Neurology

Question 1

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. Motor neurone disease

this patient has upper motor neurone signs (Brisk reflexes, upgoing plantars) combined with lower motor neurone signs in the form of fasciculations. This combined picture with no sensory involvement points towards motor neurone disease/MND (D). The bulbar signs, such as tounge wasting and fasciculation strongly supports the diagnosis.

MG (A) would not have the UMN signs we see in this case. and there is no evidence of the key feature of fatigability.

Diabetic neuropathy (B) would be purely LMN and would usually affect sensation, although moor is possible.

Myositis (C) affects the muscle resulting in tenderness, wasting and fasciculation, but would not have UMN signs.

MS (E) is uncommon in this age group , and would not have LMN signs.

Question 2

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. Absent sensation to temperature in the left hand

A hemisection of the spinal cord is known as brown-sequard syndrome. It results in an ipsilateral paralysis (corticospinal tract) and loss of light touch and vibration and proprioception (all three in dorsal column) sensation. The loss of the corticospinal tract also causes upper moor neurone signs on the ipsilateral side.

On the contralateral side the loss of the spinothalamic tract (which crosses at the level of the cord) leads to a contralateral loss of pain and temprature sensation. This is why answer (B) is correct

The diapragm (A) is controled by the phrenic nerve, arising from C3/4/5 so should be preserved.

From the description of the hemisection we know that the right hand would be paralysed with no light touch sensation, making (C) and (D) incorrect.

The biceps reflex (E) arises from C5/6, so being at the level of the hemisection will likely be completely absent. Reflexes distal to C6 would be brisk, so triceps and supinator for example.

important to note that the occulosympathetic pathway arises as T1, so patients with a lesion above this (as this case) may have an ipsilateral Horner’s syndrome.

Question 3

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. A course of oral steroids

The subacute onset of upper motor neurone signs on a background of
episodes of optic neuritis in a young woman makes relapsing–remitting
MS the likely diagnosis. MS is charecterised multiple CNS lesions seperated by time and space, the gadolinium-enhanced MRI gives an indication of the prescence of mukltiple white matter lesions of different ages.

There is no specific role of NSAIDs (A) in MS. neuropathic pain would be more likely to respond to other medications such as pregabalin.

drugs such as interferon-beta (B) or glatiramer acetate are useful disease modifying drugs used in relapsing remiting MS, but are not the appropriate immediate management drugs.

Bed rest (C) is a rather archaic management plan

Methotrexate (D) has no evidence to suport it’s use in MS

Evidence has shown that a course of oral steroids (E) has as much of a benefit as IV steroids. The treatmetn has been shown to reduce the length of relapses so the patient recovers quicker. They do not reduce teh number of relapses or the accumulation of deficits.

Question 4

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. Left cortical infarct

The involvement of Brocca’s area, as evidenced by the dysphasia, makes this a cortical event and not a capsular (B)(D) or brainstem (E) event. Given this patient’s history of AF it is likely to be an infarct (A) rather than a haemorrhage (C). Of all strokes, around 80% are infarcts and this patient has a clear risk factor, especially as he is not on warfarin, his hypertension is only mild. A CT would still be needed to confirm the clinical suspicion.

Question 5

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. 9

GCS is scored between 3 and 15, with scores below 8 being considered a coma. the maximum scores for each component are; Eyes; 4, Verbal; 5, and motor;6.

in this case the patient scores; E2 (responds to pain), V2 (incomprehensible), M5 (localises to pain), giving a total of 9.

With GCS (aa=s many other observations) the trend is more important than a one off measurement.

Question 6

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. Hypertension

stroke risk is so fundamentally linked to hypertension (A), it is such a crucial risk factor.

Other risk factors include smoking (B), lipids (E) and
diabetes (D) which promote atherosclerosis. Poor diet, lack of regular
activity and increased waist–hip ratio are as significant risk factors as
smoking. Unmodifiable risk factors include increasing age (by far the
most significant), male sex, family history (C) and ethnicity (higher in
Blacks and Asians). Patients in atrial fibrillation have an annual stroke
risk of 5 per cent. This can be lowered to 1 per cent by anticoagulating
with warfarin, aiming for an international normalized ratio (INR) of
between 2 and 3

Question 7

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. Her female gender

In this woman’s case, all of the features except her gender (C) point to a
more aggressive disease course. Although it is close to impossible to
predict an individual patient’s outcome, features of a better prognosis
include onset under 25 years (A), optic neuritis or sensory, rather than
cerebellar symptoms on initial presentation (B), a long interval (>1 year)
between relapses (D) and few lesions on MRI (E). Full recovery from
relapses is also a positive feature. Progressive MS carries a poorer prognosis
compared to relapsing–remitting MS.

