Midterm 4 Soruları

Question 1

Which one is correct for Rinne and Weber tests in “unilateral conductive hearing loss”?

Rinne Test: Bone conduction longer than air conduction in
affected ear
Weber Test: Lateralizes to unaffected ear

Rinne Test: Air conduction longer than bone conduction in
affected ear
Weber Test: Lateralizes to affected ear

Rinne Test: Bone conduction longer than air conduction in
unaffected ear
Weber Test: Lateralizes to affected ear

Rinne Test: Air conduction longer than bone conduction in
affected ear
Weber Test: Lateralizes to unaffected ear

Answer 1

Rinne Test: Bone conduction longer than air conduction in
affected ear (patolojik)
Weber Test: Lateralizes to affected ear. (conductive)

Info of Rinne: One normally should have air> bone in terms of conduction. Rinne + ise normal işitme vardır. Rinne - patolojiktir.

Info of weber: Kişi normalde bu test esnasında titreşimi ortada duyar. Conductive –> lat to affected ear. Sensorineural–> unaffected ear

Question 2

A male patient admitted to the emergency room with acute fever, severe headache, vomiting and altered mental status. The patient was 45 years old and he had no underlying chronical disease. In physical examination, body temperature was 37.9 C and the nuchal rigidity was found. White blood cell count of cerebrospinal fluid was 200 cells/mm3 (predominately lymphocytes) with normal levels of protein and glucose. Which is correct about causative microorganism of this infection?

Borrelia burgdorferi
Listeria monocytogenes
Neisseria meningitidis
Enterovirus

Answer 2

Enterovirus.

viral infection in CSF: WBC 25- 2000, lymphocytes
Bacterial infection in CSF: WBC 200- 20.000, Polymorphonuclear leukocytes

Nuchal rigidity–> ense sertliği. Menenjit!

Question 3

Which syndrome is a prototype of hypotonic / hyperkinetic extrapyramidal system disorder?

Spinocerebellar ataxia
Parkinson’s disease
Huntington’s disease
Alzheimer’s disease
Beriberi

Answer 3

Huntington’s disease

İnfo: Huntington’s disease elicits hypotonic and hyperkinetic syndrome (chorea). Alzheimer’s disease is characterized by memory impairment basically. Beriberi (B1) is caused by vitamin deficiency and does not cause a movement disorder. Spinocerebellar ataxia is another neurodegenerative disorders causing hypotonia with no abnormal movement. Parkinson’s disease causes a hypertonic hypokinetic extrapyramidal disorder.

PARKINSON IS EXTRAPYRAMIDAL

Question 4

On which physiologic process of pain do antidepressants not have effect?

Modulation
Perception
Transmission
Transduction

Answer 4

Transduction

Transduction phase occurs at free nerve endings, anti depressants have effects on altering the neurotransmitter /receptor intensity starting from second line neurons, thus sparing this phase.

Question 5

Clumsy, staggering movements with a wide-based gait with tendency to fall to the affected side can be seen in which of the following condition?

Neuropathic gait
Cerebellar ataxic gait
Myopathic gait
Parkinsonian gait
Spastic gait

Answer 5

Cerebellar ataxic gait

Question 6

Which accompanied sign(s) given below, do(es) help you to localize the lesion level of corticospinal tract lesion?

A) An association of upper motor neuron type quadriparesis and a sensory loss below the neck indicates a lesion at cervical spinal cord

B) An association of ipsilateral cranial nerve involvement and contralateral corticospinal tract lesion indicates a lesion at thalamus

C) An association of contralateral cranial nerve III involvement and ipsilateral corticospinal tract lesion indicates a lesion at the midbrain level

Answer 6

A) An association of upper motor neuron type quadriparesis and a sensory loss below the neck indicates a lesion at cervical spinal cord

B–> Brain stem.

C–> contralateral değil. Midbrain doğru

Info: An association of ipsilateral cranial nerve involvement and contralateral corticospinal tract lesion indicates a lesion at brainstem depending on the nuclear localization of the specific CN, such as; CN 3, 4, 5propr: midbrain; CN5touch, 6,7: pons; junction: CN 8; CN 9,10,11,12: bulbus.

Spinal cord lesions cause Upper motor nerve type paraparesis (at thoracal level) or quadriparesis (at cervical level) in association with sphincter abnormalities and sensory loss indicating the lesion level

Question 7

Which of the following signs and symptoms is the least likely to be associated with acute somatic pain?

Diaphoresis
Elevated blood pressure
Itching
Increased heart rate
Peripheral vasoconstriction

Answer 7

Itching.

The other four are associated with acute visceral or peripheral pain. But itching is related with chronic and neuropathic pain.

Question 8

What is the most important drainage way of humor aqueous?

Through evoporation
Through the trabecular meshwork into the canal of Schlem
Through lacrimation
Through the uveo scleral pathway

Answer 8

Through the trabecular meshwork into the canal of Schlem

Question 9

Which of the following statements about clinical phenotypes of multiple sclerosis (MS) is not correct?

Approximately 80%–90% of MS cases begin as a relapsing disease characterized by acute neurological events referable to focal inflammatory lesions.

Relapsing form of the disease is associated with a better prognosis than progressive disease.

The minimum duration for a relapse has been arbitrarily established at 15 minutes.

MS relapses are defined as the acute or subacute onset of clinical dysfunction, usually reaching its peak in days to several weeks, followed by a remission during which the symptoms and signs usually resolve partially or completely.

Answer 9

'’The minimum duration for a relapse has been arbitrarily established at 15 minutes.’’ is wrong as it is not 15 mins but 24 hours.

Other information are correct! (Diğerlerini kesinlikle iyi oku)

Question 10

Which of the following correctly fills in the blank?
Deep tendon reflexes are ………………………

decreased in cerebellar lesion
decreased in extrapyramidal disorders
increased in lower motor neuron lesion
decreased in upper motor neuron lesion

Answer 10

decreased in cerebellar lesion. (btw, it is ipsilateral!)

extrapyramidal disorders have no effect. Decreased in lower motor neuron lesion increased in upper motor neuron lesion

Question 11

Which one of the following can not be the result of eustachian tube disfunction?

mastoiditis
cholesteatoma
serous otitis media
otitis externa

Answer 11

otitis externa

Info: Mastoiditis–> infection of mastoid process. Mostly due to otitis media.
Cholesteatoma–> A skin lined cyst that begins at the margin of the eardrum and invades the middle ear and mastoid.

Question 12

A patient presents with difficulty walking, which has been worsening over the past few days. He states that his legs initially became weak, but now his arms seem
weak as well. Sensation is intact. He has areflexia. The cerebrospinal fluid (CSF) protein level is high, but the CSF white blood cell count is normal. Which of the following diagnoses should be considered?

Transverse myelitis
Cervical spondylosis
Spinal cord compression
Acute inflammatory demyelinating polyradiculoneuropathy

Answer 12

Acute inflammatory demyelinating polyradiculoneuropathy (Aka guillan barre.)

In GBS, CSF protein level is high, but the CSF white blood cell count is norma

Question 13

When trying to provide relief for your patient’s nausea besides suffering from migraine attacks, you face the dilemma that she might not be able to keep anything down if taken orally. You therefore decide to give her an i.m. injection of diphenhydramine, and write her a prescription for a drug with a similar mechanism of action that is available in a suppository formulation. Which of the following medications would you prescribe for this patient?

Rizatriptan
Promethazine
Ergotamine
Morphine

Answer 13

Promethazine

Feedback: This is a drug with anti-emetic properties that blocks H1 receptors (as well as weak antagonism of dopamine receptors). It is available in a rectal suppository formulation that is useful when the patient is likely to regurgitate any drug given orally before it can be absorbed. This was a “think outside the box” type question, since this drug was emphasized in antinausea medications besides first line drug, metoclopramide, used during migraine attacks.

Question 14

Romberg sign is indicative of which lesion?

Cerebellar lesion
Dorsal column lesion
Vestibular system lesion
Extrapyramidal system lesion

Answer 14

Dorsal column lesion

Info: The Romberg sign means the loss of balance only during eyes closed. The visual system compensates the impaired position sensation relayed through the dorsal column. Therefore, when the eyes are closed the patient loses her/his balance, but can stand almost normally when their eyes are open

Question 15

Which of the following is the Grade III glial tumor according to WHO classification of tumors of the central nervous system?

Meningioma
Anaplastic astrocytoma
Diffuse astrocytoma
Glioblastoma multiforme
Pilocytic astrocytoma

Answer 15

Anaplastic astrocytoma

Feedback: Normally, astrocytes are responsible for a variety of roles, including providing nutrients to neurons, maintaining the blood-brain barrier and modulating neurotransmission.

Anaplastic astrocytomas often develop in the cerebral hemispheres of the brain, but may occur in almost any area of the central nervous system.

Anaplastic astrocytomas are a specific type of astrocytoma, and also belong to the broader category of gliomas – tumors that arise from glial cells. For this reason, anaplastic astrocytomas (grade III) may also be called a “grade III glioma” or “high-grade glioma”

Question 16

A patient suffering from a seizure disorder is diagnosed by EEG to be suffering from a type of generalized seizure known to be caused by the abnormal activation of thalamic T-type Ca channels that produce a neuronal bursting activity that interferes with the transmission of sensory signals to the cortex necessary for staying awake. This abnormal bursting pattern results in a state of unconsciousness or sleep. Which of the following drugs is selective for treating this particular seizure disorder because it selectively blocks the channel subtype responsible for causing it?

Carbamazepine
Pregabalin
Ethosuximide
Lamotrigine

Answer 16

Ethosuximide

Feedback: Ethosuximide is a selective T-type Ca channel blocker. This is what makes it a drug specifically effective against absence seizures (it is not indicated for other types of seizures).

Very close to the best answer: Lamotrigine’s major therapeutic effect appears to be block of Na channels. However there is evidence that it can also block N- and P/Q type Ca channels as well. Although it has some efficacy against absence attacks, it is not known to block T-type Ca channels. Since it’s not a selective T-type Ca channel blocker, it’s not the best answer.

Question 17

Which of the following features for ischemic injury in brain are correct? (Choose as many as required)

A) Cells most resistant to ischemia are hippocampus pyramidal cells, cerebellar purkinje cells and cerebral cortex cells

B) The infarcts in white matter is generally hemorrhagic infarction while the gray matter infarctions are usually pale

C) Irreversible changes develop 6-8 minutes after cerebral ischemia

D) Cyanide poisoning is an example of anemic hypoxia

E) Mild cases of ischemic encephalopathy may show temporary postischemic confusion and then complete recovery while in severe cerebral ischemia extensive brain necrosis can be observed

Answer 17

C and E are correct, others are not.

A–> Cells most SUSCEPTIBLE to ischemia are hippocampus pyramidal cells, cerebellar purkinje cells and cerebral cortex cells

B–> The infarcts in white matter is generally PALE infarction while the gray matter infarctions are usually HEMORRHAGIC

D–> Cyanide poisoning is an example of HISTOTOXİC ANEMIA

Question 18

Which of the following statements regarding hydrocephalus are correct? (Choose as many as required)

A) Excess CSF production is likely to produce a communicating, nonobstructive hydrocephalus.

