Neurology MCQ

Question 1

Which of the following is NOT a feature of myotonic dystrophy?
A. Weakness and wasting of the facial muscles
B. X-linked inheritance
C. Frontal baldness
D. Diabetes mellitus
E. Cardiac conduction defects

Answer 1

A. Weakness and wasting of the facial muscles

MyD is AD inheritance (19q13.3). Features incl:
* Myotonic facies = frontal baldness, bilateral ptosis, facial muscle weakness and wasting, jaw hanging due to masticatory muscle wasting
* Myotonia
* Cataract
* Cardiac – cardiomyopathy, conduction disorder
* Endocrine – DM, testicular atrophy
* Cognitive dysfunction
* Smooth muscle disorder, e.g. gut dysmotility, urine retention

Question 2

Which of the following is true in Myasthenia gravis?
A. Thymectomy is only indicated in the presence of thymoma
B. Thymus abnormalities occur in about 75% of patients
C. It is due to a presynaptic defect with impaired release of acetylcholine
D. The tendon reflexes are diminished or absent
E. It is more common in males than females

Answer 2

B. Thymus abnormalities occur in about 75% of patients

A – also indicated in generalized MG with risk < benefit
C – post-synaptic (pre-synaptic describes congenital myasthenic syndrome)
D – reflex preserved
E – F>M = 4:3

Question 3

Brown-Sequard syndrome manifests as:
A. Ipsilateral lower motor neuron weakness, loss of vibration and proprioception, and contralateral loss of sense of pain and temperature, below the level of the lesion
B. Ipsilateral lower motor neuron weakness, loss of sense of pain and temperature, and contralateral loss of sense of vibration and proprioception, below the level of the lesion
C. Ipsilateral upper motor neuron weakness, loss of sense of pain and temperature, and contralateral loss of sense of vibration and proprioception, below the level of the lesion
D. Ipsilateral upper motor neuron weakness, and loss of sense of vibration and proprioception, and contralateral loss of sense of pain and temperature, below the level of the lesion
E. Ipsilateral upper motor neuron weakness, and loss of sensation of all modalities below the level of the lesion

Answer 3

D. Ipsilateral upper motor neuron weakness, and loss of sense of vibration and proprioception, and contralateral loss of sense of pain and temperature, below the level of the lesion

Spinothalamic tract (motor) crosses at spinal cord), while DCML crosses in brainstem)

Question 4

Which of the following is atypical for multiple sclerosis?
A. Urinary sphincter disturbance
B. Cerebellar ataxia
C. Areflexia
D. Internuclear ophthalmoplegia
E. Decreased visual acuity

Answer 4

C. Areflexia
MS is almost exclusively CNS

Question 5

Common epileptic auras include all of the following except:
A. Gastric sensation
B. Feeling of fear
C. Unusual taste or smell
D. Desire to commit violence
E. Indescribable feeling

Answer 5

D. Desire to commit violence

Visceral sensation – e.g. epigastric sensation, gustatory/olfactory hallucination
Psychiatric – specific emotions, deja vu, jamais vu, depersonalization, blank staring
Other sensory – VH/AH, visual distortion

Question 6

In subarachnoid haemorrhage,
A. Cerebral infarction is a major cause of morbidity
B. A CT scan of the brain showing no subarachnoid blood signal excludes this diagnosis
C. Surgical intervention is not indicated unless the patient deteriorates clinically
D. The actual incidence of subarachnoid haemorrhage decreases with age
E. Hypertension is not a risk factor

Answer 6

A. Cerebral infarction is a major cause of morbidity

Vasospasm is common and preventable, usu occurs d4-21.
B – CT often negative
C – rebleeding is common, essential to secure aneurysm early
E – HT increases risk of bleeding

Question 7

Which of the following types of stroke has the highest mortality rate?
A. Cortical infarct
B. Lacunar stroke
C. Supratentorial intracerebral hemorrhage
D. Subarachnoid hemorrhage
E. Subcortical infarct

Answer 7

D. Subarachnoid hemorrhage (50% mortality rate in 1 month)

Question 8

Which of the followings can help recovery from Guillain-Barré syndrome?
A. Intravenous pulse methylprednisolone
B. Intravenous cyclophosphamide
C. Intravenous human immunoglobulin (IVIgG)
D. Fresh frozen plasma
E. Cryoprecipitate

Answer 8

C. Intravenous human immunoglobulin (IVIgG)

Give IVIG 0.4g/kg/day for 5 days
Or plasmapharesis 50ml/kg/session of plasma for 5 exchanges over 2 weeks. Combination of IVIG and PE is not better than PE or IVIG alone.

Supportive mangement
Monitor pulmonary dysfunction (vital capacity). Consider mechanical ventilation if hypercarbia and/or hypoxemia, FVC <15ml per kg of BW. Bulbar weakness, impaired swallowing, insufficient cough, tachypnoea
Watch for autonomic dysfunction (potentially fatal); cardiac monitoring (arrhythmia and severe bradycardia), BP monitoring (fluctuate betwen severe hypertension and hypotension)
GI: susceptible to the development of paralytic ileus –> monitor swallowing/+/- temporary non oral feeding
Other supportive measures: DVT prevention, urinary retention, clear secretion, early mobilization, medical treatment for pain and paraesthesia

Question 9

Which is false about glioblastoma multiforme? A. Infiltrative margin B. Lung metastasis C. Spread to contralateral hemisphere D. CSF metastasis

Answer 9

B. Lung metastasis

Intracranial tumors rarely metastasize outside the CNS

Question 10

Putamen homogenous oval shape hyperdense lesion on CT brain, extending into lateral ventricles. Which is not true?
A. This condition commonest occur in cerebellum
B. Mannitol can be given to reduce ICP
C. Routine dexamethasone is given in this condition
D. Must monitor patient carefully in acute phase
E. Surgery should not be performed because of ?low GCS unless ?acute hydrocephalus developed

Answer 10

C. Routine dexamethasone is given in this condition

Question 11

An 80-year-old lady with long history of Parkinson’s disease with recent increase in dose and frequency of Sinemet from 40 mg TD to 40 mg QID and addition of bromocriptine. His daughter says his father has ‘depressed mood’. He no longer takes part in the activities that he likes in the past e.g. playing mahjong. He also has visual hallucination. Which is the likely explanation?
A. Meningitis
B. Encephalitis
C. Adverse effect of Sinemet
D. Natural aging
E. Schizophrenia

Answer 11

C. Adverse effect of Sinemet (l-dopa + carbidopa (DOPA decarboxylase inhibitor))

VH can be caused by increase in levodopa and addition of DA. Apathy/anhedonia is more likely due to progression of underlying PD.

