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Question 1
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A 40-year-old female presented in the OPD with a 4-day history of severe episodes of dizziness. She reports that her room starts spinning and then she tends to fall. She also complains of deafness, tinnitus, and a sensation of clogging in the ear. What condition do you think this patient is suffering from?
Your Answer: Meniere's disease
Explanation:The patient presents with the classic symptoms of Meniere’s disease. This is a condition in which the amount of endolymph in the internal ear increases because of an increase in endolymph production, a reduction of endolymph drainage, or as a result of an infection. Hearing and balance tests should be done for the proper analysis of the patient’s condition and to rule out other conditions.
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This question is part of the following fields:
- Nervous System
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Question 2
Correct
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A 21-year-old patient is referred to the tertiary neurology clinic because of a possible diagnosis of Juvenile Parkinson's disease. His symptoms began predominantly with dystonia affecting the lower limbs, but he now has more classical signs of older onset Parkinson's including tremor, bradykinesia, and rigidity.
You map out his family tree and understand that his sister developed Parkinson's at the age of 16 but that his parents do not have signs of Parkinson's.
Which of the following is the most likely mode of inheritance?Your Answer: Autosomal recessive
Explanation:Juvenile Onset Parkinson’s is an autosomal recessive condition that usually presents in late childhood to early adulthood, initially with gait disorders caused by lower limb dystonia that later develops to the more classical signs Parkinson’s.
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This question is part of the following fields:
- Nervous System
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Question 3
Correct
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A 50-year-old female was examined after complaining of weak limbs. It was discovered she had burn marks on her fingers, diminished reflexes, and wasted and weak hands. Additionally, she has dissociated sensory loss and weak spastic legs. What is the diagnosis for this patient?
Your Answer: Syringomyelia
Explanation:All of the symptoms experienced by this patient are consistent with Syringomyelia. The sensory features are as follows: loss of temperature and pain sensation; sensory loss in the arms, shoulders, and upper body; touch, vibration, and position senses are affected in the feet as the syrinx enlarges into the dorsal column. Motor features are as follows: muscle wasting and weakness which begins in the hand, and moves onto the forearms and shoulders; loss of tendon reflexes. Autonomic involvement, such as the bladder and bowel, can occur.
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This question is part of the following fields:
- Nervous System
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Question 4
Correct
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Which group of drugs is used to manage Trigeminal Neuralgia?
Your Answer: Anti epileptics
Explanation:The only drug currently licensed in the UK to treat trigeminal neuralgia is carbamazepine which is an anticonvulsant. It can be very effective initially, but may become less effective over time.
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This question is part of the following fields:
- Nervous System
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Question 5
Incorrect
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A 42-year-old male undergoes a routine cranial nerve examination, which reveals the following findings:
Rinne's test: Air conduction > bone conduction in both ears
Weber's test: Localizes to the right side
What do these test results imply?Your Answer: Left conductive deafness
Correct Answer: Left sensorineural deafness
Explanation:Weber’s test – if there is a sensorineural problem, the sound is localized to the unaffected side (right), indicating a problem on the left side.
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This question is part of the following fields:
- Nervous System
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Question 6
Incorrect
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A 48-year-old artist presented with tremors. Which of the following is more suggestive of parkinsonism than an essential tremor?
Your Answer: First degree relatives being affected with similar problems
Correct Answer: Unilaterality
Explanation:Essential tremors are usually symmetrical and generalized. It often affects the head and the voice of the patient. Usually it is first noticed by first degree relatives. It is improved by benzodiazepines and beta blockers. On the other hand, Parkinsonism tends to develop in older patients. It is characterised by bradykinesia and rigidity. It improves by L-dopa and dopamine agonists. A simple test is to ask the patient to write a short sentence. Parkinsonism shows micrographiam whilst essential tremors will have tremulous writing.
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This question is part of the following fields:
- Nervous System
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Question 7
Correct
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In last 5 days, an old man has complained of severe left sided headache, which was aggravated by bright lights. He has not vomited but feels nauseated. What is the most likely diagnosis?
Your Answer: Migraine
Explanation:Migraine without aura have the following characteristics: Nausea and vomiting accompanied by >5 headaches that last for 4-72 hours, plus any unilateral, pulsating headache or are aggravated by routine daily activities.
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This question is part of the following fields:
- Nervous System
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Question 8
Incorrect
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A 59-year-old surgeon presents with a progressive paraesthesia and numbness in both feet, which have deteriorated over the last six months. He has a 10 year history of type 2 diabetes mellitus and had cervical spondylosis, for which he underwent surgery eight years ago. He also confessed to drinking approximately 40 units of alcohol weekly.
On examination he had mild bilateral weakness of foot dorsiflexion and both ankle reflexes were absent. There was absent sensation to light touch to mid-shin level with loss of joint position sensation in the toes and absent vibration sensation below the hips. He had a marked sensory ataxia and pseudoathetosis of the upper limbs. He had no evidence of a retinopathy and urinalysis was normal.
Which of the following is the most likely diagnosis?Your Answer: Alcohol-induced neuropathy
Correct Answer: Vitamin B 12 deficiency
Explanation:Diabetic peripheral neuropathy usually goes in parallel with retinopathy and nephropathy. It is also slowly progressive and affects mainly the spinothalamic pathway.
Alcohol induced peripheral neuropathy is also slowly progressive and affects mainly the spinothalamic pathway.
Vitamin B 12 deficiency usually causes a more rapidly progressive neuropathy with dorsal column involvement (joint position and vibration involvement with sensory ataxia and pseudoathetosis of upper limbs). -
This question is part of the following fields:
- Nervous System
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Question 9
Correct
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A 65-year-old real estate broker presents with a tremor. Which one of the following features would suggest a diagnosis of essential tremor rather than Parkinson's disease?
Your Answer: Tremor is worse when the arms are outstretched
Explanation:Difficulty in initiating movement (bradykinesia), postural instability and unilateral symptoms (initially) are typical of Parkinson’s. Essential tremor symptoms are usually worse if arms are outstretched and eased by rest and alcohol.
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This question is part of the following fields:
- Nervous System
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Question 10
Correct
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A 52-year-old hypertensive, smoker presents to ER with right side weakness. He gives a history of multiple falls and lack of concentration. What is the most appropriate diagnosis?
Your Answer: Multi-infarct dementia
Explanation:The patient is a heavy smoker and hypertensive which are risk factors of atherosclerosis and cerebrovascular diseases. The acute onset of the weakness and the lateralization indicates a cerebral infarction.
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This question is part of the following fields:
- Nervous System
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Question 11
Incorrect
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A 34-year-old male patient is admitted with hemisection of the spinal cord at the level T5, after being stabbed in the back. Which sign would you expect to see by assessing the patient's sensory function and muscle strength?
Your Answer: Contralateral loss of temperature, ipsilateral loss of fine touch and vibration, contralateral spastic paresis
Correct Answer: Contralateral loss of temperature, ipsilateral loss of fine touch and vibration, ipsilateral spastic paresis
Explanation:Depending on the level of SCI, patients experience paraplegia or tetraplegia. Paraplegia is defined as the impairment of sensory or motor function in lower extremities. Patients with incomplete paraplegia generally have a good prognosis in regaining locomotor ability (,76% of patients) within a year. Complete paraplegic patients, however, experience limited recovery of lower limb function if their NLI is above T9. The spinothalamic tract is the one responsible for sensory information such as pain or temperature. However, it decussates at the same level the nerve root enters the spinal cord, meaning that the sensory loss will be contralateral. However, the dorsal column carries sensory fibres for fine touch and vibration and it decussates at the medulla which means that the sensory loss will be ipsilateral. The corticospinal tract is responsible for motor functions and it decussates at the medulla, meaning that the motor function loss will be ipsilateral.