B) Choroid plexus tumor can cause hydrocephaly by increasing CSF production.

C) Imbalance between production and absorption of CSF leading to accumulation of fluid in the ventricular system leading to elevation of intracranial pressure.

D) Noncommunicating hydrocephalus is usually caused by obstruction of the CSF pathways due to the presence of intracranial mass lesions

E) In adult population, hydrocephalus causes enlargement of the head

Answer 18

All except E are true. (Diğer cevapları öğren)

E–> Not adult, pediatric.

Question 19

What is the name given to “the different size of the pupils of the two eyes”?

Answer 19

Anisocoria

Question 20

A 33 years-old woman presents to her primary care physician with headache, nausea, and visual disturbances. The patient was in her usual state of health until yesterday, when she experienced a pulsatile bilateral headache that caused her to have one episode of emesis (vomiting). Her headache is accompanied by seeing a shimmering light that distorts her vision, photophobia, and phonophobia. Medical history is unremarkable, and the patient recently began menses. Ibuprofen and acetaminophen have not improved her symptoms. Neurologic examination is unremarkable. What’s the diagnosis?

Cluster headache
Idiopathic stabbing headache
Migraine
Tension type headache
Primary exertional headache

Answer 20

Migraine

Migraine is generally an episodic headache with certain associated features, such as sensitivity to light, sound or movement, and often with nausea or vomiting accompanying the headache

Question 21

Which of the following is a bacterial cell wall-inhibiting antibiotic that could adequately cross the blood brain barrier and be used to treat a 40 years old patient admitted to the emergency department with symptoms of fever, nausea, neck stiffness and severe headache? (The patient was diagnosed with bacterial meningitis caused by Haemophilus influenza.)

Ceftriaxone (3rd generation cephalosporin)
Streptomycin
Clofazimine
Cephalexin (1st generation cephalosporin)

Answer 21

Ceftriaxone (3rd generation cephalosporin)

3rd generation cephalosporins are commonly used as drugs of choice for treating bacterial meningitis.

Question 22

Which of the followings are the prominent symptoms of carotid artery syndromes? (Choose as many as required)

A) Gaze preference toward the side of the lesion
B) Ataxia
C) Homonym hemianopsia
D) Contralateral hemiparesis
E) Diplopia

Answer 22

A,C,D are the answer.

Ataxia and diplopia are prominent symptoms of vertebrobasilar system syndromes

Question 23

What are the most two common intracranial locations of meningiomas?

Intraventricular – tuberculum sella
Convexity – orbital
Parasagittal – convexity
Pineal region – olfactory groove
Foramen magnum – tentorial

Answer 23

Parasagittal – convexity

Info: The most common intracranial locations in order of highest occurrence are parasagittal,convexity, tuberculum sella, sphenoid wing, olfactory groove.

Question 24

Select the appropriate condition for this patient:
Patient with severe low back pain and motor weakness, sensory loss, or pain in one or more, commonly both legs and saddle anesthesia (unable to feel anything in the
body areas that sit on a saddle) with recent onset of bladder dysfunction indicates ………….?

Cauda equina syndrome
Brown-Sequard syndrome
Wallenberg syndrome
Anterior spinal artery syndrome
Syringomyelia

Answer 24

Cauda equina syndrome

Cauda Equina Syndrome occurs when the nerve roots of the
cauda equina are compressed and disrupt motor and sensory function to the lower extremities and bladder

Question 25

Which of the following features regarding acute hypertensive encephalopathy are correct? (Choose as many as required)

A) Most of the patients have spontaneous recovery

B) Can be presented with headache, confusion, vomiting and sometimes coma

C) Edematous brain is heavier than normal in gross examination

D) In microscopy petechiae and arteriolar necrosis in gray and white matter, fibrinoid necrosis of the vessel wall is observed

E) Characterized by diffuse cerebral dysfunction

Answer 25

Everything except A is correct ( A) Most of the patients have spontaneous recovery)

Diğerlerini oku ve öğren.

Question 26

Which of the following features regarding Alzheimer’s disease are correct? (Choose as many as required)

A)Amyloid angiopathy of the cortical and subarachnoid arteries typical for Alzheimer’s disease

B) The disease has a rapid and mild decrease in mental abilities

C) Senile/Neuritic plaques and neurofibrillary tangles are the histological manifestations

D) Cortical symmetrical atrophy, sulcus enlargement and neuron loss and compensatory ventricular enlargement is observed in gross examination

E) Not common before the age of 50

Answer 26

All except B are correct.

Diğerlerini oku ve öğren.

Question 27

Which can be the most possible cause of a tremor starting with kinetic action and occurs during entire movement trajectory?

Cerebellar ataxia
Parkinson’s disease
Dystonic tremor
Physiological tremor
Essential tremor

Answer 27

Essential tremor is a simple kinetic tremor occurs during entire movement trajectory

Question 28

In which mechanism is vitamin B12 and folate involved in relation to DNA synthesis?

sulphuration
methylation
antioxydation
decarboxylation
glycalisation

Answer 28

methylation

Question 29

A 38-year-old male construction worker fell from the 3rd floor of a construction site. He initially lost consciousness. At the emergency department, the patient regained
consciousness and again deteriorated. CT scan revealed a biconvex hyperdensity on the left temporoparietal region. The patient’s findings are most consistent with an injury of which artery?

Anterior cerebral artery
Ophthalmic artery
Middle meningeal artery
Left basilar artery
Temporal artery

Answer 29

Middle meningeal artery

Feedback: About 70 to 80% of epidural hematomas are in the temporoparietal region. A skull fracture crosses the middle meningeal artery or its dural branches. Occipital and frontal hematomas each occur in about 10% of cases. Most epidural hematomas are arterial but one-third are venous.
These usually occur at the posterior fossa or parietooccipital
region. They can cause subalpine herniation or midline shift.

Question 30

A homonymous hemianopia (loss of vision on either right or left side of both eyes) is seen in ……..

optic chiasm lesions
optic nerve lesions
subthalamic lesions
retrochiasmal lesions

Answer 30

Retrochiasmal lesions mean those between chiasm and the
occipital lobe in the visual system. This location causes a
homonymous hemianopia (loss of vision on either right or left side of both eyes)

Question 31

Which of the following statements about radiological planes are correct? (Choose as many as required)

A) A sagittal plane divides the body into sinister and dexter (left and right) portions.

B) A transvers plane divides the body into cranial and caudal (head and tail) portions.

C) A tranvers plane is also known as an axial plane

D) A frontal plane is also known as parasagittal plane

E) A coronal plane divides the body into dorsal and ventral (posterior and anterior) portions

Answer 31

All except D is correct.

D–> A frontal plane is also known as CORONAL plane

Question 32

If a patient displays a festination of gait in anteflexed posture, which system is most likely affected?

Cerebellar system
Pyramidal system
Extrapyramidal system
Sensory system

Answer 32

Extrapyramidal system

Festination of gait in anteflexed posture is a characteristics of extrapyramidal disorders, specifically of parkinsonism.

Question 33

Which of the below agents would be a good choice for producing the regional block for a 40 year old male with a history of poorly controlled hypertension, type II diabetes, and angina, which preclude general anesthesia?

Tetracaine
Lidocaine
Chloroprocaine
Procaine

Answer 33

Lidocaine

Lidocaine is an amide type local anesthetic that is commonly used (combined with epinephrine) to produce a block of the brachial plexus. The other drugs are ester type LAs (notice that ester type LAs do not have “i” before “caine” suffix).

Question 34

What is the Glasgow Coma Scale score of a patient with eye opening to pain; best motor response flexor posturing; best verbal response inappropriate words?

8
5
15
11

Answer 34

8

eye opening to pain 2; best motor response flexor posturing 3; best verbal response inappropriate words 3

Question 35

Which one is the sign of preproliferative diabetic retinopathy?

Intraretinal microabnormalities
Microaneurysms
Hard exudates
Neovascularization on or within one disc diameter of the optic nerve head or retina

Answer 35

Intraretinal microabnormalities

Question 36

Which of the visual pathway damages listed below, cause hemianopsia type (right or left half of the visual field) visual field defect? (Choose as many as required)

A) Optic nerve
B) Optic chiasm
C) Occipital cortex
D) Optic radiatio
E) Optic tracts

Answer 36

B and E

Axons from ganglion cells cross the retina as the nerve-fiber layer and become the optic nerve.
Nerve fibres from the nasal side of each retina CROSS-OVER to the opposite side. Nerve fibres from the temporal side of DO NOT CROSS but pass into optic tracts of the same side.
Optic tracts originate from the postero-lateral angle of the optic chiasma and connect to the lateral geniculate body on the posterior of the thalamus. They consist of the temporal fibres of the same side and the nasal fibres of the opposite side. The fibres of the optic tracts end in the lateral geniculate bodies (LGB) and new fibres of the optic radiations originate from them. Optic radiations extend from the LGB to the visual cortex and consist of the axons of third order neurons of visual pathway. Occipital cortex are situated above and below the calcarine fissures in the occipital lobes extending up to the occipital poles.

Question 37

You may tend to drink a lot of coffee the night before an exam. The coffee helps you stay more alert and attentive late into the night. Which of the following part of your brain is stimulated by caffeine?

Medulla oblongata
Limbic system
Reticular formation
Thalamus

Answer 37

Reticular formation

Stimulants, such as amphetamines and caffeine, increase the activity of the reticular formation (reticulospinal pathway) and are usually used or abused to stimulate the central nervous system (CNS) and maintain wakefulness.

Question 38

What is the most common pattern of muscle weakness in myopathies?

Proximal arm and distal leg weakness
Distal arm and proximal leg weakness
Proximal arm and proximal leg weakness
Distal arm and distal leg weakness

Answer 38

Proximal arm and proximal leg weakness

Weakness is symmetrical and affects the proximal more than distal muscles of the arms and legs.

Question 39

In a 42-year-old male patient, a sharply demarcated mass containing calcification is detected in the frontotemporal area in cranial imaging performed due to a newly developed epileptic attack. In the histological examination of the mass fried egg-like cells, fine anastomosing vascular structures is observed in thin fibrovascular stroma. What is the possible diagnosis for this tumor?

Ependymoma
Glioblastoma
Meningioma
Oligodendroglioma
Pilocytic astrocytoma

Answer 39

Oligodendroglioma

Oligodendroglioma–> Calcification and sharply demarcation is generally observed in the radiology of oligodendrogliomas and the patient can be presented with epiteptic attacks. In the histological examination of the oligodendrogliomas fried egg-like cells (oligodendrocyte-like), fine anastomosing vascular structures is observed in thin fibrovascular stroma is observed

Pilocytic astrocytoma–> In pylocytic astrocytoma Long thin, GFAP-positive bipolar cells with hair-like extensions, rosenthal fibrils and eosinophilic granular bodies are observed

Glioblastoma–> Mitosis and necrosis are the characteristics of glioblastomas

Ependymoma–> Ependymomas show ependymal tubulary like structures in the histology and dysembryoblastic neuroepithelial tumor has floathing neurons.