Question 12

Which of the following is most consistent with the imbalance of neurotransmitters in Parkinson’s disease?
A. Decrease in 5-HT
B. Decrease in GABA
C. Increase in dopamine
D. Decrease in dopamine decarboxylase level
E. Normal acetylcholine

Answer 12

A. Decrease in 5-HT

PD a/w:
* Dopamine depletion (neurotransmitter produced by substantia nigra)
* Acetylcholine excess
* Serotonin depletion (caudate as well as hypothalamus and frontal cortex) → accounts for PD-depression

Question 13

C6/C7 transection is NOT associated with:
A. V/Q mismatch
B. Diaphragmatic breathing
C. Long term artificial ventilation dependent
D. Sputum retention
E. Impaired cough reflex

Answer 13

A. V/Q mismatch

Extrathoracic pathologies do not cause V/Q mismatch.
B – theoretically, phrenic nerve is still intact, so the pt should still be able to breath autonomously

Question 14

Which of the following is NOT a common cause of stroke?
A. Atherothrombosis
B. Arterio-arterial embolism
C. Cardioembolism
D. Arterial dissection
E. Atrial fibrillation

Answer 14

D. Arterial dissection (can happen but not common)

Question 15

Which of the following is most suggestive of bacterial meningitis?
A. Neck stiffness
B. Kernig’s sign
C. High fever
D. Lymphocytosis in blood
E. Low sugar in CSF

Answer 15

E. Low sugar in CSF

Neck stiffness, Kernigs sign are generalized to meningitis (not subtype)
Lymphocytosis can either be acute bacterial meningitis phase/TB or viral meningitis

Question 16

Concerning Guillain-Barré syndrome, which is TRUE?
A. It can never occur in children younger than 10 years old
B. It is ascending muscle paralysis sparing facial and bulbar muscles
C. It can lead to respiratory failure
D. Hyperreflexia is a feature
E. Involvement of sensory more prominent than motor

Answer 16

C. It can lead to respiratory failure (hence requires monitoring of vital capacity –> may require mechanical ventilation)

A – can occur <10y, but increase with age
B – affects facial, oropharyngeal, EOM, respiratory muscles
E – affect motor > sensory

Question 17

Regarding motor neuron disease, which statement is FALSE?
A. Deep tendon reflex is usually retained until late stage of disease
B. Non-fluent dysphasia is a recognized feature
C. Abdominal reflexes are usually retained
D. Muscle fasciculation is a conspicuous feature
E. Positive family history is found in 5–10% of patients

Answer 17

B. Non-fluent dysphasia is a recognized feature

Although MND is a/w FTD, it is usu a/w behavioural variant FTD instead of primary progressive aphasia. A – weak and wasted muscles with retained reflexes is highly suggestive of MND
C – abdominal reflexes usu retained until late stage

Question 18

A 68-year-old right-hand dominant man presented with transient episode of speech disturbance and right sided weakness. He has history of hypertension and type 2 DM. Physical exam shows BP 140/80, neurological exam normal, irregular pulse. On investigation CT brain is normal, Duplex Doppler shows 50% carotid stenosis. Atrial fibrillation confirmed by ECG. Which is the MOST appropriate stroke prevention approach?
A. Aspirin
B. Aspirin + clopidogrel
C. Carotid endarterectomy
D. Warfarin
E. ACEI

Answer 18

D. Warfarin

CHAD VASc: TIA already scores 2 + HT + DM + Age
Carotid endarterectomy only indicated if >70% stenosis

Question 19

Which one is characteristic of trigeminal neuralgia? A. Chemosis
B. Bilateral involvement
C. Diclofenac can be a treatment of choice
D. Amendable to microvascular decompression
E. Continuous pain

Answer 19

D. Amendable to microvascular decompression

TN is characterized by attacks of brief shock-like severe pain in V2/3 distribution. 80-90% a/w vascular loop compression, therefore is amenable to microvascular decompression esp in young. Classic TN usu treated by carbamazepine (75% responsive) or other anti-epileptics

Question 20

Which drug cannot be used in patients with myasthenia gravis?
A. Atropine
B. IVIG
C. Penicillamine
D. Penicillin

Answer 20

C. Penicillamine

Penicillamine (copper chelator) notorious for A/I manifestation, can precipitate MG crisis.

Question 21

Which of the following is true in Parkinson’s disease?
A. Use of metoclopramide is indicated in nausea in L-dopa treatment
B. You will usually find affected family members
C. Painful dystonia can complicate L-dopa therapy

Answer 21

C. Painful dystonia can complicate L-dopa therapy

Dystonia can occur as part of motor fluctuation with prolonged levodopa therapy. A – domperidone is preferred as it does not cross BBB B – usu not familial

Question 22

Which of the following is not a clinical feature of lateral medullary syndrome?
A. Dysphagia
B. Ipsilateral loss of trigeminal sensation
C. Ipsilateral Horner’s syndrome
D. Ipsilateral loss of spinothalamic sensation of limbs and trunk
E. Ipsilateral ataxia of limb

Answer 22

D. Ipsilateral loss of spinothalamic sensation of limbs and trunk

Lateral medullary syndrome a/w PICA and vertebral artery infarct.
Contralateral loss of fine touch, vibration, 2 point discrimination and proprioception (DCML decussates at the medulla oblongata)
Contralateral loss of pain and temp sensation (spinothalamic tracts already decussate at spinal cord)
Ipsilateral Cerebellar Ataxia and Ptosis (i.e. Horner)
Vertigo, Vocal cord dysfunction and other bulbar functions

Question 23

A patient presented with right sided facial sensation defect and left sided body sensation defect, which is the most likely location of the lesion?
A. Right-sided brainstem
B. Left-sided brainstem
C. High cervical spine
D. Putamen
E. Right-sided parietal lobe

Answer 23

A. Right-sided brainstem

Right sided facial sensation defect that means located at the medulla oblongata if combined with the hemiparesthesia
Left sided body sensation defect –> therefore the DCML are already decussated at the medulla oblongata on the right side

Question 24

A 40-year-old man presented of recurrent strange sensation of tongue, smells something strange, with sensation of deja vu. What is the most likely diagnosis? A. Acute psychosis B. Delirium tremens C. Hypoglycaemia D. Subarachnoid haemorrhage E. Temporal lobe epilepsy

Answer 24

E. Temporal lobe epilepsy

Question 25

Which is not a common cause of meningitis? A. Neisseria meningitidis B. Streptococcus pneumoniae C. Haemophilus influenzae D. Cryptococcus neoformans E. Streptococcus suis

Answer 25

D. Cryptococcus neoformans (immunocompromised state)

Question 26

Which of the following is characteristic of myasthenia gravis?
A. Generalized muscle weakness
B. Complete ptosis with ophthalmoplegia
C. Absence of muscle jerk
D. Absence of sensory loss

Answer 26

D. Absence of sensory loss

Question 27

20/F previously healthy, NKDA, presented with increasingly worsen headache over 24 hours, fever 39 degree, neck stiffness and generalized petechial rash. She has otherwise no neurological signs. Your immediate management should be: A. Immediate IV meningitic dose of penicillin, blood culture, lumbar puncture B. CT head, blood culture, LP C. CT head, ESR, temporal artery biopsy and analgesics D. MRI head, EEG, phenytoin E. MRI head, EEG, (???)