Question 8

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. Orthostatic hypotension

Question 9

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. Cluster headache

Cluster headaches (E) are more common in men and present as an excruciating unilateral headache associated with autonomic features such as miosis, ptosis, conjunctival infection, tearing, sensation of nasal congestion and facial flushing. The timing here is vital for diagnosis, cluster headaches occur in clusters of multiple episodes over a couple of weeks and then resolve spontaneously, and then will reoccur months or years later. There is no association with aura or signs of raised ICP (nausea and vomiting, papiloedema, or meninginism) making (A) unlikely, especially as this patient has had episodes in the past.

A tension headache (B), is classically felt as a tight band around the head and is less severe in nature. It is also associated with stress.

an intracebral haemorrhage (C) would present with focal neurology, depending on the location of the bleed. Hypertension is an important risk factor.

Migraine (D) is classically heralded by aura and is asociated with nausea and vomiting with osmo- (smell), phono- (sound) and photophobia. Patients prefer to curl up in a dark, quiet room, whereas patients with cluster headache feel the need to move around.

Question 10

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. Amaurosis fugax

this is classic for amaurosis fugax (C), which is described as a black curtain falling on the vision on one side, it is painless, and of short duration. It is due to retinal artery occlusion, due to embolus, likely from a cardiac source due to AF.

Thrombotic (A) and occlusive/atherosclerotic (B) vascular compromise is also painless and sudden onset but is seen in much older patients and there is a prolonged visual deterioration. Amaurosis fugax may herald retinal artery occlusion which is
confirmed on ophthalmoscopy showing oedema and a cherry red macula. It
is also a complication of giant cell (temporal) arteritis. Retinal haemorrhages
and cotton wool spots are typically seen in retinal vein occlusion.

Optic neuritis (D) is associated with MS and patients will report painful blurred vision. It affects the fovea first leading to a central scotoma and loss of colour vision.

acute angle glaucoma (E), is another condition that primarily affects older individuals, they present wth painful blurred vision, often describing a ‘halo’ effect.

Question 11

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 mouth

Answer 11

E. Place nil by mouth

this is a suspected stroke, and as such, a medical emergency. The patient needs to be thrombolysed (B) as soon as possible, the time limit being 3 hours for a suspected cerebral stroke. Before thrombolysis she needs to have imaging to ensure this isn’t a haemorrhagic stroke, requiring a different management. CT (A) is the imaging modality of choice for excluding a haemorrhagic stroke, it is faster and more readily avalible than MRI (C).

If there is a contraindication to thrombolysis then a treatment dose of 300mg aspirin (D) would be used to treat an ischaemic stroke.

However, all things considered, the most appropriate immediate action is to stop this woman eating her luch (E) to reduce the risk of aspiration pneumonia or choking.

Question 12

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. Time of onset

this man is presenting with a stroke, there is no clinical method of determining if it is haemorrhagic or ischaemic (D), he will need a CT. The only absolute contraindication to thrombolysis in this scenario is the unclear time of onset (C). There is a 3 hour time limit for thrombolysis, with the patient unable to speak it is not going to be possible to determine this and so thrombolysis is contraindicated.

Warfarin treatment (E) needs to be considered in the case of a decision about thrombolysis and an INR above 1.7 would be cause for concern.

the absolute contraindications for thrombolysis are: onset of symptoms more than 3
hours ago, seizures at presentation, uncontrolled blood pressure (over
180/110), previous intracranial bleed, lumbar puncture in the last week,
ischaemic stroke or head injury in the last three months, active bleeding (not
menstruation), surgery (B) or major trauma (including CPR) within the last
2 weeks or non-compressible arterial puncture within the last week

Question 13

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. Spinal stenosis

This is a classic history of spinal stenosis (C), which casues lower back pain and sciatica on walking. any movements that lengthen the spine, such as walking downhill, make the symptoms worse. converesly any movements that shorten the spine, such as walking uphill or sitting, improve symptoms.

This is fundamentally different in presentation to intermittent claudication due to peripheral vascular disease (A) which is related to ischaemia of the muscles and so is made worse on going uphill due to the increased work of walking.

There is no suggestion here of an osteoporotic fracture (B), which would be unusual without a casuative factor due to being male.

