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NeurologyQ001A55yearoldmanpatientpresentswithan8monthhistoryofprogressivedifficultyinswallowing, and dysarthria. He has lost 6 kg in weight. On examination he has afasciculationonthetongueandabriskjawjerk.Whatisthelikelydiagnosis?

A.AmyotrophiclateralsclerosisB.SubacutecombineddegenerationofthecordC.SeniledementiaD.MultiplesclerosisE.GuillainBarresyndrome

Answer:a)amyotrophiclateralsclerosis.Afifthofpatientswithamyotrophic lateralsclerosishavebulbar involvement.This isaclassicpresentationofapatientwiththisvariantofmotorneurondisease.

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NeurologyQ003A42yearoldmanhasweakness intheextensorsoftheupper limbandflexorsofthelowerlimbmuscles.Hisspeechhasanasalquality.Thereistonguefasciculation.Whatisthelikelydiagnosis?

A.Wilson'sdiseaseB.CreutzfeldtJakobdiseaseC.MotorneurondiseaseD.MyastheniagravisE.Thyrotoxicosis

Answer:c)Motorneurondisease.Inmotorneurondisease,UMNsigns includemusclespasticity,slowed recruitmentofvoluntarymusclestrength,weaknessespecially intheextensorsoftheupper limbandflexorsofthelowerlimbmuscles,pseudobulbarpalsy.LMN features includemusclewastingand fasciculation,depressedreflexesandbulbarpalsy. Onset of the disease is usually in mid to late adult life with the incidenceincreasingwithadvancingage.

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NeurologyQ006A20yearold ladypresentswithahistoryofasingletonicclonicseizure.Shehadnotbeentakinganyillicitdrugs.Shealsoreportstheoccurrenceofoccasionalabsentspellsandbriefjerkingofhisupperlimbs,whenshehasbeenoutlatepartying.WhichoftheFollowingdrugsismostappropriate?

A.LorazepamB.CarbamazepineC.PhenytoinD.GabapentinE.Sodiumvalproate

Answer:e)sodiumvalproate.This patient is likely to have juvenilemyoclonic epilepsy (JME), and valproate is thetreatment of choice. Juvenile myoclonic epilepsy (JME) is an idiopathic generalizedepileptic syndrome characterizedbymyoclonic jerks,generalized tonicclonic seizures(GTCSs),andsometimesabsenceseizures.These can be precipitated when the patient is sleep deprived. Apart from sodiumvalproate,lamotrigineandtopirimatecanalsobeused.



NeurologyQ007A30yearoldpatienthasrecurrentepisodesofsevere,unilateral,painfeltintheregionoftheeyeandforeheadassociatedwithlacrimation.Themostlikelydiagnosisis:

A.MigraineB.SubarachnoidhaemorrhageC.RetroorbitaltumourD.ClusterheadacheE.Migranousneuralgia

Answer:d)clusterheadache.Clusterheadachecausessevere,usuallyunilateral,painfeltintheregionoftheeyeandforeheadassociatedwith lacrimation,conjunctival injectionandoccasionally transientHornerssyndrome.Oxygen and triptansmay arrest attacks, prophylaxiswith propranolol, pizotifen, andespeciallyverapamilmaypreventfurtherepisodes.

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NeurologyQ009A50patientisassessedforgraduallyprogressivedementiaoverseveralmonths.Whilsthewasonthewardhewasnoticedtohavemyoclonicjerksofhishands.Whatisthelikelycause?

A.HIVencephalopathyB.ParkinsonsdiseaseC.AlzheimersdiseaseD.PicksdiseaseE.CreutzfeldtJakobdisease

Answer:E)CreutzfeldtJakobdiseaseCreutzfeldt Jakobdisease (CJD)usuallyoccurs in the 4575 year age group andmostcommonlypresentsasarapidlyevolvingmultifocaldementiawithmyoclonicjerksinthelatterstages.NewvariantCJD,whichhasbeenstrongly linked to infection frommeatproducts of cows with BSE, tends to present with behavioural and psychiatricdisturbancesprogressingtoincoordinationanddementiawithmyoclonicjerks.



NeurologyQ010A 45 year old man has presented with lower back pain, radiating to his buttocks,associatedwith lower limbparathesiaoverthe lastfewdays.He isunabletowalkduetolegweakness.Theanklereflexesareabsent.Whatisthediagnosis?

A.DiscprolapseB.TransversemyelitisC.GuillainBarresyndromeD.MultiplesclerosisE.Friedrich'sataxia

Answer:c)GuillainBarresyndrome.Guillain Barr syndrome is preceded by respiratory or gastrointestinal symptoms intwothirds,butnotall,cases.Lowerbackpain,oftenradiatingtothebuttocksoccursinathirdofcases.DifficultywalkinginthiscaseisduetodistalweaknessandabsentdistalreflexessuggestGBS.



NeurologyQ011A62yearoldmanpresentswitharestingtremorofhisrightarm.Hewasfoundtohavecogwheelingandbradykinesia.Hisgaitisshufflinginnature.WhichoneoftheFollowingdrugsismostlikelytohelphertremor?

A.AmantadineB.BenzhexolC.BromocriptineD.CoCareldopaE.Selegiline

Answer:B)Benzhexol.Benzhexol isananticholinergicdrug (usedtoalleviatetremors inparkinsonsdisease).The first line treatment is with Ldopa which is themetabolic precursor of Ldopa.Benzhexolisnoteffectiveagainstbradykinesia.



NeurologyQ012A46yearoldfemalehadatraumaticleftsidedtoothextraction6yearsago.Sincethenshe iscomplainingof facialpainmainlyoverupperpartof left facewith intermittentexacerbation.Occasionallythepainradiatestorightsideoftheface.Whatisthelikelydiagnosis?

A.AtypicalfacialpainB.TrigeminalneuralgiaC.DrysocketcystD.BellspalsyE.Periodontitis

Answer:A)atypicalfacialpain.Complicateddentalproceduresorotherformsoftraumacanleadtoaformofatypicalfacial painswhich is also known as post traumatic facial pain/ neuralgia. The pain isusuallyselflimitingafterseveralyears.



NeurologyQ013A25yearoldsecretaryhashadseveralepisodesofbrief jerkingoftherightarmoverthepastfewweeks.Thereisnolossofconsciousness.ACTscanoftheheadisunremarkable.Whichisthebestmedicationtocommence?

A.CarbamazepineB.PhenytoinC.LorazepamD.DiazepamE.Levodopa

Answer:a)carbamazepine.Brief episodes of jerking suggests simple partial seizures. Carbamazepine is first linetherapyforthis.



NeurologyQ014A 63 year old man who has been diagnosed with a glioma is commenced onchemotherapy.4dayslater,hebeginstobehavestrangely,andhassuicidalideation.WhichoneoftheFollowingismostlikely?

A.VincristineencephalitisB.HyponatraemiaC.SteroidpsychosisD.HypoglycaemiaE.Hypocalcaemia

Answer:C)steroidpsychosis.Incidence of steroid associated cognitive changes including psychosis are highparticularlywhenhighdosesteroidsareused(e.g.dexamethaxone).

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NeurologyQ016A 65 year old man has a history of hypertension. He presents with sudden onsetdysarthria,vomitinghiccupandvertigo.Onexamination,hehasarightsidedHornerssyndrome,rightsidedcerebellarataxia,lossofpainand temperaturesensationontherighthandsideof the face,and lossofpainandtemperaturesensationintheleftupperandlowerlimbs.Whatisthelikelydiagnosis?

A.CerebellarinfarctB.InferiorparietalinfarctC.SuperiortemporalinfarctD.SubthalamicnucleusinfarctE.Lateralmedullaryinfarct

Answer:E)lateralmedullaryinfarct.Inthelateralmedullarysyndrome(inferiorcerebellararteryinvolvement),9thand10thnerveinvolvelementleadstodysphagiaanddysarthria.ThereisalsoipsilateralHornerssyndromeand facialsensory loss,andcontralateralpain/ temperaturesensory loss toupperandlowerlimbs.



