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Question 1
Correct
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A 25-year-old woman with Charcot-Marie-Tooth disease (type 1) asks how likely it is that any future children will have the disease. What is the most accurate answer?
Your Answer: 0.5
Explanation:Because Charcot-Marie-Tooth disease (type 1) is an autosomal dominant condition; therefore, there is a 50% chance that the children of this patient will be affected.
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This question is part of the following fields:
- Nervous System
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Question 2
Correct
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All of the following statements suggesting a poor prognosis of Guillain-Barre syndrome are correct except?
Your Answer: Evidence demyelination on nerve conduction studies
Explanation:Guillain barre syndrome is a neurological disorder characterised by neuropathy along with ascending paralysis. Denervation rather than demyelination suggests poor prognosis in GB syndrome.
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This question is part of the following fields:
- Nervous System
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Question 3
Correct
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Which is the most appropriate agent for the prophylaxis of cluster headaches?
Your Answer: Verapamil
Explanation:Verapamil, can effectively reduce the number of attacks during a cluster headache period of exacerbation. Oral sumatriptan has not been shown to be effective prophylactically. Verapamil in dosages of 360 to 480 mg daily is one of the few treatments for episodic cluster headache tested in a randomized controlled trial (RCT) and found effective in reducing attack frequency.
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This question is part of the following fields:
- Nervous System
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Question 4
Incorrect
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A 29 year-old new mother presented with a headache that was first noticed as she was picking up her 5 week-old baby. On admission, she was unable to tolerate the lights and complained of feeling sick. Fundoscopy showed bilateral papilledema, and she was complaining that she was unable to see on her left side. CT head showed a small right occipital bleed. Which of the following treatments is most appropriate?
Your Answer: Nimodipine
Correct Answer: Heparin
Explanation:This patient has developed a venous sinus thrombosis peri-partum, resulting in her symptoms. Anticoagulation therapy including Heparin improves outcomes.
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This question is part of the following fields:
- Nervous System
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Question 5
Incorrect
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A 61-year old mechanic recently attended A&E, with a 3 month history of bilateral paresthesia and twitching affecting the thumb, first finger and lateral forearm. He denied any trauma. An MRI scan of his spine was performed and revealed cervical canal stenosis with mild cord compression. He was discharged and advised to see his GP for follow-up. Which of the following is the most appropriate initial step in management?
Your Answer: Enlist on the weekly minor ops clinic for carpal tunnel decompression
Correct Answer: Refer to spinal surgery services
Explanation:Bilateral median nerve dysfunction is suggestive of degenerative cervical myelopathy (DCM) rather than bilateral carpal tunnel syndrome. DCM should be suspected in elderly patients presenting with limb neurology. This patient’s twitches are probably fibrillations, a sign of lower motor neuron dysfunction.
Degenerative cervical myelopathy is associated with a delay in diagnosis. It is most commonly misdiagnosed as carpal tunnel syndrome. In one study, 43% of patients who underwent surgery for degenerative cervical myelopathy had been initially diagnosed with carpal tunnel syndrome.
Management of these patients should be by specialist spinal services (neurosurgery or orthopaedic spinal surgery). Decompressive surgery is the mainstay of treatment and has been shown to stop disease progression. Physiotherapy and analgesia do not replace surgical opinion, though they may be used alongside. Nerve root injections do not have a role in management. -
This question is part of the following fields:
- Nervous System
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Question 6
Incorrect
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A 24-year-old gentleman presents with visual loss in his right eye, and this is diagnosed as optic neuritis.
Which one of the following statements would be seen in an afferent pupillary defect?Your Answer: Pupil of affected eye smaller than the unaffected eye
Correct Answer: Accommodation response is unaffected
Explanation:Afferent pupillary defect is simply a delayed pupillary response to light. Accommodation is otherwise unaffected.
