NEUROLOGY PASTEST QUESTIONS
1. A 50 year old man is known to have chronic polyneuropathy. On his most recent clinic visit, he
mentions that he has started having diarrhoes, especially at night. He has also noticed that he
feels dizzy when he stands up and indeed collapsed while standing at a bus stop a few days ago.
On further questioning he admits to having had erectile problems for quite some time. His BP is
160/88 lying, and 136/60 standing. His signs of reduced knee jerks, absent ankle jerks and
reduced pinprick and vibration sense to the knees are unchanged from his last clinic visit,
Given the development of these recent symptoms, what underlying cause is most likely for his
neuropathy?
A. amyloidosis
B. Charcot-marie-tooth disease
C. paraneoplastic neuropathy
D. Vitamin B12 deficiency
E. Vitamin E deficiency
Answer: A
Explanation: Amyloidosis associated neuropathy is classically associated with an autonomic
neuropathy, which this patient describes symptoms of.
2. In a patient with diplopia which one of the following findings is most suggestive of myasthenia
gravis?
A. Absent pupillary light reflex with preserved accommodation reflex
B. Elevated creatinine kinase
C. Loss of pin-prick sensation around the chin area
D. Proptosis
E. Thymoma on computed tomography scan of the chest
Answer: E
Explanation: Myasthenia gravis is an acquired autoimmune disorder associated with acethylcholine
receptor antibodies which block the nicotinic acetylcholine receptors(ligand gated ion channels) on the
motor end plate. Direct blocking, as well as a reduction in receptors numbers secondary to the
inflammatory response induced by antibody binding, leads to dysfunction in neuromuscular transmission.
The ocular muscle involvement is usually bilateral and associated with ptosis and diplopia. Pupillary and
accommodation reflexes are characteristically normal. Two-thirds of patients with myasthenia gravis have
thymic hyperplasia and 10-15% will have thymoma. The role of thymectomy is clear in those with
thymoma, but remains controversial in those with thymic hyperplasia only. The creatinine kinase is
typically normal in myasthenia gravis and proptosis is not a feature.
3. A 48 years old man is admitted to hospital after being brought in by an ambulance unconscious. On
taking a collateral history from his wife, you learn that after having breakfast he developed left sided
weakness, difficulty in understanding others, appeared to have a headache and collapsed a short time
later. He also has a background of insulin dependent type 2 diabetes, poorly controlled hypertension, a
significant 20 pack year smoking history and an average alcohol consumption of 50 units per week. On
examination, he remains unconscious with a GCS of 3 and a left sided hemi-paresis, there is also a
dysconjugate gaze with the right eye being deviated laterally and the right pupil being larger than the left
with no response to light.
What is the most likely cause of his coma?
A. Midbrain haemorrhage involving the cerebral peduncle
, B. Midbrian infarction of the dorsomedial midbrain
C. Lateral pontine haemorrhage
D. Inferior pontine infarction
E. Temporal lobe haemorrhage with oedema
Answer: E
Explanation: the patient has focal neurological signs suggestive of a right sided temporal lobe
stroke(fluent, receptive dysphasia and headache), as well as evidence of a right third nerve palsy and elft
sided hemiparesis. He has significant risk factors for both ischemia and haemorrhagic stroke, but given the
presence of the ipsilateral third nerve palsy and contralateral hemiparesis, the most likely diagnosis in this
case is a haemorrhagic temporal lobe stroke with associated oedema, causing uncal herniation with
brainstem compression.
5. A 60 years old lady complains of a sensation of something crawling up her legs and then has an
irresistible urge to move her legs just before falling asleep. She gets up several times per night, but finds
the symptoms settle around 5 am and she can then sleep until 11 am. She has an hb of 116g/l and is
currently being treated by her GP for iron deficiency anaemia.
Ix:
HB: 116
TWC: 6.7x10/l
Plt: 190x10
Na: 141
K:4.7
Creat: 142
Which one of the following is the most likely diagnosis?
A. Narcolepsy
B. Sleep apnea syndrome
C. Restless legs syndrome
D. Nocturnal leg cramps
E. Peripheral neuropathy
Answer: C
6. A 48 years old man presents to the emergency department after moving a number of heavy boxes at
home. On examination there is pain on straight leg raising and movement of the lower limbs is limited by
pain. There is mild weakness of ankle dorsiflexion and weakness of big toes extension. Ankle jerk reflexes
are normal. Sensation is altered over the lateral border of the shin. This suggests an L5 nerve root lesion.
Which one of the following represents the management of choice in this case?
A. Gentle mobilisation and physiotherapy
B. Immobilisation and complete bed rest
C. Local corticosteroid injection
D. Referral for microdisecotomy
E. Referral for open discectomy
,Answer: A
Explanation: this patient has symptoms typical of lumbar radiculopathy due to disc disease. Gentle
mobilisation and physiotherapy represents the management of choice in this case, as most patients will
make a spontaneous improvement within 4-6 weeks.