NeurologyQ017A60yearoldmanpresentswithdrowsinessandconfusion.Afriendsayshehasbeenconfabulatingabouthavinghiswalletstolen.Onexamination,he isunkempt,hispupilreflexes are normal and eyemovements are normal. Therewere otherwise no focalneurologicaldeficits.ACT scanof thebrain showedmild cerebral atrophy.Hehas aMCVof105fl.Whichdiagnosisismostlikely?

A.TransientglobalamnesiaB.Korsakoff'spsychosisC.Wernicke'sencephalopathyD.Alzheimer'sE.Pick'sdisease

Answer:b)Korsakoff'spsychosis.ThehighMCVsuggestsheavyalcoholdrinking.Heisdelusional(havinghiswalletstolen)and also there are no signs of nystagmus or cerebellar signs to supportWernicke'sencephalopathy.Shorttermmemory loss,amnesiaandpersonalitychangesarealsoseen inKorsakoff'spsychosis.



NeurologyQ018A 17 year old boy with mild learning disability presents for assessment. He wasapparentlywell5yearsago,whenhedevelopedjaundicewhichpersistedfor4months.He was found to have difficulty speaking, walking up the stairs and he also hadchoreoathetoidmovementsofthearms.On examination, there was jaundice, but no clubbing, cyanosis or peripherallymphadenopathy. A neurological examination showed weakness and wasting ofmuscles acting on the shoulder and hip joints and brisk deep reflexes. The plantarresponseswere flexor. Therewere no extrapyramidal signs. The patient had KayserFleisherringsconfirmedbyslitlampexamination.Whatisthelikelydiagnosis?

A.NewvariantCJDB.AlzheimersdiseaseC.MotorneurondiseaseD.WilsonsdiseaseE.Picksdisease

Answer:D)Wilsonsdisease.Wilsondisease isarareautosomalrecessive inheriteddisorderofcoppermetabolism.Theconditionischaracterizedbyexcessivedepositionofcopperintheliver,brain,andothertissues.Wilsons disease usually presents at ages less than 40. Hepatic dysfunction is thepresentingfeatureinmorethanhalfofpatients.Apartfromhepatitis,neuropsychiatricpresentation and movement disorders are common presentations. KayserFleischerringsareobservedinupto90%ofindividualswithsymptomaticWilsondisease.Manifestations include dystonia, choreoathetoid movements, spasticity, grand malseizures,rigidity,andflexioncontractures.



NeurologyQ019A60yearoldman isonhighdoseprednisolone foradiagnosisofgiantcellarteritis4monthsago.Hecomplainsofaheadache,whichhadworsened forthepastweekanddoublevision.Onexamination,thereisneckstiffness,andrightsided7thnervepalsy.Histemperatureis38degrees.Alumbarpuncturerevealsaproteinof0.8g/l,glucoseof3.5,WCCof30(predominantneutrophils).Whatisthemostlikelycausativeorganism?

A.ListeriamonocytogenesB.MycobacteriumtuberculosisC.MycoplasmapneumoniaeD.BorreliaburgdoferiE.Herpessimplex

Answer:a)listeriamonocytogenes.ThelumbarpuncturefindingsareconsistentwithabacterialmeningitisbuttheglucoseisnotlowenoughtosuggestTB.Listeriamonocytogenesisanaerobicandfacultativelyanaerobicgrampositivebacillus.Theriskoflisteriosisismarkedlyincreasedinimmunocompromised patients, particularly among those undergoing renal transplantation,receivinghighdosesofcorticosteroids,orsufferingwithAIDSorcancer.Ampicillinorpenicillinhasgenerallybeenrecommendedasthetreatmentofchoice.



NeurologyQ020A45yearold ladypresentswithaweek'shistoryofspontaneous,deep,rightshoulderpainradiatingtotheneck.There is also weakness and then wasting of the right deltoid, spinati and tricepsmuscles.Whichisthelikelydiagnosis?

A.SpinobulbardystrophyB.C5andC6myelopathyC.GuillainbarresyndromeD.RotatorcufftendonitisE.Brachialneuritis

Answer:e)brachialneuritis.Idiopathic brachial neuritis is an immunemediated disorder, often preceded by anupperrespiratorytractinfectionorimmunisation.Theinitialfeatureistheabruptonsetofunilateralarmpainorshoulderpain.Thereisalsoevolvingweakness,whichisworst23weeksaftertheonsetofpain.



NeurologyQ021A 60 year oldman presentswith difficultywith hismobility.He has increased tone,bradykinesia,apillrollingtremorandashufflinggait.Whichmedicationshouldbecommencedfirst?

A.BenztropineB.AmantadineC.SelegilineD.ApomorphineE.Cocareldopa

Answer:e)cocareldopa.Cocareldopaisthefirstmedicationusedtoincreasedopaminergicactivityinthebasalganglia. Apomorphine is used for onoff fluctuations. Benztropine is used foranticholinergic side effects. Selegiline is an MAO inhibitor, and Amantadine is anantiviraldrug.Both areused as a second linedrugs.Apomorphine isused foronofffluctuations.



NeurologyQ022A50yearoldmanpresentswitha5yearhistoryofheadaches.Thepainhasgraduallyworsenedandisnowpresentdaily,particularlyonwaking.Hedescribesthepainasdull,generalisedandconstant. It isexacerbatedbybright light.Neurologicalexamination isunremarkable.Sheneedstotakeatleasttwoparacetamolandtwotramadoltabletsperday.Whichisthelikelydiagnosis?

A.ClusterheadachesB.AnalgesicinducedheadachesC.MigrainousheadachesD.SpaceoccupyingtumourE.Trigeminalneuralgia

Answer:b)analgesicinducedheadaches.Frequentuseofsomeimmediatereliefmedicationscanresultinrecurringorpersistentheadacheinthosewithpreexistingheadacheandanindividualsusceptibility.Threeormore simple analgesics (aspirin and/ or acetaminophen) a day (more than 1000mg)moreoftenthan5daysaweek.FrequentuseofshortactingNSAIDssuchasibuprofenandalsoopiatebaseddrugscanalsobeacause.



NeurologyQ023A60yearoldpatienthasdiplopialookingtotheleft.Whenthelefteyeiscovered,theouterimagedisappears.Whichnerveisinvolved?

A.LeftabducensB.RightabducensC.LefttrochlearD.RighttrochlearE.Leftoculomotor

Answer:a)leftabducens.Covering the affected eye causes the false image (outer image) to disappear. In thiscase,thelefteyeisinvolvedhenceleftlateralrectus(abducensnerve).



NeurologyQ024A22yearoldmanhadanaccident3yearsago.DuringthattimehewasdocumentedtohaveaT12lesiononthespinalcord.Henowpresentswithnumbnessonhistrunk.Onexamination,thereisreducedsensationtopinprickfromT6toT10.Whatisthemostlikelycauseofthis?

A.BrownsequardsyndromeB.SubacutecombineddegenerationofthecordC.AnteriorspinalarterythrombosisD.PosttraumaticsyrinxE.Arteriovenousmalformation

Answer:D)posttraumaticsyrinx.Posttraumaticsyringomyelia(PTS)referstothedevelopmentandprogressionofacystfilledwith cerebrospinal fluid (CSF)within the spinal cord. Other symptoms includeincreasedweakness, numbness, increased spasticity, and hyperhidrosis (increased sweating).Ascendingsensorylevelandsensorydissociation(selectivelossofpainandtemperaturesensation) are very sensitive indicators for detecting progressive PTS. MRI is thepreferredinitialimagingstudyforthediagnosisofPTS.



NeurologyQ025A42yearoldwomanpresentswithahistoryofheadaches.Shealsoreportsmenstrualirregularities. On examination, she was noted to be obese. Fundoscopy revealedbilateralpapilloedema.Tone,powerandreflexesinthelimbswerenormal.InvestigationsshowanormalCTscanandMRI.EEGnormal.Lumbarpuncture revealselevatedCSFpressurebuttheconstituentsofCSFarenormal.Inthisparticularpatient,whichoftheFollowingwouldsuggestthatacomplicationhasarisen?

