Neurology

Question 1

1. Motor neurone disease
   A 66-year-old woman complains of stiffness and weakness climbing stairs. She has
   a history of hypertension and diet-controlled type 2 diabetes. On examination,
   there is mild upper arm weakness, hip flexion is 4−/5 bilaterally, with bilateral
   wasting and flickers of fasciculations in the right quadriceps. Knee extension is 4/5.
   Dorsiflexion and plantar flexion are strong. Brisk knee and ankle reflexes are
   elicited, as well as a positive Hoffman’s and Babinski’s sign. Sensory examination
   and cranial nerves are normal. Her BM is 8.9, her pulse is regular and her blood
   pressure is 178/97. What is the most likely diagnosis?
   A. Myasthenia gravis
   B. Diabetic neuropathy
   C. Myositis
   D. Motor neurone disease
   E. Multiple sclerosis (MS)

Answer 1

D

Question 2

2. Lesion localization (1)
   A 23-year-old man is stabbed in the neck. Once stabilized, his MRI shows a right
   hemisection of the cord at C6. What is the expected result of this injury?
   A. Paralysed diaphragm
   B. Absent sensation to temperature in the left hand
   C. Paralysis of the left hand
   D. Absent sensation to light touch in the left hand
   E. Brisk right biceps reflex

Answer 2

B

Question 3

3. Multiple sclerosis treatment
   A 23-year-old woman complains that her right leg has become progressively stiff
   and clumsy over the last couple of weeks. She is worried as she has not been able
   to go to work for the last 4 days. On examination, tone is increased and there is a
   catch at the knee. She has six beats of clonus and an upgoing plantar. Power is
   reduced to 3-4/5 in the right leg flexors. There is no sensory involvement and the
   rest of the neurological exam is normal other than a pale disc on opthalmoscopy.
   On further questioning, she admits that she has had two episodes of blurred vision
   in her right eye in the last two years. Each lasted a couple of weeks from which she
   fully recovered. What is the most appropriate initial treatment?
   A. A non-steroidal anti-inflammatory drug (NSAID)
   B. Interferon-beta
   C. Bed rest
   D. Methotrexate
   E. A course of oral steroids

Answer 3

E

Question 4

4. Lesion localization (2)
   A 78 year old right-handed male collapses and is brought into accident and
   emergency. He seems to follow clear one-step commands but he gets very frustrated
   as he cannot answer questions. He is unable to lift his right hand or leg. He has an
   irregularly irregular pulse and his blood pressure is 149/87. He takes only aspirin
   and frusemide. What is the most likely diagnosis?
   A. Left cortical infarct
   B. Right internal capsule infarct
   C. Left cortical haemorrhage
   D. Left internal capsule haemorrhage
   E. Brainstem haemorrhage

Answer 4

A

Question 5

5. Glasgow Coma Scale
   A 19-year-old woman collapses at a concert and is witnessed to have a tonic-clonic
   seizure lasting 2 minutes. When the paramedics arrive and ask her questions, she
   mumbles but no-one can understand what she is saying. Only when the paramedic
   applies pressure to her nailbed does she open her eyes and reach out with her other
   hand to rub her nail and then push him away. What is her Glasgow Coma Scale
   (GCS)?
   A. 12
   B. 11
   C. 10
   D. 9
   E. 8

Answer 5

D

Question 6

6. Risk factors in stroke
   A 79-year-old man is admitted with left hemiparesis. CT reveals a middle cerebral
   artery infarct. What is his most significant risk factor for stroke?
   A. Hypertension
   B. Smoking
   C. Family history
   D. Diabetes
   E. Cholesterol

Answer 6

A

Question 7

7. Multiple sclerosis prognosis
   A 42-year-old woman presents with ataxia. Gadolinium-enhanced MRI reveals
   multiple subcortical white matter lesions as well as enhancing lesions in the
   cerrebellum and spinal cord. She is diagnosed with MS. Two months later she
   develops optic neuritis. What feature is associated with a milder disease course?
   A. Her age of 42
   B. Her initial presentation of ataxia
   C. Her female gender
   D. The interval between the two episodes of two months
   E. Her MRI scan appearance