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This question is part of the following fields:
- Nervous System
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Question 12
Correct
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A 75-year-old retired tailor is examined for involuntary, jerking movements of his arms. His symptoms seem to resolve when he is asleep. Damage to which one of the following structures may lead to hemiballism?
Your Answer: Subthalamic nucleus
Explanation:Hemiballismus or hemiballism in its unilateral form is a very rare movement disorder. It is a type of chorea caused in most cases by a decrease in activity of the subthalamic nucleus of the basal ganglia, resulting in the appearance of flailing, ballistic, undesired movements of the limbs. Symptoms may decrease while the patient is asleep. Antidopaminergic agents (e.g. Haloperidol) are the mainstay of treatment.
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This question is part of the following fields:
- Nervous System
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Question 13
Incorrect
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A 51 year-old teacher presents complaining of numerous falls. He states he has difficulty walking up stairs, and he thinks it is because of his weak legs rather than blackouts. He is hypertensive and has suffered chronic back pain for many years. He has smoked for many years as well and has a chronic smokers cough. Upon examination, he has weakness of hip flexion and particularly knee extension. He is unable to keep his fingers flexed against force, with the right being weaker than the left. There are no sensory abnormalities and reflexes are preserved bilaterally. Which of the following is the most likely diagnosis?
Your Answer: Polymyositis
Correct Answer: Inclusion body myositis
Explanation:The pattern of muscle involvement seen with quadriceps and long-finger flexors is characteristic of inclusion body myositis, an inflammatory myopathy. Polymyositis is likely to cause a predominantly proximal weakness, associated with muscle pain. The signs and symptoms are not consistent with upper cord compression, as there would likely be sensory signs, reflex changes, and possible urinary symptoms. Motor neuron disease cannot be ruled out, but there are no findings of upper motor neuron or bulbar features.
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This question is part of the following fields:
- Nervous System
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Question 14
Correct
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A 43 year-old female artist with no past medical history presents to the emergency department with a 2-day history of pins and needles in the lower limbs, and progressive walking difficulties. She states she had diarrhoea 1 week ago. On examination, there is a loss of pinprick sensation noted to the lower limbs from mid-thigh distally and in the upper limbs from MCP joints distally. There is bilateral weakness of ankle dorsiflexion, noted at 3/5, and knee flexion and extension weakness, noted at 4/5 bilaterally. Power in upper and lower limbs is otherwise normal. Knee and ankle deep tendon reflexes are absent. Which of the following is the most likely diagnosis?
Your Answer: Guillain-Barre syndrome
Explanation:Guillain-Barre syndrome is an immune mediated demyelination of the peripheral nervous system often triggered by an infection (classically Campylobacter jejuni). Characteristic features include progressive weakness of all four limbs, and it is classically ascending, affecting the lower extremities first. Sensory symptoms tend to be mild.
Functional neurological syndrome can be discounted due to presence of hard neurological signs. Multiple sclerosis can be excluded because of the presence of lower motor neuron signs and absence of upper motor neuron signs. Chronic inflammatory demyelinating polyneuropathy is the chronic form of Guillain-Barre syndrome.
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This question is part of the following fields:
- Nervous System
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Question 15
Incorrect
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A 42-year-old male has suffered a stroke - he is unable to walk in a straight line and has slurred speech. From the list of options, choose the most appropriate investigation to proceed with.
Your Answer: MRI (brain)
Correct Answer: CT scan brain
Explanation:CT scans are used to produce images of the brain. It can be used to detect a stroke from a blood clot or bleeding within the brain.
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This question is part of the following fields:
- Nervous System
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Question 16
Incorrect
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A 75-year-old woman experiences weakness of her left hand. Clinical examination reveals wasting of the hypothenar eminence and weakness of finger abduction and thumb adduction. The lesion is most probably located at:
Your Answer: Median nerve
Correct Answer: Ulnar nerve
Explanation:Patients with compressive neuropathy of the ulnar nerve typically describe numbness and tingling of the ulnar-sided digits of the hand, classically in the small finger and ulnar aspect of the ring finger. Among the general population, symptoms usually begin intermittently and are often worse at night, particularly if the elbow is flexed while sleeping. As the disease progresses, paraesthesia may occur more frequently and during the daytime.
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This question is part of the following fields:
- Nervous System
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Question 17
Correct
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A 34 year male is brought to the emergency by the paramedics who found him unconscious after being hit by a car. However, he regained consciousness and began talking. While waiting for the doctor's review, he suddenly becomes comatose and the condition deteriorates. What will be the most likely diagnosis?
Your Answer: Extradural haemorrhage
Explanation:Extradural haemorrhage occurs as a result of head trauma and subsequent acute haemorrhage, primarily from the middle meningeal artery between the skull and the dura mater. Typical symptoms are due to compression of the brain and appear after a lucid interval that follows an initial loss of consciousness. Increased intracranial pressure leads to a decline in mental status and anisocoria, in which the ipsilateral pupil is dilated. Diagnosis is confirmed by CT (biconvex, hyperdense, sharply demarcated mass). Emergency treatment is necessary and involves neurosurgical opening of the skull and hematoma evacuation.
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This question is part of the following fields:
- Nervous System
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Question 18
Correct
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A 51-year-old presents with muscle atrophy. He has a high BMI and finds it difficult to climb stairs. If the patient also has polydipsia and polyuria, what is the most likely diagnosis?
Your Answer: Amyotrophy
Explanation:(Diabetic) Amyotrophy is a condition that presents with muscle wasting and consequent difficulty in climbing stairs. The onset is relatively sudden and symptoms of diabetes are characteristic.
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This question is part of the following fields:
- Nervous System
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Question 19
Incorrect
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A 57-year-old architect presents with weakness of the right hand. You note global wasting of the small hand muscles. There is also sensory loss over the medial border of the forearm around the elbow. Which of the following nerve roots is damaged?
Your Answer: C6
Correct Answer: T1
Explanation:This patient has Klumpke’s paralysis due to damage to the T1 nerve root. This root eventually supplies the median and ulnar nerves. The ulnar nerve supplies all of the intrinsic hand muscles except for those of the thenar eminence and the first and second lumbricals, which are innervated by the median nerve.
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This question is part of the following fields:
- Nervous System
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Question 20
Correct
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An 83-year-old retired musician is examined for progressive cognitive impairment. Which one of the following features is most suggestive of Lewy body dementia?
Your Answer: Symptoms worsen with neuroleptics
Explanation:Lewy body dementia is an increasingly recognised cause of dementia, accounting for up to 20% of cases. The characteristic pathological feature is alpha-synuclein cytoplasmic inclusions (Lewy bodies) in the substantia nigra, paralimbic and neocortical areas. Neuroleptics should be avoided in Lewy body dementia as patients are extremely sensitive and may develop irreversible parkinsonism. Questions may give a history of a patient who has deteriorated following the introduction of an antipsychotic agent.
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This question is part of the following fields:
- Nervous System
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Question 21
Correct
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A 25-year-old farmer presents with a fever, headache, malaise and neck stiffness. The first line empirical antibiotic is?
Your Answer: Ceftriaxone
Explanation:The most likely diagnosis is meningitis which requires admission and iv antibiotics. The drug of choice is a 3rd generation cephalosporin. In patients older than 55 , ampicillin cefotaxime combination is used.