Answer 27

A. Immediate IV meningitic dose of penicillin, blood culture, lumbar puncture

Neisseria meningitidis (petechial rash): gram -ve intracellular diplococci
Petechiae due to bacteremia and sepsis sydnrome: fever, petechiae and purpura

Question 28

A 67-year-old man with Parkinson’s for 7 years on levodopa experiences nausea after taking the medication. Which of the following drug is most appropriate for treating his nausea?
A. Metoclopramide (Maxolon)
B. Cinnarizine (Stugeron)
C. Prochlorperazine (Stemetil)
D. Ondansetron (Zofran)
E. Domperidone (Motilium)

Answer 28

E. Domperidone (Motilium)

Domperidone is a peripheral D2 blocker. It does not cross BBB, and therefore does not interfere with levodopa.

Domperidone will act on the chemoreceptor trigger zone of vomiting center located on the dorsal surface of medulla oblongata: floor of the 4th ventricle of the brain (no BBB)

Question 29

Patient on warfarin. Conscious. Right-sided ataxia and nystagmus. SBP 160 mmHg. Right cerebellar haemorrhage seen on CT brain. Which of the following is an appropriate action?
A. Monitor GCS qid
B. Insert Ryle’s tube for feeding and giving medication
C. Lower blood pressure by giving nifedipine via Ryle’s tube
D. Give IV phenytoin to control seizure
E. Look for coagulopathy, give FFP if necessary

Answer 29

E. Look for coagulopathy, give FFP if necessary

Reversal of anticoagulation is most important in this case, although PCC may be preferred.
D – infratentorial lesion will not cause seizures
C – BP lowering is indicated in ICH when (1) SBP >200 or MABP >150, or (2) SBP >180 or MABP >130 if no signs of ↑ICP

Question 30

30/M, presented with continuous GTC. URTI 5 days before convulsion. Physical exam showed fever of 37.8°C otherwise normal. Intubated and ventilated. What is the best treatment for seizure control?
A. IV sodium valproate
B. Carbamazepine via Ryle’s tube
C. Lamotrigine via Ryle’s tube
D. IV phenobarbitone
E. IV diazepam + loading dose of phenytoin

Answer 30

E. IV diazepam + loading dose of phenytoin
Status epilepticus

Question 31

68/M, GPH, sore throat, fever, rhinorrhoea for 1 week followed by slurred speech. Found unconscious in home. Has involuntary movement of left upper and lower limbs followed by generalized jerky movement and LOC. CBC, L/RFT, electrolytes normal. Urgent CT brain normal. What is your next step?
A. IV ceftriaxone and something
B. Empirical anti-TB and phenytoin
C. LP and IV acyclovir after CSF PCR + VE
D. LP and empirical acyclovir
E. LP and empirical acyclovir and phenytoin

Answer 31

E. LP and empirical acyclovir and phenytoin

Likely viral encephalitis. AED can be started to cover the acute period where acute symptomatic seizure can recur.

Question 32

A 53-year-old patient presented with 3 days of fever, worsening headache, nausea and vomiting. He was later diagnosed to have acute hydrocephalus with dilated ventricles. What will be your immediate management?
A. Lumbar puncture
B. Treat with anti-tuberculous drugs and steroids
C. Refer to neurosurgery for urgent drainage
D. Empirical acyclovir
E. Close observation

Answer 32

B. Treat with anti-tuberculous drugs and steroids

Hydrocephalus is classical for TBM. It may be managed medically provided that neurological status is not deteriorating rapidly.

Question 33

25/F, swimming coach, presents with 3 episodes of GTC seizures in the past year. Good past health, no family history, no personal history of febrile seizure, all physical and neurological examinations normal. EEG and MRI brain normal.
A. Do not give AED because reproductive age
B. Normal EEG and MRI rules out epilepsy
C. Use valproate as AED
D. Use lamotrigine as AED
E. She is suffering from temporal lobe epilepsy

Answer 33

D. Use lamotrigine as AED

Lamictal is a/w lowest teratogenicity.
A – not prescribing is not an option because maternal seizure causes fetal hypoxia and has devastating consequences
B – interictal EEG is only 50% abnormal
E – TLE is usu a/w temporal lobe aura and a/w hippocampal sclerosis on MRI

Question 34

Young female preparing for pregnancy, admitted to AED. Her friends and family reported she had repeated episodes of staring into space and decreased alertness lasting for minutes. Some episodes had concurrent smacking of lips. On current occasion, initial presentation was similar to previous episodes, then loss of consciousness and generalized tonic-clonic seizure lasting for more than 10 minutes, spontaneously stop with residual drowsiness, thus admitted to AED. What most likely happened?
A. Absence seizure
B. Autonomic epilepsy with partial seizure, secondary complex generalized tonic-clonic seizure
C. Cortical epilepsy with partial seizure, secondary complex generalized tonic-clonic seizure

Answer 34

C. Cortical epilepsy with partial seizure, secondary complex generalized tonic-clonic seizure

TLE with SGTCS (temporal lobe epilepsy with secondarily generalized tonic clonic seizure)

Question 35

Anti-aquaporin 4 antibodies are specific markers for which disease?
A. Devic’s disease
B. Wilson’s disease
C. Huntington’s disease
D. Steele-Richardson-Olszewski syndrome

Answer 35

A. Devic’s disease (NMO)

Question 36

A female presented (1) past history of autoimmune thyroiditis; (2) PE shows decreased reflex in both UL, (3) eyes movement restricted, appeared that multiple CN and extraocular muscles affected, (4) history of fatigue for 1 month. Which of the above is not compatible with diagnosis of myasthenia gravis? A. 1
B. 2
C. 3
D. 4

Answer 36

B. 2

Question 37

Concerning the management of a patient presenting with acute stroke. Choose the correct statement:
A. Acute lowering of BP is indicated
B. Body cooling should be indicated
C. Cerebral imaging can be delayed 72 hours
D. Intravenous thrombolysis is indicated if intracerebral bleeding is excluded and the patient presents early
E. Patients should be given intravenous heparin

Answer 37

D. Intravenous thrombolysis is indicated if intracerebral bleeding is excluded and the patient presents early (<4.5 hours, <3 hours is ideal for benefit)

Question 38

An elderly female patient, good past health, presented with diffuse distending headache, which worsens on coughing and sneezing. There is no nausea or vomiting. Physical examination showed no focal neurological signs. Which is most likely?
A. Acute meningitis
B. Brain tumour
C. Headache due to cervical spondylosis
D. Late onset migraine
E. Giant cell arteritis