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This question is part of the following fields:
- Nervous System
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Question 7
Correct
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A 68-year-old male presented with unbalances and vomiting for 1 week. Which of the following is the best investigations that can be performed to arrive at a diagnosis?
Your Answer: MRI of Cerebellum
Explanation:Lesions in cerebellum and pontine region should be excluded. So the most appropriate investigation is MRI of cerebellum.
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This question is part of the following fields:
- Nervous System
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Question 8
Incorrect
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A 41-year-old gentleman undergoes a temporal lobectomy after the discovery of a brain tumour. Which one of the following consequences would be least likely to develop?
Your Answer: Auditory agnosia
Correct Answer: Astereognosis
Explanation:Astereognosis is associated with lesions to the parietal lobe, not the temporal lobe, so this symptom would not arise in this patient.
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This question is part of the following fields:
- Nervous System
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Question 9
Incorrect
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A 58-year-old psychologist with small cell lung cancer complains of muscle weakness. Each one of the following are features of Lambert-Eaton syndrome, except:
Your Answer: Hyporeflexia
Correct Answer: Repeated muscle contractions lead to decreased muscle strength
Explanation:In myasthenia gravis, repeated muscle contractions lead to reduced muscle strength. The opposite is however classically seen in the related disorder Lambert-Eaton syndrome. Lambert-Eaton myasthenic syndrome is seen in association with small cell lung cancer, and to a lesser extent breast and ovarian cancer. It may also occur independently as an autoimmune disorder. Lambert-Eaton myasthenic syndrome is caused by an antibody directed against pre-synaptic voltage gated calcium channel in the peripheral nervous system.
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This question is part of the following fields:
- Nervous System
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Question 10
Correct
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A 48-year-old patient with diabetes is referred from the Emergency department complaining of dizziness and vomiting.
On examination he is alert and oriented, his pulse is 80 irregularly irregular and BP 160/90 mmHg. There is nystagmus on left lateral gaze and his speech is slurred. On examination of the limbs, you note intention tremor and past pointing. He is ataxic when mobilised.
What is the likely diagnosis?Your Answer: Cerebellar CVA
Explanation:The patient’s presentation with slurred speech, intention tremor and past pointing, as well as ataxia and nystagmus, paired with a history of vertigo suggest the cerebellum as the site of cerebrovascular accident (CVA) or stroke.
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This question is part of the following fields:
- Nervous System
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Question 11
Correct
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A 19-year-old patient in casualty only opens her eyes upon painful stimuli, extends her limbs, and occasionally says inappropriate words. What is her Glasgow coma score?
Your Answer: 7
Explanation:The Glasgow Coma Scale provides a score for assessment of impaired consciousness in response to specific stimuli considering the eye opening, verbal response and motor response. The score runs from 3 to 15, a coma being defined as a GCS of 8 or less. According to this patient’s responses and the respective points for each response, the score is 7 and the patient is in a coma.
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This question is part of the following fields:
- Nervous System
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Question 12
Incorrect
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A 67-year-old male presented with a history of chronic backache and altered sensation over the lateral side of his right calf and foot. Which of the following nerve roots will most likely be involved in this patient?
Your Answer: L3-L4
Correct Answer: L5-S1
Explanation:Lesions in L5-S1 region leads to altered sensation on the lateral side of calf and foot, along with back pain. There might be difficulty in extension of the leg, foot inversion, plantar flexion and toe flexion, as muscles controlling these functions are supplied by S1.
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This question is part of the following fields:
- Nervous System
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Question 13
Correct
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A 40 year-old lawyer suffered a road traffic accident. MRI reveals that he may have hemisection of the spinal cord. Which of the following findings is most likely to occur?
Your Answer: Ipsilateral hyperreflexia
Explanation:Spinal cord hemisection, also known as Brown-Sequard syndrome, is associated with symptoms affecting one spinothalamic and one corticospinal tract. Symptoms include ipsilateral paralysis, loss of vibration and position sense, and hyperreflexia below the level of the lesion. Contralateral loss of pain and temperature sensation is also seen, usually beginning 2-3 segments below the level of the lesion.