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This question is part of the following fields:
- Nervous System
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Question 22
Correct
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An 18-year-old female patient presents with a history of headache and photophobia. You believe that the diagnosis is subarachnoid haemorrhage but your colleague insists on bacterial meningitis. Which of the following would you use to support your diagnosis?
Your Answer: A family history of polycystic renal disease
Explanation:Hypertension could be the result of polycystic renal disease and is a risk factor for subarachnoid haemorrhage (SAH). What are common in polycystic renal disease are cerebral aneurysms which could rupture if hypertension is present. Both meningitis and SAH can lead to a fluctuating level of consciousness and opiate abuse is not a risk factor for either SAH nor meningitis. Finally, diabetes is not linked with none of the possible diagnoses because hypertension is not a risk factor of diabetes.
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This question is part of the following fields:
- Nervous System
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Question 23
Correct
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A 48-year-old woman presented to you with a history of left side weakness that resolved within 2 hours. A CT scan was done showing reduced blood flow in a certain area. What is the next step regarding investigations?
Your Answer: Carotid Doppler plus angiography
Explanation:This is a case of a transient ischemic attack. It is better investigated by carotid duplex to exclude carotid artery stenosis or atherosclerotic changes.
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This question is part of the following fields:
- Nervous System
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Question 24
Incorrect
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The drug of choice for delirium tremens will be?
Your Answer: IV Lorazepam
Correct Answer: IV Chlordiazepoxide
Explanation:The drugs of choice for delirium tremens are benzodiazepines such as chlordiazepoxide, diazepam or lorazepam. Chlordiazepoxide is a long acting drug and is the preferred drug, before the other benzodiazepines. Barbiturates are the 2nd drugs of choice.
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This question is part of the following fields:
- Nervous System
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Question 25
Incorrect
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A 68-year-old woman with contralateral hemisensory loss presents with severe burning pain in this area. In which of the following areas has arterial occlusion most probably occurred?
Your Answer: Superior division of middle cerebral artery (dominant hemisphere)
Correct Answer: Thalamogeniculate artery
Explanation:The woman’s clinical evolution suggests that there was a thalamic stroke in the contralateral hemisphere. The artery most likely affected is the thalamogeniculate artery. Sensory loss is usually unilateral and presents at the opposite side of the brain lesion. This kind of stroke can result in severe burning pain which is responsive to tricyclics.
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This question is part of the following fields:
- Nervous System
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Question 26
Incorrect
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Which of the following peripheral neuropathy inducing clinical diagnoses is predominantly associated with sensory loss?
Your Answer:
Correct Answer: Uraemia
Explanation:Diseases that cause predominantly sensory loss include diabetes, uraemia, leprosy, alcoholism, vitamin B12 deficiency, and amyloidosis.
Those that cause predominantly motor loss include Guillain-Barre syndrome, porphyria, lead poisoning, hereditary sensorimotor neuropathies, chronic inflammatory demyelinating polyneuropathy, and diphtheria. -
This question is part of the following fields:
- Nervous System
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Question 27
Incorrect
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Question 28
Incorrect
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A 27-year-old realtor presented with progressive weakness of both legs over the last 3 years. He complained of being unable to see well at night and having an impaired sense of smell. On examination he had a shortened fourth toe bilaterally with pes cavus. Neurological examination revealed a loss of pinprick sensation to bilateral knees, and weakness of both legs that was more prominent distally. Which of the following would be the best blood test to order to make a diagnosis?
Your Answer:
Correct Answer: Phytanic acid
Explanation:The diagnosis is Refsum’s disease. This is an autosomal recessive disorder that causes a sensorimotor peripheral neuropathy. It is caused by defective alpha oxidation of phytanic acid leading to its accumulation in tissues. Cardiac conduction abnormalities and cardiomyopathies may also occur.
Epiphyseal dysplasia causes a characteristic shortening of the fourth toe. Serum phytanic acid levels are elevated. Treatment is by dietary restriction of foods containing phytanic acid (dairy products, fish, beef and lamb). -
This question is part of the following fields:
- Nervous System
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Question 29
Incorrect
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A 44 year-old electrician is referred to you complaining of increasing problems with concentration. He also complains of irregular jerky movements of his extremities and fingers. He consumes approximately 25 units of alcohol per week. His father was diagnosed with dementia at the age of 40. Apart from generalized choreiform movements, his neurological and systemic examinations were normal. Which of the following is the most likely diagnosis?
Your Answer:
Correct Answer: Huntington's disease
Explanation:Huntington’s disease is an autosomal inherited condition characterized by progressive dementia and worsening choreiform movements. Symptoms typically appear between ages 30 and 50. Ultimately the weakened individual succumbs to pneumonia, heart failure, or other complications.
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This question is part of the following fields:
- Nervous System
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Question 30
Incorrect
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An iv-drug abuser sustains an open head injury and is admitted overnight for observation. The next morning she is ok and is discharged. A week later she is re-admitted with fluctuating hard neurological signs. Blood results show neutrophilia and raised C-reactive protein (CRP).
Which of the following is the best initial treatment step?Your Answer:
Correct Answer: Computed tomography (CT) scan with contrast
Explanation:Increased WBC count and CRP suggest infection. But with the fluctuating hard neurological signs, there is suspicion of the presence of a cerebral mass, which is an indication for requesting for a CT scan with contrast, to rule out an abscess or haematoma. The lumbar puncture can be considered after the CT scan.
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This question is part of the following fields:
- Nervous System
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Question 31
Incorrect
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A 51-year-old woman admitted to the hospital for 3 days due to haemoptysis developed an ataxic gait, visual problems, and altered state of consciousness. What is the most appropriate management of this patient?
Your Answer:
Correct Answer: High potent vitamins
Explanation:Wernicke’s encephalopathy presents with neurological symptoms as a result of biochemical deficits in the central nervous system due to depleted B-vitamin reserves, particularly thiamine (vitamin B1). Classically, Wernicke encephalopathy is characterised by the triad – ophthalmoplegia, ataxia, and confusion. Thiamine treatment should be started immediately and usually continued until clinical improvement ceases.
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This question is part of the following fields:
- Nervous System
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Question 32
Incorrect
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Which of the following statements regarding restless leg syndrome is not true?
Your Answer:
Correct Answer: It is three times as common in females
Explanation:In restless leg syndrome (RLS), males and females are thought to be equally affected. RLS is a syndrome of spontaneous, continuous lower limb movements that may be associated with paraesthesia. It is extremely common, affecting between 2-10% of the general population and a family history may be present.
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This question is part of the following fields:
- Nervous System
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Question 33
Incorrect
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A 27-year-old lady presents with severe morning headaches associated with nausea. Head MRI reveals a large compressive tumour arising from the falx cerebri. The tumour is well delineated. What is the most probable diagnosis?
Your Answer:
Correct Answer: Meningioma
Explanation:Meningiomas are the most common benign tumours of the brain. Their name is derived from the fact that they arise from the dura mater which together with the pia matter and arachnoid mater form the meninges. The chances that a meningioma is benign are almost 98%. They are non-invasive and well delineated, causing sign and symptoms of brain compression.
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This question is part of the following fields:
- Nervous System
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Question 34
Incorrect
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A 11-year-old is referred to neurology due to episodes her GP feels are epileptiform. Her mother reports that she appears to just 'stop', sometimes even in mid conversation, for several seconds at random times during the day. During these episodes, she can be unresponsive to questioning and has no recollection of them.