A.BitemporalhemianopiaB.LossofcolourvisionC.4thnervepalsyD.VisuallossE.Torticollis

Answer:d)visualloss.Thediagnosisisidiopathicintracranialhypertension(benignintracranialhypertesion).Inthisconditionpapilloedemamayresultinanenlargedblindspot.Uniocularvisual losswouldsuggest infarctionoftheopticnerveconsequentonsevereandlongstandingpapilloedema.



NeurologyQ026A 70 year old man presents with sudden onset dysphagia and dysarthria, vomitinghiccupandvertigo.Onexaminationhehasa right sidedHorners syndrome, rightsidedcerebellarataxia,lossofpainand temperaturesensationon the righthandsideof the faceand lossofpainandtemperaturesensationintheleftupperandlowerlimbs.Whereisthelesion?

A.PonsB.LateralmedullaC.CerebellumD.MidbrainE.Tectum

Answer:b)lateralmedulla.Thepatienthasthelateralmedullarysyndrome.Multipleareasare involved :9thand10thnerve dysphagiaanddysarthriaVestibularnuclei vertigo Inferior cerebellar peduncle ipsilateral cerebellar ataxiaDescendingautonomicfibresHornerssyndromeFifthnervenucleuslossofpainandtemperaturesensationover the face (ipsilateral) Lateral leminiscus lossofpain and temperaturesensationinthecontralaterallimbs



NeurologyQ027Apatientpresentswithweaknessofkneeextensionandankleinversion.WhichoftheFollowingnerverootscouldbedamaged?

A.L2B.L3C.L4D.L5E.S1

Answer:c)L4.L4 is involved in kneeextension and ankle inversion.The tibialnerve carries L4& L5roots.

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NeurologyQ029A42yearoldladypresentswithweakness,diplopiaandfatigue.Shehasapastmedicalhistoryofrheumatoidarthritis.Onexamination therewasbilateralpartialptosis andweaknessofabductionofbotheyes.Whatisthelikelydiagnosis?

A.MyastheniagravisB.MononeuritismultiplexC.GuillainBarrsyndromeD.ParaneoplasticsyndromeE.LambertEatonmyasthenicsyndrome

Answer:a)Myastheniagravis.The most likely diagnosis is myasthenia gravis. There is an association betweenmyastheniagravis,perniciousanaemia, systemic lupuserythematosisand rheumatoidarthritis.The condition ismorecommon inwomenwithapeak incidencearound theage of 30. It characterised by fatiguability of the proximal limbmuscles, ocular andbulbarmuscles.Reflexesareinitiallypreservedbutmaybefatiguable.



NeurologyQ030A 30 year old man presents with a 6 month history of recurrent episodes alteredbeaviour. During these episodes, he develops amotionless starewith associated lipsmacking,grimacing,chewingmovements,scratchingorgesturing.Hispartnerdescribeshimashavinglabileemotions,hemaygetsuddenoutburstsofaggressionoragitation.WhichoftheFollowingisthelikelydiagnosis?

A.TransientglobalamnesiaB.FrontallobeepilepsyC.TemporallobeepilepsyD.ParietallobelesionE.Migraine

Answer:c)temporallobeepilepsy.The featuresof seizuresbeginning in the temporal lobe canbeextremelyvaried,butcertain patterns are common. In temporal lobe epilepsy, theremaybe amixture ofdifferent feelings, emotions, thoughts, and experiences, which may be familiar orcompletely foreign.Temporal lobeepilepsymay, forexample,causesuddenoutburstsof unexpected aggression or agitation, or it may be characterized by auralikephenomena.Complexpartialseizuresarecharacterizedbyimpairedawareness.Theyloseawarenessand tend to have a motionless stare accompanied by automatisms stereotyped,repetitive, involuntarymovements such as lip smacking, chew ing,picking atobjects,scratching,andgesturing.In some cases, a series of oldmemories resurfaces. Hallucinations of voices,music,people, smells,or tastesmayoccur.These features are called aurasor warnings.Theymaylastforjustafewseconds,ormaycontinueaslongasaminuteortwo.Carbamazepineandphenytoinareusedtotreatthecondition.



NeurologyQ031A55yearolddruguserwho ishomelesspresentswith lethargy.Generalexaminationrevealspoorhygieneandasacralsore.Hehasbilateralptosis,anddifficultyswallowing.Thereisalsogeneralweaknessinalllimbs.Hislethargyisworseintheevenings.WhichoftheFollowingisthelikelydiagnosis?

A.MyastheniagravisB.LamberteatonmyasthenicsyndromeC.BotulismD.MotorneurondiseaseE.HIVneuropathy

Answer:c)botulism.Themain differentials aremyasthenia gravis, LEMS and botulism, but in this contextbotulism ismore likely. Botulism is a paralytic disease caused by the neurotoxins ofClostridiumbotulinum.Woundbotulism,causedbysystemicspreadoftoxinproducedbyorganismsinhabitingwounds,trauma,surgeryandsubcutaneousheroininjection.Theneurologicsymptomatologyoftenhasbeendescribedasaprogressive,descendingweaknessorparalysisthataffectsmusclesinnervatedbythecranialnerves.Respiratorydifficulty arises from airway obstruction and diaphragmatic weakness. Diplopia,dysarthria, dry mouth, and generalized weakness are among the most commonpresentingsymptoms.



NeurologyQ032A50yearoldteacherdevelopsasidedfacialweakness inassociationwithhearinglossandpainintherightear.On examination, there is a vesicular rash over the right ear, and right lowermotorneuron7thnervepalsy.Whatisthelikelycause?

A.LymediseaseB.HerpeszosterC.DiabetesD.PolyarteritisnodosaE.Syphilis

Answer:b)herpeszoster.ThisisRamsayHuntsyndrome.TheprimarypathophysiologyofRamsayHuntsyndromeislocatedinthegeniculateganglionoftheseventhcranialnerve(CNVII).Classically,RamsayHuntsyndromehasbeenassociatedwithVZV. It isassociatedwith7thnervepalsy,vertigo,ipsilateralhearinglossandtinnitus.



NeurologyQ033A55yearoldmanhas leftsidedhearing lossandvertigo.Onexamination,hehasanabsentcornealreflexontheleft.Thereisalsomildleftsidedfacialweakness.WhichoneoftheFollowingismostlikely?

A.FrontallobetumourB.CavernoussinusthrombosisC.RamsayHuntsyndromeD.CerebellopontineangletumourE.Syringomyelia

Answer:D)cerebellopontineangletumour.Cerebellopontine angle (CPA) tumors can cause vertigo,unilateralhearing loss. Largetumors may cause subtle facial weakness, decreased corneal reflex, and facialdysesthesia. If there was opthalmoplegia or chemosis, then a cavernous sinusthrombosiswouldbemorelikely(itcanalsocauseabsentcornealreflexes).

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NeurologyQ035A35yearoldwomanwakesupwithasuddenonsetseveresharpheadache.Shehasnoneurologicalsigns.CTofherheadisnormal.Whatisthebestnextinvestigation?

A.MRVB.LumbarpunctureC.SerumelectrophoresisD.EEGE.Bonescan

Answer:b)lumbarpuncture.Thediagnosisofsubarachnoidhaemorrhageneedstobeexcludeinapatientwithacutesudden onset severe headache. The CSF sample should be sent for xanthochromia.Lumbarpuncture isrecommended12hoursaftertheeventtoallowxanthochromiatodevelop. It is a yellow ish pigment (subtle and needs spectrophotometry) whichindicatesthepresenceofbilirubinintheCSF.



NeurologyQ036A30yearoldmanhasahistoryofepilepsy.HewasfoundonthestreethavingaseizureandwasbroughttoA+E.Rectaldiazepamhadbeengivenbytheambulancecrew.Hisseizurelastsmorethan15minutes.Whatisthebestmanagementstep?

A.IntravenouslorazepamB.IntravenousphenytoinC.OralcarbamazepineD.IntravenousphenobarbitoneE.CTscanofthehead

Answer:b)intravenousphenytoin.Thispatienthasstatusepilepticus.Hehasnotrespondedtoabenzodiazepineandhencethenextstepistoloadwithintravenousphenytoinatadoseof15mg/kg.