Sciatica (D) is a symptom and not a diagnosis in of itself.

Metastatic bone disease (E) could be a primary cause for teh spinal stenosis or sciatica, but doesn’t explain the symptoms directly. There is nothing in the case to suggest a malignant process is at work.

Question 14

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. Guillain–Barré syndrome (GBS)

This presentation of ascending polyneuropathy involving both motor and sensory neurones is classic for GBS (B). This is an inflammatory disoder of peripheral nerves often preceeded by a gastrointestinal infection such as campylobacter.

Multiple sclerosis (A) would result in upper motor neurone signs. which the absent reflexes in this case go against.

Myasthenia gravis (C) is a disorder of the neuromuscular junction and as such is lower motor neuone but has no sensory involvement. There is no involvement in this case of cranial nerves, and there is no suggestion of fatigueablity, which is a hallmark of myastenia gravis.

Although this woman is diabetic, the progression here is far too fast for a diabetic polyneuropathy (D), it will commonly lead to loss of vibration and pain sensation, leading to a stomping gait, ulcer development, and in extreme cases a Charcot joint.

Infective neuropathies (E) include conditions such as Lyme disease and leprosy which is very rare in the UK, and this patient has no history of travel.

Question 15

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. Broad-based gait

This man has many features of parkinsonism, however parkinsonian gait is usually narrow not broad (D).

Parkinson’s syndrome is classically described as a triad of; bradykinesia, tremor, and rigidity. Postural instability (A) is also common and is tested by retropulsion, as in this case. During REM sleep (B) in parkinson’s there is a loss of the usually paralysis of muscle movement, leading to patients kicking and yelling.

Hypomimia (C) is the term for mask-like facies or reduced facial expression.

Symptoms of autonomic dysfunction (E) are common and include
constipation, postural hypotension and sexual dysfunction. Very prominent
autonomic symptoms may suggest Shy–Drager’s, a type of multiple system
atrophy (which in turn is one of the Parkinson’s plus syndromes).

Question 16

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. Stop all medication

This woman has a rebound headache due to the long term analgesic use, she needs a trial of no medication (A). This will initailly worsen the headache but will allievate it in the long run. It is not advisable for a patient with a simple headache to take analgesics for more than 2 days a week.

Paracetamol must not be started (B) as this would be an overdose with her QDS co-codamol (already 1g paracetamol QDS).

Once she is off of her medications the migraine can be reviewed and it may become advisable for her to start sumatriptan (C) or propranolol (D). Continuing on the current medication (E) will not help matters.

Question 17

A 17-year-old girl is brought into accident and emergency with generalized tonic clonic
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. Phenytoin loading

Status epilepticus is a medical emergency, where seizure activity lasts for more than 5 minutes. If untreated it has a mortality of 20%, given that this girl has been seizing for 20 minutes dispite two doses of diazepam, she needs urgent phenytoin loading (E).

The next step if phenytoin is unsuccesful would be phenobarbital (B) and a trip to ITU (D). Intubation (C) and general anaestesia may be required at that stage.

IV Lorazepam (A) is the preferred initial treatment option for status epilepticus, but there is a maximum dose of 2 treatments with a benzodiazepam, which she has had. ANy further benzodiazepam use runs a risk of serious respiratory depression.

Question 18

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

C. Confirm patient compliance

Routine measurement of phenytoin levels (A) is not good practice, they
should be ordered with a question in mind. They can be helpful either for
adjustment of phenytoin dose or looking for toxicity or patient compliance.
Phenytoin levels are useful when adjusting the dose to avoid toxicity as
phenytoin has zero-order kinetics (once elimination reaches saturation
rates, it cannot be cleared any faster so a small change in the dose may
result in high blood levels), but there is no reason to change this patient’s
dose. There is no reason to suspect phenytoin toxicity either (B) as there
are no signs or symptoms such as nystagmus, diplopia, dizziness, ataxia,
confusion. However, his high blood pressure may be caused by noncompliance
with his medication (C). Although target levels exist (D), they
are imprecise and not applicable to all patients. Seizures may be well
controlled with low levels, thus phenytoin should be adjusted according to
the clinical picture and not levels. Levels are not helpful in reassuring the
patient in this situation (E).

Question 19

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. Complex partial

complex partial seizures (D) start focally, classically in the temporal lobe, and they result in reduced awareness. Patient’s will not remember the seizure, which contrasts with a simple partial (C) where the patient will remain concious.

Automatisms, such as the picking at the clothes seen here, characterize complex partial seizures.