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This question is part of the following fields:
- Nervous System
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Question 14
Incorrect
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A 43 year-old female artist with no past medical history presents to the emergency department with a 2-day history of pins and needles in the lower limbs, and progressive walking difficulties. She states she had diarrhoea 1 week ago. On examination, there is a loss of pinprick sensation noted to the lower limbs from mid-thigh distally and in the upper limbs from MCP joints distally. There is bilateral weakness of ankle dorsiflexion, noted at 3/5, and knee flexion and extension weakness, noted at 4/5 bilaterally. Power in upper and lower limbs is otherwise normal. Knee and ankle deep tendon reflexes are absent. Which of the following is the most likely diagnosis?
Your Answer: Multiple sclerosis
Correct Answer: Guillain-Barre syndrome
Explanation:Guillain-Barre syndrome is an immune mediated demyelination of the peripheral nervous system often triggered by an infection (classically Campylobacter jejuni). Characteristic features include progressive weakness of all four limbs, and it is classically ascending, affecting the lower extremities first. Sensory symptoms tend to be mild.
Functional neurological syndrome can be discounted due to presence of hard neurological signs. Multiple sclerosis can be excluded because of the presence of lower motor neuron signs and absence of upper motor neuron signs. Chronic inflammatory demyelinating polyneuropathy is the chronic form of Guillain-Barre syndrome.
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This question is part of the following fields:
- Nervous System
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Question 15
Incorrect
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A 55-year-old female school teacher complains of double vision when she writes on the school blackboard. She has no history of trauma. Her most recent visit to her GP was to seek attention for a rash which developed after she was bitten when walking through the forest on a school trip. Choose the cranial nerve most likely to be affected here.
Your Answer: Trigeminal
Correct Answer: Abducens
Explanation:This nerve is responsible for the side to side movement of the eye, hence why damage can cause double vision.
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This question is part of the following fields:
- Nervous System
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Question 16
Correct
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A young woman is complaining of a sensation of spinning and loss of balance every time she moves sideways on the bed while lying supine. What would you do next?
Your Answer: Head roll test
Explanation:The most probable diagnosis is benign paroxysmal positional vertigo (BPPV). It is a peripheral vestibular disorder characterized by short episodes of mild to intense dizziness and influenced by specific changes in head position. BPPV is the most common cause of vertigo accounting for nearly one-half of patients with peripheral vestibular dysfunction. In order to establish the diagnosis, the head roll test is performed where the head is turned about 90° to each side while supine.
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This question is part of the following fields:
- Nervous System
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Question 17
Incorrect
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A 75-year-old woman experienced right sided weakness shortly after she woke up. However, the weakness resolved in 30 minutes and left no disability. Her CT and ECG appear normal. What extra actions should be taken if she is already on Aspirin, Simvastatin, Amlodipine and Bendroflumethiazide?
Your Answer: Clopidogrel + Dipyridamole
Correct Answer: Start Aspirin 300 mg for 2 weeks
Explanation:The patient has most probably experienced a transient ischemic attack which should be initially managed with aspirin 300 mg for two weeks.
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This question is part of the following fields:
- Nervous System
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Question 18
Incorrect
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A 45-year-old male, came to the OPD with a complaint of severe headache on the right side with right-sided jaw pain and additional blurred vision in the right eye. The headache was throbbing in character. What is the single most appropriate investigation?
Your Answer: BUE
Correct Answer: ESR
Explanation:The age of the patient, one sided headache and loss of vision on that side suggest temporal arteritis, also known as giant cell arteritis. The laboratory hallmark of this condition is a raised ESR.
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This question is part of the following fields:
- Nervous System
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Question 19
Incorrect
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A 52-year-old hypertensive, smoker presents to ER with right side weakness. He gives a history of multiple falls and lack of concentration. What is the most appropriate diagnosis?