Answer 7

C

Question 8

8. Seizure (1)
   A 71-year-old man with atrial fibrillation is seen in clinic following an episode of
   syncope. He describes getting a poor night’s sleep and, as he got out of bed in the
   morning, feeling dizzy for a couple of seconds before the lights dimmed around
   him. He was woken a couple of seconds later by his wife who had witnessed the
   event. She says he went pale and fell to the floor and his arms and legs jerked. After
   waking, he was shaken but was ‘back to normal’ a few minutes after the event. His
   medication includes aspirin, atenolol and frusemide. What is the most likely
   diagnosis?
   A. Vasovagal syncope
   B. Orthostatic hypotension
   C. Cardiogenic syncope
   D. Transient ischaemic attack (TIA)
   E. Seizure

Answer 8

B

Question 9

9. Headache (1)
   A 41-year-old man complains of terrible headache. It started an hour ago, without
   warning, while stressed at work. It affects the right side of his head. He scores it
   ‘11/10’ in severity. When asked, he agrees that light does bother him a little. He had
   a similar episode six months ago, experiencing very similar headaches over 2 weeks
   which resolved spontaneously. On observation, he looks quite distressed and prefers
   to pace up and down, unable to sit still. What is the diagnosis?
   A. Subarachnoid haemorrhage
   B. Tension headache
   C. Intracerebral haemorrhage
   D. Migraine
   E. Cluster headache

Answer 9

E

Question 10

10. Visual loss
    A 49-year-old man complains of sudden onset, painless unilateral visual loss
    lasting about a minute. He describes ‘a black curtain coming down’. His blood
    pressure is 158/90, heart rate 73 bpm. There is an audible bruit on auscultation of
    his neck. His past medical history is insignificant other than deep vein thrombosis
    of his right leg ten years ago. The most likely diagnosis is:
    A. Retinal vein thrombosis
    B. Retinal artery occlusion
    C. Amaurosis fugax
    D. Optic neuritis
    E. Acute angle glaucoma

Answer 10

C

Question 11

11. Stroke treatment
    A 77-year-old woman is admitted to hospital with a urinary tract infection. She
    receives antibiotics and seems to be responding well. On the fourth day she is
    eating her lunch when she suddenly drops her fork. She calls for the nurse who
    notices the left side of her face is drooping. What is the best next course of action?
    A. CT head
    B. Thrombolysis
    C. MRI head
    D. Aspirin
    E. Place nil by mouthE

Answer 11

E

Question 12

12. Contraindications for thrombolysis
    A 71-year-old right-handed male is brought in by ambulance at 17:50 having
    suffered a collapse. His wife came home to find him on the floor unable to move
    his right arm or leg and unable to speak. Her call to the ambulance was logged at
    17:30. He has a past medical history of well-controlled hypertension, ischaemic
    heart disease and atrial fibrillation for which he is on warfarin. He had a hernia
    repair three months ago and his brother had a ‘bleed in the brain’ at the age of 67.
    What is the absolute contraindication to thrombolysis in this male?
    A. Family history of haemorrhagic stroke
    B. History of recent surgery
    C. Time of onset
    D. Current haemorrhagic stroke
    E. Warfarin treatment

Answer 12

C

Question 13

13. Guillain–Barré syndrome
    A 69-year-old man presents to clinic with a six-month history of progressive lower
    back pain which radiates down to his buttock. He found the pain was exacerbated
    while taking his daily morning walk and noticed that it eased going uphill but
    worsened downhill. He stopped his daily walks as a result and he now walks only
    slowly to the shops when he needs to, taking breaks to sit down and ease the pain.
    He has a history of hypertension, diabetes and prostatic hyperplasia. What is the
    diagnosis?
    A. Peripheral vascular disease
    B. Osteoporotic fracture
    C. Spinal stenosis
    D. Sciatica
    E. Metastatic bone disease

Answer 13

C

Question 14

14. Spinal claudication
    A 31-year-old woman presents to accident and emergency with progressive
    difficulty walking associated with lower back pain. A few days ago she was tripping
    over things, now she has difficulty climbing stairs. She describes tingling and
    numbness in both hands which moved up to her elbows, she is unable to write. On
    examination, cranial nerves are intact but there is absent sensation to vibration and
    pin prick in her upper limbs to the elbow and lower limbs to the hip. Power is 3/5
    in the ankles and 4−/5 at the hip with absent reflexes and mute plantars. Her blood
    pressure is 124/85, pulse 68 and sats 98 per cent on air. She has a past medical
    history of type I diabetes and recently recovered from an episode of food poisoning
    a month or two ago. What is the diagnosis?
    A. MS
    B. Guillain–Barré syndrome (GBS)
    C. Myasthenia gravis
    D. Diabetic neuropathy
    E. Infective neuropathy

