side.
All of the following drugs will increase urine porphyrins in a susceptible individual with disordered haem metabolism except
Select one:
1. Oestrogens
2. Diclofenac
3. Barbiturates
4. Chlorpromazine
5. Benzodiazepines
Chlorpromazine
Acute intermittent porphyria is episodic in nature and the episodes are often triggered by certain medications including oestrogens, barbiturates and benzodiazepines. Diclofenac can precipitate an episode. Psychiatric manifestations include depression, anxiety, delirium and psychosis.
The brain region with most prominent changes observed using neuroimaging in ADHD is
Select one:
1. Frontal cortex
2. Occipital cortex
3. Thalamus
4. Parietal cortex
5. Insula
Frontal cortex
Frontal brain dysfunction is notable in many unmedicated children with ADHD
In schizophrenia, the anatomical structure in the brain that is most consistently reduced in size is
Select one:
1. striatum
2. insula
3. hypothalamus
4. cerebellum
5. hippocampus
Insula
Most of the listed structures have been observed to have structural abnormalities in schizophrenia. In fact, the hippocampus has been repeatedly shown to have a reduced volume though not in all studies. Insula, which forms a part of the paralimbic cortex, has been unequivocally shown to have volumetric abnormalities in schizophrenia. Other consistently affected structures include anterior cingulate cortex, dorsolateral prefrontal cortex and thalamus.
Which of the following is not a frontal release sign?
Select one:
1. Rooting reflex
2. Glabellar tap
3. Snout reflex
4. Cremasteric reflex
5. Grasp reflex
Cremasteric reflex
Primitive reflexes include the glabellar tap, rooting, snout, sucking, and palmomental reflexes. These are generally absent in adults. When present in the adult, these signs signify diffuse cerebral damage,
particularly of the frontal lobes (hence called frontal-lobe release signs). Cremastric reflex is a superficial reflex.
A lactate solution is infused in a 32-year-old woman. This results in acute anxiety, palpitations, sweating, fear of loss of control and dizziness. What is the most likely diagnosis?
Select one:
1. Lactic acidosis
2. Malingering
3. Generalized anxiety disorder
4. Panic disorder
5. Lactose intolerance
Panic disorder
Nearly 72% patients with panic disorder have a panic attack when administered IV injections of sodium lactate. Therefore, lactate provocation is used to confirm a diagnosis of panic disorder. Hyperventilation and CO2 inhalation have been used. Panic attacks triggered by sodium lactate are not inhibited by peripherally acting beta-blockers but are inhibited by benzodiazepines and tricyclic drugs.
One of the most well established anatomical changes seen in schizophrenia is
Select one:
1. Enlargement of the lateral ventricle
2. Enlargement of corpus callosum
3. Enlargement of the amygdala
4. Enlargement of the third ventricle
5. Enlargement of cerebellar peduncles
Enlargement of the lateral ventricle
A decrease in brain weight, brain length and volume of the cerebral hemispheres enlargement of the lateral ventricles is reported commonly in patients with schizophrenia.
A tremor, which decreases with volitional movements and appears primarily when not engaged in tasks, is most likely to be a
Select one:
1. postural tremor
2. cerebellar ataxia
3. physiologic tremor
4. senile tremor
5. resting tremor
Resting tremor
A resting tremor occurs with the body part in complete repose and often dampens or subsides entirely with action.
In MRS, which nuclei are commonly used for in vivo measure of phosphocreatinine?
Select one:
1. H-1
2. Na-23
3. Li-7
4. F-19
5. P-31
P-31
Na-23 is employed for intra and extra cellular sodium measurement. P-31 is employed for quantifying energy handling and cellular metabolism (ATP/ADP), membrane physiology, phosphomono/ diester quantification and phophocreatinine measurement.
H1 is used for quantifying glutamate, lactate, N-acetylaspartate, choline, creatinine. F-19 MRS is used to study labelled drugs and deoxyglucose.
A patient undergoing an assessment for dementia is asked to draw a circle and place numbers inside the circle to depict the face of a clock. All of the following domains of cognition are crucial for successful completion of this task except.