Absence (A) and tonic clonic (B) are both generalised seizures, with absence seizures typically seen in children and last seconds, with children reported to be observed staring blankly. Tonic-clonic seizures typify the seizure type people will most often think of, with ridgid jerking and contracting movements, associated with incontinece and tounge biting.

Complex partial seizures may subsequently generalize but this has not
been reported by this patient. Carbamazepine, lamotrigine and valproate
are first-line monotherapy.

Question 20

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. L4

quick points of refernce:

L1 - inguinal

L2 - upper thigh

L3 - Knee

L4 - medial calf

L5 - big toe

S1 - little toe /sole of foot

S2/3/4 - perineal area

Question 21

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. Spinal cord

The normal power of the upper limbs combined with the complete paralysis of the lower limbs means this must be a cord transection (D). It could thoretically be a lesion of the midline of the frontal cortex (E), but that would be very unlikely.

(A)(B) and (C) would not completely spare the upper limbs.

Question 22

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

D. L1

Sensory level is defined as the most caudal dermatome with a normal score of 2/2 for pinprick and light touch.

We know the the umbilicus is approximately at a dermatome of T10, so the lesion must be just caudal (distal) to this, therefore L1 (D) is the best answer here.

Question 23

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. Left brainstem

This patient has mixed signs, with left sided facial weakness and right sided arm and leg weakness. The most parsimonoius explaination is that there is a lesion above the cord and it is affecting the limbs via the motor pathway but has occured near to to facial nerve after it has left the brainstem, this makes option (C) most likely here.

The only other explaination is that there are bilateral cortical lesions (A) and (B), but that is less likely.

(D) is the wrong side, and (E) is too low.

Question 24

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. Relative afferent lesion

in this swinging torch test we see a classic description of a relative afferent pupilliary defect, RAPD (C). This indicates a defect in the optic nerve of the affected eye, which leads to a greater consensual response to light compared with the direct responce.

It is seen in conditions such as optic neuritis, where the optic nerve is functioning but damaged.

Question 25

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. Fatigability

Disease of the muscle and neuromuscular junction can be similar. Both
generally tend to affect proximal muscles (A). Cranially, this may result in
ptosis and ophthalmoplegia (C) as well as bulbar symptoms (E) such as dysphagia and hypophonia. In both cases, reflexes (B) and muscle bulk
tend to be preserved or, if severe and longstanding, reduced. A key clinical
feature that differentiates myopathies and MG is fatigability (D). As
patients with myasthenia use their muscles, they exhaust the supply of
acetylcholine, resulting in increasing weakness. This can be elicited by
asking the patient to repeatedly abduct and adduct one arm and compare
it to the other arm that has remained at rest. Alternatively, you can ask the
patient to count to 100 and their voice will fatigue.

Question 26

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. Lung cancer

This patients presentation has some similarities with myastenia gravis, except that there is increased strength on repitition, compared to MG which characteristically presents with fatigueability. This patient has Lambert-Eaton myasthenic syndrome (LEMS), a rare autoimmune condition where there are antibodies to voltage-gated calcium channels on the pre-synaptic motor nerve termnal. It is a paraneoplastic syndrome most commonly associated with small-cell lung cancer (E). EMG is key for diagnosis of LEMS, and then searching for the primary malignancy.

Myaestenia is associated with other autoimmune conditions such as thyrotoxicosis (A), haemolytic and pernicious anaemia, connective tissue disease, as well as thymomas (a thymectomy is often performed).

Neither MG or LEMS is associated with (B)(C) or (D).

Question 27

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 tumour

Answer 27

A. Right middle cerebral artery stroke

This patient has a facial nerve VII palsy, it is forehead sparing which makes this an upper motor neurone lesion. This excludes any pathology that will cause compression of the facial nerve itself such as (B) and (E) as well as Bell’s palsy (D). In the case of a CPA tumours there would likely be cerebellar, V and VIII involvement too.

The most common cause of an upper motor neurone facial nerve palsy is a stroke, here the symptoms are on the left so it must be a right sided stroke (A)

Question 28

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. MS

Here we have a patient who is unable to execute conjugate lateral gaze to the right, this is an ability that requires communication between the abducens of the right eye and the occulomotor of the left eye. This communication is enabled by the medial longitudinal fasciculus (MLF), which in this patient is not functioning properly, this is termed an intranuclear opthalmoplegia (INO).

A common cause of an INO is multiple sclerosis (D) and that is the likely pathology here.