Which of these drugs is contraindicated in this condition?Your Answer:
Correct Answer: Carbamazepine
Explanation:The patient’s history points to absence seizures. Carbamazepine has been shown to aggravate generalized seizure types, especially absence seizures, because it acts directly on the ventrobasal complex of the thalamus which is critical to the neurophysiology of absence seizures.
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This question is part of the following fields:
- Nervous System
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Question 35
Incorrect
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A 61-year-old man presented with a TIA and loss of consciousness for 30 min. His CT brain scan is normal and his ECG shows atrial fibrillation. Which risk assessment score is best used in this case?
Your Answer:
Correct Answer: CHADS2
Explanation:CHADS2 score provides a comprehensive prediction of thromboembolic events in avalvular AF patients:
C Congestive heart failure – 1
H Hypertension: blood pressure consistently above 140/90 mmHg (or treated hypertension on medication) – 1
A Age >75 years – 1
D Diabetes mellitus – 1
S2 Prior Stroke or TIA or Thromboembolism – 2 -
This question is part of the following fields:
- Nervous System
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Question 36
Incorrect
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A 29-year-old physiotherapist with a history of bilateral vitreous haemorrhage is referred due to progressive ataxia. Which of the following is the most likely diagnosis?
Your Answer:
Correct Answer: Von Hippel-Lindau syndrome
Explanation:Retinal and cerebellar haemangiomas are key features of Von Hippel-Lindau syndrome. Retinal haemangiomas are bilateral in 25% of patients and may lead to vitreous haemorrhage. Von Hippel-Lindau (VHL) syndrome is an autosomal dominant condition predisposing to neoplasia. It is due to an abnormality in the VHL gene located on short arm of chromosome 3.
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This question is part of the following fields:
- Nervous System
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Question 37
Incorrect
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A 19 year-old male was brought to the OPD with GCS of 15 after a head injury. After admission his GCS deteriorated to 12. What investigation needs to be done?
Your Answer:
Correct Answer: CT head
Explanation:CT scan head will be the investigation of choice in this case. The best possible cause will be an intracranial haemorrhage which can be visualized easily with CT scan brain.
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This question is part of the following fields:
- Nervous System
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Question 38
Incorrect
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During the examination of an elderly confused and non-coherent gentleman who was brought to casualty by a concerned neighbour, you notice that he has bilaterally small pupils, which do not appear to react to light. Under the circumstances, it is difficult to judge their response to accommodation.
Which of the following conditions may not account for the pupillary appearance in this patient?Your Answer:
Correct Answer: Acute alcohol intoxication
Explanation:Acute alcohol intoxication presents with pupillary dilation, thus, this is ruled out in this patient. All the other listed causes present with small pupils bilaterally.
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This question is part of the following fields:
- Nervous System
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Question 39
Incorrect
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A 22-year-old patient was diagnosed with glioblastoma multiforme, after he was investigated for seizures. The cell of origin of this tumour is?
Your Answer:
Correct Answer: Astrocytes
Explanation:Glioblastoma multiforme is the most common anaplastic malignant tumour of the glial cells. It is a mixture of poorly differentiated anaplastic astrocytes.
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This question is part of the following fields:
- Nervous System
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Question 40
Incorrect
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A 51-year-old man speaks fast and does not take enough breaths before speaking again. He ignores interruptions and does not want to pause in between. What best describes this kind of speech?
Your Answer:
Correct Answer: Pressure of speech
Explanation:A pressured speech is too fast for the listener to understand and is very difficult to interrupt.
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This question is part of the following fields:
- Nervous System
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Question 41
Incorrect
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A 23-year-old patient was involved in a MVA. Clinical examination reveals a fixed dilated pupil and reduced consciousness. Which of the following nerves is most likely damaged?
Your Answer:
Correct Answer: Oculomotor nerve
Explanation:The oculomotor nerve is the 3rd cranial nerve. When damaged it affects the ocular motility causing mainly ptosis or diplopia. Damage to it can also affect the pupillary functions causing pupil dilation and light reflex impairment.
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This question is part of the following fields:
- Nervous System
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Question 42
Incorrect
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Which of the following abnormal facial movements is not a well-recognised association?
Your Answer:
Correct Answer: Facial synkinesis - Wilson's disease
Explanation:Wilson’s disease may have an asymmetric tremor which is variable in character and may be predominantly resting, postural, or kinetic.
Progressive supra-nuclear palsy – blepharospasm, apraxia of lid opening and/or apraxia of lid closing.
Tourette’s syndrome – one or more motor or vocal tics.
Multiple Sclerosis – continuous facial myokymia.
Tardive dyskinesia is a side-effect of conventional antipsychotics, neuroleptics, anticholinergics, and toxins resulting in stiff, jerky movements of your face and body -
This question is part of the following fields:
- Nervous System
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Question 43
Incorrect
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A drunken man has fallen asleep in a position with his arm hanging down. After waking up he complained of wrist drop and sensory loss at the web of the thumb. Which of the following structures is most likely to be affected?
Your Answer:
Correct Answer: Radial nerve
Explanation:This presentation is known as ‘Saturday night palsy’. When someone falls asleep with a arm hanging over the arm rest of a chair, the radial nerve compresses and causes wrist drop and loss of sensation at the web of the thumb.
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This question is part of the following fields:
- Nervous System
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Question 44
Incorrect
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A 48-year-old patient with diabetes is referred from the Emergency department complaining of dizziness and vomiting.
On examination he is alert and oriented, his pulse is 80 irregularly irregular and BP 160/90 mmHg. There is nystagmus on left lateral gaze and his speech is slurred. On examination of the limbs, you note intention tremor and past pointing. He is ataxic when mobilised.
What is the likely diagnosis?Your Answer:
Correct Answer: Cerebellar CVA
Explanation:The patient’s presentation with slurred speech, intention tremor and past pointing, as well as ataxia and nystagmus, paired with a history of vertigo suggest the cerebellum as the site of cerebrovascular accident (CVA) or stroke.
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This question is part of the following fields:
- Nervous System
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Question 45
Incorrect
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A 36 year-old accountant presents with a sudden onset of headache which progressed to him collapsing. Upon arrival in A&E, he has a heart rate of 76 bpm, blood pressure 220/140, and Glasgow Coma Score of 9 (E2, M5, V2). Which of the following should be done immediately?
Your Answer:
Correct Answer: Give high flow oxygen via a non-rebreather mask
Explanation:This man is likely suffering from a subarachnoid haemorrhage or intracerebral bleed. The priority is to prevent a secondary brain injury. Important first steps include ensuring a secure airway, normalizing cardiovascular function, and treating seizures. His airway is likely to be protected with a GCS of 9, although he may benefit from a nasal or oral airway, and close attention should be paid to his airway if going for a CT scan. He should receive high flow oxygen and his blood pressure should not be treated acutely, as i is often appropriate to compensate for a rise in intracranial pressure. Nimodipine should be given if a subarachnoid haemorrhage is proven. Attention should also be given to maintaining a normal blood sugar, as hyperglycaemia worsens outcomes.
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This question is part of the following fields:
- Nervous System
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Question 46
Incorrect
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An 18-year-old, previously well boy was admitted following a generalized tonic-clonic convulsion for 5 minutes with urinary incontinence and eye rolling. On examination, he was drowsy and had bilateral upgoing plantar reflexes. A short while ago he had been playing rugby and had taken a hit to the head. He was apparently normal for a few minutes before fitting. His blood sugar level was normal. Which of the following is the most probable reason for this presentation?