Your Answer: Alzheimer's
Correct Answer: Multi-infarct dementia
Explanation:The patient is a heavy smoker and hypertensive which are risk factors of atherosclerosis and cerebrovascular diseases. The acute onset of the weakness and the lateralization indicates a cerebral infarction.
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This question is part of the following fields:
- Nervous System
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Question 20
Correct
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Which group of drugs is used to manage Trigeminal Neuralgia?
Your Answer: Anti epileptics
Explanation:The only drug currently licensed in the UK to treat trigeminal neuralgia is carbamazepine which is an anticonvulsant. It can be very effective initially, but may become less effective over time.
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This question is part of the following fields:
- Nervous System
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Question 21
Incorrect
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A 44-year-old hairdresser with a history of myasthenia gravis is admitted to the Emergency Department. She is currently taking pyridostigmine, but there has been a significant worsening of her symptoms following antibiotic treatment for a chest infection. On examination she is dyspnoeic and cyanotic with quiet breath sounds in both lungs. Other than respiratory support, what are the two other treatments of choice?
Your Answer: IV methylprednisolone or atropine
Correct Answer: Plasmapheresis or intravenous immunoglobulins
Explanation:This patient is having a myasthenic crisis. Opinions vary as to whether plasmapheresis or intravenous immunoglobulins should be given first-line. Plasmapheresis usually works much faster, but is more costly due to equipment.
Myasthenia gravis is an autoimmune disorder resulting in insufficient functioning acetylcholine receptors. Antibodies to acetylcholine receptors are seen in 85-90% of cases. Myasthenia gravis is more common in women (2:1). -
This question is part of the following fields:
- Nervous System
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Question 22
Correct
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A 41-year-old male experiences hand tremors that are absent at rest, but aggravated on extension and continuous with movement. What is the most probable diagnosis?
Your Answer: Benign essential tremor
Explanation:Tremors that linger on movement, seen on an outstretched hand, and absent on rest are called benign essential tremors.
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This question is part of the following fields:
- Nervous System
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Question 23
Incorrect
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A 52-year-old chef presents to the ED with acute visual changes. He has a past medical history of hypertension and type 2 diabetes mellitus. On neurological examination, his upper and lower limbs are normal however he has a homonymous hemianopia with central preservation. Where is the most likely cause of his problems within the central nervous system?
Your Answer: Optic tract
Correct Answer: Optic radiation
Explanation:Lesions in the optic radiation can cause a homonymous hemianopia with macular sparing, as a result of collateral circulation offered to macular tracts by the middle cerebral artery.
Lesions in the optic tract also cause a homonymous hemianopia, but without macular sparing.
Lesions in the optic chiasm, optic nerve, and temporal lobe cause bitemporal hemianopia, ipsilateral complete blindness, and superior homonymous quadrantanopia respectively. -
This question is part of the following fields:
- Nervous System
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Question 24
Correct
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A 18-year-old gentleman is referred to dermatology. He has around 10 hyperpigmented macules on his torso which vary in size from 1.5-5 cm in size. His GP also noted some freckles in the groin region. He is also currently under orthopaedic review due to a worsening scoliosis of the spine. His father suffered from similar problems before having a fatal myocardial infarction two years ago. Which chromosome is most likely to have a gene defect?
Your Answer: Chromosome 17
Explanation:The patient’s history and presentation and familial history, meets the diagnostic criteria for Neurofibromatosis type I, presenting with neurofibromas noted in this patient as hyperpigmented macules and freckles, musculoskeletal disorders like the scoliosis in this case, and a familial history. Neurofibromatosis type I is caused by a mutation on Chromosome 17.
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This question is part of the following fields:
- Nervous System
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Question 25
Incorrect
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A 68-year-old woman with contralateral hemisensory loss presents with severe burning pain in this area. In which of the following areas has arterial occlusion most probably occurred?