Select one:
1. Executive function
2. Constructional praxis
3. Comprehension
4. Orientation to time
5. Visuospatial ability
Orientation to time
CDT (Clock Drawing Test) does not assess one’s orientation to time.
Inability to attend to the parts and the whole of an object at the same time is called
Select one:
1. Somatognosia
2. Visuospatial apraxia
3. Prosopognosia
4. Simultanagnosia
5. Anosognosia
Simultanagnosia
Simultanagnosia is characterized by the failure of an individual to perceive more than a single object at a time.
In MMSE, intersecting pentagons test primarily assesses which of the following functions?
Select one:
1. Constructional praxis
2. Language
3. Copying skills
4. Visual retention
5. Orientation
Constructional praxis
Visuospatial ability, especially constructional praxis, is tested using intersecting polygons test.
Which of the following clinical examination for apraxias is abnormal more commonly with a right than a left cerebral damage?
Select one:
1. Imitating a toothbrush action
2. Construction of polygons
3. Mimicking hand movements
4. Using tools appropriately
5. Whistling and coughing on command
Construction of polygons
Constructional apraxia is inability to construct elements to a meaningful whole. E.g. inability to draw or copy simple diagrams or figures. This is typically caused by a lesion in the right cerebral hemisphere.
In a secluded patient, behavioural observation is carried out every 5th minute through a glass window. This
technique is called
Select one:
Event sampling
None of the above
Time sampling
Functional analysis
ABC analysis
Behavioural observation methods include observing and recording behavioural events, to study mental
state or plan intervention. They are of 2 types: Event sampling: e.g. every fifth or tenth event is coded in
detail. Time sampling: observations may be made only every 5 or 10 mins.
The correct answer is: Time sampling
Select the most appropriate investigation for a patient on antipsychotic medications presenting with weight gain, excessive thirst and fatigue.
Select one:
1. Fasting glucose
2. Liver function tests
3. Full blood count
4. Electrocardiogram
5. Fasting lipids
Fasting glucose
The symptoms of weight gain, excessive thirst and fatigue are suggestive of impaired glucose tolerance. A fasting blood glucose is indicated to diagnose antipsychotic related diabetes mellitus.
In occasional cannabis user, how long is cannabis detected in urine after last use?
Select one:
1. 3 hours
2. 4 weeks
3. 12 hours
4. 8 days
5. 3 days
3 days
Occasional use - up to 3 days. High daily use for long time - up to 4 weeks.
A patient presenting with carbon monoxide poisoning is suspected to have bilateral posterior parietal damage due to anoxia. If this turns out to be a case of Balint’s syndrome which of the following will NOT be a presenting feature?
Select one:
1. Simultanagnosia
2. Diplopia
3. Oculomotor apraxia
4. Optic ataxia
5. Intact oculocephalic reflexes
Balint’s syndrome consists of a triad of simultanagnosia (inability to attend to more than one item of a complex scene at a time), optic ataxia (inability to guide reaching or pointing despite adequate vision), and oculomotor apraxia (inability to voluntarily direct saccades to a visual target). Fields may be full when challenged with gross stimuli, and oculocephalic reflexes are intact. This syndrome results from bilateral damage including the superior-parieto-occipital region, which disrupts the dorsal (‘where’) visual processing stream linking visual with parietal association areas. Possible causes include carbon monoxide poisoning, watershed infarction, leucodystrophy, and the posterior cortical variant of Alzheimer’s disease.
Patients with schizophrenia are least likely to perform poorly on which of the following tests?
Select one:
1. Category test
2. Trail B of the Halstead-Reitan battery
3. Wisconsin card sort test
4. Speech sounds perception test
5. MMSE
MMSE
Patients with schizophrenia perform far more poorly than controls on category test (assess higher-order reasoning), Wisconsin card sort test (tests higher-order reasoning), speech sounds perception test, Trail B of the Halstead-Reitan battery (tests the ability to shift flexibility between cognitive sets). Tests of overall cognitive ability such as MMSE are usually intact in schizophrenia.