Meningioma–> they can also have calcification but they are extraaxial tumors with meningothelial cell proliferation.

Question 40

Which of the following is correct concerning central nervous system infections? (NOT: Doğru cevap niye doğru biliyorum ama yanlışlar neden yanlış bilmiyorum)

A) Meningitis is characterized by the onset of fever, headache, neck stiffness, and photophobia over a period of hours to days.

B) Haemophilus influenzae type B used to be an important cause in young children, but the widespread use of the conjugate polysaccharide vaccine has greatly decreased its incidence.

C) The most common bacterial cause of acute meningitis overall is S. pneumoniae.

D) Microbiologic diagnosis of bacterial infections rarely is made using Gram stain and culture of spinal fluid and blood.

E) Polymerase chain reaction (PCR) assays are not useful.

F) Viral meningitis is often called aseptic meningitis because routine cultures for bacterial pathogens are negative.

Answer 40

F) Viral meningitis is often called aseptic meningitis because routine cultures for bacterial pathogens are negative.

Microbiologic diagnosis of bacterial infections is frequently made using Gram stain and culture of spinal fluid and blood. Polymerase chain reaction (PCR) assays are also useful.

Question 41

Which of the following features related to muscular dystrophies are correct? (Choose as many as required)

A) Becker muscular dystrophy results from the absence of the dystrophin gene and there is dystrophin deficiency in Duchenne muscular dystrophy.

B) Dystrophin is a protein located in the musculoskeletal structure that stabilizes muscle membrane functions and in its absence, the tendency to muscle damage increases.

C) Ocular and bulbar muscles are effected which leads to visual problems.

D) In Duchenne muscular dystrophy the first muscles involved are the pelvic and pectoral muscles and pseudohypertrophies are observed which is particularly prominent in the gastrocnemius muscles.

E) Duchenne muscular dystrophy is the most common type of muscular dystrophies and shows X-linked recessive inheritance.

Answer 41

B, D and E are correct.

UNUTMA–> Muscle distrophylerde ocular ve bulbar kaslar etkilenmez.

Hangi hastalılarda etkilenir–> Myasthenia gravis, Guillan barre (başka varsa onları da ekle)

Question 42

Which of the following features regarding demyelinating diseases are correct? (Choose as many as required)

A) Clinical deficit is due to a defect in the transmission of electrical impulses along the axon with loss of myelin

B) The axon is relatively protected in demyelinating diseases

C) The signs are associated with the breakdown of myelin

D) Oligodendrocytes is the only cause of the breakdown

E) Multiple sclerosis is one of the most common demyelination
diseases

Answer 42

D hariç hepsi doğru

Info: Multiple Sclerosis (MS), devic’s disease (Neuromyelitis optica), acute disseminated encephalomyelitis (ADEM), acute necrotizing hemorrhagic encephalomyelitis, central pontine myelinosis, Marchiafava-Bignami disease and progressive
massive encephalopathy are among demyelinating diseases but one of the most common form of the disease is MS.

Question 43

Which of the following neurotransmitter/substance has excitatory effect in transmission of pain?

GABA
Glutamate
Alpha-2 agonists
Glycine

Answer 43

Glutamate

Feedback: Glutamate is an excitator neurotransmitter, both in pathways of pain and central nervous system. Glysine, GABA, alpha-2 agonists have inhibitory roles.

Question 44

For some antimicrobial agents, time spent above the MIC is essential for effective killing. These antibiotics are called as time-dependent killers. Among the drugs listed below which has time-dependent killing activity?

Daptomycin
Aminoglycoside
Vancomycin
Fluoroquinolone

Answer 44

Vancomycin

Question 45

Which of the followings is not a clinical feature of “temporal seizures”?

A rising epigastric sensation
Oro-alimentary automatisms
Deja vu
Legs kick, cycle, dance movements
Olfactory, gustatory hallucinations

Answer 45

Legs kick, cycle, dance movements

This is a frontal lobe seizure feature

Question 46

Which of the following features are correct for a “simple febrile seizure”? (Choose as many as required)

A) Generalized at onset
B) Occurs in a neurologically and developmentally normal child
C) Lasts less than 15 minutes
D) Occurs only once in a 24-hour period
E) Needs long term therapy with daily antiepileptic drugs
F) The child usually has some preexisting neurological challenges
G) The prognosis of children with simple febrile seizures is excellent

Answer 46

E, F hariç hepsi doğru

Feedback: Since simple febrile seizures are brief and the outcome is benign, most children require no treatment.

Only rectal diazepam can be administered during a seizure to abort a prolonged convulsion; it is appropriate to provide a “rescue medication” for children with a history of prolonged febrile seizures, but not a long term daily treatment with antiseizure medications. Since antiseizure medications have side effects and children with febrile seizures have an excellent prognosis, daily antiseizure
medication to prevent febrile seizures is not recommended

Feedback 2: Simple febrile seizures occur in otherwise healthy and normal children. Complex febrile seizures occur in children having preexisting neurological challenges.

Question 47

Which of the following treatment approaches would not be reasonable for a patient with myasthenia gravis if the disease progresses too far, the number of receptors remaining may be insufficient to produce an adequate end plate potentials (EPPs)?

Inhibit antibody production with immunosuppressant drugs
Increase the dose of anticholinesterase drug being used
Surgically remove thymus
Remove circulating antibodies by plasma exchange

Answer 47

Increase the dose of anticholinesterase drug being used

Info: Anticholinesterase drugs will not be effective as the number of receptors remaining become insufficient to produce an adequate EPPs. Alternative approaches are to remove circulating antibodies (Abs) by plasma exchange (transiently effective) or to inhibit Ab production with immunosuppressant drugs (e.g. prednisolone, azathioprine, mycophenolate, cyclosporine and tacrolimus) or thymectomy.

Question 48

Which of the followings are correct about penumbra and ischemic core in acute ischemic stroke? (Choose as many as required)

A) Tissue in the penumbra can remain viable for several hours because of marginal tissue perfusion

B) Penumbra and core are presumed to die within minutes of stroke onset and are not salvageable with any treatment options

C) Affected regions with cerebral blood flow of lower than 10 mL/100 g of tissue/min are referred to collectively as the core

D) Zones of decreased or marginal perfusion (cerebral blood flow < 25 mL/100g of tissue/min) are collectively called the ischemic penumbra

Answer 48

All correct except B

Penumbra–> kan akımının azaldığı ama kalıcı hasarın henüz oluşmadığı çekirdek etrafındaki bölgedir. Kurtarılabilir bölge de denebilir.

Ischemic core–> Kurtarılamaz bölge, kan akışı geri gelse bile.

Question 49

A preterm infant is found to have a cystic lesion measuring 4 cm in diameter over his lumbosacral spine. Further physical examination reveals intact neurological assessment apart from decreased lower limb tone and reflexes. Which of the following is the most likely diagnosis of the patient in the figure below?

Dermoid cyst
Spina bifida occulta
Anencephaly
Myelomeningocele
Type I Arnold-Chiari malformation

Answer 49

Myelomeningocele

Info: Neural tube defects are a spectrum of congenital anomalies which include cranial defects and open or closed spinal dysraphism. Open spinal dysraphism or spina bifida aperta are visible lesions and include several malformations; one of them is myelomeningocele.

Closed spinal dysraphism and spina bifida occulta are non visible lesions with no obvious signs recognized during physical examination. Patients often go asymptomatic with no future complications and usually do not require treatments.

Myelomeningocele could be associated with other anomalies such as Type II Arnold-Chiari malformation. Dermoid cyst, terminal myelocystocele, sacral agenesis, and sacrococcygeal teratomas are another differential diagnoses of myelomeningocele.

Question 50

Consciousness is often described as having two main components: awareness and wakefulness. Which of the following anatomical structures are responsible for them?

Parietooccipital cortex - brain stem
Frontoparietal cortex - brain stem
Cingulate gyrus - mesencephalon
Thalamus - medulla spinalis
Cerebellum - brain stem

Answer 50

Frontoparietal cortex - brain stem

Question 51

Which of the associations below is correct?

Lower motor neuron and rigidity
Lower motor neuron and increased muscle tone
Upper motor neuron lesion and spasticity
Upper motor neuron and atrophy

Answer 51

Upper motor neuron lesion and spasticity

Upper motor neuron lesion causes spasticity type increased motor tone, whilst lower motor neuron causes atrophy and decreased motor tone.

Question 52

Which is the most common predisposing condition for cranial subdural empyema and epidural abscess?

Paranasal sinusitis
Metastatic infection
Head trauma
Epidural injections

Answer 52

Paranasal sinusitis

Question 53

What is the major component of inhibitory effects of general anesthetics on central nervous system pharmacology?

Blockade of K channels
Enhancement of GABA effects
Inhibition of glycine effects
Activation of NDMA receptors

Answer 53

Enhancement of GABA effects

Info: GABA is the major inhibitory neurotransmitter (NT) in the CNS. Enhancing its effects will result in symptoms ranging from sedation to surgical anesthesia . Activation of NMDA (an excitatory NT) would not produce anesthesia, nor would blocking K channels (which would most likely increase excitablity). Blocking the effects of glycine, an inhibitory NT would also not make sense as a mechanism of general anesthesia.

Question 54

Which of the following informations about spinal muscular atrophy (SMA) are correct? (Choose as many as required)

AA) Heredity pattern of SMA is autosomal dominant.

A) SMA classified into clinical subtypes based on mutation type in the SMN1 gene.

B) Clinical findings occur as a result of irreversible degeneration of anterior horn cells.

C) SMA occurs mostly as a result of homozygous deletions in the SMN1 gene.

D) The severity of the disease is inversely proportional to the copy number of the SMN2 gene.

E) There are genetic-based treatment options related to SMA

Answer 54

AA and A is incorrect. Others are correct.

Question 55

Which statements regarding suprasellar brain tumors in children are correct? (Choose as many as required)

A) Suprasellar region tumors and 3rd ventricular region tumors may manifest initially as neuroendocrine deficits.

B) Medulloblastoma is the most common suprasellar tumor in children.

C) Majority of the optic pathway gliomas occur in children with neurofibromatosis type 1.

D) Infants with suprasellar tumors tend to exhibit relatively nonspecific symptoms, such as vomiting, irritability, macrocephaly, failure to thrive, loss of developmental milestones.

E) Supratentorial tumors predominate during the 1st year of life and after 10 years of age.

Answer 55

All except B is correct.

Medulloblastoma is a malignant embryonal tumor of the posterior
fossa (cerebellar hemispheres &vermis) so it locates at the
infratentorial region. It is thought to be the most common malignant
embriyonal brain tumor in children (accounts for 90% of embryonal
CNS tumors) and comprises up to 20% of all pediatric brain tumors

Question 56

Which is consistent with a diagnosis of peripheral vertigo?