Your Answer:
Correct Answer: Post-traumatic seizure
Explanation:The history is suggestive of a post-traumatic seizure which frequently occurs after moderate or severe traumatic brain injury. Although upgoing plantars can be identified in a post-ictal status, an intracranial bleed has to be excluded. A single seizure cannot be considered epilepsy
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This question is part of the following fields:
- Nervous System
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Question 47
Incorrect
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Which one of the following medications is most useful for helping to prevent attacks of Meniere's disease?
Your Answer:
Correct Answer: Betahistine
Explanation:Betahistine is a histamine analogue that has been the mainstay treatment drug for Meniere’s disease.
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This question is part of the following fields:
- Nervous System
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Question 48
Incorrect
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A 67-year-old male presented with a history of chronic backache and altered sensation over the lateral side of his right calf and foot. Which of the following nerve roots will most likely be involved in this patient?
Your Answer:
Correct Answer: L5-S1
Explanation:Lesions in L5-S1 region leads to altered sensation on the lateral side of calf and foot, along with back pain. There might be difficulty in extension of the leg, foot inversion, plantar flexion and toe flexion, as muscles controlling these functions are supplied by S1.
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This question is part of the following fields:
- Nervous System
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Question 49
Incorrect
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A 45-year-old female has presented to her doctor with rotational vertigo, nausea, and vomiting (especially when she moves her head). She had a similar incident 2 years ago. It is noted that these vertigo episodes follow a runny nose, cough, cold, and a fever. Given the symptoms, what is the most likely diagnosis for the patient?
Your Answer:
Correct Answer: Vestibular neuritis
Explanation:In this patient, there is no sensorineural hearing loss (which is often present in Meniere’s disease, labyrinthitis, and acoustic neuroma). Additionally, a runny nose, cold, cough, and fever are all recognised as triggers of vestibular neuritis (but not BPPV).
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This question is part of the following fields:
- Nervous System
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Question 50
Incorrect
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Which of the following is MOST suggestive of a lesion of the sciatic nerve?
Your Answer:
Correct Answer: Foot drop
Explanation:The sciatic neve originates in the sacral plexus, mainly from spinal segments L5-S2. It supplies muscles that cause extension of the thigh and flexion of the leg. It divides into two main branches, the tibial nerve and common peroneal nerve, which are responsible for all foot movements. Anterior thigh and medial leg sensory loss is typical of a femoral nerve lesion. The femoral nerve also mediates flexion of the hip.
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This question is part of the following fields:
- Nervous System
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Question 51
Incorrect
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A 74-year-old retired judge who is known to have Alzheimer's disease is examined in clinic. His latest Mini Mental State Examination (MMSE) score is 18 out of 30. Which of the following is the most appropriate treatment option?
Your Answer:
Correct Answer: Supportive care + donepezil
Explanation:NICE now recommends the three acetylcholinesterase inhibitors (donepezil, galantamine and rivastigmine) as options for managing mild to moderate Alzheimer’s disease. Memantine is reserved for patients with moderate to severe Alzheimer’s.
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This question is part of the following fields:
- Nervous System
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Question 52
Incorrect
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A 27 year-old ballet instructor presents with 1-day history of left-sided facial weakness and an increased sensitivity to noise in her left ear. She is very anxious because 2 years ago she had some problems with her vision and was told that multiple sclerosis was a possibility. Her medical history is significant only for type 1 diabetes mellitus managed with insulin, and she is also taking a combined oral contraceptive pill. Upon examination, she has a lower motor neuron lesion of the left VII (facial) nerve with Bell's phenomenon present and difficulty closing her left eye. There is no objective hearing loss and no sensory signs. Examination of the auditory meatus and canal is unremarkable. The remainder of the neurological examination appears normal. The next management step in her care should be:
Your Answer:
Correct Answer: Eye patch and artificial tears
Explanation:From the given history and physical examination findings, this patient has Bell’s palsy. There is no evidence to suggest involvement of any other cranial nerves, which might raise suspicion of a cerebello-pontine angle space-occupying lesion. With her history of possible optic neuritis, there is a possibility that the lesion is in fact a manifestation of multiple sclerosis, although this should be differentiated by examination of an upper motor neuron lesion (with sparing of the forehead facial muscles because of bilateral innervation). In light of her diabetes and the limited evidence of benefit from corticosteroid use, the most sensible first management step for her would be meticulous eye care to avoid corneal ulceration, as a result of the difficulty she is having closing her left eye.
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This question is part of the following fields:
- Nervous System
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Question 53
Incorrect
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A 61-year old mechanic recently attended A&E, with a 3 month history of bilateral paresthesia and twitching affecting the thumb, first finger and lateral forearm. He denied any trauma. An MRI scan of his spine was performed and revealed cervical canal stenosis with mild cord compression. He was discharged and advised to see his GP for follow-up. Which of the following is the most appropriate initial step in management?
Your Answer:
Correct Answer: Refer to spinal surgery services
Explanation:Bilateral median nerve dysfunction is suggestive of degenerative cervical myelopathy (DCM) rather than bilateral carpal tunnel syndrome. DCM should be suspected in elderly patients presenting with limb neurology. This patient’s twitches are probably fibrillations, a sign of lower motor neuron dysfunction.
Degenerative cervical myelopathy is associated with a delay in diagnosis. It is most commonly misdiagnosed as carpal tunnel syndrome. In one study, 43% of patients who underwent surgery for degenerative cervical myelopathy had been initially diagnosed with carpal tunnel syndrome.
Management of these patients should be by specialist spinal services (neurosurgery or orthopaedic spinal surgery). Decompressive surgery is the mainstay of treatment and has been shown to stop disease progression. Physiotherapy and analgesia do not replace surgical opinion, though they may be used alongside. Nerve root injections do not have a role in management. -
This question is part of the following fields:
- Nervous System
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Question 54
Incorrect
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A 37-year-old woman presents with sudden blindness. She claims she had a similar episode last year which resolved in three months. Fundoscopy is normal. Upon examination, mild weakness of the right upper limb is found. Reflexes on the same limb are exaggerated. What is the best treatment?
Your Answer:
Correct Answer: Corticosteroids
Explanation:The age of the patients together with sudden loss of vision, remission and relapse of optic neuritis, focal neurological symptoms and exaggerated reflexes all suggest multiple sclerosis. This is treated with corticosteroids.
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This question is part of the following fields:
- Nervous System
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Question 55
Incorrect
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Regarding cranial nerves, which of the following statements is true?
Your Answer:
Correct Answer: The vagus nerve supplies the palatal muscles
Explanation:In addition to the pharynx and larynx, the vagus nerve also innervates the palatoglossus of the tongue, and the majority of the muscles of the soft palate.
The lacrimal gland is supplied by the facial nerve.
The glossopharyngeal nerve supplies the parotid salivary gland controlling salivary secretions.
The oculomotor nerve carries parasympathetic efferents to the sphincter pupillae muscle and innervates the superior rectus.
The optic nerve carries sympathetic postganglionic fibres to the dilator pupillae muscle.
The trochlear nerve supplies the superior oblique muscle. -
This question is part of the following fields:
- Nervous System
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Question 56
Incorrect
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Which is the most appropriate agent for the prophylaxis of cluster headaches?