Myaestenia (A) often results in opthalmoplegia, but this would be at the nuromuscular junction not the MLF.

Cerebellar syndromes (C) would result in nystagmus but not opthalmoplegia.

Peripheral neuropathies (E) would not cause nystagmus or opthalmoplegia.

Vertigo (B) is a symptom not a diagnosis.

Question 29

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. Hoffman’s

The neurologist has elicited a positive Hoffman’s reflex (C) suggestive of
upper motor neurone disease. It would have been negative if the thumb
had not contracted in response to flicking the patient’s distal phalanx

Question 30

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. Frontotemporal dementia

This patient’s negative symptoms could be explained as depression (A) but the subsequent development of difficulties with word finding and disinhibition indicate a pathology of the temporal and frontal lobes, respectively. This makes a diagnosis of frontotemporal dementia (B) most likely.

despite the hypertension his deterioration has been gradual and not step-wise as would be expected in vascular dementia (D). Patients suffering vascular dementia often have preceding vascular events.

There are no features of parkinson’s, and no hallucinations so lewy body (E) is not likely

Alzheimer’s diseas (C) tends to affect memory and language before personality, there may also be a family history especially in a young presentation as we see here.

Distinguishing betwen dementias clinicaly is difficult, imaging may help but the definitive diagnosis is made histologically.

Question 31

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. MS

The abscence of ankle jerks combined with upgoing planters implies combined UMN and LMN involvement. This mixed pattern is commonly seen in spinal cord compression (D) affecting both the cord and the nerve roots, it can also be seen in combined subacute degeneration of the cord as in B12 deficiency (B).

It is often more common for this mixed picture to be as a result of two overlapping pathologies, such as an old stroke with a peripheral neuropathy.

MND (E) will present with a mixture of UMN and LMN signs with no sensory involvement.

In Friedrich’s ataxia (A) both cord and peripheral nerve involvement accompany the cerebellar degeneration. The patient will also have pes cavus, sensory loss, and may have complicatins such as HOCM and diabetes.

MS (C) may cause a mixture of pyramidal signs, sensory loss and ataxia, but will never cause LMN signs.

Question 32

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. Hemiplegic

This patient is essentially demonsrating a decorticate posture on the right leg, indicating damage to the motor pathway on the left side above the brainstem. This would be consistent with a lesion of the internal capsule or cortex, such as a stroke. It is also known as a pyramidal pattern of weakness.

Question 33

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. Left parietal lobe

Hemianopas and quadrantanopias are contralateral to the side of the lesion, thus a left parietal lobe lesion (B) results in a right lower quadrantanopia. a Temporal (C) lesion would lead to an upper quadrantanopia.

A complete optic radiation lesion (D) would lead to a hemianopia.

Optic chiasm (A) lesions result in the classic bitemporal hemianopia.

Finally an optic nerve (E) lesion would result in complete monocular vision loss.

Question 34

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. Benign paroxysmal positional vertigo

Benign paroxysmal positional vertigo (BPPV) (B) is a disorder of the
vestibular system. If the calcium carbonate crystals in the semicircular
canals dislodge, they can send conflicting information with regards to
head position, resulting in vertigo. Vertigo is triggered by movement,
starts suddenly and lasts minutes to seconds. Eliciting the timeline of
symptoms is particularly important. Although the sudden onset may
suggest a stroke (A), it would not spontaneously resolve and return
specifically on movement. Because the brainstem is a small area with
many neural structures, a lesion here would most likely result in
accompanying deficits. Ménière’s (C) disease is often accompanied by
tinnitus, hearing loss and a sensation of increased ear pressure. Vertigo
lasts from minutes to hours. It is thought to be due to excessive endolymph.
Vestibular neuronitis (D) is of uncertain aetiology and has a similar timecourse to Ménière’s; however hearing is not affected. Migraine sufferers
(E) have an increased incidence of vertigo which may occur with or
without headache. In this case, the headache is not a central feature and
the story is more consistent with BPPV.

Question 35

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. Neurofibromatosis type I

The café au-
lait spots, axillary freckling and neurofibromas are characteristic of neurofibromatosis type I (A). Lisch nodules (hamartomas on the iris) may also be evident

Conversely the cutaneous features of neurofibromatosis type II (B) are much less common, it does have a link with bilateral acoustic neuromas. Both forms are autosomal dominant.