7. A 38 years old woman presents to the clinic complaining that she is bumping into door frames when
she walks around. She has recently crashed into a parked car while driving along her street. Over the past
few months she has been feeling increasingly tired. The only medication of note includes the combined
oral contraceptive pill. On examination her BP is 142/82 mmhhg. Neurological examination is normal
apart from a bitemporal hemianopia
Where is the most likely site of the lesion which has led to her visual disturbance?
A. Frontal lobe
B. Occipital lobe
C. Optic chiasm
D. Optic nerve
E. Temporal lobe
Answer: C
Explanation: bitemporal hemianopia raises the possibility of compression at the level of the optic chiasm.
This is usually caused by a pituitary tumour. The feelings of tiredness seen here also raise the possibility
of reduced production of thyroid-stimulating hormone(TSH) and other anterior pituitary hormones. She
requires a full battery screen of pituitary hormones including tsh, gonadotrophins, growth hormone and
prolactin and an mri brain scan. Patients with a pituitary macroadenoma need rapid referral for surgery to
reduce the chances of permanent visual loss.
8. A 60 years old man with chronic atrial fibrillation is on warfarin. He has had two unprovoked
tonic-clonic seizures that were witnessed by his wife. Ct brain shows only some diffuse ischaemic changes
in the white matter. The GP wants to start him on an epileptic drug.
Which one of the following antiepileptic drugs does not have important drug interactions with warfarin?
A. Carbamazepine
B. Lamotrigine
C. Phenobarbital
D. Phenytoin
E. Primidone
Answer: B
Explanation: lamotrigine has no effect on liver enzymes and does not interact with warfarin. Drug
interactions and side effect profiles should always be considered before introducing antiepileptic drugs.
Choice of AED should be made in collaboration with the patient. Particularly taking into account the
patient’s other medical problems and other medications(particularly oral contraceptives) taken.
9. A 24 year old man with a family history of myotic dystrophy visits you for advice about starting a family.
He has the typical features of frontal male pattern balding and is beginning to develop features of muscle
weakness. He has read on the internet about a phenomenon called anticipation which is associated with
the condition.
What does anticipation mean in this setting?
A. Symptoms develop which prevents fathering children
, B. Symptoms begin at an earlier stage in successive generations.
C. Symptoms are less severe in successive generations
D. Warning signs appear which can pre-date the main symptoms associated with the condition
E. Patients can anticipate the severity of their condition by looking at their parents.
Answer: B
Explanation: symptoms begin at an earlier stage in successive generations.
10. A 26 years old develops foot drop after a motorcycle accident. You find weakness of foot dorsiflexion
and eversion
Which structure is most likely to have been damaged?
A. Common peroneal nerve
B. Lumbar nerve roots
C. Lumbosacral plexus
D. Sciatic nerve
E. Tibial nerve
Answer: A
Explanation: the common peroneal nerve is the motor supply to the peronei and anterior tibial muscles, so
lesions result in paralysis of dorsiflexion and inability to evert the foot. A lesion above the lateral
cutaneous branch results in anaesthesia over the anterolateral lower leg and dorsum of the foot.
11. A 36 years old woman presents to the Emergency Department by ambulance with ongoing
tonic-clonic seizures. She initially suffered a seizure 25 minutes before arrival, which responded to rectal
diazepam. She remained confused and drowsy before exhibiting further tonic-clonic activity for the last
two minutes. Intravenous lorazepam 4mg and a loading dose of levetiracetam is given. Tonic-clonic
seizures stop, but she remains only responsive to pain(withdraws from painful stimulus) and without eye
opening and no vocal sounds. Her epilepsy is usually controlled with lamotrigine. Her heart rate is 99bpm,
blood pressure 110/76mmhg, respiratory rate 10 breaths per minute, oxygen saturations 100% on 15
litres via a non-rebreather mask and her temperature 37.5
What is the next step in this patient’s management?
A. Intravenous sodium valproate
B. Intravenous benzodiazepine infusion
C. Intravenous phenytoin infusion
D. Intravenous phenobarbital infusion
E. Intubation and ventilation
Answer: E
Explanation: the patient has been treated for status epilepticus and now has a decreased conscious level.
Being responsive to pain only is roughly equivalent to a GCS of <8. The patient should have a rapid
sequence induction, followed by a propofol infusion, to protect her airway and prevent aspiration of
gastric contents.