Answer 38

B. Brain tumour

Worsen on coughing/sneezing typical for ↑ICP.
D – migraine usu unilateral
E – GCA usu temporal (jaw claudication, temporal tenderness)

Question 39

35/F, present with distal muscle wasting and numbness with glove and stocking pattern. Physical examination shows distal muscle wasting and absence of deep tendon reflexes. Babinski’s response is absent. What is the most likely site of the lesion?
A. Cauda equina
B. Cervical plexus
C. Cervical spinal cord
D. Neuromuscular junction
E. Peripheral nerves

Answer 39

E. Peripheral nerves

Glove and stocking loss of sensation (not dermatomal distribution –> not spinal root)

Question 40

A 20-year-old patient with known epilepsy after HSV encephalitis 2 years ago is currently on Epilim chrono (sodium valproate) 500mg BD. He recently travelled from Singapore to Hong Kong on a busi- ness trip. His mother said he left his medication in at home 5 days ago. He was admitted for a generalized tonic-clonic seizure lasting for 5 minutes. At the medical ward, he experienced another generalized tonic-clonic seizure before consciousness has been fully regained. Which of the following is to be given immediately?
A. IV midazolam + IV levetiracetam
B. IV midazolam + IV maintenance midazolam
C. IV midazolam + IV loading dose of phenytoin
D. IV midazolam + IV sodium valproate
E. IV midazolam + sodium valproate via NG tube

Answer 40

D. IV midazolam + IV sodium valproate

Stage 1: Early status use short acting BDZ as 1st line: IV midazolam
Stage 2 (10-60 mins): best to use long acting AED that patient was previously using –> IV sodium valproate

Question 41

Mrs. Lam is a 60-year-old professor of biology. She has known atrial fibrillation on warfarin. At 8:00 am she woke up with dense right sided weakness, severe dysarthria and moderate aphasia. Urgent CT brain at 10:00 am was normal. Her blood pressure was 180/100 mmHg. Her urgent INR was 1.5. You saw her at 11:00 am. Why is intravenous thrombolysis contraindicated?
A. Blood pressure too high
B. INR prolonged
C. Severe neurological deficit
D. Stroke due to AF
E. Time window exceeded

Answer 41

E. Time window exceeded

rtPA is not used for WAKE-UP STROKE (i.e. unknown time onset here).
C/I for rtPA incl:
* Extensive early infarct changes on CT
* Active internal bleeding
* Use of warfarin with INR >1.7
* Prior ICH, any intracranial surgery, serious head injury or previous ischemic stroke ≤3m
* Known intracranial AVM or aneurysm
* Clinical picture suggestive of SAH
A – BP should be controlled to normotension for rtPA use, but it is not a C/I to rtPA use

Question 42

A 58-year-old lady with 10-year history of diabetes mellitus and hypertension, woke up complaining of slurred speech and weakness of her right upper and lower limbs. On examination, there was upper motor neuron weakness in her right upper and lower limbs, and the right side of her face. She was completely oriented, with no dysphasia, apraxia or visual field deficit. She also did not have cerebellar ataxia, dysphagia, or neurological deficits in her head and neck regions. She was well when she went to bed the night before. Where in her nervous system would you find a lesion that best explains her neurological deficits?
A. Left internal capsule
B. Left temporo-parietal lobe
C. Medulla oblongata
D. Midbrain
E. Pons

Answer 42

A. Left internal capsule

Right hemiplegia with no cortical sign → compatible for small vessel occlusion causing Lt IC stroke.
Pure motor stroke (lenticulostriate artery affecting the posterior part of internal capsule (contains the corticobulbar and corticospinal tracts)

Question 43

Which is of the following is most suggestive of mid-thoracic cord transverse myelitis?
A. Absent anal tone
B. Bilateral Babinski’s sign
C. Absent ankle reflexes
D. Bilateral foot drop
E. Bilateral upper limb brisk jerks

Answer 43

A. Absent anal tone

B. Bilateral Babinski’s sign (UMN signs may be absent on initial presentation (spinal shock phase when above T6)

Question 44

A 42-year-old lady presented to the outpatient clinic complaining of painless double vision. Which of the following clinical features would MOST LIKELY support a diagnosis of partial III cranial (oculomotor) nerve palsy?
A. Complete ptosis
B. Diurnal variation in the severity of the double vision
C. Inability to abduct the eye
D. Inability to adduct the eye
E. Unequal pupillary size

Answer 44

D. Inability to adduct the eye

Question 45

Which of the following is true about migraine aura? A. Migraine aura starts one hour after headache subsides
B. Migraine aura is always visual in nature
C. Migraine aura is considered as a form of partial seizure as cortical spreading epileptiform discharge occurs during migraine aura
D. Migraine aura usually lasts for 2–5 minutes
E. Migraine aura typically precedes onset of migraine headache

Answer 45

E. Migraine aura typically precedes onset of migraine headache

Migraine aura correlates to cortical spreading depression, it is NOT a form of partial seizure. Usu develop over 4-60min and headache follows ≤1h.

Question 46

A 52-year-old man presents with increasing confusion and falls. He had history of alcohol excess. On clinical examination, he has left abducens nerve palsy. His abbreviated mental test score is 2/10. He was given potent intravenous vitamins. What is the most important treatment in this condition? A. Ascorbic acid B. Nicotinamide C. Pyridoxine D. Riboflavin E. Thiamine

Answer 46

E. Thiamine

Wernicke encephalopathy = acute thiamine deficiency (alcohol interferes w/conversion of thiamine to active form, prevents absorption (decreased gene expression for thiamine transporter 1), chronic alcohol abuse –> cirrhosis –> interferes w/storage of thiamine).

Triad of encephalopathy + oculomotor dysfunction (e.g. ophthalmoplegia, nystagmus, pupil abnormality) + truncal ataxia.

Question 47

A 48-year-old lady presents with diplopia. P/E shows no limitation of eye movements. Patient complains of diplopia when looking down and left. The INNER image disappears when the left eye is covered.
A. Lambert Eaton
B. 3rd nerve palsy
C. Myasthenia gravis
D. 4th nerve palsy
E. 6th nerve palsy

Answer 47

D. 4th nerve palsy

Inner image = normal eye (right). Cannot depress when adducted (look at the nose), hence Rt 4th nerve palsy.

