Neurology Flashcards

1
Q

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

A
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1
Q

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

A
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2
Q

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

A
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3
Q

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

A
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4
Q

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

A
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5
Q

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

A
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6
Q

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

A
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7
Q

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

A
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8
Q

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

A
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9
Q

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

A
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10
Q

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

A
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11
Q

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

A
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12
Q

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

A
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13
Q

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

A
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14
Q

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

A
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15
Q

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

A
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16
Q

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

A
17
Q

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

A
18
Q

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

A
19
Q

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

A
20
Q

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

A
21
Q

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

A
22
Q

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

A
23
Q

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

A
24
Q

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

A
25
Q

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

A
26
Q

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

A
27
Q

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

A
28
Q

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

A
29
Q

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

A
30
Q

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

A
31
Q

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

A
32
Q

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

A
33
Q

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

A
34
Q

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

A
35
Q

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

A
36
Q

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

A
37
Q

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

A
38
Q

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

A
39
Q

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

A