12. A 16 years old woman presents to the emergency department complaining of weakness and
heaviness of her arms and legs, which has been developing over an hour. She has generalised weakness
of all muscle groups in her upper and lower limbs, together with hyporeflexia. Blood tests show:
Na: 143
K:2.8
1. A 50 year old man is known to have chronic polyneuropathy. On his most recent clinic visit, he
mentions that he has started having diarrhoes, especially at night. He has also noticed that he
feels dizzy when he stands up and indeed collapsed while standing at a bus stop a few days ago.
On further questioning he admits to having had erectile problems for quite some time. His BP is
160/88 lying, and 136/60 standing. His signs of reduced knee jerks, absent ankle jerks and
reduced pinprick and vibration sense to the knees are unchanged from his last clinic visit,
Given the development of these recent symptoms, what underlying cause is most likely for his
neuropathy?
A. amyloidosis
B. Charcot-marie-tooth disease
C. paraneoplastic neuropathy
D. Vitamin B12 deficiency
E. Vitamin E deficiency
Answer: A
Explanation: Amyloidosis associated neuropathy is classically associated with an autonomic
neuropathy, which this patient describes symptoms of.
2. In a patient with diplopia which one of the following findings is most suggestive of myasthenia
gravis?
A. Absent pupillary light reflex with preserved accommodation reflex
B. Elevated creatinine kinase
C. Loss of pin-prick sensation around the chin area
D. Proptosis
E. Thymoma on computed tomography scan of the chest
Answer: E
Explanation: Myasthenia gravis is an acquired autoimmune disorder associated with acethylcholine
receptor antibodies which block the nicotinic acetylcholine receptors(ligand gated ion channels) on the
motor end plate. Direct blocking, as well as a reduction in receptors numbers secondary to the
inflammatory response induced by antibody binding, leads to dysfunction in neuromuscular transmission.
The ocular muscle involvement is usually bilateral and associated with ptosis and diplopia. Pupillary and
accommodation reflexes are characteristically normal. Two-thirds of patients with myasthenia gravis have
thymic hyperplasia and 10-15% will have thymoma. The role of thymectomy is clear in those with
thymoma, but remains controversial in those with thymic hyperplasia only. The creatinine kinase is
typically normal in myasthenia gravis and proptosis is not a feature.
3. A 48 years old man is admitted to hospital after being brought in by an ambulance unconscious. On
taking a collateral history from his wife, you learn that after having breakfast he developed left sided
weakness, difficulty in understanding others, appeared to have a headache and collapsed a short time
later. He also has a background of insulin dependent type 2 diabetes, poorly controlled hypertension, a
significant 20 pack year smoking history and an average alcohol consumption of 50 units per week. On
examination, he remains unconscious with a GCS of 3 and a left sided hemi-paresis, there is also a
dysconjugate gaze with the right eye being deviated laterally and the right pupil being larger than the left
with no response to light.
What is the most likely cause of his coma?
A. Midbrain haemorrhage involving the cerebral peduncle
, B. Midbrian infarction of the dorsomedial midbrain
C. Lateral pontine haemorrhage
D. Inferior pontine infarction
E. Temporal lobe haemorrhage with oedema
Answer: E
Explanation: the patient has focal neurological signs suggestive of a right sided temporal lobe
stroke(fluent, receptive dysphasia and headache), as well as evidence of a right third nerve palsy and elft
sided hemiparesis. He has significant risk factors for both ischemia and haemorrhagic stroke, but given the
presence of the ipsilateral third nerve palsy and contralateral hemiparesis, the most likely diagnosis in this
case is a haemorrhagic temporal lobe stroke with associated oedema, causing uncal herniation with
brainstem compression.
5. A 60 years old lady complains of a sensation of something crawling up her legs and then has an
irresistible urge to move her legs just before falling asleep. She gets up several times per night, but finds
the symptoms settle around 5 am and she can then sleep until 11 am. She has an hb of 116g/l and is
currently being treated by her GP for iron deficiency anaemia.
Ix:
HB: 116
TWC: 6.7x10/l
Plt: 190x10
Na: 141
K:4.7
Creat: 142
Which one of the following is the most likely diagnosis?
A. Narcolepsy
B. Sleep apnea syndrome
C. Restless legs syndrome
D. Nocturnal leg cramps
E. Peripheral neuropathy
Answer: C
6. A 48 years old man presents to the emergency department after moving a number of heavy boxes at
home. On examination there is pain on straight leg raising and movement of the lower limbs is limited by
pain. There is mild weakness of ankle dorsiflexion and weakness of big toes extension. Ankle jerk reflexes
are normal. Sensation is altered over the lateral border of the shin. This suggests an L5 nerve root lesion.
Which one of the following represents the management of choice in this case?
A. Gentle mobilisation and physiotherapy
B. Immobilisation and complete bed rest
C. Local corticosteroid injection
D. Referral for microdisecotomy
E. Referral for open discectomy
,Answer: A
Explanation: this patient has symptoms typical of lumbar radiculopathy due to disc disease. Gentle
mobilisation and physiotherapy represents the management of choice in this case, as most patients will
make a spontaneous improvement within 4-6 weeks.