Answer 14

B

Question 15

15. Parkinson’s associated symptoms
    A left-handed 79-year-old man presents with a troublesome resting tremor of his
    left hand. The tremor is evident in his writing. He has also noticed his writing is
    smaller than it used to be. He complains he has difficulty turning in bed to get
    comfortable and his wife complains that he sometimes kicks her in the middle of
    the night. When he gets out of bed in the morning he feels a little woozy, but this
    resolves after a while. On examination, he blinks about three times a minute and
    his face does not show much emotion. Glabelar tap is positive. He has a slow,
    shuffling gait. He has difficulty stopping, starting and turning. He holds his feet
    slightly apart to steady himself. When you pull him backwards, he is unable to right
    himself and stumbles back. Which of the signs and symptoms is not commonly
    associated with parkinsonism?
    A. Postural instability
    B. Rapid eye movement (REM) sleep disturbance
    C. Hypomimia
    D. Broad-based gait
    E. Autonomic instability

Answer 15

D

Question 16

16. Migraine treatment
    A 33-year-old woman attends her six-month follow-up appointment for headache.
    They are migrainous in nature but whereas she used to have them every few
    months, over the last three months she has experienced a chronic daily headache
    which varies in location and can be anywhere from 3–7/10 severity. Her last
    migraine with aura was two months ago. She takes co-codamol qds and ibuprofen
    tds. What is the best medical management?
    A. Stop all medication
    B. Start paracetamol
    C. Start sumatriptan
    D. Start propranolol
    E. Continue current medication

Answer 16

A

Question 17

17. Seizure (2)
    A 17-year-old girl is brought into accident and emergency with generalized tonicclonic
    seizure. Her mother had found her fitting in her bedroom about 20 minutes
    ago. The ambulance crew handover state that her sats are 96 per cent on 15 L of
    oxygen and they have given her two doses of rectal diazepam but she has not
    stopped fitting. What is the most appropriate management?
    A. Lorazepam
    B. Phenobarbital
    C. Intubation
    D. Call ITU
    E. Phenytoin loading

Answer 17

E

Question 18

18. Phenytoin levels
    A 72-year-old man with known epilepsy and hypertension is admitted with
    pneumonia. His drug history includes aspirin, phenytoin, bendroflumethiazide and
    amlodipine. His heart rate is 67, blood pressure 170/93, sats 96 per cent on 2 L of
    oxygen. Neurological examination is normal. His doctor requests blood tests
    including phenytoin level. What is the correct indication for this test?
    A. Routine check
    B. Ensure levels are not toxic
    C. Confirm patient compliance
    D. Ensure therapeutic level reached
    E. Reassure the patient

Answer 18

X

Question 19

19. Seizure (3)
    A 23-year-old woman is seen in clinic for recurrent funny turns. She is not aware
    of them, but her family and friends have noticed them. They say she looks around
    blankly, then starts picking at her clothes and sometimes yawns, then she comes
    back after a minute. She can get drowsy after these episodes. What seizure type
    does this patient describe?
    A. Absence
    B. Tonic clonic
    C. Simple partial
    D. Complex partial
    E. Generalized

Answer 19

D

Question 20

20. Dermatomes (1)
    You are asked to perform a lower limb peripheral neurological examination on
    a 45-year-old diabetic male. The patient has normal tone, 5/5 power, normal
    plantars and proprioception. However, you notice that the patient does not respond
    to any sensory stimulus on the medial side of the right lower leg. Which dermatome
    is affected?
    A. L1
    B. L2
    C. L3
    D. L4
    E. L5

Answer 20

D

Question 21

21. Lesion pattern location (1)
    On examination, a patient has 5/5 power in all muscle groups of his upper limbs,
    0/5 power in all the muscle groups of his lower limbs. Cranial nerves are intact.
    Where is the lesion?
    A. Muscle
    B. Neuromuscular junction
    C. Peripheral nerves
    D. Spinal cord
    E. Brain

Answer 21

D

Question 22

22. Dermatomes (2)
    On examination, a patient has 5/5 power in his upper limbs, 0/5 power in his lower
    limbs. Further examination reveals a sensory level at the umbilicus. Cranial nerves
    are intact. Where is the lesion?
    A. C4
    B. T4
    C. T10
    D. L1
    E. L3