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NeurologyQ038A 45 year oldwoman has sensory loss andwasting of the small handmuscles.Oneexamination, she also has a right sided Horner's syndrome. Her arms demonstratethickeningofthesubcutaneoustissues.ThereisalsoevidenceofCharcotsjointsonthewrists.Whatisthediagnosis?

A.HereditaryspinocerebellarataxiaB.HereditaryspasticparaparesisC.MotorneurondiseaseD.SyringomyeliaE.Multiplesclerosis

Answer:d)Syringomyelia.Syringomyelia is chronicdisorder characterisedby thepresenceof gliallined cavitiessituatedinthecentralpartofthespinalcord.Recognised causes include Chiari type I malformation, central cord tumours, basalarachnoiditisandtrauma.Theremaybesensoryloss,wastingofthesmallhandmuscles,uniorbilateralHornerssyndrome,abnormalitiesofsweating,thickeningofsubcutaneoustissues,atrophyanddecalcificationofbones,developmentofCharcotsjointsandChiariImalformation(duetoarachnoiditis).



NeurologyQ039A27yearoldladypresentswithasevereheadache,whichwokeherupfromsleep.Sheis not pregnant and was on no drugs in particular she was not on hormonalcontraception.Onexaminationshewasafebrileandalert.Onexaminationoftheopticfundus the cup of the optic discwas filled and themedialmargins of the discwereblurred.TherewasnootherCNSabnormality,inparticularnoneckstiffness.ACTscanwasasnormal.Whatisthelikelydiagnosis?

A.MeningiomaB.SagittalsinusthrombosisC.BenignintracranialhypertensionD.MigraineE.Meningitis

Answer:b)sagittalsinusthrombosis.Thisisthemostlikelycause,despitenotbeingpregnantorontheOCP.Inonly10%ofcases is cerebral venous thrombosis due to damage to the vesselwall by infection,tumourortrauma.Commonest causes are inherited disorders of coagulation of which factor V Leidenmutation is found in around 20% of cases. Often there is combination of causativefactors:e.g.proteinSdeficiencyandchildbirth,pregnancyandBehcet'sdisease,OCPandfactorVLeidenmutation.



NeurologyQ040A 25 year old female patient presents with a 5day history of ascending muscleweaknessinbothhandsandfeet.EMGsconfirmacutedemyelinatingsensoryandmotorneuropathy.Whattreatmentshouldbestarted?

A.PhenytoinB.DiazepamC.AmitriptylineD.IntravenousimmunoglobulinE.Pyridostigmine

Answer:d)intravenousimmunoglobulin.The diagnosis is Guillain Barre syndrome. It is preceded by diarrhea (e.g.campylobacter) and chest infections (e.g. mycoplasma) in two thirds of cases.Autonomic dysfunction and hyporeflexia are associated. Studies have shown thatplasmaexchange and IVIg areequallyeffective in treatingpeoplewithin two to fourweeksofonsetofGBS.

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NeurologyQ042Apatienthas,onexamination,weakness inplantar flexionand foot inversionon theleft.Healsoisunabletotiptoeonthesamefoot.Anklejerkisabsent.Whichnervelesionismostlikely?

A.CommonperonealnerveB.L4nerverootC.TibialnerveD.SciaticnerveE.Femoralnerve

Answer:c)tibialnerve.Thetibialnervesuppliesthegastrocnemiusmuscleandleadstotheabovefindings.Thecommonperonealnervecausesweaknessofeversionanddorsiflexion.



NeurologyQ043A50yearoldmanhassubjectivelydiminishedlighttouchandpinpricksensationinthelefthandextendingtoabovetheelbow.Jointpositionsense is intact.Hehasdifficultydistinguishingacigarettefromapenusingtherighthandwithhiseyesclosed.Histwopointdiscriminationis11mm.Whereisthelesion?

A.AnteriorfrontalB.PosteriorfrontalC.AnteriorparietalD.PosteriorparietalE.Cingulategyrus

Answer:c)anteriorparietal.Thesensorysignsdescribedhereareindicativeofalesionoftheanteriorparietalcortex(mid postcentral gyrus). The cingulate gyrus is part of the limbic system (mood andemotions).



NeurologyQ044A55yearoldmanhasbeenprogressivelygettingmoreconfused.Hissymptomsbeganaboutthreeyearsagowhenhenoticedlegstiffness.Atpresenthisentirebodyfeelsstiffandhehasarestingtremorinthelimbs.Hiswritinghasbecomesmall.Overthelastsixmonths,hehasdevelopedhallucinationsand reports seeingghost figures,and isalsobecomingforgetful,ononeoccasionleavingthegascookerfireon.Onexamination,hisminimental scorewas10/30.Hehas increased tone throughoutwhich is spastic and cogw heeling. There is a tremor in all limbs. Cranial nerveexamination revealsmild restrictionofconjugateupgazeeyemovement.Hisgaitwasshufflingwithatendencytofallbackwards.Whatisthemostlikelydiagnosis?

A.Parkinson'sdiseaseB.Pick'sdiseaseC.LewybodydementiaD.Huntington'sdiseaseE.Motorneurondisease

Answer:c)Lewybodydementia.The combination of progressive cognitive decline, fluctuating symptoms, visualhallucinations, extrapyramidal signs (rigidity and bradykinesia more prominent thantremor)suggestLewybodydementia. It isprogressive.Patientsareatriskoffallsandsyncope. Symptoms and signs of lew y body dementia probably result in part fromdisruptionofinformationflowfromthestriatumtotheneocortex,especiallythefrontallobe.Thecauseismultifactorial.Alteredneuromodulatorand/orneurotransmitterlevels(eg,acetylcholine,dopamine)influencethefunctionofmanyneuronalcircuits.



NeurologyQ045A35yearoldpatientpresentedtothehospitalwithgeneralisedunsteadinessandlimbweakness. There was a history of ascending weakness, beginning five days beforeadmission. On examination, she had distalweaknesswith decreased reflexes in thelowerlimbs.Shehada lumbarpuncture.TheresultsoftheCSFshowed7x10^9/l lymphocytes,noerythrocytes,and1.2g/lprotein.EMGsshowedreductionofmeanconductionvelocityandprolongeddistallatency(DL)wereobservedinthemedian,ulnar,andtibialnerves.Whatisthediagnosis?

A.MultiplesclerosisB.ViralmeningitisC.SyphilisD.TrigeminalneuralgiaE.GuillainBarresyndrome

Answer:e)GuillainBarresyndrome.Conditionssuchasviralmeningitisandmultiplesclerosiscausemildproteinelevation(above0.5g).However,GuillainBarresyndromecausesmarkedproteinelevation,oftenapproachingormorethan1g.MIn Guillain Barre syndrome, there is acute demyelination of the nerves, leading toreducedconductionvelocitiesontheEMGs.



NeurologyQ046A43yearoldmanpresentswithfrequentheadachesandlossoflibido.Hewasfoundtohave hypopituitarism on investigation. The CT scan shows a pituitary tumour withsuprasellarextension.WhichoftheFollowingstructuresislikelybecompressed?

A.AbducensnerveB.HypothalamusC.TrochlearnerveD.OpticchiasmE.3rdVentricle

Answer:D)OpticchiasmSuperior extension (suprasellar) of a pituitary tumour can lead to compression andinvasionoftheopticchiasmandnerve.



NeurologyQ047A32yearoldwomanhasknownmigraine.Shegetsperiodicepisodesofheadacheswithassociatedvisualsymptoms.WhichoneoftheFollowingdrugsshouldbeusedfirstinamigraineattack?

A.IbuprofenB.MethysergideC.SubcutaneoussumatriptanD.OralsumatriptanE.Morphine

Answer:a)ibuprofenInacutemigraineattack,thefirstlinetreatmentsaresimpleanalgesicssuchasaspirin,ibuprofenorparacetamol.Second linetreatment inacutemigrainearethetriptans(e.gsumatriptan)whichworkbyselectivelystimulating5hydroxytriptamine1(5HT1)receptors.