Multidirectional nystagmus
Nausea, vomiting, unidirectional nystagmus, and tinnitus
Nystagmus not related to head position
Minimal nausea

Answer 56

Nausea, vomiting, unidirectional nystagmus, and tinnitus

Info: Peripheral vertigo usually has prominent nausea and vomiting,
inhibition of nystagmus by ocular fixation, and unidirectional
nystagmus aggravated by head position (Hallpike maneuver).
Central vertigo often has dysarthria, facial numbness, or leg
weakness, which are brainstem signs.
Central vertigo has minimal nausea, nystagmus not related to
head position, and nystagmus which is multi-directional.
Vertigo caused by a dysfunction of the vestibular system or
inner ear, which is composed of the semicircular canals, the
vestibule, and the vestibular nerve is called “peripheral,”
“otologic” or “vestibular” vertigo. The most common cause is
benign paroxysmal positional vertigo. Other causes include
Ménière’s disease, superior canal dehiscence syndrome,
labyrinthitis, and visual vertigo. The common cold, influenza,
and bacterial infections may cause transient vertigo if it
involves the inner ear, as may aminoglycosides, or physical
trauma. Motion sickness is also a cause of peripheral vertigo.
Patients with peripheral vertigo typically present with mild to
moderate imbalance, nausea, vomiting, hearing loss, tinnitus,
and pain in the ear. Also, lesions of the internal auditory canal
may be associated with facial weakness on the same side.
Acute vertigo as a result of a peripheral lesion usually improves
in a short period of time (days to weeks).

Question 57

Please localize the patient’s lesion site according to the condition given below: Left hemiparesis with a Babinski sign + peripheral type right facial paresis

Right bulbus
Right pons
Right internal capsule
Right midbrain

Answer 57

Right pons

Left hemiparesis with a Babinski sign + peripheral type Right facial
paresis localize the patient’s lesion to the brainstem level (crossed
hemiparesis); since the facial nerve lesion is lower motor neuron
type and its nucleus is placed at the level of pons, the site has to be
at Right pons.

Question 58

Which part of the ear is affected in sensorineural hearing loss?

Tympanic membrane
Ossicles
Eustachian tube
Cochlea
External auditory canal

Answer 58

Cochlea

Sensorineural hearing loss result from cochlear abnormalities and/or an abnormality of the vestibulocochlear nerve or central auditory pathways.

Question 59

Please indicate true comments among the following choices regarding “neostriatum consisting from caudate and putamen”. (Choose as many as required)

projects mainly to globus pallidus

receives cortical afferents

is part of the pyramidal system

controlling muscle tone

is directly linked to olfactory system

is part of cholinergic pathway

Answer 59

The first 2 are correct only.

Info: Neostriatum consisting from caudate and putamen, receives
cortical afferents and projects mainly to globus pallidus.
Neostriatum consisting from caudate and putamen is not part of
either pyramidal system or cholinergic pathway; and is not directly
linked to olfactory system.

Question 60

A mass with cystic nodule including a solid area is detected in the cerebellum on radiological examination in a 9-year old male patient. Long thin, GFAP-positive bipolar cells with hair-like extensions and rosenthal fibrils are seen in the histopathological examination of the resection material.
What is the possible diagnosis for this tumor which has no necrosis and mitosis?

Ependymoma
Dysembryoblastic neuroepithelial tumor
Glioblastoma
Meningioma
Pilocytic astrocytoma

Answer 60

Pilocytic astrocytoma

Long thin, GFAP-positive bipolar cells with hair-like extensions, rosenthal fibrils and eosinophilic granular bodies are the histological features of pilocytic astrocytoma which is mostly seen in young age -in cerebellum- and presented with cystic mural nodule. Mitosis and necrosis is not observed in pylocytic astrocytoma while glioblastomas
have. Ependymomas also seen mostly in childhood but there is ependymal tubulary like structures in the histology and dysembryoblastic neuroepithelial tumor has floathing neurons. Meningiomas are mostly adulthood tumors with meningothelial cell proliferation.

Question 61

A-1-month old female infant presents to the emergency department with a fever, poor feeding, and a bulging fontanelle. During her physical examination, she begins to convulse. A Gram stain of the CSF reveals Gram positive cocci. Which of the following organisms is the most likely causal agent?

Klebsiella pneumoniae
Streptococcus agalactiae
Haemophilus influenzae
Neisseria meningitidis
Escherichia coli

Answer 61

S.agalactiae is the answer. The CSF shows Gram positive
cocci.

Question 62

Cerebellar signs include which of the followings? (Choose as many as required)

Ipsilateral hemiparesis
Chorea
Ataxia
Dysmetria

Answer 62

Ataxia and dysmetria

Cerebellar lesions cause ipsilateral dysmetria, hypotonus,
dyssynergia, dysdiadokokinesia, ataxia.

(Diğer ikisi neden olmadı bak)

Question 63

Choose the functions of the extrapyramidal system among items below. (Choose as many as required)

Olfactory sensation
Vibrational sensation
Spasticity of muscle tone
Control of muscle tone
Coordination of movements

Answer 63

Control of muscle tone and Coordination of movements

On the other hand, extrapyramidal system does not involve in
sensation of vibration or olfaction. The muscle tone increase in
extrapyramidal system disorders is either leadpipe type or cogwheel
type rigidity; not spastic type

Question 64

If you see fever and skin rush with headache, what is the most possible diagnosis?

Pituitary apoplexy
Subarachnoid hemorraghe
Epidural hematoma
Meningitis

Answer 64

Fever and skin rush may address to an underlying problem of
menenjitis in a patient with headache

Question 65

Localize the patient’s lesion site according to the condition given below: Right hemiparesis with Babinski sign + aphasia of Wernicke’s type (in other terms fluent type aphasia or sensory type aphasia)

Left temporal
Left cerebellar
Left occipital
Left internal capsule

Answer 65

Left temporal

Feedback: Right upper motor neuron type hemiparesis indicates a contralateral
corticospinal lesion (meaning left corticospinal tract).
The sensory type of aphasia (or Wernicke type) accompanies to the
condition and this localizes the lesion site to neocortical level of
temporal lobe.
Wernicke’s area on the left has specialized in comprehension of
language that is among the higher cortical functions. Higher cortical
function abnormality indicates a neocortical involvement in the brain.

Question 66

Neglect is a localizing accompanying sign in patients with corticospinal tractus lesion, in favor of a lesion site in ……..

Major hemisphere (mostly left)
Minor hemisphere (mostly right)
Cerebellum
Ascending reticular activating system

Answer 66

Minor hemisphere (mostly right)

Feedback: Neglect accompanying a left “upper motor neuron type” hemiparesis
indicates a lesion in the minor hemisphere cortical lesion. A focal sign
of higher cognitive impairment is indicative of neocortical lesion
depending on the cortical site. For example if it is aphasia, the lesion
must be in the major hemisphere which the left hemisphere in majority
of people (over 90%)

Question 67

What’s the difference between upper motor neuron (UMN) and lower motor neuron (LMN) syndromes? Match the findings below with syndrome.

[A] Spastic paresis
[B] Flaccid paresis
[C] No or very mild atrophy
[D] Severe atrophy
[E] Increased deep tendon reflexes
[F] Absent deep tendon reflexes
[G] Fasiculation and fibrilation

Answer 67

UMN Spastic paresis
LMN Flaccid paresis
UMN No or very mild atrophy
LMN Severe atrophy
UMN Increased deep tendon reflexes
LMN Absent deep tendon reflexes
LMN Fasiculation and fibrilation

Question 68

Where in the following visual pathways is damaged, visual field loss occurs in the hemianopsia type (right or left half of the visual field) ?

Optic tracts
Occipital cortex
Optic nerve
Optic radiatio

Answer 68

Optic tracts

Feedback: Optic chiasm is a flat band-like structure lying above the pituitary
fossa.
Nerve fibres from the nasal side of each retina CROSS-OVER to the
opposite side at this site.
Nerve fibres from the temporal side of DO NOT CROSS but pass into
optic tracts of the same side.
Due to this crossing, visual field loss occurs in the form of
hemianopsia in both optic chiasma and damage to the optic tract,
which is the visual pathway that follows. However, while the damage
to the optic chiasm causes heteronym hemianopsia (bitemporal half
visual field loss), a homonym (half visual field loss on the same side in
both eyes) occurs in the optic tract damage.

Question 69

Which cranial nerve (CN) may be involved in a patient with diplopia?

CN 2
CN 6
CN 7
CN 9

Answer 69

6

Diplopia can be resulted lesion from the three possible CNs:
CN 3, 4, 6.

Question 70

Which of the following drugs would be contraindicated for a 17 year-old high school athlete with a history of asthma seeking a preventative medication for migraine headaches?

Valproate
Topiramate
Amitriptyline
Propranolol

Answer 70

Propranolol

Propranolol is NOT a good choice for this patient. Propranolol would
likely keep the patients’ heart rate down during exercise, and would
interfere with any beta-2 bronchodilator used to treat asthma

Question 71

Which of the following features related to the myopathies are correct? (Choose as many as required)

A) Lambert-Eaton Myasthenic Syndrome is caused by antibodies to acetylcholine receptors and can be fatal due to respiratory involvement.

B) Myastenia gravis is accompanied by thymoma in 15-20% of the patients.

C) Inclusion body myositis effects small muscles with asymmetrical involvement and there are clear vacuoles within the sarcolemma.

D) Myastenia gravis is a disease which is caused by voltage-gated calcium channel (VGCC) autoantibodies.

E) Heliotropic erythema of the upper eyelid and Gottron papules are caused by a disease associated autoantibodies against the endothelium of small arterioles.

Answer 71

B, C, E are correct.

Feedback: Heliotropic erythema of the upper eyelid and Gottron papules are
caused by a disease called dermatomyositis and associated
autoantibodies against the endothelium of small arterioles. Inclusion
body myositis effects small muscles with asymmetrical involvement
and there are clear vacuoles within the sarcolemma as well as amyloid
in these inclusions. Myastenia gravis is a disease which is caused by
caused by antibodies to acetylcholine receptors and can be fatal due
to respiratory involvement. Thymoma is seen in 15-20% of the patients
with myasthenia gravis and muscle weakness is evident in the late
hours of the day. While voltage-gated calcium channel (VGCC)
autoantibodies are observed in Lambert-Eaton Myasthenic Syndrome
an it is usually paraneoplastic.

Question 72

Which of the following statements is the correct definition of allodynia?

Red flare with nerve damage
Pain caused by stimuli that are usually not painful
Due to reflex sympathetic dystrophy
The ‘burning’ sensation of causalgia

Answer 72

The definition of allodynia is pain caused by stimuli that are
usually not painful.

Question 73

Which of the followings are the clinical manifestations of peripheral neuropathies? (Choose as many as required)

Neuropathy is named mononeuropathy if only one nerve is effected and if more than one it is named as polyneuropathy.

In axonal diseases, slowly progressing symmetrical loss of sensation often spreads in the form of gloves and socks.