Your Answer:
Correct Answer: Verapamil
Explanation:Verapamil, can effectively reduce the number of attacks during a cluster headache period of exacerbation. Oral sumatriptan has not been shown to be effective prophylactically. Verapamil in dosages of 360 to 480 mg daily is one of the few treatments for episodic cluster headache tested in a randomized controlled trial (RCT) and found effective in reducing attack frequency.
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This question is part of the following fields:
- Nervous System
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Question 57
Incorrect
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A 51-year-old male patient presents with acute back pain, which worsens on prolonged walking and sitting. The pain radiates towards the lower limbs and seems to be relieved by lying down. What is the best next step?
Your Answer:
Correct Answer: Magnetic resonance imaging (MRI)
Explanation:A herniated disc seems to be the cause of the patient’s pain. MRI is the investigation of choice, since it can show soft tissue and establish a differential diagnosis.
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This question is part of the following fields:
- Nervous System
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Question 58
Incorrect
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A 48-year-old hairdresser presented to her GP complaining of tingling in the right palm and right wrist pain. She had intermittently experienced these symptoms; however, recently they had been keeping her awake all night. She had noticed a reduction in grip and was struggling to work at the salon. Otherwise, she felt well in herself and had not noticed any weakness in the other hand or lower limb. Her weight was stable, and she denied any neck problems or swallowing difficulties. She had a past medical history of hypothyroidism and hypertension and took regular thyroxine, Bendroflumethiazide and ibuprofen. She was a non-smoker and rarely drank alcohol. On examination, she appeared alert and oriented. Fundoscopy and cranial nerve examination were all normal and neck movements were full.
On examination of the upper limb, there was wasting over the right thenar eminence and fasciculations with a small burn over the right index finger. There was weakness of thumb abduction and opposition, with loss of pinprick and light touch sensation over the thumb, index and middle finger in the right hand. Nerve conduction studies showed absent sensory action potential in right median palmar branches and denervation of the right abductor pollicis brevis.
What is the most likely diagnosis?Your Answer:
Correct Answer: Median nerve palsy
Explanation:The history is consistent with carpal tunnel syndrome (CTS) arising as a result of pressure on the median nerve in the carpal tunnel. The median nerve supplies the muscles of the thenar eminence: the abductor pollicis (C7, C8), flexor pollicis brevis and opponens pollicis, and the lateral two lumbricals. The nerve conduction studies confirm marked denervation and absent sensory potentials within the median nerve territory.
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This question is part of the following fields:
- Nervous System
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Question 59
Incorrect
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A 63-year-old gentleman presents with left-sided eye pain and diplopia for the past 2 days. Examination of his eyes shows his pupils equal and reactive to light with no proptosis. There is however an apparent palsy of the 6th cranial nerve associated with a partial 3rd nerve palsy on the left side. Examining the remaining cranial demonstrates hyperaesthesia of the upper face on the left side. Where is the likely lesion?
Your Answer:
Correct Answer: Cavernous sinus
Explanation:A lesion on the cavernous sinus would explain the palsy observed on the III and VI cranial nerves because the cranial nerves III, IV, V, and VI pass through the cavernous sinus. Pain in the eye is due to the nearby ophthalmic veins that feeds the cavernous sinus. Additionally, the lesions in the other structures would have presented with pupil abnormalities and less localized pain and symptoms.
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This question is part of the following fields:
- Nervous System
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Question 60
Incorrect
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A 24-year-old male was involved in a traffic collision. X-rays indicated that the neck of the humerus had suffered a fracture. Choose the single most associated nerve injury from the list of options.
Your Answer:
Correct Answer: Axillary nerve
Explanation:Fractures in the neck of the humerus are well documented to cause damage to the auxiliary nerve.
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This question is part of the following fields:
- Nervous System
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Question 61
Incorrect
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A 30-year-old painter presents with a burning pain in both feet, which has deteriorated over the last six months. He drinks 60 units of alcohol weekly and has a family history of pernicious anaemia.
On examination he has impairment of all modalities of sensation in both feet but particularly pain, temperature and absent ankle jerks.
What is the most likely diagnosis?Your Answer:
Correct Answer: Alcoholic peripheral neuropathy
Explanation:Because of the patient’s history of excessive alcohol consumption, there is a strong suspicion of alcoholic peripheral neuropathy. In the UK, alcohol abuse and diabetes are the most common causes of peripheral neuropathy.
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This question is part of the following fields:
- Nervous System
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Question 62
Incorrect
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A 20-year-old gentleman presents to the A&E department complaining of a sudden-onset occipital headache associated with vomiting. His symptoms started 2 hours previously and are continuing. He has a previous history of infrequent migraine without aura, which also causes nausea but not vomiting. He rated his current headache as much more severe than his usual migraine. Examination is unremarkable. In particular, there is no neck stiffness or photophobia.
Which of the following management options would be the most appropriate?Your Answer:
Correct Answer: CT brain scan, followed by lumbar puncture if CT normal
Explanation:The patient presented with sudden-onset headache that is more painful than his usual migraine attacks. This gives a high suspicion of subarachnoid haemorrhage; thus, a CT brain scan should be ordered first to rule this out. However, a normal CT scan is apparent in 30% of patients with subarachnoid haemorrhage and should be referred for lumbar puncture to look for red blood cells.
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This question is part of the following fields:
- Nervous System
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Question 63
Incorrect
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A 53 year-old dancer presents to the ED with increasing weakness. She has no pertinent past medical history aside from a recent diarrhoeal illness, which she attributes to an undercooked chicken meal. Her husband says that she has been unable to get up out of a chair for the past day. Upon examination, there is bilateral limb weakness and areflexia noted, but it is more severe in the lower limbs. You notice that if she lies flat in the bed, her oxygen saturations fall by around 2% on the pulse oximeter and she is unable to perform spirometry. Which of the following represents the most appropriate immediate management of choice in this patient?
Your Answer:
Correct Answer: ITU review for consideration of ventilation
Explanation:This woman has a history that is suggestive of Guillain- Barre syndrome. This may be precipitated by Campylobacter, and her history of recent diarrhoeal illness is pointing towards that. Certain features point to a poor prognosis, including rapidity of onset, reduced vital capacity or respiratory failure, age >40 and reduced amplitude of compound muscle action potential. Her inability to perform spirometry and desaturating whilst lying flat are suggestive of impending respiratory muscle weakness. Review for consideration of ventilation is recommended. Further management of choice for Guillain-Barre syndrome is IV immunoglobulins. Steroids have no value in the treatment of the condition.
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This question is part of the following fields:
- Nervous System
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Question 64
Incorrect
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Which of the following signs is least suggestive of cervical myelopathy?
Your Answer:
Correct Answer: Bladder disturbance
Explanation:Cervical myelopathy is mostly caused by spondylosis of C5-C7. Sphincters are usually not involved. The lower limbs usually are hypertonic with weakness and up going planter reflex. Vibration and proprioception tend to be lost. Biceps jerk is inverted or even absent. Although cervical spondylosis is the most common cause, an intrinsic lesion might give a similar picture.
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This question is part of the following fields:
- Nervous System
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Question 65
Incorrect
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A 52-year-old man presents with numbness and tingling in his left hand. On examination he has weakness of elbow extension, metacarpophalangeal joint flexion and extension and distal interphalangeal joint flexion. All other movements and reflexes are normal. Sensation is normal apart from reduced pinprick sensation over the medial aspect of the hand. An MRI scan of the cervical spine is performed due to suspicion of a nerve lesion.