The investigation that has no helpful role in diagnosing narcolepsy is
Select one:
1. CSF analysis
2. Human leucocyte antigen typing
3. Multiple Sleep Latency test
4. Sleep polysomnogram
5. Sleep deprivation test
Sleep deprivation test
Sleep deprivation test is not helpful to diagnose narcolepsy. The multiple sleep latency test is helpful in supporting the diagnosis. Findings in sleep polysomnogram include sleep latency of less than 10 min and sleep-onset rapid eye movement (REM) periods. There is a strong association with the HLA-DQB1*0602 marker in almost all individuals regardless of ethnicity. An abnormally low concentration of hypocretin-1 (orexin-A) is noted in CSF. In some cases, human leukocyte antigen typing may be helpful in determining whether narcolepsy is likely caused by a lack of hypocretin or another cause.
Which of the following arteries on occlusion leads to symptoms suggestive of dorsolateral prefrontal
dysfunction?
Select one:
1. Middle cerebral
2. Peduncular Check Check
3. Basilar
4. Posterior cerebral
5. Anterior cerebral
Middle cerebral
DLPFC consists of the lateral portions of Brodmann areas 9 - 12, areas 45, 46, and the superior part of
area 47. These regions receive their blood supply from the middle cerebral artery.
During the course of a clinical interview, the psychiatrist says, ‘So from what you have been telling me, your sleep is poor, you have excessive disturbing thoughts and you have lost weight in last 2 months. Is that right?’ What technique is he using?
Select one:
1. Interpretation
2. Summation
3. Facilitation
4. Clarification
5. Repetition
Summation
Summation is brief summarisation of what the patient has said up to a point in the interview. Helps the patient to check if he has said what he intended to say. Helps the doctor to form an idea of the narration so far.
An anorexic patient repeatedly vomits. Which of the following is a possible complication?
Select one:
1. None of the above
2. Hyponatraemia
3. Hypokalaemia
4. Metabolic alkalosis
5. Metabolic acidosis
Metabolic alkalosis
Loss of gastric acid can lead to metabolic alkalosis.
A girl attending your outpatient unit is 165 cm tall and weighs 50kg. What is her body mass index?
Select one:
1. 20 to 21
2. 16 to 17
3. 17 to 18
4. 18 to 19
5. 19 to 20
18 to 19
BMI can be calculated using the formula weight /(squared value of height). The weight must be in kgs and height must be in meters.
All of the following help localizing a neurological lesion to cerebellum EXCEPT
Select one:
1. Ankle clonus
2. Hypotonia
3. Dysdiadochokinesia
4. Ataxia
5. Past pointing
Ankle clonus
Cerebellar signs: Ataxia, hypotonia, dyssynergia (incoordination), dysmetria (past pointing),
dysdiadochokinesis, dysrhythmia and dysarthria.
Which of the following investigations involve introducing a synthetic radionucleotide for obtaining brain images?
Select one:
1. T2 weighted scan
2. PET scan
3. fMRI
4. T1 weighted scan
5. Diffusion Imaging
PET scan
PET involves using radionucleotides to study neuronal activity, neurochemistry and pharmacology of the brain.
In SPECT imaging iomazenil (I-123) is used to label
Select one:
1. GABA-A receptors
2. D-2 receptors
3. Alpha-2 receptors
4. 5-HT2 receptors
5. Glycine receptors
GABA-A receptors
Iomazenil is used for GABA-A receptors.
Alexia without agraphia (pure alexia) is seen in lesions of
Select one:
1. Middle meningeal artery
2. Posterior inferior cerebellar artery
3. Middle cerebral territory
4. Posterior cerebral territory
5. Anterior cerebral territory
Posterior cerebral territory
In alexia without agraphia or pure word blindness, patients retain the ability to write, but are unable to read (even words that they have just written) and often have right homonymous hemianopia. This disorder results from the loss of visual input to the language area [usually the dominant (left) angular gyrus] without the involvement of the language area or output from the language area to the motor cortex. The ability to process visual input into language (i.e. reading) is lost in these patients. The pathways involved in this syndrome are believed to be localized to the inferior portion of the splenium of the corpus callosum on the side of the dominant (usually left) cerebral hemisphere. This is associated with posterior cerebral artery damage.