Postural hypotension and constipation in the sensorial system

In motor deficits weakness is observed with reduced or absent deep tendon reflexes.

Asymmetric neurological deficits can be associated in neuropathies caused by vasculitis.

Answer 73

All except 3rd one are correct

Feedback: The findings vary depending on the type and cause of peripheral
neuropathy. For example in axonal diseases, slowly progressing
symmetrical loss of sensation often spreads in the form of gloves and
socks reflecting the injury of the distal axonal processes. Motor deficits
are presented with weakness and reduced or absent deep tendon
reflexes. Findings such as postural hypotension and constipation is
observed in deficits of the autonomic system. Moreover there may be
asymmetric neurological deficits. Since it may cause randomly
distributed multiple nerve involvement, especially in neuropathies
caused by vasculitis. In the clinical identification neuropathy is named
mononeuropathy if only one

Question 74

Which of the followings is correct about acute ischemic stroke management?

A) Non contrast head CT is not valuable for emergent exclusion of hemorrhage or mass lesions.

B) Recanalization purpose is to increase the ischemic core tissue.

C) Mechanical thrombectomy is an option for recanalization.

D) Time is not effective on treatment.

Answer 74

C) Mechanical thrombectomy is an option for recanalization.

Question 75

Which structure forms the outer blood retinal barrier?

Choriocapillaries
The retinal nerve fiber layer
Retinal blood vessels endothelium
The retinal pigment epithelium

Answer 75

Retinal blood vessels endothelium

Retinal blood vessels endothelium that are similar to cerebral blood
vessels maintain the inner blood-ocular barrier.

The retinal pigment epithelium maintains the outer blood–retinal
barrier.
Choriocapillaries supply outer third of the retina
Retinal nerve fibre layer consist of axons of the ganglion cell bodies

Question 76

Which tumor type is not among the common brain tumors in childhood?

Craniopharyngioma
Astrocytoma
Ependymoma
Medulloblastoma
Metastatic adenocarcinoma

Answer 76

Metastatic adenocarcinoma

Astrocytomas , medulloblastoma, ependymoma and
craniopharyngioma are among the most common brain tumor types in
children.
Majority of brain tumors are primary tumors in children, metastatic
adenocarcinoma is very rare/exceptional in pediatric age group

Question 77

Which vessel does not contribute the circle of Willis?

Posterior communicating artery
Basiller artery
Anterior cerebral artery
Posterior cerebral artery
Anterior communicating artery

Answer 77

Basiller artery

Question 78

You are investigating the intracellular effects of certain hormones and neurotransmitters on their respective receptors. After exposing a culture of cells to a catecholamine solution, you saw an increase in the intracellular calcium concentration. Stimulation of which of the following receptors would cause this?

α1-adrenergic
α2-adrenergic
β1-adrenergic
Dopaminergic-1 (D1)

Answer 78

α1-adrenergic

Catecholamines include epinephrine, norepinephrine, and dopamine. All of these receptors are G protein–coupled receptors (GPCRs), but only α1-adrenergic receptors cause an increase in the intracellular calcium concentration. Stimulation of this receptor releases the Gq
subunit, which in turn activates phospholipase C leading to inositol
triphosphate (IP3). One of the downstream effects of IP3 is to bind
calcium channels in the smooth endoplasmic reticulum to release
stored calcium and raise the intracellular calcium concentration.

Question 79

A 32-year-old man is brought to the emergency department after he had a fitting attack one hour ago. He reports feeling dizzy and then losing consciousness. His girlfriend who was present at that time says that the patient’s collapsed, his body went stiff and he then had violent shakings of all his limbs. There was also drooling of saliva from the patient’s mouth. The patient tells the emergency doctor that this is the first fit he has had during his life but recently he has been having a dull headache, especially in the morning. He has also noticed that his right arm is a bit weak but thought that this might be due to his work as an electrician. The emergency department contacts the neurologist and a referral is made a magnetic resonance imaging scan. The
results come back showing an area of hyperintensity and chicken-wire capillary pattern and calcification in the right frontal lobe.

Which one of the following is the origin of the pathology present in this patient?

Cerebral capillaries
Arachnoid cells
Oligodendrocytes
Astrocytes
Anterior pituitary cells

Answer 79

Oligodendrocytes

This patient presented with the signs and symptoms characteristic of a space-occupying lesion. This is supported by the morning headaches,
focal neurological signs such as arm weakness as the new-onset seizure in a man of this age. The magnetic resonance imaging scan showed
an area of hyperintensity confirming the presence of a mass lesion in the right frontal lobe. In addition, it was revealed that the mass had a
chicken-wire capillary pattern and calcification, and this indicates the mass is most likely to be a brain tumor known as oligodendroglioma.
This a brain tumor which presents in adulthood and is derived from the myelin-producing oligodendrocytes in the central nervous system.
- Arachnoid cells are the cells from which meningiomas originate. Meningiomas are commonly benign and they may present in adulthood with
symptoms of a space-occupying lesion such headaches and seizures. They are often located close to the brain surface and in the parasagittal
region. Histopathology often reveals the presence of psammoma bodies.
- Astrocytes are the cells from which glioblastoma multiforme originate. Glioblastoma multiforme is a highly malignant brain tumor presenting
in adulthood and have a very bad prognosis. They are commonly located in the cerebral hemispheres and are referred to as butterfly glioma if
they spread across the corpus callosum. Histopathology usually shows that they glial fibrillary acidic protein (GFAP) positive with pleomorphic
tumor cells close to necrotic and hemorrhagic areas.
- Anterior pituitary cells are the cells from which pituitary adenomas originate. Pituitary adenomas can cause various symptoms based on the
type of endocrine cells affected. The hormonal symptoms can be related to elevated levels of GH, TSH or ACTH amongst others. Symptoms
due to mass effect will often cause bitemporal hemianopia due to compression of the optic chiasm.
- Oligodendrocytes are the cells from which oligodendrogliomas originate. Oligodendrogliomas are a brain tumor which presents in adulthood
and is derived from the myelin-producing oligodendrocytes in the central nervous system. Magnetic resonance imaging will often show a
chicken-wire capillary pattern and histopathology often shows cells with a clear cytoplasm and round nuclei, referred to as ‘’fried egg’’ cells.
- Capillaries and blood vessels cells are the cells from which hemangioblastomas originate. Hemangioblastomas are often present in the
cerebellum. If retinal angiomas are also present in the patient, they are often associated with von Hippel-Lindau cancer syndrome.
Histopathology will often show capillaries with a thin wall and minimal parenchyma.

Question 80

A 33-year-old woman presents to her primary care physician with headache, nausea, and visual disturbances. The patient was in her usual state of health
until yesterday, when she experienced a pulsatile unilateral left sided headache that caused her to have one episode of emesis. Her headache is
accompanied by seeing a shimmering light that distorts her vision, photophobia, and phonophobia. Medical history is unremarkable, and the patient recently
began menses. Ibuprofen and acetaminophen have not improved her symptoms. Neurologic examination is unremarkable.
What’s the diagnosis?

Migraine
Tension type headache
Idiopathic stabbing headache
Cluster headache

Answer 80

Migraine

Migraine is generally an episodic headache with certain associated features, such as sensitivity to light, sound or
movement, and often with nausea or vomiting accompanying the headache

Question 81

A 6-year-old boy is brought to the child assessment unit by his mother. He has lower leg pain that has not resolved for over 3 weeks. She reports that he
has been falling more than usual but puts it down to her new oak laminate flooring. Recently he has been lazy to get out of bed and sometimes struggles to
get out of bed. The child looks well in himself but has a runny nose. During the examination, he slips off the bed and lands on the floor. He uses his arms
and legs to help him get off the floor as he attempts to stand up.
Which one of the following options describes the sign seen?

Idiopathic toe walking
Tinel’s sign
Idiopathic heel walking
Gower’s sign
Horner’s sign

Answer 81

Gower’s sign

A positive Gower’s sign is seen in children with Duchenne muscular dystrophy.
Gower’s sign has moderate sensitivity and high specificity and is classically seen in children with duchenne muscular dystrophy, and is due
to weakness of the proximal muscles, mainly those of the lower limbs.
Idiopathic toe walking may also be seen in DMD but is more classically seen in cerebral palsy, however, it is not the correct answer as it
does not fit the description in the vignette.
Allis sign, also known as Galeazzi’s test, is used to assess for hip dislocation, primarily in order to test for developmental dysplasia of the
hip.
Tinel’s sign is a way to detect irritated nerves. It is performed by lightly tapping (percussing) over the nerve to elicit a sensation of tingling or
‘pins and needles’ in the distribution of the nerve.

Question 82

In which of the following disease group glove-&-stocking pattern of sensory disturbance usually develops?

The spinal cord
The thalamus
The muscle
The brainstem
Peripheral nerves

Answer 82

Peripheral nerves

Question 83

What diagnostic method can be used to determine whether the angle where the iris meets the cornea is open or closed?

Visual field examination
Ophthalmoscopy
Tonometry
Gonioscopy

Answer 83

Gonioscopy

*Tonometry is often used as a diagnostic tool
*The Tonometer is gently pressed against the eyeball, and the resistance (internal pressure) is measured.
*Open-angle glaucoma, IOP is usually between 22 and 32 mm Hg
*Acute angle-closure glaucoma- IOP may be over 50 mm Hg
*Gonioscopy can be used to determine if the angle where the iris meets the cornea is open or closed
*Visual field (Perimetry) is an essential method used to determine if there is any loss of the visual field
*Measurement of Retinal Nerve Fiber Layer thickness with OCT is the most recent advancement in technology that aids in the
diagnosis of glaucoma

Question 84

What do you observe in a patient with uncal herniation who develops third nerve compression?

Contralateral ptosis
Contralateral irresponsive pupil
Ipsilateral midriasis
Deviation of the ipsilateral eye to nasal side
Ipsilateral pinpoint pupil

Answer 84

Ipsilateral midriasis

Question 85

Which nutrient’s deficiency can cause unresponsive seizures in infancy?

Pyridoxine
Vitamine A
Thiamine
Vitamine B12
Niacin (nicotinic acid)

Answer 85

Pyridoxine

Question 86

Which of the following are among the presentations of degenerative diseases involving the basal ganglion and brain stem? (Choose as many as required)

A Movement disorders such as Chorea
B Increase in voluntary movements, decrease in involuntary movements
C Abnormal posture
D Difficulty in walking
E Rigidity

Answer 86

B is not, but others are.

Degenerative diseases involving basal ganglion and brain stem often presents with: rigidity like difficulty in walking or decrease in facial
movements, abnormal posture like stooped posture, movevement disorders such as Chorea, decrease in voluntary movements, increase in
involuntary movements.

Question 87

Which of the following conditions can develop with secondary brain injury?

Cerebral edema and ischemia
Cerebral concussion
Cerebral epidural hematoma
Cerebral laseration

Answer 87

Cerebral edema and ischemia

If secondary injury is not be cured, brain edema and ischemia can devolop.