NeurologyQ048A30yearoldwomanhasan18monthhistoryofunsteadygait,difficultytospeakandto perform finemovementswith the fingers. She has a history ofmoderate alcoholintake.Neurological examination showed scanning dysarthria, horizontal nystagmus in thelateral gaze, severe bilateral dysmetria in the upper and lower limbs, bilateraldysdiadochokinesis,severegaitataxiaandinabilitytomaintainthesitting.Whatisthediagnosis?

A.Parkinson'sdiseaseB.SubacutecombineddegenerationC.CerebellarsyndromeD.MotorneurondiseaseE.Myastheniagravis

Answer:c)cerebellarsyndrome.Amnemonic for cerebellar signs isVANISHD Vertigo,Ataxia,Nystagmus, Intentiontremor,Scanningspeech,HypotoniaandDysdiadochokinesis.Cerebellarsyndromesarecommonlyduetoalcohol,cerebellarspaceoccupyinglesions,multiple sclerosis, and rarely, inherited sydromes such as Friedrich's Ataxia orSpinocerebellarataxia.



NeurologyQ049A 30 year oldman presentswith a 5 day history ofweakness in the arms and legs,accompaniedbytingling.Hehadseveralepisodesofbloodydiarrhoeaillnesstwoweeksago.Onexaminationtherewaslegandarmweaknessandflacciddeeptendonreflexes.Whichtestwouldbesthelpconfirmthediagnosis?

A.EMGB.EEGC.MRID.HIVserologyE.AntiAchantibody

Answer:a)EMG.The diagnosis is likely to be Guillain Barre syndrome. The two best tests are EMG(showsacutedemyelinationchanges)andCSF(raisedprotein).Campylobacterserologyshouldalsobesentforthispatient.



NeurologyQ050A70yearoldmanwhohadmultipleepisodesofunilateralamaurosisfugax.Hehasriskfactorsofbeingasmokerandhypertension.Heisonatenololandaspirin.AnECGshowsatrialfibrillation.Carotiddopplersshow80%rightcarotidstenosis.Whatisthemostappropriatemanagement?

A.WarfarinB.Carotidendarterectomy,thenwarfariniseC.ClopidogrelD.Highdoseaspirin300mgwithaprotonpumpinhibitorE.Tighthypertensivecontrol

Answer:b)carotidendarterectomy,thenwarfarinise.As there is > 70% carotid artery stenosis and symptoms suggestive of emboli,endarterectomyisrecommended.Thepatientshouldalsobeanticoagulatedafterwardsinviewofatrialfibrillation.

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NeurologyQ052A 66 year old man has had longstanding tremors in both his hands and forearms.Examinationrevealsnormaltone,powerandreflexesinhisarms.Thetremorsimprovewhenhedrinksalcohol.Whatisthediagnosis?

A.Parkinson'sdiseaseB.MotorneurondiseaseC.BenignessentialtremorD.PrioninfectionE.Hemiballismus

Answer:c)Benignessentialtremor.TheFollowingfeaturessupportadiagnosisofEssentialTremor:(1)bilateralactiontremorofthehandsandforearms(2)absenceofotherneurologicalsigns,exceptthecogwheelphenomenon(3)mayhaveisolatedheadtremorwithnosignsofdystoniaSecondary criteria includea longdiseaseduration (more than threeyears),apositivefamilyhistoryandbeneficialresponsetoalcohol(notanticholinergics).

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NeurologyQ055A40yearoldpatienthasbeenhavingfevers,neckstiffnessandconfusion.TherewasapastmedicalhistoryofHIVinfectionanddiabetes.A CT scan was normal and lumbar puncture was performed. The opening pressureduringLPwasnormal,andtherewereelevatedCSFlymphocytes(88),andelevatedCSFprotein(5.5g/l),andalowglucose.GramstainingandIndiainkpreparationrevealed47m,roundbuddingyeastswithcapsuleand810lymphocytesperhighpowerfield.Whatisthediagnosis?

A.MumpsmeningitisB.MycobacteriumtuberculosisC.CryptococcalmeningitisD.CarcinomatousmeningitisE.Meningococcalmeningitis

Answer:c)cryptococcalmeningitis.Cryptococcalmeningitis isoftenseen in immunosuppressedpatients.Theorganism isCryptococcus Neoformans. Meningitis manifests with diffuse, nonfocal findings (eg,alteredmentalstatus,vomiting).ACTscanorMRI inpatientswithcryptococcal infectionmayrevealdiffuseatrophyorcerebraledemawithfocal,homogenous,orcontrastenhancedareas.An India inkpreparation is commonlyusedwithCSF to identify theorganism and tosupport a presumptive diagnosis. If performed correctly, 2550% of patients withcryptococcalmeningitisshowcryptococci.InpatientswithAIDS,amphotericinB isgivenfor2weeks,withorwithout2weeksofflucytosine,followedbyfluconazoleat400mg/dforaminimumof10weeks.



NeurologyQ056A young lady visits her neurologist complaining of episodes of generalisedweaknessafterargumentswithherpartner.Shealsocomplainsofseeinggoblinsuponwakingup.Atworkasasecretary,shehasdifficultystayingawakeandmayhavesleepattacks.Whatisthelikelydiagnosis?

A.NarcolepsyB.GeneralisedepilepsyC.PetitmalseizuresD.ObstructivesleepapnoeaE.Jacksonianseizures

Answer:a)narcolepsy.Theconditiondescribedisnarcolepsy.Theepisodesdescribedarelikelytobecataplexy.TheHLAassociationisDQB1,Clomipramineisatricyclicantidepressantwhichmayhelp,thereisearlyREMsleepandhypnagogichallucinationsoccur.



NeurologyQ057A68yearoldwomanhasneckpainsandoccipitalheadachesfor2years.Sheisreferredtotheneurologyoutpatientsforassessment.InvestigationsshowedanormalCTofthebrain.CervicalXrayshoweddegenerativechangesofnarroweddiscspacesandlossofcervicallordosis.Whatisthelikelydiagnosis?

A.CerebellarhaemorrhageB.TemporalarteritisC.OccipitalneuralgiaD.EpiduralhaemorrhageE.Cervicalspondylosis

Answer:E)cervicalspondylosis.Incervicalspondylosis,severaloverlappingsyndromesareseen:neckandshoulderpain,suboccipital pain and headache, radicular symptoms, and cervical spondyloticmyelopathy.Examinationfindings includeneckpain,radicularsigns,andmyelopathicsigns.Cervicalspine films can demonstrate disk space narrow ing, osteophytosis, loss of cervicallordosis,uncovertebraljointhypertrophy,apophysealjointosteoarthritis,andvertebralcanaldiameter.



NeurologyQ58A 45 year oldwoman is referred to you for investigation of headache. She has hadheadachesfor10years.Initially itrespondedtoproprietarypainkillers,butshe iscurrentlyusingthemaximumdoseofparacetamol,tramadolanddiclofenac.Theheadachesarefrequentthroughoutthedayandlastforhours.Therearenoassociatedvisualsymptoms.Whichisthenextbestmanagementstep?

A.IvaspirinB.CaffeineC.WithdrawalofanalgesicsD.PizotifenE.Sumatriptan

Answer:c)withdrawalofanalgesics.The history of chronic use of analgesics and nature of headaches suggests analgesicinducedheadache.Insomepatientstheheadacheswillimprove.

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A.NecroticmusclefibresB.AbsenceofdystrophinC.ExcessivelipidstorageD.MacrophageinfiltrationE.Vasculiticchanges

Answer:b)absenceofdystrophin.Mutation in the dystrophin gene causes deficiency of dystrophin in Duchenne'smusculardystrophy.Patientsdevelopprogressiveupperandlowerlimbweaknesswithpseudohypertrophyofcalvesandquadriceps.



NeurologyQ61A 30 year old lady is found to have a left sided posterior communicating arteryaneurysmoncerebralangiography.WhichoftheFollowingwouldyouexpecttofind?