Which of the following pathologies is most likely to be found on the scan based on the clinical findings?Your Answer:
Correct Answer: Disc herniation between C7 and T1
Explanation:The C8 nerve forms part of the radial and ulnar nerves via the brachial plexus, and therefore has motor and sensory function in the upper limb. It originates from the spinal column from below the cervical vertebra 7 (C7).
The C8 nerve receives sensory afferents from the C8 dermatome. This consists of all the skin on the little finger, and continuing up slightly past the wrist on the palmar and dorsal aspects of the hand and forearm.
The other options available correspond to the C6 or C7 roots and these are unaffected as evidenced by normal elbow flexion and thumb sensation (C6) and normal sensation over the middle finger (C7). Elbow extension is weak as it has roots from both C7 and C8 and so cannot be used alone to decide between the two levels clinically.
The C8 nerve contributes to the motor innervation of many of the muscles in the trunk and upper limb. Its primary function is the flexion of the fingers, and this is used as the clinical test for C8 integrity, in conjunction with the finger jerk reflex.Trunk:
– Pectoralis major – Medial and lateral pectoral nerves (C5, C6, C7, C8, T1)
– Pectoralis minor – Medial pectoral nerve (C5, C6, C7,C8, T1)
– Latissimus dorsi – Thoracodorsal nerve (C6, C7, C8)
Upper arm:
– Triceps brachii – Radial nerve (C6, C7,C8)
Forearm
– Flexor carpi ulnaris – Ulnar nerve (C7, C8, T1)
– Palmaris longus – Median nerve (C7,C8)
– Flexor digitorum superficialis – Median nerve (C8, T1)
– Flexor digitorum profundus – Median and Ulnar nerves (C8, T1)
– Flexor pollicis longus – Median nerve (C7,C8)
– Pronator quadratus – Median nerve (C7,C8)
– Extensor carpi radialis brevis – Deep branch of the radial nerve (C7,C8)
– Extensor digitorum – Posterior interosseous nerve (C7,C8)
– Extensor digiti minimi – Posterior interosseous nerve (C7,C8)
– Extensor carpi ulnaris – Posterior interosseous nerve (C7,C8)
– Anconeus – Radial nerve (C6, C7,C8)
– Abductor pollicis longus – Posterior interosseous nerve (C7,C8)
– Extensor pollicis brevis – Posterior interosseous nerve (C7,C8)
– Extensor pollicis longus – Posterior interosseous nerve (C7,C8)
– Extensor indicis – Posterior interosseous nerve (C7,C8)
Hand
– Palmaris brevis – Superficial branch of ulnar nerve (C8, T1)
– Dorsal interossei – Deep branch of ulnar nerve (C8, T1)
– Palmar interossei – Deep branch of ulnar nerve (C8, T1)
– Adductor pollicis – Deep branch of ulnar nerve (C8, T1)
– Lumbricals – Deep branch of ulnar, Digital branches of median nerve
– Opponens pollicis – Recurrent branch of median nerve (C8, T1)
– Abductor pollicis brevis – Recurrent branch of median nerve (C8, T1)
– Flexor pollicis brevis – Recurrent branch of median nerve (C8, T1)
– Opponens digiti minimi – Deep branch of ulnar nerve (C8, T1)
– Abductor digiti minimi – Deep branch of ulnar nerve (C8, T1)
– Flexor digiti minimi brevis – Deep branch of ulnar nerve (C8, T1) -
This question is part of the following fields:
- Nervous System
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Question 66
Incorrect
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When considering the anatomical location of intracranial meningiomas, which of the following relations is well recognised?
Your Answer:
Correct Answer: Parasagittal - spastic paraparesis
Explanation:The localisation of intracranial lesions (based on both history and examination) is crucial. Meningiomas are slow in growth, and its subtle effects are very different from the more aggressive, intrinsic lesions. Olfactory groove lesions affect the sense of smell and may produce ipsilateral optic atrophy. Sphenoid ridge lesions will produce exophthalmos. Chiasmal lesions usually produce bitemporal hemianopia.
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This question is part of the following fields:
- Nervous System
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Question 67
Incorrect
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A 41-year-old gentleman undergoes a temporal lobectomy after the discovery of a brain tumour. Which one of the following consequences would be least likely to develop?
Your Answer:
Correct Answer: Astereognosis
Explanation:Astereognosis is associated with lesions to the parietal lobe, not the temporal lobe, so this symptom would not arise in this patient.
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This question is part of the following fields:
- Nervous System
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Question 68
Incorrect
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A 26-year-old graduate student with a history of migraines presents for examination. His headaches are now occurring about once a week. He describes unilateral, throbbing headaches that may last over 24 hours. Neurological examination is unremarkable. Other than a history of asthma, he is fit and well. What is the most suitable therapy to reduce the frequency of migraine attacks?
Your Answer:
Correct Answer: Topiramate
Explanation:It should be noted that as a general rule 5-HT receptor agonists are used in the acute treatment of migraine whilst 5-HT receptor antagonists are used in prophylaxis. NICE produced guidelines in 2012 on the management of headache, including migraines. Prophylaxis should be given if patients are experiencing 2 or more attacks per month. Modern treatment is effective in about 60% of patients. NICE advises either topiramate or propranolol ‘according to the person’s preference, comorbidities and risk of adverse events’. Propranolol should be used in preference to topiramate in women of child bearing age as it may be teratogenic and it can reduce the effectiveness of hormonal contraceptives.
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This question is part of the following fields:
- Nervous System
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Question 69
Incorrect
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A 71-year old gentleman presents with a subacute history of intermittent difficulty in walking, dry mouth, and variable slurring of speech. When the latter is severe he also has difficulty in swallowing. He has lost 3 kg in weight in the last 2 months.
On examination he has bilateral mild ptosis, dysarthria, and proximal weakness of the upper and lower limbs, and he is areflexic. The degree of weakness is variable. Nerve conduction studies confirm the clinical suspicion of a neuromuscular junction disorder.
Which of the following autoantibodies is likely to be the underlying cause of his neurological symptoms?Your Answer:
Correct Answer: Anti-voltage-gated, calcium-channel antibody
Explanation:The clinical picture points to Lambert- Eaton myasthenic syndrome (LEMS) which often presents with weakness of the arms and legs. In LEMS, antibodies against voltage-gated calcium channels (VGCC) decrease the amount of calcium that can enter the nerve ending, causing autonomic symptoms like dry mouth and slurring of speech, as seen in this patient.
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This question is part of the following fields:
- Nervous System
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Question 70
Incorrect
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A 38-year-old female patient is brought into the emergency department with a 5 day history of altered personality, and visual and auditory hallucinations. On palpation of the abdomen, a mass is felt in the left iliac fossa. Ultrasound of the abdomen suggests a left ovarian tumour. Her basic observations are as follows:
Oxygen saturation 99% on air
Heart rate 98 beats/minute
Respiratory rate 28 breaths/minute
Temperature 37.9 °C
What is the most likely diagnosis?Your Answer:
Correct Answer: Anti-NMDA receptor encephalitis
Explanation:The case presents with an underlying ovarian tumour, associated with psychiatric symptoms; thus, an organic illness must first be ruled out before considering the other conditions listed which often present with psychiatric features without an underlying organic disease. Among the listed conditions Anti-NMDA receptor encephalitis is the only condition that presents with psychiatric features including agitation, hallucinations, delusions and disordered thinking that is associated with tumours 50% of the time.
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This question is part of the following fields:
- Nervous System
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Question 71
Incorrect
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A 41-year-old male experiences hand tremors that are absent at rest, but aggravated on extension and continuous with movement. What is the most probable diagnosis?