Question 88

Which of the following items define the cerebral perfusion pressure the best?

Intracranial venous pressure
Arterial systolic pressure
Arterial diastolic pressure
Median arterial pressure and intracranial pressure difference

Answer 88

Median arterial pressure and intracranial pressure difference

Intracranial pressure and intracranial venous pressure difference
CPP = MAP – ICP
CPP ≥ 60-80mmHG

Question 89

Which of the following statements regarding muscle diseases / disorders is not correct?

A) Congenital myopathies tend to cause rapidly progressive clinical worsening

B) Muscular dystrophies are genetic myopathies usually caused by a disturbance of a structural protein or enzyme, resulting in necrosis of muscle fibers and replacement by adipose and connective tissue.

C) Disorders of skeletal muscle encompass a variety of illnesses that cause weakness, pain, and fatigue in any combination

D) Myositis implies an autoimmune or infectious disorder in which the muscle histology shows an inflammatory response

E) Myopathy simply refers to an abnormality of the muscle and has no other connotation.

Answer 89

A) Congenital myopathies tend to cause rapidly progressive clinical worsening

Question 90

Which of the following tremor type is intentional (progressively increases towards intended target)?

Cerebellar tremor
Essential tremor
Parkinson’s tremor
Physiological tremor

Answer 90

Cerebellar tremor

Cerebellar tremor is intentional and usually seen with other cerebellar symptoms like dysmetria and dysdiadocokynesia

Question 91

Which of the following tumor groups is the most common primary brain tumor?

Nerve sheath tumors
Meningiomas
Gliomas
Embryonal tumors
Pituitary adenomas

Answer 91

Gliomas

Gliomas (45-50%): They are the most common brain tumors.
Astrocytic tumors (75%),
Oligodendroglial tumors (5%),
Ependymal tumors (5-7%)

Question 92

Which syndrome is a prototype of Hypertonic / Hypokinetic extrapyramidal system disorder?

Huntington’s disease
Parkinson’s disease
Beriberi
Spinocerebellar ataxia
Alzheimer’s disease

Answer 92

Parkinson’s disease

Question 93

Which wall of the orbit has the highest number of bones?

Floor of orbit
Roof of orbit
Lateral wall of the orbit
Medial wall of the orbit

Answer 93

Medial wall of the orbit

Roof of orbit
Composed of the lesser wing of the sphenoid, and orbital plate of the frontal bone

Lateral wall of orbit
*Separated from the roof by the superior orbital fissure
*Composed of the greater wing of the sphenoid and zygomatic bone

Floor of orbit
*Separated from the lateral wall by the inferior orbital fissure
*Composed of maxillary bone, zygomatic bone and palatine bone
*Orbital contents can herniate into the maxillary sinus in trauma cases

Medial wall
*Composed of the ethmoid bone, sphenoid bone, lacrimal bone and maxilla

Question 94

Which of the following agents would be contraindicated for a patient with migraine headaches besides a history of mild hypertension and classic angina
pectoris?

Her headaches are preceded by bilateral light flashes and dizziness that last about 10 minutes prior to the onset of pain. Her headaches are also frequently
accompanied by photophobia, severe nausea and occasional vomiting.

Acetaminophen
Caffeine
Sumatriptan
Propranolol

Answer 94

Sumatriptan

Question 95

After having a difficult delivery, an upper limb palsy has been determined in the newborn with some degree of internal rotation. On physical examination: Moro reflex is negative. The grasping reflex is positive. Shoulder abduction and elbow flexion are paralyzed.
What is your best diagnosis?

Klumpke palsy (lower part of plexus brachialis)
Total plexus palsy
Erb Duchenne Paralysis (upper part of Plexus brachialis)
Humerus proximal part fracture
Clavicle fracture

Answer 95

Erb Duchenne Paralysis (upper part of Plexus brachialis)

Erb’s palsy or Erb–Duchenne palsy is a form of obstetric brachial plexus palsy. It occurs when there’s an injury to the brachial plexus,
specifically the upper brachial plexus at birth. The injury can either stretch, rupture or avulse the roots of the plexus from the spinal cord.

Question 96

A 20-year-old female presents for the 3rd time to the emergency department with a dry cough and repeated episodes of breathlessness. The previous two times she
was treated with antibiotics to no avail. As of now, she finds herself more lethargic throughout the day where she is able to do her job effectively in the morning but is extremely tired towards the end of the workday. There is no family history of note, she drinks 30 units per week and has a 2 pack year smoking history. CT reveals a 4.0 × 3.0 cm mass in the anterior mediastinum. What is the most likely cause of her new symptoms?

Anaemia
Sarcoidosis
Lung carcinoma
Myasthenia gravis (MG)
Fibromyalgia

Answer 96

Myasthenia gravis (MG)

Feedback: Myasthenia gravis is an autoimmune condition that is characterised
by autoantibodies directed at the post-synaptic anticholinergic
receptors. Thymomas are present in a subset of MG patients and CT’s are done to exclude this. The CT mass is a thymoma and local invasion of this mass is causing the patient’s dry cough and breathlessness. The increased lethargy throughout the day and dysphagia are common symptoms of MG sufferers. Anaemia and may present with some similar symptoms but would not account for the mass. Lung carcinoma is a possibility but the
characteristic worsening of symptoms in the evening more likely points to MG. Sarcoidosis would reveal different CT findings such as lymphadenopathy, ground grass appearance, nodules and
0 out of 1 points granulomas. Fibromyalgia typically would present with a different picture including widespread pain, insomnia, stiffness and fatigue.

Question 97

A 70-year-old man is brought to see his family physician accompanied by his wife. The wife reports that her husband has been misplacing objects around the house,
such as putting the car keys in the microwave oven. The also wife mentions that the man has been unable to find his way home on two occasions. The man cannot remember recent things but can remember his childhood and early adulthood very well. He denies having any visual or auditory hallucinations or any problems with his movements. The wife further adds that the change in her husband’s behavior has been gradual rather than any sudden changes. A CT scan shows significant widening of the brain sulci.
Which of the following best describes the pathology underlying this man’s most likely diagnosis?

Intracellular Lewy bodies
Hyperphosphorylated tau bodies
Extracellular amyloid plaques and intracellular fibrillary tangles
Insoluble beta-pleated protein sheets
Multiple infarcts in the cortex and subcortex of the brain

Answer 97

Extracellular amyloid plaques and intracellular fibrillary tangles

Question 98

A 79-year-old man presents with 4 days of headache and fever. A lumbar puncture is performed, and cerebral spinal fluid cultures are obtained. Bacterial meningitis is confirmed. The bacterium responsible can translocate from cell to cell via actin polymerization.
Which of the following was most likely seen on Gram stain?

Gram-negative rod
Gram-negative diplococci
Gram-positive cocci
Gram-positive rod

Answer 98

Gram-positive rod

Listeria monocytogenes cause listeriosis, a foodborne illness. Listeria is a gram-positive, facultatively anaerobic, non-spore-forming bacillus. It is contracted by consuming prepared foods that are contaminated with L. monocytogenes. L. monocytogenes contains
0 out of 1 points several virulence factors that aid in disease progression. Actin polymerization allows the bacteria to move quickly from cell to cell.

Question 99

A seizure starting with the sudden loss of consciousness and tonic-clonic movement
can be defined as __________?

Primary generalized seizure
Complex focal (partial) seizure
Petit mal absence seizure
Focal (partial) motor seizure
Atonic seizure

Answer 99

Primary generalized seizure

Question 100

Cerebellar signs include which of the followings? (Choose as many as required)

Hypotonus
Ataxia
Rigidity
Slurred speech
Nystagmus

Answer 100

All except rigidity

Question 101

Choose the related manifestations of Parkinson’s disease (Choose as many as required)

Postural instability
Rigidity
Bradykinesia
Resting tremor

Answer 101

All

Question 102

What is the type of edema seen in traumatic brain injury?

Cytotoxic edema
Transependymal edema
Central edema
Interstitial cerebral edema
Vasogenic edema

Answer 102

Vasogenic edema

Patients suffering TBI often develop oedema, which increases ICP
and impairs tissue perfusion.
The result of increased vascular permeability associated with BBB
disruption, (or vasogenic oedema) is the paracellular leakage of
protein and ion rich fluid into the brain

Question 103

Which of the following structures are related to consciousness? (Choose as many as required)

A) Left Parietal lobe
B) Brainstem Ascending Reticular Activating System
C) Occipital lobes
D) Diffuse cortical structures

Answer 103

B ve D doğru.

Question 104

Which of the following structures does the retinal blood vessels endothelium make up?

Outer blood–retinal barrier
Retinal nerve fibre layer
Inner blood-ocular barrier
The inner limiting membrane of the retina

Answer 104

Inner blood-ocular barrier

Info: Retinal blood vessels endothelium that are similar to cerebral
blood vessels maintain the inner blood-ocular barrier.
*The retinal pigment epithelium maintains the outer blood–retinal
barrier.
*The inner limiting membrane of the retina consists of the
basement membrane elaborated by Müller cells.
*Retinal n

Question 105

Which of the following tremor type is intentional (progressively increases towards intended target)?

Physiological tremor
Essential tremor
Parkinson’s Tremor
Cerebellar Tremor

Answer 105

Cerebellar Tremor

Cerebellar tremor is intentional and usually seen with other
cerebellar symptoms like dysmetria and dysdiadocokynesia

Question 106

Which test is not among the sections in the Glasgow coma scale?

Motor response
Vestibulo-ocular reflex response
Verbal response
Eye-opening

Answer 106

Vestibulo-ocular reflex response

Question 107

In pain physiology, spinal part of the afferent system is created by:________.

Second afferent neuron
Cortex
Thalamus
First afferent neuron
Limbic system

Answer 107

Second afferent neuron

Question 108

To make a more definitive diagnosis of myasthenia gravis besides a serological antibody testing, which of the following agents produces a rapid transient reversal of
symptoms such as muscle weakness around the eyes (ptosis), as well as generalized muscle fatigue observed in a 40 y.o. patient with thymus gland disorder?

Echothiophate
Edrophonium
Succinylcholine
Pralidoxime

Answer 108

Edrophonium

Edrophonium is a quaternary alcohol that is a rapidly-acting
cholinesterase inhibitor with a 5-10 minute duration of action. It
binds reversibly to the anionic site of cholinesterase. Historically,
edrophonium has been used for the differential diagnosis of
myasthenia gravis (the Tensilon test).

Question 109

What is the mechanism of action of carbidopa in enhancing the action of levodopa in the treatment of Parkinson’s disease?

A) It promotes the conversion of levodopa to dopamine in the periphery.

B) It promotes the conversion of levodopa to dopamine in the basal ganglia.

C) It inhibits the conversion of levodopa to dopamine in the basal ganglia.