Tuberous sclerosis (C) is also autosomal dominant, they may have ashleaf
macules (hypopigmented macules which glow under a Wood's light), Shagreen patches (plaques with an orange peel texture often seen in sacrolumbar region) and adenoma sebaceum (clusters of pink papules on cheeks and chin). There is a strong
association with epilepsy and benign tumours

Hereditary haemorrhagic telangectasia (D) also known as Osler–Weber–Rendu disease, as the name suggests is associated with telangectasia, epistaxis and vascular disorders of the CNS.

Sturge–Weber syndrome (E) patients may have facial portwine
stains and intracranial lesions and calcification which result in
epilepsy, hemiplegia and mental retardation.

All five syndromes are
genetic, and all have distinct mutations on different chromosomes. There
is no association between any of these conditions.

Question 36

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. Blood along the sulci and fissures

Convex (lenticular) haematoma (A) is seen in extradural haemorrhages as the blood forms a lens shape betwen the skull and dura, and stopping at the suture lines. They are often sen after rupture of the middle meningeal artery in trauma.

Crescent-shaped haematomas (C) indicate blood betwen the dura and arachnoid, a subdural haemorrhage, and is as a result of bleeding from bridging veins. It is often due to atrophy of the brain in old age, alcohol excess or schizophrenia.

Blood along the sulci and fissure (D) indicates bleeding between the arachnoid and pia mater, a subarachnoid haemorrhage. These calssically present as a thunderclap headache which may be associated with reduced GCS and seizures.

Intraventricular blood (E) and midlne shift (B) are relatively non-specific signs that give an indication of severity rather than diagnosis.

Question 37

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. Posterior circulation

The temporal lobes (A) are involved in memory, and on the dominant side, with receptive language. half of the optic radiation also passes through this lobe so lesions can also result in a contralateral upper quadrantonopia.

The parietal lobes (B)(C) can result in aphasia if the left side is affected or neglect if the right side is affected.

an anterior circulation stroke (D) would have effects on one of ; parietal, temporal or frontal lobes, which is not the case here.

The posterior circulation (E) supplies the brainstem, cerebellum (coordination)
and occipital lobe (vision). This would be consistent with the vertigo, right
hemianopia, nystagmus and ataxia seen in this case.

Question 38

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. GBS

The key to differentiating the different conditions here is the timing; the speed of onset, time to peak symptoms, and then resolution. In this case there is an acute peripheral polyneuropathy involving sensory and motor nerves, the picture fits with a GBS (E).

CIDP (C) would have an onset over months and a resoloution over many months, and may never completely resolve. The patients are prone to relapse.

Miller Fisher (A) is a variant of GBS and presents with a triad of opthalmoplegia, ataxia, and areflexia. This patients ataxia may well be due to his alcohol consumption. Neuropathy in miller fisher classically starts proximally which is the opposite to GBS.

Alcoholic neuropathy (B) is slow to develop and may spontanously resolve on abstinence.

Charcot marie tooth (D) is a rare heridetary neuropathy, with symptoms starting early in life and there is usually a family history. His mother’s history here is a red herring and is likely due to her diabetes.

Question 39

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 high 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. Viral meningitis

Basic
signs of meningitis that you should always look for include: photophobia,
neck stiffness, Kernig’s sign (patient’s leg is held flexed at the hip and knee
and there is pain and resistance on subsequent knee extension – not
particularly sensitive but useful if present).

CSF results give the answer away;

Bacterial meningitis; turbulant fluid, neutrophillia, high protein, low glucose

Viral meningitis; clear fluid, lymphocytosis, high protein, normal glucose (low in herpes simplex infection)

TB meningitis; clear/opaque, lymphocytosis, low glucose, high protein

the answer here is that this is a viral meningitis (A)

Asceptic meningitis (C) is a broad term that simply means non-bacterial and should be avoided.

Question 40

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. Proprioceptive problem

The test performed is Romberg’s test. It is positive in patients with
proprioceptive loss (D). Central postural control is maintained by three
systems, the vestibular, visual and proprioceptive. Patients with cerebellar
problems (B) may find it difficult to stand with their feet together despite
maintaining their eyes open. This is not a positive Romberg’s test.
Romberg’s test is complete when patients close their eyes, thus removing
visual cues. If a patient has problems with joint position sense, they will
no longer be able to maintain their balance. Romberg’s test does not
diagnose visual problems (E). Diabetes (A) and alcohol (C) may each cause
peripheral neuropathies and diminished joint position sense. However,
beware of offering an underlying cause for the proprioceptive problem
without enough information. By definition, D is the better answer as it
includes both these and many other causalities.