Which one of the following has been used in vitro as a powerful method of analytical chemistry and enables the measurement of the concentration of different metabolites in the brain?
Select one:
1. Structural MRI scan
2. CT Scan
3. Functional MRI scan
4. X-Ray
5. Magnetic Resonance Spectroscopy.
Magnetic Resonance Spectroscopy.
MRS utilizes the principle of nuclear magnetic resonance and can be used to measure metabolite
concentration without the need for radio isotopes.
The wavelet of EEG that is greater than 13Hz in frequency is
Select one:
1. Delta
2. Beta
3. Theta
4. Gamma
5. Alpha
Beta
Beta is the frequency range from 12 Hz to about 30 Hz.
A patient who sustained a head injury reports loss of memory for events that happened between 13th
September 2014 and 20th September 2014, though he retained full consciousness soon after the injury was sustained on 13th September 2014. Which of the following cognitive dysfunctions is he describing?
Select one:
1. Semantic dementia
2. Retrograde amnesia
3. Selective amnesia
4. Transient global amnesia
5. Anterograde amnesia
Anterograde amnesia
Anterograde memory refers to the newly encountered information from the time of a lesion. Anterograde memory loss is also commonly elicited when examining a dementing patient - e.g. forgetting appointments, losing items around the home, inability to remember conversation leading to repeated questions, etc.
A 32-year-old school teacher is admitted for constipation and acute abdominal pain. She develops motor weakness of her legs on the administration of hypnotics and diclofenac. She experiences visual and tactile hallucinations with intense anxiety. Which of the following laboratory test is indicated?
Select one:
1. Serum folate
2. Urine porphyrins
3. Serum lipid levels
4. Serum ceruloplasmin
5. Urine glucose
Urine porphyrins
The scenario depicts acute intermittent porphyria (AIP). It is one of the groups of disorders of haem
metabolism, characterised by neurological and psychiatric manifestations without obvious cutaneous markers. AIP manifests itself by abdomen pain, neuropathies, and constipation, but, unlike most types of porphyria, patients with AIP do not have a rash. It is an autosomal dominant disorder with the presentation starting between ages 18 and 40. It is episodic in nature and the episodes are often triggered by certain medications including estrogens, barbiturates and benzodiazepines. Diclofenac can precipitate an episode. Psychiatric manifestations include depression, anxiety, delirium and psychosis. Most important lab test is demonstrating increased urinary porphobilinogen during acute attacks. Treatment is aimed at reducing haem synthesis by administering haemin.
Which neuroimaging modality can give information about metabolic changes in the brain?
Select one:
1. Structural MRI Scan
2. PET scan
3. Ultrasonogram brain
4. SPECT scan
5. CAT scan
PET scan
Both PET and SPECT scan give information about regional cerebral blood flow and ligand binding but PET scan also gives information about metabolic changes in the brain. The most commonly used isotopes in PET are fluorine-18, nitrogen-13, and oxygen-15. These isotopes are usually linked to another molecule, except in the case of oxygen-15 (15O). The most commonly reported ligand has been [18F]fluorodeoxyglucose (FDG). This gives information directly about neuronal metabolism.
Which of the following will you use to assess orientation in a hospitalised patient?
Select one:
1. Ability to repeat a phone number immediately after reading out
2. Tap the table once whenever the examiner reads letter ‘E’ from a random list of
alphabets
3. Ability to recognise pictures of famous personalities
4. Ability to correctly identify the doctor when asked to point out
5. Ability to remember his/her own address
Ability to correctly identify the doctor when asked to point out
Orientation to person is a stable domain which is generally lost only late in the course of a confusional state.
Inability to recognise familiar faces is seen in
Select one:
1. Anosognosia
2. Simultanagnosia
3. Prosopognosia
4. Somatognosia
5. Visuospatial apraxia
Prosopognosia
Prosopagnosia (face blindness) is a disorder of face perception where the ability to recognize faces is
impaired.