D) It inhibits the conversion of levodopa to dopamine in the
periphery

Answer 109

D) It inhibits the conversion of levodopa to dopamine in the
periphery

Carbidopa inhibits the enzyme that converts levodopa to dopamine
so that more levodopa passes into the brain before being converted
to dopamine. It also prevents the peripheral side effects of levodopa.
Carbidopa does not cross the blood–brain barrier, and therefore,
does not prevent the conversion of levodopa to dopamine in the
basal ganglia

Question 110

Which of the following agents are used intravenously for induction of anesthesia?

Nitrous oxide, isofluorane
Benzodiazepines and barbiturates
Ketamine, thiopental
Propofol and etomidate

Answer 110

Propofol and etomidate

Propofol, etomidate and thiopental are normally used for induction
of anesthesia. Thiopental was mostly replaced by the first two
agents because of its CVC and respiratory depression potential.

Question 111

Which of the following brain regions was most likely involved in daytime sleepiness
in a 45-y.o. woman who had started taking an antihistamine for allergic rhinitis one
day earlier?

Ventral posterior hypothalamus
Nucleus tractus solitarius
Nucleus basalis of Meynert
Caudatum
Hippocampus
Amygdala

Answer 111

Ventral posterior hypothalamus

Histamine and antihistamines have long been known to produce
signifcant effects on animal behavior. Biochemical detection of
histamine synthesis by neurons and direct cytochemical localization
of these neurons have de ned the histaminergic system in the CNS.
Most of these neurons are located in the ventral posterior
hypothalamus. They give rise to long ascending and descending
tracts that are typical of the patterns characteristic of other aminergic
systems. The central histaminergic system is thought to affect arousal
(H1 antagonists cause drowsiness), attention, feeding,
thermoregulation, and vascular dynamics

Question 112

If a patient comes with Left sided Cranial nerve XII and Right hemiparesis and Babinski sign, where do you
locate the lesion?

Left temporal lobe
Left Pons
Right midbrain
Left Bulbus
Right frontal lobe

Answer 112

Left Bulbus

Question 113

A 10-year-old boy presents to the pediatric clinic with a six-month history of cognitive
decline, including poor school performance and decreased interaction with peers. His
parents also report episodes of involuntary jerking movements of his limbs. On
examination, the neurologist notes myoclonic jerks and a mild but distinct cognitive
impairment in the child. The parents mention that he had a history of a rash illness at
the age of 2, after which he seemed to recover fully. Further investigation reveals a
history of incomplete vaccination. An EEG shows periodic, high-amplitude, slow-wave
complexes. An MRI scan of the brain indicates diffuse brain atrophy.
Which of the following is the most likely diagnosis?

Acute Hemorrhagic Leukoencephalitis (AHLE)
Acute Disseminated Encephalomyelitis (ADEM)
Huntington’s disease
Subacute sclerosing panencephalitis (SSPE)
Creutzfeldt-Jakob disease

Answer 113

Subacute sclerosing panencephalitis (SSPE)

Subacute sclerosing panencephalitis (SSPE) - This is the correct
answer. SSPE is a progressive, fatal neurological disorder resulting
from a persistent infection with the measles virus. It typically manifests
years after the initial measles infection, commonly presenting with
cognitive decline, behavioral changes, and myoclonic jerks. The
characteristic EEG findings of periodic complexes and MRI showing
brain atrophy support the diagnosis of SSPE. The history of a rash
illness likely representing measles in early childhood, especially in the
context of incomplete vaccination, further points towards SSPE.

Question 114

If a patient comes with diplopia caused by a Right cranial nerve 3 lesion in addition to pyramidal symptoms characterized by Left hemiparesis and Babinski sign, where do you locate the lesion?

L cerebellum
R pons
R bulbus
R midbrain
L thalamus

Answer 114

R midbrain

If a patient comes with diplopia caused by an R cranial nerve 3 lesion
in addition to pyramidal symptoms characterized by L hemiparesis
and Babinski signs, it indicates an R midbrain lesion.

Question 115

A 45-year-old man presents with progressive symptoms of muscle weakness, particularly pronounced towards the end of the day. He reports difficulty in climbing
stairs and lifting objects, along with episodes of double vision and trouble chewing that seem to ameliorate after periods of rest. Physical examination reveals bilateral ptosis and muscle strength that decreases with sustained activity. Tests confirm the presence
of acetylcholine receptor antibodies. Considering the patient’s symptoms and test results, which diagnostic procedure should be performed next to investigate a potential
accompanying diseas?

Brain MRI
Muscle biopsy
Transthoracic echocardiogram
PET scan
CT scan of the chest

Answer 115

CT scan of the chest

CT scan of the chest - This is the correct answer. The symptoms
described are indicative of Myasthenia Gravis, an autoimmune disorder
affecting the neuromuscular junction. Given this diagnosis and the
association of Myasthenia Gravis with thymoma, particularly in male
patients around middle age, a CT scan of the chest is essential to
assess for the presence of a thymoma, which could be contributing to
the neuromuscular symptoms.

Question 116

Which of the following receptor activation would be coupled to increase in intracellular
calcium concentration by a pharmacological agent you are testing on cell cultures?

α2-Adrenergic
α1-Adrenergic
Dopaminergic-1 (D1)
β1-Adrenergic

Answer 116

α1-Adrenergic

Catecholamines include epinephrine, norepinephrine, and dopamine. All o
receptors are G protein–coupled receptors (GPCRs), but only a1-adrener
receptors cause an increase in the intracellular calcium concentration. Sti
this receptor releases the Gq subunit, which in turn activates phospholipa
leading to inositol triphosphate (IP3). One of the downstream effects of IP
calcium channels in the smooth endoplasmic reticulum to release stored c
raise the intracellular calcium concentration.

Question 117

Which of the following statements are correct regarding the age-related characteristics
of brain tumors in children? (Choose as many as required)

During the 1st year of life and after 10 year of age, supratentorial brain
tumors are more common

In children 0-14 yr old, the most common tumors are pilocytic
astrocytomas and medulloblastoma/primitive neuroectodermal tumors
(PNETs).
Tumors of the optic pathway and hypothalamus region, the brainstem,
and the pineal-midbrain region are exceedingly uncommon in children
and adolescents when compared to adults
In children between 1-10 years of age, CNS tumors which are locared at
the infratentorial area are more common than supratentorial tumors

Optic pathway gliomas are related with Neurofibromatosis Type 1 in 70%
of the cases.

Answer 117

Only the 3rd option is incorrect.

Tumors of the optic pathway and hypothalamus region, the brainstem,
and the pineal-midbrain region are MORE COMMON in children and
adolescents when compared to adults. Other choices are correct

Question 118

Clumsy, staggering movements with a wide-based gait with tendency to fall to the affect
be seen in ___________.

Neuropathic Gait
Cerebellar ataxic gait
Spastic gait
Parkinsonian Gait

Answer 118

Cerebellar ataxic gait

Question 119

A 28-year-old man is brought to the emergency department following a motor vehicle collision in which he sustained a blow to the left side of his head. He was initially alert
and oriented at the scene, engaging in conversation with paramedics. However, about two hours after the accident, he complains of a worsening headache and starts
to become drowsy and confused. On examination, his pupils are unequal, with the left pupil larger than the right. A CT scan of the head reveals a biconvex, hyperdense
collection on the left side, strictly limited by the midline and not crossing any suture lines. Which of the following is the most likely diagnosis?

Traumatic brain injury with diffuse axonal injury
Subarachnoid hemorrhage
Subdural hematoma
Intracerebral hemorrhage
Epidural hematoma

Answer 119

Epidural hematoma

Epidural hematoma - This is the correct answer. An epidural
hematoma is likely given the lucid interval post-injury, followed by
neurological deterioration, which is a classic presentation. The impact
from the car accident could easily lead to arterial damage, typically the
middle meningeal artery, causing blood to accumulate between the
dura mater and the skull. The CT findings of a biconvex shape that
does not cross suture lines aligns perfectly with an epidural
hematoma.

Subarachnoid hemorrhage - Typically presents with a sudden, severe
headache and is characterized by bleeding into the spaces where
cerebrospinal fluid circulates, often visible on CT as diffuse blood
layering rather than a localized biconvex collection.

Question 120

Which of the following is correct for congenital sensorineural hearing loss?

Non-syndromic hearing losses due to hereditary causes are very rare

75% of congenital hearing loss cases are hereditary

Mumps is the most common cause of acquired sensorineural hearing loss

Rubella is the most common cause of congenital viral deafness

80% of non-syndromic hereditary hearing losses are autosomal
dominant

Answer 120

Mumps is the most common cause of acquired sensorineural hearing loss

Info: Mumps is the most common cause of acquired sensorineural
hearing loss in the childhood
50% of congenital hearing loss cases are hereditary.
Non-syndromic hearing losses due to hereditary causes are
widespread.
80% of non-syndromic hereditary hearing losses are autosomal
recessive.
Cytomegalovirus is the most common cause of congenital viral
deafness.

Question 121

You see a patient with ipsilateral upper motor neuron paralysis and loss of
proprioception, as well as contralateral loss of pain and temperature sensation.
What is the possible cause?

Anterior spinal artery syndrome
Brown-Sequard Syndrome
Syringomyelia
Cauda Equina Syndrome

Answer 121

Brown-Sequard Syndrome

Question 122

A 62-year-old man is brought to the emergency department after his wife found him collapsed in the bathroom. His medical history is significant for poorly controlled
hypertension and type 2 diabetes mellitus. On examination, his blood pressure is 220/140 mmHg. He is drowsy but responds to verbal stimuli. Neurological examination reveals right-sided hemiparesis and left-sided facial droop. A non- contrast CT scan of the head shows a left basal ganglia hemorrhage without ventricular extension. Which of the following is the most likely cause of this patient’s symptoms?

Ischemic stroke with hemorrhagic transformation
Meningioma
Amyloid angiopathy
Hypertensive vasculopathy
Arteriovenous malformation

Answer 122

Hypertensive vasculopathy

Info: The correct answer is Hypertensive vasculopathy. This patient’s
history of poorly controlled hypertension and the location of the
hemorrhage (basal ganglia) are classic for hypertensive vasculopathy
leading to intraparenchymal hemorrhage. The basal ganglia is one of
the most common sites of spontaneous intraparenchymal hemorrhage
due to hypertension, which leads to chronic damage to the small
penetrating arteries, resulting in Charcot-Bouchard microaneurysms
and subsequent bleeding.

Question 123

A 35 year old HIV/AIDS patient who had a pneumonia episode 5 weeks ago admits
to the hospital with progressing fever, headache, stiff neck, nausea and vomiting
since 2 weeks. Meningeal irritation signs were all positive. Cerebrospinal fluid (CSF)
examination revealed 200 lymphocytes/mL, reduced glucose and moderately
elevated protein levels. CSF staining with indian ink showed the microscopic
appearance seen below.
What is the most probable microorganism?

Cytomegalovirus
Haemophilus influenzae
Neisseria meningitidis
Cryptococcus neoformans
Herpes simplex virus

Answer 123

Cryptococcus neoformans

Cryptococcus neoformans menengitis is seen in HIV/AIDS patients who
cellular immunity impairment. It usually happens after pneumoniae with
and the symptoms will progress slowly within weeks. The symptoms, me
irritation signs that are positive and the CSF examination results show t
menengitis. CSF staining with indian ink shows encapsulated yeasts wh
expected as a Cryptococcus neoformans menengitis.