Question 48

A 62-year-old man with a history of Parkinson’s disease and ischaemic heart disease was treated for hypertension. Which of the following antihypertensive drug is contraindicated in this patient? A. Acertil (Perindopril) B. Aldomet (Methyldopa) C. Atenolol D. Frusemide E. Norvasc (Amlodipine)

Answer 48

B. Aldomet (Methyldopa)

Methyldopa inhibits central dopa decarboxylase → interferes with levodopa action.
Other drugs to be avoided:
* Antipsychotics
* D2-blocking antiemetics EXCEPT domperidone (peripheral action only)
* Tetrabenazine (treats hyperkinetic disorder), reserpine (antiHT) – depletes dopamine stores
* MAOI – interacts with dopamine-acting agents

Question 49

21/F presented with right hemiparesis and hemisensory loss for one week. She also experienced mild slurring of speech but no dysphagia. CT brain was normal. She was treated with aspirin and simvastatin. What is the top priority investigation for this woman? A. CTA and CT perfusion scan B. Digital subtraction angiography C. MRA and MRI brain with gadolinium contrast D. Serology for vasculitic markers E. PET scan

Answer 49

D. Serology for vasculitic markers
Young female stroke more likely to be due to vasculitis. A, B – angiography studies useful but these look more for vasculopathies, e.g. atherosclerosis

?? Perhaps DSA may be considered

Question 50

An old lady, with history of congestive heart, ischaemic heart, psychotic depression etc, on frusemide, amlodipine, warfarin, antipsychotic, antidepressant, develops seizure. Which anticonvulsant would you recommend? A. Carbamazepine B. Phenobarbital C. Lamotrigine D. Phenytoin E. Sodium valproate

Answer 50

C. Lamotrigine

Lamictal is preferred as 1st line AED for elderly because of lower potential for drug-drug interactions.

Question 51

Which is correct about lateral medullary syndrome? A. Limb numbness B. Limb weakness C. Aphasia D. Apraxia

Answer 51

A. Limb numbness

Contralateral paresthesia due to spinothalamic tract affected
Ipsilateral face affected (CNV)

Question 52

Peripheral neuropathy can be associated with:
A. Amlodipine B. Furosemide C. Nitrofurantoin D. Cefotaxime E. Flucloxacillin

Answer 52

C. Nitrofurantoin

Other medications incl:
* Antibiotics – metronidazole, ethambutol, isoniazid, nitrofurantoin, dapsone, pyridoxine
* Chemotherapy – adriamycin, platinum-based, vincristine, taxanes
* HIV drugs
* Amiodarone, gold, phenytoin, allopurinol, lithium, thalidomide, colchicine

Question 53

A 75-year-old man with hypertension had an episode of sudden monocular blindness affecting the lower half of his left eye. His right eye was unaffected. He was assessed in the clinic and an embolic phenomenon was suspected to have caused this condition. What is the most likely source of the embolus? A. Anterior choroidal artery B. Anterior communicating artery C. External carotid artery D. Internal carotid artery E. Middle cerebral artery

Answer 53

D. Internal carotid artery
Diagnosis is left superior branch retinal artery occlusion (BRAO). Central retinal artery is a branch of ophthalmic artery from ICA.

Question 54

Elderly man, ≥1 year history of worsening memory, urinary incontinence, unsteady gait. CT brain showed dilated ventricles. What is the treatable cause you have to rule out?
A. Alzheimer’s disease
B. Normal pressure hydrocephalus
C. Serum B12
D. Hypothyroidism

Answer 54

B. Normal pressure hydrocephalus (dementia, urinary incontinence, wide based gait (gait instability)

Question 55

Young man presented with fever and status epileptics. Infusion with midazolam and phenytoin. CT showed cerebral edema, so LP is not done. What is your management? A. Empirical anti TB drugs B. Empirical anti TB + ceftriaxone + acyclovir C. Empirical ceftriaxone + acyclovir D. Empirical acyclovir E. Empirical ceftriaxone

Answer 55

B. Empirical anti TB + ceftriaxone + acyclovir

Question 56

A patient with migraine presented to A&E with worsening headache. He has multiple comorbidities on multiple medications. Which of the following drugs is responsible for the worsening headache? A. Amlodipine B. Metoclopramide (Maxolon) C. Amitriptyline D. Propranolol (Inderal) E. Topiramate (Topamax)

Answer 56

A. Amlodipine

Amlodipine causes headache.

Question 57

A 69-year-old lady with history of minor stroke and on low dose aspirin. 4 years of right eyebrow twitching and 1 year of right cheek twitching. She cannot open her eyes during an attack. What is the diagnosis? A. Bell’s Palsy B. Blepharospasm C. Focal epileptic seizure D. Hemifacial spasm E. Transient ischaemic attack

Answer 57

D. Hemifacial spasm

Question 58

Parkinson syndrome with asymmetrical hand tremor. Which drug should be given? A. Donepezil B. Primidone C. Ropinirole D. Memantine E. Propranolol

Answer 58

A. Donepezil

Tremor-dominant PD should be treated by anticholinergic.

Question 59

An old patient with Parkinson disease on treatment (Sinemet, etc.) Memory deterioration + visual hallucination + executive function deterioration. What investigation to diagnose the cause of the cognitive decline? A. CT brain B. Lumbar puncture C. Blood tests D. PET brain

Answer 59

D. PET brain

Question 60

A question about a young man with features of (cervical spondyloarthropathy): bilateral UL numbness for months, PE sensory to C4 level, upgoing plantar reflex, normal gait but failed tandem and Romberg’s positive. A. MRI brain with gadolinium contrast B. MRI cervical spine with gadolinium contrast C. PET CT whole body

Answer 60

B. MRI cervical spine with gadolinium contrast

Question 61

55-year-old lady come to your clinic presenting with 1 year of involuntary muscle spasms of her neck causing abnormal posture. Which is the following is suggestive of cervical dystonia? A. Muscle spasms are relieved by exercise B. Muscle spasms are relieved by metoclopramide C. Muscle spasms are relieved by prochlorperazine D. Muscle spasms disappear during sleep E. There is family history with multiple relatives affected

Answer 61

D. Muscle spasms disappear during sleep

Question 62

Madam Chan is an 89-year-old widow living in an elderly home. She is taking medications for her hypertension and hypercholesterolaemia. She is also taking aspirin at low dose for her history of transient ischaemic attack. Whilst she was reading newspaper in one morning shortly after breakfast, she noted some blurring over the lower part of her visual field. She used her hand to cover one eye at a time. When her right eye was covered, her vision was normal. When her left eye was covered, her vision was lost over the lower half. Where is the lesion? A. Occipital lobe B. Optic nerve C. Parietal lobe D. Retina E. Temporal lobe

Answer 62

D. Retina

If it was parietal or temporal lobe it would be quadrantanopia.
In this case it is a monocular visual field defect. Often retinal lesions are small and do not follow the boundaries of the visual field quadrants. Such a visual field disorder is called a scotoma.

Question 63

A 60-year-old Chinese man was admitted complaining of increasing weight loss and poor appetite over 2 months. He was a smoker but has no significant past medical history. On examination, he was thin but alert and fully orientated. He was found to have an ataxic gait with dysdiadochokinesia and intention tremor bilaterally. He has no visual symptoms, sphincter disturbance or muscle weakness. Which of the following disorder would MOST LIKELY cause his neurological condition? A. Encephalitis B. Inherited spinocerebellar ataxia C. Multiple sclerosis D. Paraneoplastic syndrome E. Stroke

Answer 63

D. Paraneoplastic syndrome

Constitutional symptoms such as weight loss and poor appetite.