T1 images in MRI are mostly useful for
Select one:
1. Assessment of normal brain structure
2. Visualising periventricular structures
3. Visualising oedema
4. Detecting tumours
5. Localising ischemic zones
Assessment of normal brain structure
The T1 image most closely resembles a CT scan and is most useful for assessing the overall brain
structure. T1 is also the only sequence that allows contrast enhancement with the contrast agent
gadolinium-diethylenetriamine pentaacetic acid (gadolinium-DTPA).
The earliest appearance of brain atrophy in Alzheimer’s disease is most marked in which of the following brain regions?
Select one:
1. Insular lobe
2. Medial Temporal Lobe
3. Frontal lobe
4. Occipital lobe
5. Posterior Parietal Lobe
Medial Temporal Lobe
Regional atrophic changes observed in MRI studies reveal consistent associations between atrophic
changes of the medial temporal substructures (in particular hippocampus and amygdala) and amnesic deficits, or measures of the global severity of cognitive deficits.
REM pattern is recorded during daytime in a student who is studying for exams for the last two weeks. The most likely reason is
Select one:
1. Delirium
2. Antipsychotic use
3. Cocaine intoxication
4. Sleep deprivation
5. Normal pattern
Sleep deprivation
REM sleep during daytime can be seen in narcolepsy, sleep deprivation or withdrawal from stimulants.
Mr. X has been consuming a high dose of cannabis for a long time. How long will it be present in his urine?
Select one:
1. 24 hours
2. 10 days
3. 3 days
4. 7 days
5. 4 weeks
4 weeks
Cannabis can be detected in urine after occasional use for up to 3 days. After a high daily use for long time, urine drug screen can be positive for up to 4 weeks.
Mrs Y is an elderly lady with cognitive impairment and visual hallucinations. Select the best imaging
technique to diagnose her condition.
Select one:
1. CT scan
2. PET scan
3. DAT scan
4. f-MRI scan
5. MRI Scan
DAT scan
The diagnosis is most likely to be Lewy body dementia as cognitive impairment and visual hallucinations are common. The SPECT ligands 123I-FP-CIT (N-fluropropyl-2ß-carbomethoxy-3ß-4-[123I] iodophenyl tropane), 123I-ß-CIT, and the PET ligand 18F-dopa ([I18F] fluorodopa) can be used to image the presynaptic dopaminergic terminals in the corpus striatum, which are greatly reduced in Lewy body dementia (in contrast to Alzheimer’s). The 123I-FP-CIT agent is also known commercially as the
‘DaTSCAN’.
A patient is asked to hold out both arms with palms facing upwards and maintain the posture with eyes
closed. His left arm slowly drops down compared to right arm. Which of the following lesions is most likely to be present?
Select one:
1. Left hemisphere lesion
2. Cranial nerve X nuclei lesion
3. Cerebellar vermis lesion
4. Right cerebral hemisphere lesion
5. Thoracic spinal cord lesion at T12
Right cerebral hemisphere lesion
A pronator drift is elicited by having the patient extend both arms with the wrists supinated and palms facing upwards and eyes closed - slow unequal drift towards pronation indicates hemiparetic weakness. The left arm drop in this case indicates a right cerebral lesion.
Which phenomenon is commonly used in a functional MRI scan to make inferences about brain activity?
Select one:
1. Echo planar imaging (EPI)
2. Diffusion imaging
3. High angle low-frequency pulses.
4. Blood oxygen level dependent (BOLD) Phenomenon
5. Fast low angle shot radiofrequency pulses (FLASH)
Blood oxygen level dependent (BOLD) Phenomenon
The most commonly used functional MRI (fMRI) method is based on the observation that functional
activation results in an increase in cerebral cortical blood flow that is in excess of oxygen extraction. The result is a local and temporary increase in oxyhaemoglobin. The differences in the magnetic properties of oxy and de-oxy haemoglobin can be used to compute images of regional functional activation patterns (Blood oxygen level dependent-BOLD principle).