7. A 38 years old woman presents to the clinic complaining that she is bumping into door frames when
she walks around. She has recently crashed into a parked car while driving along her street. Over the past
few months she has been feeling increasingly tired. The only medication of note includes the combined
oral contraceptive pill. On examination her BP is 142/82 mmhhg. Neurological examination is normal
apart from a bitemporal hemianopia
Where is the most likely site of the lesion which has led to her visual disturbance?
A. Frontal lobe
B. Occipital lobe
C. Optic chiasm
D. Optic nerve
E. Temporal lobe
Answer: C
Explanation: bitemporal hemianopia raises the possibility of compression at the level of the optic chiasm.
This is usually caused by a pituitary tumour. The feelings of tiredness seen here also raise the possibility
of reduced production of thyroid-stimulating hormone(TSH) and other anterior pituitary hormones. She
requires a full battery screen of pituitary hormones including tsh, gonadotrophins, growth hormone and
prolactin and an mri brain scan. Patients with a pituitary macroadenoma need rapid referral for surgery to
reduce the chances of permanent visual loss.
8. A 60 years old man with chronic atrial fibrillation is on warfarin. He has had two unprovoked
tonic-clonic seizures that were witnessed by his wife. Ct brain shows only some diffuse ischaemic changes
in the white matter. The GP wants to start him on an epileptic drug.
Which one of the following antiepileptic drugs does not have important drug interactions with warfarin?
A. Carbamazepine
B. Lamotrigine
C. Phenobarbital
D. Phenytoin
E. Primidone
Answer: B
Explanation: lamotrigine has no effect on liver enzymes and does not interact with warfarin. Drug
interactions and side effect profiles should always be considered before introducing antiepileptic drugs.
Choice of AED should be made in collaboration with the patient. Particularly taking into account the
patient’s other medical problems and other medications(particularly oral contraceptives) taken.
9. A 24 year old man with a family history of myotic dystrophy visits you for advice about starting a family.
He has the typical features of frontal male pattern balding and is beginning to develop features of muscle
weakness. He has read on the internet about a phenomenon called anticipation which is associated with
the condition.
What does anticipation mean in this setting?
A. Symptoms develop which prevents fathering children
, B. Symptoms begin at an earlier stage in successive generations.
C. Symptoms are less severe in successive generations
D. Warning signs appear which can pre-date the main symptoms associated with the condition
E. Patients can anticipate the severity of their condition by looking at their parents.
Answer: B
Explanation: symptoms begin at an earlier stage in successive generations.
10. A 26 years old develops foot drop after a motorcycle accident. You find weakness of foot dorsiflexion
and eversion
Which structure is most likely to have been damaged?
A. Common peroneal nerve
B. Lumbar nerve roots
C. Lumbosacral plexus
D. Sciatic nerve
E. Tibial nerve
Answer: A
Explanation: the common peroneal nerve is the motor supply to the peronei and anterior tibial muscles, so
lesions result in paralysis of dorsiflexion and inability to evert the foot. A lesion above the lateral
cutaneous branch results in anaesthesia over the anterolateral lower leg and dorsum of the foot.
11. A 36 years old woman presents to the Emergency Department by ambulance with ongoing
tonic-clonic seizures. She initially suffered a seizure 25 minutes before arrival, which responded to rectal
diazepam. She remained confused and drowsy before exhibiting further tonic-clonic activity for the last
two minutes. Intravenous lorazepam 4mg and a loading dose of levetiracetam is given. Tonic-clonic
seizures stop, but she remains only responsive to pain(withdraws from painful stimulus) and without eye
opening and no vocal sounds. Her epilepsy is usually controlled with lamotrigine. Her heart rate is 99bpm,
blood pressure 110/76mmhg, respiratory rate 10 breaths per minute, oxygen saturations 100% on 15
litres via a non-rebreather mask and her temperature 37.5
What is the next step in this patient’s management?
A. Intravenous sodium valproate
B. Intravenous benzodiazepine infusion
C. Intravenous phenytoin infusion
D. Intravenous phenobarbital infusion
E. Intubation and ventilation
Answer: E
Explanation: the patient has been treated for status epilepticus and now has a decreased conscious level.
Being responsive to pain only is roughly equivalent to a GCS of <8. The patient should have a rapid
sequence induction, followed by a propofol infusion, to protect her airway and prevent aspiration of
gastric contents.
12. A 16 years old woman presents to the emergency department complaining of weakness and
heaviness of her arms and legs, which has been developing over an hour. She has generalised weakness
of all muscle groups in her upper and lower limbs, together with hyporeflexia. Blood tests show:
Na: 143
K:2.8