Question 64

Mrs Ho is a 35-year-old lawyer. She has a history of trigeminal neuralgia on carbamazepine. She has been taking a selective serotonin reuptake inhibitor for her depression about two years ago. She is allergic to tetracycline. She consulted her family doctor about two weeks ago because of diarrhea for a few days; her serum sodium concentration was found to be low and she was started on oral sodium chloride. She was admitted because of facial weakness, slurring of speech, drooling of saliva, generalized limb weakness and numbness. Initial assessments revealed the followings: normal body temperature, normal blood pressure, sinus tachycardia, oxygen saturation of 90% under room air, full Glasgow Coma Scale score, normal extraocular eye movements, bilateral facial weakness, dysarthria, dysphagia, limb power of grade 3 over 5, absent tendon reflexes, down-going plantar responses, unsteady limb movements, and reduced pin prick and touch sensation over hands and feet. What is the most likely diagnosis? A. Brainstem stroke B. Central pontine myelinolysis C. Guillain Barre syndrome D. Myasthenic crisis E. Serotonin syndrome

Answer 64

C. Guillain Barre syndrome

Classical presentation of GBS
Glove and stocking loss of sensation in lower limb
Affects bulbar muscles (dyspahgia, dysarthria)

Question 65

A woman with DM with diet control and recently started on gliclazide. Also in recent one week, she developed flu like symptoms. Sudden GTCS. Enter ambulance, got an energy drink with sugar, feels better. On examination, completely conscious, no neurological deficit. Waiting for further management. Patient wait for lunch in hospital, suddenly GTCS again. Most likely diagnosis: A. Viral encephalitis B. Hypoglycemia C. Acute bacterial meningitis D. Brain abscess E. Brain tumor

Answer 65

B. Hypoglycemia

Glicizide is an example of an sulphonylurea (hypoglycemia is an AE that you must be aware of)

Question 66

Man 6x years old chronic smoker, wake up left hemiparesis. What to do first? A. Aspirin 300mg and clopidogrel must be given immediately B. Aspirin 300mg must be given immediately C. Clopidogrel must be given immediately D. Computed tomography of the brain must be done immediately E. Magnetic resonance imaging of the brain must be done immediately

Answer 66

D. Computed tomography of the brain must be done immediately

Must do CT brain to rule out intracerebral hemorrhage (before administration of IV tPA or risk worsening the hemorrhage)

Question 67

65/F, newly diagnosed early stage Parkinson’s disease, started Sinemet 100/2 5mg, 3x/day. Her Parkinson symptoms respond well to Sinemet (L dopa + carbidopa). What is the most likely adverse effect of Sinemet at this early stage of her disease? A. Gait freezing B. L dopa induced dyskinesia C. L dopa induced psychosis D. Nausea E. Sudden on-and-off fluctuation

Answer 67

D. Nausea

Question 68

A 23-year-old female student complained of increased weakness such that she has difficulty climbing up stairs, standing up from a low chair, and combing her hair for the NS past 3 months. She has no sensory symptoms. On examination, she has weakness in her proximal muscles. Her limb reflexes were normal and symmetrical. She has no Babinski’s sign. She did not have any cranial nerve or sensory deficit, or cerebellar signs. Which of the following disorders would best explain her clinical features? A. Brainstem glioma B. Cervical myelopathy C. Myopathy D. Parasagittal meningioma E. Peripheral neuropathy

Answer 68

C. Myopathy

There are no cortical signs so not involving the brain so not A and D. No UMN signs so not C. No sensory loss so not E.

Question 69

Mr. Hui is a 21-year-old university student. He is well all along. He is an active member of the university’s rugby team. He noted mild left neck pain after a friendly rugby match two days ago. On the day of admission, he had left facial weakness, double vision on looking to his left side, slurring of speech, vertigo, left sided clumsiness and right sided weakness. On examination, he had left facial weakness, impaired left eye abduction, left sided ataxia, right sided weakness, normal tendon reflexes and intact sensations. Urgent CT brain was unremarkable. His ECG was in sinus rhythm. What is the most likely cause of his stroke? A. Arterial dissection B. Atherosclerosis C. Cardioembolism D. Moyamoya disease E. Small vessel disease

Answer 69

A. Arterial dissection

Question 70

A 58-year-old man presented with a gradually progressive weakness and numbness of both lower limbs, associated with urinary retention over 1 week. Examination of his cranial nerves and neurological examination of his upper limbs were normal. His lower limb examination showed reduced power 3+/5 in both lower limbs. His knee and ankle tendon reflexes, and plantar responses were absent bilaterally. Which of the following lesion or disorder would best explain his neurological deficit? A. Cauda equina lesion B. Cervical spinal cord lesion C. Myopathy D. Peripheral neuropathy E. Thoracic spinal cord lesion

Answer 70

CN and UL normal therefore lesion should be lower than cervical spinal cord

A. Cauda equina lesion (affecting babinski reflex (S1 root and tibial nerve) a disorder of the spinal roots

Question 71

A 42-year-old lady presented to the outpatient clinic complaining of painless double vision. Which of the following clinical features would MOST LIKELY support a diagnosis of partial III cranial (oculomotor) nerve palsy? A. Complete ptosis B. Diurnal variation in the severity of the double vision C. Inability to abduct the eye D. Inability to adduct the eye E. Unequal pupillary size

Answer 71

D. Inability to adduct the eye

Question 72

A 39-year-old lady presented with left partial ptosis, diplopia and weakness of four limbs one month ago, and was diagnosed to have myasthenia gravis seropositive for anti-AChR antibodies. She was treated with pyridostigmine 60 mg QID and prednisiolone 25 mg daily (oral) was initiated 2 weeks ago. She was admitted via the Accident & Emergency Department due to productive cough and fever for 4 days. Physical examination revealed a lethargic patient with marked respiratory distress, copious yellowish sputum and saliva; her voice was weak and spoke barely with short sentences. Pulse oximetry was 99% on 6L/min oxygen via nasal cannula. Which of the following statements is true? A. Blood should be urgently sent to be tested for anti-muscle specific kinase (anti-MuSK) antibodies B. Intensive care unit (ICU) team should be consulted C. Prednisolone dose should be reduced D. Pyridostigmine dose should be increased to 90 mg QID E. Urgent contrast CT thorax should be performed to look for thymoma