Question 124

Which of the following therapeutic approaches would be appropriate to reduce the
resting tremors of a 80-year-old man who had been suffering from Parkinson’s
disease for 5 years?
Note: Resting tremor, presently is one of the most debilitating symptoms of his
disease. His therapy with levodopa/carbidopa had resulted in improvement in rigidity, bradykinesia, and posture, as well as improvement in the “on-off” effects, but he had experienced little if any improvement in tremor.

Decrease the dose of carbidopa
Start brief periods of “drug holidays” during therapy
Substitute levodopa/carbidopa with pramipexole
Add propranolol to the present drug regimen
Add benztropine to the present drug regimen

Answer 124

Add propranolol to the present drug regimen

Question 125

Which of the following ion channels is activated by a GABA B type receptor agonist
medication both in the brain and in the spinal cord of a 50-year-old man suffering
from episodic leg cramps?

Mg2+
K+
Na+
Ca2+
Cl

Answer 125

K+

The patient was most likely receiving baclofen, a spasmolytic drug that
activating GABAB receptors, a member of G-protein-coupled receptors
This activation most likely opens K+ channels, causing K+ efflux, thus
membrane stabilization (hyperpolarization).

Question 126

Which one is a sign of Preproliferative diabetic retinopathy (PPDR) ?

Microaneurysms
Cotton wool spots
Hard exudates
Retinal nerve fibre layer haemorrhages

Answer 126

Cotton wool spots

Background diabetic retinopathy (BDR) Signs
*Microaneurysms: tiny red dots that tend to be the earliest signs

*Retinal nerve fibre layer haemorrhages: superficial and flame-
shaped intraretinal haemorrhages: located in the compact middle

layers of the retina and have a red ‘dot/blot’configuration
*Deeper dark round haemorrhages: haemorrhagic infarcts located
within the middle retinal layers; risk marker for progression to retinal
neovascularization
*Hard exudates: waxy yellow lesions with distinct margins, often
arranged in clumps and/or rings surrounding leaking
microaneurysms

Question 127

In a ischemic cerebrovascular accident patient presenting with these clinical
symptoms: contralateral gaze palsy, hemiplegia, hemisensory loss, spatial neglect,
hemianopsia, global aphasia and decreased consciousness.
Which cerebral vascular territory is affected?

Middle Cerebral Artery
Anterior Cerebral Artery
Posterior Inferior Cerebellar Artery
Posterior Cerebral Artery

Answer 127

Middle Cerebral Artery

contralateral gaze palsy, hemiplegia, hemisensory loss, spatial
neglect, hemianopsia, global aphasia and decreased consciousness
can be seen in middle cerebral artery entire territory lesions

Question 128

Provide the basic systems providing the peripheral inputs for maintenance of
“balance” (Choose as many as required)

Vestibular system
Visual system
Somatosensory peripheral system
Hypoglossus Nerve
Accessorius Nerve
Cerebellar system
Vagus Nerve

Answer 128

All the ‘system’ answers are correct whereas ‘nerve’ answers are not.

Question 129

Before initiating a patient on carbamazepine, you should be aware of its most common side effects of dizziness, lethargy, and double vision. You need to discuss about rare but more serious side effects for which the drug has black box warnings, such as aplastic anemia.
What other black box warning should you also warn your patient about?

Gingival hyperplasia
Hepatic failure
Mania
Serious dermatologic reactions

Answer 129

Serious dermatologic reactions

Info: Carbamazepine may develop potentially fatal dermatologic reactions
(1 to 6 per 10,000 new users), including toxic epidermal necrolysis
and Stevens-Johnson syndrome in patients with the HLA-B 1502
inherited allelic variant of the HLA-B gene.

Question 130

What is the GCS (Glasgow Coma Scale) score of a patient with eyes closed but
opens eyes with shouted request, verbal response only with moans and groans,
best motor response is extension of arms at elbow after a physical stimuli to
supraorbital notch?

6 7 8 9

Answer 130

7

Question 131

Which of the complication listed below are seen in especially 25% of survivors of
bacterial meningitis as a moderate or severe sequelae?

Osteoarthritis
Hearing loss
Renal impairment
Peripheral neuropathy
Myocardial infarction

Answer 131

Hearing loss

Info: Hearing loss is a a moderate or severe sequelae seen in survivors
of bacterial meningitis
Peripheral neuropathy, renal impairment, myocardial infarction and
osteoarthritis is not a special moderate or severe sequelae seen
after bacterial menengitis

Question 132

Which of the following is not one of the infections abbreviated as TORCH that
causes central nervous system malformations?

Toxoplasmosis
Rubella
Herpes simplex
Cytomegalovirus
Candida albicans

Answer 132

Candida albicans

TORCH(toxoplasmosis, other, rubella, cytomegalovirus
and herpes simplex)

Question 133

Which one below is not correct for TIA’s(Transient Ischemic Attacks)?

One-third of untreated TIA patients having a stroke within 5 years

About 1 in 10 patients with TIA experience a stroke in the next 3 months

A TIA is a temporary and “non-marching” neurological deficit of sudden onset; attributed to focal ischemia of the brain, retina, or cochlea; and lasting less than half an hour

Most TIAs last only a few minutes

Answer 133

‘A TIA is a temporary and “non-marching” neurological deficit of sudden onset; attributed to focal ischemia of the brain, retina, or cochlea; and lasting less than half an hour’ is an incorrect statement.

Info: TIA is a prognostic indicator of stroke, with one-third of untreated TIA
patients having a stroke within 5 years. About 1 in 10 patients with TIA
experience a stroke in the next 3 months. TIA is a temporary and
“non-marching” neurological deficit of sudden onset; attributed to focal
ischemia of the brain, retina, or cochlea; and lasting less than 24
hours. Most TIAs last only a few minutes. Episodes that last longer
than 1 hour are usually due to small infarctions

Question 134

Which sign/symptom is the pathognomonic one for bacterial conjunctivitis?

Itching
Sero-mucous discharge
White, gum-like discharge
Sticky, yellow-green discharge

Answer 134

Sticky, yellow-green discharge

Question 135

Which extraocular muscle that provides the movement of the eye does not originate
from the orbital apex?

Inferior oblique
Superior oblique
Superior rectus
Inferior rectus

Answer 135

Inferior oblique

*The orbital apex is anatomically the posterior part of the orbit where
the four orbital walls converge and it is the site of origin of all
extraocular muscles except the inferior oblique.
*The inferior oblique originates from the orbital floor just lateral to the
nasolacrimal groove.

*Orbital apex syndrome (OAS) involves cranial neuropathies in associ
optic nerve dysfunction. Orbital apex syndrome is symptomatically rela
superior orbital fissure syndrome and cavernous sinus syndrome with
etiologies.
*The distinction is the precise anatomic involvement of the disease pro

Question 136

What is the range of cerebral perfusion pressure (CPP) at normal intracranial
pressure (ICP) levels?

CPP ≥ 30-40 mmHG
CPP ≤ 20 mmHG
CPP ≤ 60 mmHG
CPP ≥ 60-80 mmHG
CPP ≤ 50 mmHG

Answer 136

CPP ≥ 60-80 mmHG

Question 137

What are the characteristics of simple febrile seizures? (Choose as many as
required)

Last less than 15 minutes
The child has preexisting neurological challenges
Occur only once in a 24-hour period
The prognosis of children with simple febrile seizures is excellent.
Generalized at onset

Answer 137

All except the second one are true

Question 138

Ceftriaxone and dexamethasone were administered to a 6-y.o. girl with seizure
caused by fever (38.8°C) and disorientation. The next day, she became lethargic and
lapsed into a coma. After seeing no bacteria in the CSF, intravenous acyclovir was
started, and 5 days later, the child was alert, responsive, and actively moving.
Which of the following diseases most likely caused the patient’s signs and
symptoms?

CMV encephalitis
Toxoplasmic encephalitis
Cryptococcal meningitis
Herpes encephalitis
Neisseria meningitis

Answer 138

Herpes encephalitis

The patient’s signs and symptoms suggested the presumptive
diagnosis of bacterial meningitis, but the lack of efficacy of antibiotic
therapy and the negative cerebrospinal fluid result raised the
suspicion of herpes simplex virus (HSV) encephalitis, the most
common sporadic viral infection of the CNS. Acyclovir is the first-line
agent for HSV infection, and the efficacy of therapy confirms that the
patient was suffering from herpes encephalitis.
Toxoplasmic encephalitis and Cryptococcal meningitis are rare in
patients without HIV and cannot be cured with antiviral drugs.
Cytomegalovirus (CMV) infection occurs mainly in
immunocompromised patients or is congenital, and acyclovir is not
active against CMV.

Question 139

Which can be the most possible cause of a tremor starting with kinetic action and
occurs during entire movement trajectory?

Parkinson’s Disease
Essential tremor
Cerebellar Ataxia
Dystonic tremor

Answer 139

Essential tremor

Question 140

Among which tissues is the term ‘angle’ used in the glaucoma classification?

Iris and lens
Iris and retina
Iris and sclera
Iris and cornea

Answer 140

Iris and cornea

The place where the outflow occurs is called the angle because it
is the angle where the iris meets the cornea

Question 141

Which of the following is not correct regarding rational use of antimicrobial agents?

In patients with nasal carriage of S. aureus preoperative decolonization with nasal imipenem reduces the rate of S. aureus surgical site infections.

Avibactam and vaborbactam inhibit a broader spectrum of βlactamases than the other inhibitors, including extended spectrum βlactamases (ESBLs), AmpC βlactamases, and some carbapenemases

Oral amoxicillin may be an option for otitis media, respiratory tract infections, and urinary tract infections

Piperacillin-tazobactam is a useful agent for broad coverage in febrile neutropenic patients

Answer 141

‘In patients with nasal carriage of S. aureus preoperative decolonization with nasal imipenem reduces the rate of S. aureus surgical site infections.’

This statement is incorrect.

In patients with nasal carriage of S. aureus preoperative
decolonization with nasal mupirocin reduces the rate of S.
aureus surgical site infections

Question 142

If a patient comes with quadriparesis with bilateral Babinski sign, an uncontrolled
sphincter, and sensory loss under the shoulders, where do you locate the lesion?

Bilateral cerebellum
Bilateral occipital lobe
Thoracal spinal cord
Cervical spinal cord

Answer 142

Cervical spinal cord

Question 143

Which orbital wall is fractured most frequently after blunt trauma in the orbit?

Superior wall
Medial wall
Lateral wall
Inferior wall

Answer 143

Inferior wall

*An orbital blowout fracture is a fracture of the orbital bones.
Typically results from impact of a blunt object.
*Inferior blowout fractures are the most common type.
*Amongst the orbital walls, the medial wall takes the second
place in the frequency of blow-out fractures.