Answer 22

C

Question 23

23. Lesion pattern location (2)
    A patient is unable to move his right arm or leg. When asked to smile, the left side
    of his mouth droops. Where is the lesion?
    A. Left motor cortex
    B. Right motor cortex
    C. Left brainstem
    D. Right brainstem
    E. Cervical spine

Answer 23

C

Question 24

24. Visual pathway lesion
    A light is shone into a patient’s right eye and it constricts. When moved to the left
    eye, the left eye constricts. When moved back to the right eye, the right eye dilates.
    What is the diagnosis?
    A. Afferent lesion
    B. Efferent lesion
    C. Relative afferent lesion
    D. Relative efferent lesion
    E. Normal

Answer 24

C

Question 25

25. Myasthenia gravis
    A 55-year-old woman complains of double vision. She finds that she is more tired
    than usual and has difficulty climbing stairs, especially when they are very long.
    She has difficulty getting items off high shelves at work and lately even brushing
    her hair is a problem. During the consultation, her voice fades away during
    conversation. Reflexes are present and equal throughout. Which sign or symptom
    is most indicative of myasthenia gravis?
    A. Proximal weakness
    B. Normal reflexes
    C. Diplopia
    D. Fatigability
    E. Bulbar symptoms

Answer 25

D

Question 26

26. Lambert–Eaton syndrome
    A 55-year-old woman complains of double vision. She finds that she is tired all the
    time and has difficulty climbing stairs. She has difficulty getting items off high
    shelves at work. Reflexes are absent but elicited after exercise. Shoulder abduction
    is initially 4−5 but on repeated testing is 4 +/5. What pathology is associated with
    this female’s diagnosis?
    A. Thyrotoxicosis
    B. Peptic ulcer
    C. Diabetes
    D. Stroke
    E. Lung cancer

Answer 26

E

Question 27

27. Cranial nerve palsy
    On observation, a patient has a left facial droop. On closer examination his
    nasolabial fold is flattened. When asked to smile, the left corner of his mouth
    droops. He is unable to keep his cheeks puffed out. Eye closure is only slightly
    weaker compared to the right and his forehead wrinkles when he is asked to look
    up high. What is the diagnosis?
    A. Right middle cerebral artery stroke
    B. Parotid gland tumour
    C. Left internal capsule stroke
    D. Bell’s palsy
    E. Cerebellar pontine angle tumourA

Answer 27

A

Question 28

28. Opthalmoplegia
    A female presents with diplopia. On closer examination, when asked to look right,
    her left eye stays in the midline but her right eye moves right and starts jerking.
    What is the diagnosis?
    A. Myasthenia gravis (MG)
    B. Vertigo
    C. Cerebellar syndrome
    D. MS
    E. Peripheral neuropathy

Answer 28

D

Question 29

29. Neurological signs
    A neurologist is examining a patient. She takes the patient’s middle finger and flicks
    the distal phalanx, her thumb contracts in response. What sign has been elicited?
    A. Chvostek’s
    B. Glabellar
    C. Hoffman’s
    D. Tinel’s
    E. Babinksi’s

Answer 29

C

Question 30

30. Dementia
    A 69-year-old man is taken to his GP by his concerned wife. She complains that he
    has not been himself for the last year. He has slowly become withdrawn and stopped
    working on his hobbies. Now she is concerned that he often forgets to brush his
    teeth. She has noticed he sometimes struggles to find the right word and this has
    gradually become more noticeable over the last couple of months. She presented
    today because she was surprised to come home to find him naked and urinating in
    the living room last week. He has a history of hypertension and is an ex-smoker.
    The most likely diagnosis is:
    A. Depression
    B. Frontotemporal dementia
    C. Alzheimer’s disease
    D. Vascular dementia
    E. Lewy Body disease

Answer 30

B

Question 31

31. Upgoing plantars
    Which of the following is not a cause of absent ankle jerks and up-going plantars?
    A. Freidreich’s ataxia
    B. B12 deficiency
    C. MS
    D. Cord compression
    E. Motor neurone disease

Answer 31

C

Question 32

32. Gait abnormality
    A patient has difficulty walking. His gait is unsteady. He seems to have difficulty
    raising his right leg and swings it round in an arc as he walks. He holds his right
    arm and wrist flexed. What type of gait does this patient exhibit?
    A. Hemiplegic
    B. Scissoring
    C. High stepping
    D. Spastic
    E. Stomping