Answer 72

B. Intensive care unit (ICU) team should be consulted

Question 73

Mrs. Chan is a 51-year-old housewife. She is known to have diabetes mellitus on oral medications. About 4 weeks ago, she had shortness of breath on exertion. Painless acute STelevation myocardial infarction was diagnosed, and she was started on aspirin. On the day of admission, she had right facial weakness, slurring of speech, word finding difficulty and right sided weakness. On examination, she had right facial weakness, dysarthria, expressive aphasia, right sided weakness, right sided hyperactive tendon reflexes and intact sensations. Urgent CT brain was unremarkable. Her ECG was in sinus rhythm and revealed old anterior myocardial infarction. What is the most likely cause of her stroke? A. Arterial dissection B. Carotid artery stenosis C. Cardioembolism D. Moyamoya disease E. Small vessel disease

Answer 73

C. Cardioembolism

Question 74

A 69-year-old lady has hypertension and non-valvular atrial fibrillation on metoprolol 50 mg BD and aspirin 100 mg daily as she refused anticoagulation therapy. She is ambulatory and presented to the A&E Department for sudden onset of left sided weakness and slurring of speech at 1 pm while having lunch with her son in a restaurant. She arrived at the A&E Department and urgent CT brain revealed no acute haemorrhage or infarction. Her blood pressure was 168/92 mmHg and the medical officer was assessing her at 2:45 pm. She had left hemiparesis (power grade 2/5), hemisensory loss and global aphasia. Her NIHSS score was 12. What drug should be given as soon as possible ? A. Aspirin 300 mg B. Aspirin plus clopidogrel C. Clopidogrel 300 mg D. Intravenous recombinant plasminogen activator E. Low molecular weight heparin

Answer 74

D. Intravenous recombinant plasminogen activator

Question 75

30/F, myasthenia gravis on pyridostigmine, admitted for myasthenia crisis, what to do? A. Add azathioprine B. IV methylprednisolone C. IV human immunoglobulin D. Increase dose of pyridostigmine E. IV tensilon

Answer 75

C. IV human immunoglobulin

Do not do IV tensilon test (will exacerbate the condition)

Question 76

Graves patient treated in remission, presents with left eye partial ptosis and diplopia in multiple directions. Cover-uncover test shows false image from left eye. Normal, reactive pupils. What is the cause? A. Graves’ ophthalmopathy B. Myasthenia gravis C. Myasthenic syndrome D. Partial third nerve palsy E. Horner’s syndrome

Answer 76

D. Partial third nerve palsy (EOM thickening with relative sparing of tendon on CT)

Question 77

A 65-year-old heavy smoker complained of progressive clumsiness, dysarthria and unsteadiness of gait over one month. The doctor elicited bilateral dysmetria and dysdiadochokinesia. Which of the following disorders would most likely cause his clinical features? A. Atrial fibrillation B. Bronchial carcinoma C. Chronic hepatic failure D. Chronic renal failure E. Type II diabetes mellitus

Answer 77

B. Bronchial carcinoma

Question 78

Young woman on carbamazepine for trigeminal neuralgia, presented with URTI and diarrhea, incidentally found hyponatremia treated by family doctor. Now have normal eye movement, facial weakness, dysarthria, dysphagia, normal tendon reflex, upgoing plantar response, bilateral pin prick sensation loss, muscle power 3⁄5. A. Brainstem stroke B. Central pontine myelinolysis C. GBS D. Miller Fisher syndrome

Answer 78

B. Central pontine myelinolysis

Question 79

F/5x Acute confusion for 2 days, history of URTI 10 days ago, visit fam med doctor given paracetamol and antihistamine. Develop GTC for 1 minute with 15 post-ictal drowsiness. Fever 38.x, CBC normal. A. Viral encephalitis B. Delirium complicating URTI C. Acute psychotic episode D. Complex partial seizures, temporal lobe epilepsy E. Psychotic depression

Answer 79

A. Viral encephalitis

Question 80

A 62-year-old gentleman presented with sudden onset of left sided weakness. He is a chronic smoker with good past health. He was well the night before when he went to bed and noticed left sided weakness and slurred speech on wakening in the morning. Physical examination revealed left facial weakness of upper motor neuron type, grade 3/5 power of left upper and lower limbs and left sided sensory loss of light touch and pain sensation. Which of the following statements is true ? A. Aspirin 300 mg and clopidogrel 75 mg should be immediately given B. Aspirin 300 mg should be given immediately C. Clopidogrel 75 mg should be given immediately D. Computerized tomography (CT) brain should be performed immediately E. Magnetic resonance imaging (MRI) brain should be performed immediately

Answer 80

D. Computerized tomography (CT) brain should be performed immediately

Wake up stroke (unknown exact time of onset) is not indicated for thrombolytic therapy (more risk than benefit)

Question 81

A 35-year-old woman complained of distal limb weakness and numbness in a glove and stocking distribution affecting all 4 limbs. On examination, there was distal muscle wasting with absent tendon reflexes. Plantar responses were absent bilaterally. Where is the MOST LIKELY site of the neurological lesion? A. Cauda equina B. Cervical plexus C. Cervical spinal cord D. Neuromuscular junction E. Peripheral nerves

Answer 81

E. Peripheral nerves

Affecting all 4 limbs rules out Cauda equina (just the lumbrosacral roots)

Question 82

Miss Hui is a 40 year-old nurse. She has a past history of thyrotoxicosis. She complains of tiredness and diplopia. Her symptoms are worse in the evening or after her night shift duty. Examination reveals bilateral partial ptosis and hypoactive reflexes. Her extra-ocular eye movements are full but she reports double vision upon looking to the extremities; cover and uncover tests indicated involvement of multiple cranial nerves or multiple extra-ocular muscles. Which of the above clinical history/features/findings does not support the diagnosis of myasthenia gravis? A. Bilateral partial ptosis B. Diplopia due to multiple cranial nerves or multiple extra-ocular muscles C. History of thyrotoxicosis D. Hypoactive reflexes E. Tiredness

Answer 82

D. Hypoactive reflexes

Question 83

A 59-year-old gentleman has hypertension on amlodipine 5 mg daily. He is ADL (activities of daily living) independent and working in a supermarket. He presented to the Emergency Department with sudden onset of severe explosive headache over the occipital region while working in the supermarket. Examination revealed a fully conscious gentleman with no fever, neck rigidity or focal neurological signs. Urgent CT brain revealed no acute haemorrhage or infarction. His blood pressure was 178/98 mmHg. Which of the following statements is correct? A. Lumbar puncture should be performed B. The likely diagnosis is cluster headache C. The likely diagnosis is post-herpetic neuralgia D. The likely diagnosis is thunderclap headache E. The likely diagnosis is vertebral artery dissection

Answer 83

A. Lumbar puncture should be performed

Question 84

Middle aged man, presents with sudden onset generalized headache. Left eye complete ptosis and dilated pupil, impaired adduction and elevation. Right eye and other rest of neurological exam normal. A. CT brain and angiography of the cerebral vasculature B. MRI brainstem C. Anti acetylcholine esterase inhibitor D. Tensilon test E. HbA1c