A.FacialnervepalsyB.LeftpupillaryconstrictionC.SensorylosstotheleftsideofthefaceD.DowngazepalsyE.Thirdnervepalsy

Answer:e)thirdnervepalsy.Aposteriorcommunicatingarteryaneurysmwillcausecompressionofthethirdnerve,and therefore pupillary involvement from compressionof the parasympathetic fibresthatrunontheoutsideofthethirdnerve.Thisleadstoadilatedpupil.Otherfeaturesofathirdnervepalsy includeptosis,anda downandouteye.Upgazeandadduction isaffected.

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NeurologyQ63A75 yearoldmanhasdysphasia and left sided armweakness.He is known tohavehypertension, asthma and rheumatoid arthritis. In addition he suffered from clusterheadaches.Hesmokes20cigarettesaday.On examination, he has some weakness of the left hand. Visual fields, speech andsensationarenormal.Bloodpressureis190/90mmHg.WhichoftheFollowingismostlikely?

A.PartialposteriorcirculationinfarctB.RighthemispherelacunarinfarctC.RightpontinehaemorrhageD.TotalanteriorcirculationinfarctE.Vertebrobasilarinsufficiency

Answer:b)righthemispherelacunarinfarct.Thehistorysuggests thedysarthriaclumsyhandsyndrome,oneof theclassic lacunarsyndromesthatarestrokesinthesubcorticalregions(orbrainstem)secondarytosmallvesseldisease.Theusualsiteofdamageinthedysarthriaclumsyhandsyndromeistheinternalcapsuleorpons.



NeurologyQ64A 65 year old lady presents to the hospitalwith an ataxic gait.On examination, thepatienthaddifficulty standingwithout assistance andminormovementsofherheadandbodycausedvertigo.Therewasmildposturaltremorandmarkedhypotoniaoftherightlimbs,mostlythearm.Finger tonose testingelicitedmarked intention tremoranddisdiadochokinesis in therightarm.Speechwasdysarthricbutcomprehensionwasgood.Whereisthelesionlikelytobe?

A.RightponsB.LeftmedullaC.RightcerebellarhemisphereD.CorpuscallosumE.Rightbasalganglia

Answer:c)rightcerebellarhemisphere.Lesions of the cerebellum (intention tremor, disdiadochokinesis) lead tomotor signsipsilateraltothelesion.



NeurologyQ65A25yearoldmanisknowntohaveepilepsy.Hehadageneralizedtonicclonicseizuresfor15minutes.Whatdrugshouldbegiven?

A.IVphenytoinB.IVsodiumvalproateC.IVgabapentinD.IVlamotrigineE.IVlorazepam

Answer:E)IVlorazepam.Current consensus is that a benzodiazepine, notably lorazepam (Ativan), is the initialclassofdrugforthetreatmentofstatusepilepticus.Aphenytoin,phenytoinsodiumorfosphenytoinisthenextdrugtobeadministered.



NeurologyQ66A 28 year old woman is 30 weeks pregnant. She complains of a sudden onsetgeneralisedheadache.Onexamination,shehaspupilsarewhichreactivebilaterallyandthere isarightsidedthirdnervepalsy.Whichtestismostappropriate?

A.MRAB.MRVC.MRID.CTheadE.Lumbarpuncture

Answer:b)MRV.Aheadacheinapregnantpatient,withassociatedcranialnervepalsysuggestscerebralvenous sinus thrombosis. Treatment is with intravenous or low molecular weightheparin.



NeurologyQ67A45yearoldmanhassevereepisodesofdizzinesswithassociatedvomitingandpaininthe right ear. This occurs once or twice a week. During these attacks he feels thesurrounding environment spinning around. He also mentions a high pitched soundfrequentlybeingpresent.On examination, during an attack, he has right horizontal nystagmus. Audiologicaltestingrevealsrightsidedsensorineuraldeafness.Whatisthediagnosis?

A.VestibularnystagmusB.Meniere'sdiseaseC.BenignparoxysmalpositionalvertigoD.AcousticneuromaE.Cerebellopontineangletumour

Answer:b)meniere'sdisease.Meniere'sdisease is causedbydistensionof theendolymphatic compartmentof theinnerear.ThesymptomsofMeniere'sdiseaseincludevertigo,hearinglossandtinnitus.Thedizzinessisdescribedasaspinningorwhirlingfeelingandmaycauseproblemswithbalance.Somepeople feelnauseatedandvomitduringanattack.Tinnitus refers toaringingorroaringsoundintheear.Othersmaynoticesomehearingloss,especiallywithsoundsthathavealowfrequency.Horizontalnystagmus ismorecommonlyseenonexamination,butverticalnystagmusmayalsooccur.



NeurologyQ68A30yearoldgynmasthassuddenonsetvertigoanddizziness.Onexamination,thereishorizontalnystagmus,withafullrangeofeyemovements.Herspeechisslurred.Thereisintentiontremoranddisdiadochokinesiswhichisasymmetrical.Shehasanataxicgait.WhichoftheFollowinginvestigationswouldbemostappropriate?

A.CToftheheadB.MRIandMRAofheadandneckC.MRIwithenhancementD.LumbarpunctureE.Otologicaltesting

Answer:b)MRIandMRAofheadandneck.Theclinicalpicture isofanacuteonsetcerebellarsyndrome,whichsuggestavascularcause.Thiswouldinvolvetheposterior(vertebrobasilar)circulation.Ifheadacheorneckpainwereassociated,avertebralarterydissectionwouldbemostimportanttoexclude.AMagneticResonanceAngiography(MRA)willhelptodiagnosedissection,stenosisorthrombosis.

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NeurologyQ70A40yearoldmanpresentedwithdoublevisionandwasfoundtohavenormalverticaleyemovements.Onleftlateralgaze,therewasabsenceofadductionoftherighteye,andnystagmusintheabductinglefteye.Thiseyemovementdisordercanbeexplainedbyalesioninthe:

A.LeftcerebellopontineangleB.RightparietalareaC.RightmediallongitudinalfasciculusD.LeftmediallongitudinalfasciculusE.Leftlateralmedulla

Answer:c)rightmediallongitudinalfasciculus.Thediagnosis isright internuclearophthalmoplegiaduetoa lesion intherightmediallongitudinalfasciculus.Thelikelyunderlyingpathologyismultiplesclerosis,othercausesofINOincludeagliomaorvascularlesion.



NeurologyQ71A70yearoldmanpresentswithahistoryoffalls.Hehasdifficultyreadingandwalkingdown stairs.Hehasdysarthria,akinesiaand rigidity.Powerof themuscles isnormal,reflexesarebrisk.Whatphysicalsignwillhelptoconfirmthediagnosis?

A.GaitB.EyemovementsC.RombergssignD.AbdominalreflexesE.Plantarreflexes

Answer:b)Eyemovements.Thepatienthasprogressivesupranuclearpalsy parkinsonianfeaturesandgazepalsy.Demonstrationofimpairmentofvoluntarygazewillhelpconfirmthediagnosis.

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NeurologyQ75A45yearoldmanpresentswithasuddenonsetofheadache in theposteriorregion,associatedwithvomiting.Neurological examination, including fundoscopy is unremarkable apart from slightlybriskreflexes.Thereisnoneckstiffnessorphotophobia.WhichoftheFollowingmanagementoptionswouldbethemostappropriate?

A.CToftheheadandlumbarpunctureB.MRIoftheheadC.CToftheheadD.SkullXrayE.Dischargefromhospital

Answer:a)CToftheheadandlumbarpuncture.Asubarachnoidhaemorrhage(SAH)needstobeexcluded.CTbrainscan isnormal inathird of patientswith SAH.A lumbar puncture to look for xanthochromia in the CSFshouldthenbeperformed.



NeurologyQ76A40yearoldpatienthaspresentedwithageneralisedtonicclonicseizureforthefirsttime.Thislastedfor10minutes.Whatadviceshouldbegivenregardingdrivingacar?

A.Nodrivingfor1monthB.Nodrivingfor6monthsC.Nodrivingfor1yearD.DrivingisallowedifEEGisnormalE.DrivingisallowedifCTscanisnormal

Answer:c)nodrivingfor1year.For a single seizure, driving is not permitted for 1 year. Also, a medical review isrequiredbeforeone is todo soand it isa requirement for thepatient to inform theDriverandVehicleLicensingAuthority.