Answer 32

A

Question 33

33. Visual fields
    A patient is admitted with a stroke. On examination of her visual fields, she is
    unable to see in the right lower quadrant of her field. Where is the lesion?
    A. Optic chiasm
    B. Left parietal lobe
    C. Right temporal lobe
    D. Right optic radiation
    E. Left optic nerve

Answer 33

B

Question 34

34. Dizziness
    A 43-year-old woman presents with dizziness to accident and emergency. It started
    suddenly this morning, she awoke with a headache and the dizziness started when
    she sat up in bed. She describes the room spinning for a couple of minutes. It settles
    if she keeps still, but returns on movement. There is no tinnitus or deafness, but
    some nausea and no vomiting. The most likely diagnosis is:
    A. Brainstem stroke
    B. Benign paroxysmal positional vertigo
    C. Ménière’s disease
    D. Vestibular neuronitis
    E. Migraine

Answer 34

B

Question 35

35. Dermatological manifestations
    A 40-year-old woman seen in clinic has multiple fleshy nodules and several light
    brown, round macules with a smooth border on her back, arms and legs. There are
    also freckles under her arms. What is the underlying disorder?
    A. Neurofibromatosis type I
    B. Neurofibromatosis type II
    C. Tuberous sclerosis
    D. Hereditary haemorrhagic telangectasia
    E. Sturge–Weber syndrome

Answer 35

A

Question 36

36. Imaging
    A 19-year-old man is admitted with a GCS of 12. He was doing push ups when he
    complained of a sudden-onset, severe headache and collapsed. What would you
    expect on his CT?
    A. Convex haematoma
    B. Midline shift
    C. Crescent-shaped haematoma
    D. Blood along the sulci and fissures
    E. Intraventricular blood

Answer 36

D

Question 37

37. Stroke territories
    A 60-year-old man presents with visual problems and dizziness. The dizziness
    started suddenly, he sees the room spinning around and he has noticed he keeps
    bumping into things on his right. His blood pressure is 159/91, heart rate 72. On
    examination, there is nystagmus and dysdiadochokinesia. Where is his stroke?
    A. Temporal lobe
    B. Left parietal lobe
    C. Right parietal lobe
    D. Anterior circulation
    E. Posterior circulation

Answer 37

E

Question 38

38. Paraesthesia
    A 45-year-old man presents with a 5-day history of progressive tingling and
    numbness of his hands and feet. He insists that he has never had this problem
    before and that he was perfectly fine a week ago. Over the last 2 days he has had
    some difficulty walking but mostly he complains about difficulty rolling up
    cigarettes. On examination, there is mild symmetrical distal weakness, mild gait
    ataxia and dysdiadochokinesia. He smokes 30 cigarettes a day and drinks 1–2
    bottles of wine. He has a family history of hypertension and his 63-year-old mother
    has type 2 diabetes, whom over the last year has complained of numbness and
    burning in her feet. He self-discharges. A week later, his symptoms have peaked. He
    displays moderate distal weakness and numbness to his knees, after which he turns
    a corner and his symptoms start to slowly resolve. What is the diagnosis?
    A. Miller Fisher syndrome
    B. Alcoholic neuropathy
    C. Chronic idiopathic demyelinating polyneuropathy
    D. Charcot Marie Tooth disease
    E. GBS

Answer 38

E

Question 39

39. Headache (2)
    A 28-year-old junior doctor has been complaining of a headache for the last 24
    hours. It started gradually, intensifying slowly and involving the entire cranium,
    but over the last couple of hours she has noticed that turning her head is
    uncomfortable. She feels generally unwell and prefers to lie in a dark room. Her
    boyfriend has noticed that she seems irritable. On examination, she exhibits
    photophobia and there is neck stiffness. There is no papilloedema. Close examination
    of her skin reveals no rashes. Kernig’s sign is negative. A lumbar puncture (LP)
    reveals low protein, normal glucose and lymphocytosis. What is the diagnosis?
    A. Viral meningitis
    B. Migraine
    C. Aseptic meningitis
    D. Bacterial meningitis
    E. TB meningitis

Answer 39

A

Question 40

40. Loss of balance
    A 36-year-old woman presents to clinic with neurological symptoms. On
    examination, she is able to stand with her feet together. Upon closing her eyes,
    however, she is unable to keep her balance. What is the diagnosis?
    A. Diabetes
    B. Cerebellar problem
    C. Alcohol abuse
    D. Proprioceptive problem
    E. Visual problem

Answer 40

D