Answer 84

A. CT brain and angiography of the cerebral vasculature

Question 85

Patient presents with sudden onset left-sided facial weakness. On physical examination, you found hyperacusis of the left ear, loss of taste sensation in the anterior part of the tongue and also lower motor neuron signs on the left face. Which of the following is the most appropriate treatment? A. CCB B. Triptyline C. Prednisolone D. Warfarin E. Aspirin

Answer 85

C. Prednisolone
Bells palsy

Question 86

A 55-year-old man was admitted with a first episode of generalised tonic clonic seizures. He is a chronic smoker and has a history of poorly controlled hypertension and diabetes mellitus. He also drinks up to 3 large bottles of beer per day but admitted to have significantly reduced his alcohol intake in the recent week. On examination, apart from the presence of a tongue haematoma, the patient was oriented, had no neck stiffness and no focal neurological signs. What is the most likely cause of this man’s seizure? A. Alcohol withdrawal B. Brain tumour C. Encephalitis D. Hippocampal sclerosis E. Stroke

Answer 86

A. Alcohol withdrawal

Question 87

A 65-year-old gentleman, non-smoker and non-drinker, has good past health. He presented to the outpatient clinic for insidious onset of bilateral lower limb numbness for 2 months and bilateral hand numbness for 1 month. He reported no weakness, slurred speech, double vision, dysphagia or facial numbness. Physical examination revealed normal cranial nerves, normal tone, full power, generalised hyperreflexia with bilateral upgoing plantar response of lower limbs; and loss of light touch, pinprick and joint position sense over bilateral hands, distal legs and feet. His gait was steady but tandem gait revealed mild instability. Which of the following investigations is the most important? A. Lumbar puncture for cerebrospinal fluid analysis B. MRI bilateral thighs with gadolinium contrast C. MRI brain with gadolinium contrast D. MRI cervical spine with gadolinium contrast E. Thyroid function test

Answer 87

D. MRI cervical spine with gadolinium contrast

Question 88

A 55-year-old overweight businessman with history of hypertension and diabetes mellitus collapsed at home. On arrival to the Accident and Emergency Department, he was found to be unarousable. Which of the following is an unlikely diagnosis of his acute condition? A. Acute myocardial infarction B. Drug overdose C. Hypoglycaemia D. Subarachnoid haemorrhage E. Transient ischaemic attack

Answer 88

E. Transient ischaemic attack

TIA is temporary and normally lasts for a few minutes and should be arousable afterwards.

Question 89

Which of the following feature(s) would confirm bacterial meningitis? A. Fever and headache B. Pleocytosis in the cerebrospinal fluid C. Positive blood culture D. Positive Gram smear in the cerebrospinal fluid E. Raised protein level in the cerebrospinal fluid

Answer 89

D. Positive Gram smear in the cerebrospinal fluid

Question 90

Answer 90

E. Warfarin

CHAD VASc (hypertension + diabetes +vascular evnet (stroke) + sex category (female))

Question 91

Mr Howe was a 74-year-old retired lawyer. He was known to have hypertension and hyperlipidaemia. He had presented with a 4-month history of intermittent ptosis, diplopia, dysphagia, dysarthria and limb weakness. Serum anti-acetylcholine receptor antibody was negative. Repetitive nerve stimulation showed a decremental response. Tensilon test was positive. He responded well to oral mestinon and prednisolone. Despite receiving his seasonal flu vaccine 5 days ago, he had fever, cough and sputum for 2 days. He had noted shortness of breath with marked worsening of his symptoms on the day of consultation. His oxygen saturation on room air was 88%. Which of the following treatment is most appropriate? A. Haemodialysis B. High dose mestinon C. Intravenous immunoglobulin D. Intravenous pulse steroid E. Intubation for mechanical ventilation

Answer 91

E. Intubation for mechanical ventilation

Question 92

A 23 year old lady had the 1st episode of GTCS at age 20. Blood tests, MRI brain and interictal EEG detected no abnormalities. She had 2nd episode of GTCS 3 months later with no precipitating factors. She was started with valproate 300 mg BD in mainland China. She had 3rd episode of GTCS 2 months later and valproate was stepped up to 300 mg TDS. She had no breakthrough seizures since then. She is now living in Hong Kong and expects to get pregnant soon. She prefers resuming AED as she worries about the seizures during pregnancy may harm her baby. What is the most appropriate treatment plan for her? A. Continue valproate B. Check HLAB 1502 then switch to carbamazepine C. Switch to levetiracetam D. Switch to phenytoin

Answer 92

C. Switch to levetiracetam

Question 93

Mid thoracic transverse myelitis A. Loss of anal tone B. Bilateral upgoing Babinski C. Bilateral areflexia

Answer 93

B. Bilateral upgoing Babinski

Question 94

90/M retired prof in law. Sudden slurring of speech when talking with wife at 1030. He progressively developed stroke symptoms. He arrived at the hospital with my wife at 1430. You saw him at 1440. Wife asked can you do IV tPA. Why IV tPA is contraindicated in this patient? A. Passed time frame B. AF On NOAC C. Severe neurological symptoms (dysarthria, dysphagia, left facial weakness, left sided limb weakness) D. High BP

Answer 94

A. Passed time frame

Question 95

A patient with Parkinson’s disease treated by Madopar and Ropinirole. What is the most common side effect arising from dopamine agonist? A. Constipation B. Visual hallucinations C. Morning dystonia D. Depression

Answer 95

B. Visual hallucinations

Question 96

Someone with AF taking dabigatran BD. RLQ pain, to undergo appendicectomy. What to give? A. Idarucizumab B. Rituximab C. Alemtuzumab D. Infliximab

Answer 96

A. Idarucizumab

Question 97

46 years old housewife, with HT HL DM, non smoker and teetotaller. Presented with left sided numbness and weakness and dysarthria. Urgent CTB was normal, CT cerebral angiography was also normal. What is the likely cause of her symptoms? A. Artery-artery embolization B. Artherothrombotic C. Cardioembolic D. Small vessel disease

Answer 97

D. Small vessel disease

Question 98

27 years old lady presenting with subacute onset of confusion and psychotic symptoms over a week, no fever, travel history etc. myotonic jerks. CTB normal. A. Autoimmune encephalitis B. Viral encephalitis C. Viral meningitis D. Metabolic encephalopathy

Answer 98

A. Autoimmune encephalitis

Question 99

Old man, some Parkinson symptoms, no tremor, severe axial rigidity, vertical gaze palsy. No autonomic features or cerebellar signs. A. Progressive supranuclear palsy B. Multiple system atrophy C. Idiopathic PD D. Vascular dementia

Answer 99

A. Progressive supranuclear palsy

Question 100

COPD exacerbation, given oxygen with non-rebreathing mask on ambulance. Then comatose. Likely diagnosis? RR 25. A. Carbon dioxide narcosis B. Hyperventilation C. Mechanical airway obstruction D. Sepsis due to pneumonia

Answer 100

A. Carbon dioxide narcosis