NeurologyQ77The sisterof apatientwhodied from a subarachnoidhemorrhagedue to a cerebralaneurysm isworriedand isaskingaboutherchancesofhavingthesameproblem.Shementions that there family history of other deaths from subarachnoid haemorrhage.Sheishowever,asymptomatic.Whatshouldbedone?

A.ReassureandnothingelseB.CTscanofheadC.MRIheadscanD.CerebralangiographyE.Lumbarpuncture

Answer:C)MRIheadscan.Thismay be a case of familial subarachnoid haemorrhage. In thosewho have a firstdegreerelativewhogenuinelysufferedaSAH,theirriskofalsosufferingoneis37timesthatofthegeneralpopulation.MRIisbetterthanCTscanforscreening.Angiographyisdiagnosticbuttooinvasiveforscreening.

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NeurologyQ79A40yearoldladypresentswithdroopingofhereyelidsanddoublevision.Shedoesnothave proptosis. There is no muscle wasting around the face. She has diplopia ondowngazeduringexaminationandalsoproximalmuscleweaknessofherupper limbs.Myastheniagravisisdiagnosed.Whichdrugismostlikelytoimprovehersymptoms?

A.BetainterferonB.IntravenousimmunoglobulinC.BenztropineD.PyridostigmineE.Bromocriptine

Answer:d)pyridostigmine.The condition described is Mysthenia Gravis rather than Grave's eye disease orMyotonic dystrophy (frontal balding). Pyridostigmine is an anticholinesterase whichreduces acetylcholine breakdown and hence improve symptoms of fatiguability inmyastheniagravis.



NeurologyQ80A40yearoldbankclerkpresentswithaheadache,nauseaandptosisof the lefteyewithblurredvision.Shedoesnothavefatiguabilityofhereyemovements.Examinationrevealedswellingon the leftsideof face,proptosisandchemosisof the lefteye, leftmastoidswellingandleftophthalmoplegiainvolvingcranialnerves.Thepupilsizeswereequal.ACTofherheadisnormal.Whatisthelikelydiagnosis?

A.ThirdnervepalsyB.MyastheniagravisC.PituitarytumourD.CavernoussinusthrombosisE.Horner'ssyndrome

Answer:d)cavernoussinusthrombosis.Ahistoryofheadacheandnootherobviouscauseofptosis issuggestiveofcavernoussinus thrombosis. Third nerve palsy is associated with dilated pupil and Horner'ssyndromeisassociatedwithmiosis.ACTcanbenormal,anddiagnosisisconfirmedwithMRI.



NeurologyQ81A65yearoldmanpresentswithanepisodeofamnesiaforthesecondtime.2daysagohehadanepisodeofconfusion,accordingtohiswife.Hewas,however,abletohaveanormalconversationdespitehavingbeen foundwandering.After2hours,heabruptlyreturnedtonormalandcouldnotrememberwhathappened.Whatisthemostlikelydiagnosis?

A.AlcoholicencephalopathyB.SubarachnoidhaemorrhageC.ComplexpartialseizureD.TransientischaemicattackE.Transientglobalamnesia

Answer:E)tranbsientglobalamnesia.Transientglobalamnesia(TGA) isatemporaryand isolateddisorderofmemorywhichmaylastseveralhours.Heavyexerciseandthecoldareknownprecipitants.



NeurologyQ82A40yearoldmanpresentswithfingerweaknesswhichwasdiagnosedasanulnarnervelesion.WhichoftheFollowingmusclesissuppliedbytheulnarnerve?

A.InterosseiB.LateraltwolumbricalsC.OpponenspollicisD.AbductorpollicisbrevisE.Flexorpollicisbrevis

Answer:a)interossei.The interosseimusclesandmedialtwo lumbricalsaresuppliedbytheulnarnerve.Thelateral two lumbricals (anatomicalposition),opponenspollicis,abductorpollicisbrevisandflexorpollicisbrevisaresuppliedbythemediannerve.



NeurologyQ83A35yearoldalcoholicpresentswithunsteadinesswhilstwalking.Onexaminationhehasincreasedtoneandbriskreflexesintherightleg.Proprioceptionisabnormalintheright leg.There is lossofvibrationsense intheright leg.There isdecrease inpainandtemperaturesensationintheleftleg.Whichoneofthefollowingconditionsismostlikelytoberesponsibleforhisweakness?

A.SyringomyeliaB.SubacutecombineddegenerationofcordC.Friedrich'sataxiaD.GuillainBarresyndromeE.BrownSequardsyndrome

Answer:e)BrownSequardsyndrome.Brown Sequard syndrome which describes hemisection of the spinal cord, causesipsilateral UMN signs and proprioception loss (corticospinal tract and dorsal columndecussateat themedulla),andcontralateralsensory loss inpainand temprature (thespinothalamic tracts decussate at the same level). The rest of the conditions(syringomyelia,subacutedegenerationofcord,Friedrich'sataxia)cancausecerebellarsignsorpatchysensorylossbutshouldbebilateral.

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NeurologyQ85A50yearoldalcoholicisadmittedtoA+Ewithunsteadinessandconfusion.BMis7.Whichisthemostappropriatetreatment?

A.GlucoseB.LorazepamC.IVthiamineD.IVvitaminB12E.IVvitaminK

Answer:c)IVthiamine.ThispatientislikelytohaveWernicke'sencephalopathycausingconfusion.IVthiamineshouldgiventoreducetheprogression.ThisiscontainedinPabrinex.



NeurologyQ86A man presents with generalised weakness. On examination, fatiguability wasdemonstrated.AdiagnosisofEatonLambertsyndromewasmade.Whatformofantibodyisfoundinthiscondition?

A.AntiPurkinjeB.AnticholinesteraseC.NeuromuscularjunctionD.PotassiumchannelsE.Voltagegatedcalciumchannels

Answer:E)voltagegatedcalciumchannelsEatonLambertsyndromeisfrequentlyassociatedwithamalignancye.g.bronchial.Thedisorderisassociatedwithantibodiesagainstvoltagegatedcalciumchannels.

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NeurologyQ88An18yearoldwomanisreferredtotheGPbyherteacher.Theteacherwasconcernedabout frequent episodes of day dreaming during class and poor examination resultsoverthepastyear.WhichoneoftheFollowingneedstobeexcluded?

A.VasovasagalsyncopeB.PseudoseizureC.AnxietydisorderD.VisualhallucinationsE.Absenceseizures

Answer:E)Absenceseizures.Daydreaming in children can be easily confused with absence or complex partialseizures, inwhichstaring isaprominentandcommonfeature.However, lipsmacking,eyeblinking,orstiffeningofmusclegroups iscommonduringseizuresbutnotduringdaydreaming.



NeurologyQ89A20yearoldmanpresentswitha6monthhistoryofdepressionandpainfulsensorydisturbanceinbothlegs.Hehasalsobecomeveryconfused.Therearemyoclonicjerksobservedinhislegs.HisMRIscanrevealsthalamichyperintensityandEEGisnormal.Themostlikelydiagnosisis:

A.NewvariantCJDB.Huntington'sdiseaseC.Wilson'sdiseaseD.ProgressivemultifocalleucoencephalopathyE.Paraneoplasticsyndrome

Answer:a)newvariantCJD.NewvariantCJDcommonlypresents inyoungadultspainfulsensorysymptoms inthelower limbs and also psychiatric symptoms. Cognitive impairment, pyramidal signs,myoclonusandprimitivereflexesthendevelop.MRI commonly shows high signal on T2w eighted images in the pulvinar (posterioraspectofthalamus).EEGisoftennormal,unlikesporadicCJD,inwhichtriphasicwavesareobserved.



NeurologyQ90A 60 year old woman is admitted with a severe headache. CT scan conforms asubarachnoidhaemorrhage.Sheinitiallymakessatisfactoryprogressbut7dayslaterherlevelofconsciousnessbeginstodeteriorate.Themostlikelycauseofthedeteriorationis:

A.CerebraloedemaB.ConingofthemedullaC.MeningitisD.EncephalitisE.Acutehydrocephalus

Answer:e)acutehydrocephalus.Organised blood in the subarachnoid space may cause obstruction to the flow ofcerebrospinal fluid (impaired absorption in the arachnoid villi). 10% of patients willrequireCSFdiversionorshunting.