Your Answer: Basilar artery
Correct Answer: Thalamogeniculate artery
Explanation:The woman’s clinical evolution suggests that there was a thalamic stroke in the contralateral hemisphere. The artery most likely affected is the thalamogeniculate artery. Sensory loss is usually unilateral and presents at the opposite side of the brain lesion. This kind of stroke can result in severe burning pain which is responsive to tricyclics.
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This question is part of the following fields:
- Nervous System
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Question 26
Incorrect
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A 62-year-old male has woken up to find his speech is altered. He recently suffered from a flu-like illness. The movement of his eyelids and lips are weak on the right-hand side. Which anatomical site is most likely to be affected in this patient?
Your Answer: Trigeminal nerve
Correct Answer: Facial nerve
Explanation:Viral infection is a very common cause of facial nerve palsy, which is consistent with the symptoms described.
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This question is part of the following fields:
- Nervous System
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Question 27
Incorrect
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A 19 year-old male was brought to the OPD with GCS of 15 after a head injury. After admission his GCS deteriorated to 12. What investigation needs to be done?
Your Answer: Shift to OR
Correct Answer: CT head
Explanation:CT scan head will be the investigation of choice in this case. The best possible cause will be an intracranial haemorrhage which can be visualized easily with CT scan brain.
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This question is part of the following fields:
- Nervous System
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Question 28
Correct
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A 27-year-old realtor presented with progressive weakness of both legs over the last 3 years. He complained of being unable to see well at night and having an impaired sense of smell. On examination he had a shortened fourth toe bilaterally with pes cavus. Neurological examination revealed a loss of pinprick sensation to bilateral knees, and weakness of both legs that was more prominent distally. Which of the following would be the best blood test to order to make a diagnosis?
Your Answer: Phytanic acid
Explanation:The diagnosis is Refsum’s disease. This is an autosomal recessive disorder that causes a sensorimotor peripheral neuropathy. It is caused by defective alpha oxidation of phytanic acid leading to its accumulation in tissues. Cardiac conduction abnormalities and cardiomyopathies may also occur.
Epiphyseal dysplasia causes a characteristic shortening of the fourth toe. Serum phytanic acid levels are elevated. Treatment is by dietary restriction of foods containing phytanic acid (dairy products, fish, beef and lamb). -
This question is part of the following fields:
- Nervous System
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Question 29
Incorrect
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A 45-year-old male who is a heavy alcoholic was admitted with loss of memory, hallucinations and difficulty walking. On examination, he had an ataxic gait. He was given Acamprosate. Which one of the following can be given with the above drug?
Your Answer: Disulfiram
Correct Answer: Thiamine
Explanation:Wernicke’s encephalopathy is characterised by the triad of ophthalmoplegia, ataxia, and confusion. It must be viewed as a medical emergency with rapid correction of thiamine deficiency as the goal of therapy. Acamprosate is a medication used to treat alcohol dependence by stabilizing chemical signalling in the brain that would otherwise be disrupted by alcohol withdrawal
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This question is part of the following fields:
- Nervous System
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Question 30
Incorrect
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A 47-year-old hypertensive man presents with difficulty using his right arm, slow walking and occasional loss of balance. He has a broad-based gait with cogwheel rigidity and intention tremor of his right arm. His blood pressure is 140/80 mmHg sitting and 100/60 mmHg standing. Which of the following is the most likely diagnosis?
Your Answer:
Correct Answer: Multiple system atrophy
Explanation:This patient presents with a combination of akinetic rigid syndrome, cerebellar signs and the suggestion of autonomic features. This is most indicative of a diagnosis of multiple system atrophy.
Multiple system atrophy (MSA) is a rare neurodegenerative disorder characterized by autonomic dysfunction, tremors, slow movement, muscle rigidity, and postural instability (collectively known as parkinsonism) and ataxia.
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This question is part of the following fields:
- Nervous System
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SESSION STATS - PERFORMANCE PER SPECIALTY