NeurologyQ91A62yearoldwomanhasseveralepisodesofdizzinessparticularlywhensheturnsherhead.2monthsago,shehadanattackofvertigo,withoutdeafnessortinnitus, lastingfor a few minutes. Over the last month, she had five further attacks of vertigo,accompaniedbymoderateheadache and a lefthomonymoushemianopia, lasting forabout a quarter of an hour. After the last episode she developed persistentunsteadinessofgait,andwasadmittedtohospital.Onexaminationtherewasnormalvisualfields.werefull.Therewasrhythmichorizontalnystagmus, slightweaknessof the rightexternal rectusmusclewithoutdiplopia, andataxiaofgait,provokedbyturning.Thebloodpressurewas160/80mmHg.Whatisthediagnosis?

A.ParietallobeCVAB.FrontallobeCVAC.VertebrobasilarinsufficiencyD.SyringomyeliaE.Brownsequardsyndrome

Answer:c)vertebrobasilarinsufficiency.Vertebrobasilar(posterior)circulationconstitutesthearterialsupplytothebrainstem,cerebellum, and occipital cortex. Bilateral visual loss, dizziness, speech disturbances,dropattacksandtransientglobalamnesiaarefeaturesofvertebrobasilar insufficiency.MRI/MRAaregoodinvestigationstoinvestigateforvertebralorbasilararterialdisease.



NeurologyQ92A55yearoldmanhasdevelopedweaknessoverthepast3weekswhichhasaffectedhiswalking.Hehasnosignificantpastmedicalhistory.Onexamination,hehaddecreasedsensationperipherallyinthelegsandalsoflaccidreflexesintheankles.ACToftheheadwasnormalandlumbarpuncturewasdone.Resultswere:protein0.75(

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NeurologyQ94A60yearold ladypresentswithacuteonsetunsteadinessanddizziness.NeurologicalexaminationshowsarightsidedHornerssyndromeandnystagmus.Thereisalsolossofpainandtemperaturesensationontheleftsideofthetrunkandintheleftarmandleg.Hergaitisataxic.Whichisthecorrectdiagnosis?

A.PosteriorinferiorcerebellararteryocclusionB.MedullaryinfarctC.PosteriorcerebralarteryocclusionD.MiddlecerebralarteryocclusionE.Posteriorcommunicatingarteryhaemorrhage

Answer:a)posteriorinferiorcerebellararteryocclusion.There are a complex of symptoms caused by occlusion of the posterior inferiorcerebellararteryoroneof itsbranchessupplyingthe lowerportionofthebrainstem,resultinginsensoryandsympatheticdisturbances,cerebellarandpyramidaltractsigns,and evidence of partial involvement of the fifth, ninth, tenth, and eleventh cranialnerves.Onsetisusuallyacutewithseverevertigo.Nausea,vomiting,ipsilateralataxia,muscularhypertonicity, pastpointing and other cerebellar signs are often present. Horner'ssyndrome isusuallypresent. Sensorydisturbances include ipsilateral lossofpain andtemperature perception of the face and contralateral hypoesthaesia for pain andtemperatureofthetrunkandextremities.Theaffectedpersonshavedifficultyinswallowing.Personswellover40yearsofagearemostoftenaffected.

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NeurologyQ96A35yearoldman isadmittedwithacuterightsidedweaknessandslurredspeech.Hedoesnothaveahistoryofhypertension,diabetesorhighcholesterol.ThereisnofamilyhistoryofCVA.Hedoesnot smoke.He complainsofheadachesandgeneralised limbweaknessinfrequently.Onexamination,hehashypotoniaandweaknessintheproximalmusclesmorethanthedistalmuscles.Hislaboratorytestsshowahighlactatetopyruvateratio.Whatisthelikelydiagnosis?

A.PolymyositisB.InclusionbodymyositisC.MELASD.PolymorphonuclearleukoencephalopathyE.Neuroacanthocytosis

Answer:c)MELAS.This patient has MELAS (myopathy, encephalopathy, lactic acidosis and stroke likeepisodes).Lacticacidosisisaveryimportantfeatureofthisdisorder,asmeasuredbyahighlactatetopyruvateratio.However,ingeneral,lacticacidosisdoesnotleadtosystemicmetabolicacidosis,anditmaybeabsentinpatientswithimpressiveinvolvementofthecentralnervoussystem.Patientshaveamyopathy causingproximalmuscleweaknessandhypotonia, seizuresandstrokelikeepisodes.Itisamitochondrialinheriteddisorder.



NeurologyQ97A75yearoldladycomplainsofaheadachefor2daysintherightsideofthehead.Thepainisworsewhensheischewingortalking.Shehasalsohadmildfeversandsweats.HerESRis80mm/hr.Thevisionintherighteyeis6/18andherlefteyeis6/6.Whatisthebestcourseofaction?

A.StartivmethylprednisoloneB.OrganiseandawaittemporalarterybiopsyC.CToftheheadtoexcludespaceoccupyinglesionD.MRIofthebrainE.Refertoanophthalmologist

Answer:a)startivmethylprednisolone.Thereareearlysignsofvisuallosssohighdosesteroidsshouldbecommencedwiththesuspicionoftemporalarteritis.Althoughalltheotheroptionsarereasonable,theymaytaketimeandthereshouldnotbedelayincommencingsteroids.

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NeurologyQ99A65yearoldmanhasmuscleweakness,particularlyaroundthethighsandshoulders.HisCKis2,200U/l.EMGshowsreducedamplitudeanddurationofmotorunits.Whatisthelikelydiagnosis?

A.DermatomyositisB.MyastheniagravisC.MyotonicdystrophyD.PeripheralneuropathyE.Multiplesclerosis

Answer:a)dermatomyositis.TheseEMGchangesareconsistentwithamyositis.Inmotorneurondisease,fibrillationisseen.Inmyasthenia,thereisdiminishedresponsetorepetitivestimulation.



NeurologyQ100A42 yearoldmanpresents toA+E complainingof severe lowerbackpain Followingcarpentrywork.Thepainradiatestohisleftbuttockandthigh.Onexamination,hewasabletostraightlegraiseto45degreesonlyontheleftside.Thesciatic stretch test is positive.He has difficulty plantar flexing his left ankle and hasabnormalsensationontheplantaraspectofthefoot.Whatisthediagnosis?

A.CaudaequinasyndromeB.L2/L3discprolapseC.L4/L5discprolapseD.L5/S1discprolapseE.Commonperonealnerveinjury

Answer:D)L5/S1disease.AnkledorsiflexionisgenerallysuppliedbyL4/L5andplantarflexionsuppliedbyS1/S2.thiscaseislikelytobeduetosciaticnervepalsy.



NeurologyQ101A60yearoldman isbroughttohospitalhavingcollapsedtothegroundsuddenlyandwasunable tomovehis left legorarm.Therewasno lossofconsciousness.Hehasapastmedicalhistoryofhypertensiononly.Theepisodelastedafewsecondsandhehasbeenrelativelywell.Examinationrevealsamildhemiparesisoftheleftarmandleg.Whichisthelikelydiagnosis?

A.PontinehaemorrhageB.PrimaryepilepsyC.MedullaryhaemorrhageD.RightinternalcapsuleinfarctE.Leftinternalcapsuleinfarct

Answer:d)rightinternalcapsuleinfarct.This patient is likely to have a lacunar infarct involving the internal capsule, causingtransientcontralateralhemiparesis.



NeurologyQ102A25yearoldmanhashadbehaviouraldisturbancerecently.Hisparentsmentionedthathisbrotherhasbeeninvestigatedforliverproblemsrecently.Onexamination,hehasaMMSEscoreof28/30.Hehasamasklikefaceandwasnoticedtohavehypersalivation.Wheninvestigationsarecomplete,whichdrugismostlikelytobeusedfortreatment?

A.DesferrioxamineB.CocareldopaC.PenicillamineD.InterferonalphaE.Chlorpromazine

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