Your Answer:
Correct Answer: Benign essential tremor
Explanation:Tremors that linger on movement, seen on an outstretched hand, and absent on rest are called benign essential tremors.
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This question is part of the following fields:
- Nervous System
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Question 72
Incorrect
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A young woman is complaining of a sensation of spinning and loss of balance every time she moves sideways on the bed while lying supine. What would you do next?
Your Answer:
Correct Answer: Head roll test
Explanation:The most probable diagnosis is benign paroxysmal positional vertigo (BPPV). It is a peripheral vestibular disorder characterized by short episodes of mild to intense dizziness and influenced by specific changes in head position. BPPV is the most common cause of vertigo accounting for nearly one-half of patients with peripheral vestibular dysfunction. In order to establish the diagnosis, the head roll test is performed where the head is turned about 90° to each side while supine.
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This question is part of the following fields:
- Nervous System
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Question 73
Incorrect
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A 30-year-old patient has ataxia, nystagmus and vertigo with a history of headaches. Where is the most likely site of the lesion?
Your Answer:
Correct Answer: Cerebellum
Explanation:Damage to the cerebellum can cause asynergia, dysmetria, adiadochokinesia, intention tremor, staggering, ataxic gait, tendency toward falling, hypotonia, ataxic dysarthria and nystagmus.
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This question is part of the following fields:
- Nervous System
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Question 74
Incorrect
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A 60-year-old lady has been admitted to the stroke ward following a sudden onset of dizziness and visual disturbances, which started yesterday morning. She initially thought she was just dehydrated, however, later realised she was unable to read her own shopping list. On the ward rounds, the consultant examines her and finds she is indeed unable to read. She is, however, able to write. When she writes a sentence it makes perfect sense, although she is again unable to read it out. She has no problems with her speech and is able to converse normally. She has no motor focal neurological deficit. The consultant asks you where the lesion is likely to be?
Your Answer:
Correct Answer: Corpus callosum
Explanation:The patient presents with sudden onset of alexia (the inability to read) WITHOUT agraphia (inability to write) which is consistent with lesions of the corpus callosum where there is a disconnect syndrome and the patient’s language and visual centres are actually in tact, but are unable to communicate between hemispheres. In this case, the damage due to the stroke is most likely in the left visual cortex, leaving visual processing to the intact right hemisphere which unfortunately cannot communicate the information to the language centres (Broca and Wernicke’s) in the left hemisphere, hence the alexia. Alternatively, the speech and writing are unaffected as the language centres can still communicate with the primary motor cortex.
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This question is part of the following fields:
- Nervous System
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Question 75
Incorrect
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A 37-year-old male fell whilst walking home and landed on his outstretched hand. He is now complaining of pain in his right arm. X-rays were conducted and indicate a fracture of the radial head. Choose the most commonly associated nerve injury from the list of options.
Your Answer:
Correct Answer: Radial nerve
Explanation:There will be a radial nerve injury due to finger drop with both sensation intact and a normal wrist.
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This question is part of the following fields:
- Nervous System
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Question 76
Incorrect
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A 55-year-old male visited his diabetic clinic with a complaint of inability to walk properly due to weakness of his lower limbs. On examination, dorsiflexion was found to be weak bilaterally and there was diminished sensation on the dorsum of his feet as well as on the lower lateral portions of his legs. Which of the following could have led to this condition?
Your Answer:
Correct Answer: Compression of the common peroneal nerve
Explanation:The branches of the common peroneal nerve innervate the skin of the dorsum of the foot as well as the muscles which help to carry out dorsiflexion of the foot. Compression of the common peroneal nerve cause foot drop as well as the loss in sensation of the skin on the dorsum of the foot.
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This question is part of the following fields:
- Nervous System
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Question 77
Incorrect
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A 46-year-old plumber develops chronic, severe pain after sustaining a brachial plexus injury as a result of a motorbike accident. He has had no benefit from paracetamol or ibuprofen. In addition, he has had an unsuccessful trial of amitriptyline. Following recent NICE guidelines, which of the following is the most appropriate medication to consider?
Your Answer:
Correct Answer: Pregabalin
Explanation:Neuropathic pain may be defined as pain which arises following damage or disruption of the nervous system. It is often difficult to treat and responds poorly to standard analgesia.
The most recent update to the NICE guidelines for management of neuropathic pain occurred in 2013: first-line treatment* includes amitriptyline. If the first-line drug treatment does not work then move on to one of the other 3 drugs: duloxetine, gabapentin or pregabalin. Tramadol may be used as ‘rescue therapy’ for exacerbations of neuropathic pain. Topical capsaicin may be used for localised neuropathic pain (e.g. post-herpetic neuralgia). Pain management clinics may be useful in patients with resistant problems.*please note that for some specific conditions the guidance may vary. For example carbamazepine is used first-line for trigeminal neuralgia.
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This question is part of the following fields:
- Nervous System
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Question 78
Incorrect
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A 69 year-old librarian with motor neuron disease is seen in clinic. Which of the following interventions will have the greatest effect on survival?
Your Answer:
Correct Answer: Non-invasive ventilation
Explanation:Motor neuron disease is a neurological condition of unknown cause which can present with both upper and lower motor neuron signs. It rarely presents before age 40 and various patterns of disease are recognised, including amyotrophic lateral sclerosis, progressive muscular atrophy and bulbar palsy.
Non-invasive ventilation (usually BIPAP) is used at night, with studies having shown a survival benefit of around 7 months. Riluzole prevents stimulation of glutamate receptors, used mainly in amyotrophic lateral sclerosis and has been shown to prolong life by about 3 months. -
This question is part of the following fields:
- Nervous System
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Question 79
Incorrect
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A 68-year-old male presented with unbalances and vomiting for 1 week. Which of the following is the best investigations that can be performed to arrive at a diagnosis?
Your Answer:
Correct Answer: MRI of Cerebellum
Explanation:Lesions in cerebellum and pontine region should be excluded. So the most appropriate investigation is MRI of cerebellum.
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This question is part of the following fields:
- Nervous System
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Question 80
Incorrect
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A 55-year-old male, known hypertensive on antihypertensive medications, presented with complaints of dizziness and lethargy, especially when rising from the chair. The most appropriate test would be?
Your Answer:
Correct Answer: Ambulatory blood pressure
Explanation:Ambulatory blood pressure recording is used to monitor BP for 24 hours whilst continuing the daily routine activities.
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This question is part of the following fields:
- Nervous System
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Question 81
Incorrect
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A 38-year-old musician presented with a two-day history of sudden-onset occipital headache associated with nausea and vomiting. The next day, his right hand became weak for a few hours. On the same day he had an episode of sensory disturbance in his right upper limb consisting of tingling in his hand that spread up the arm, to his shoulder lasting less than two minutes in total. On the day of admission he had a similar episode of sensory disturbance lasting 30 seconds in total. On examination he had bilateral papilledema, no neck stiffness and an otherwise normal neurological examination. Which of the following is the most likely diagnosis?
Your Answer:
Correct Answer: Venous sinus thrombosis
Explanation:Cerebral venous sinus thrombosis (CVST) is associated with headache (>90% of cases), seizures, focal weakness (40%) and papilledema (40%), all seen in this patient.
Risk factors for CVST include genetic or acquired prothrombotic disorders, pregnancy, the oral contraceptive pill, vasculitis, malignancy, dehydration and infection. However, there are multiple other associated factors.
Diagnosis is normally confirmed with magnetic resonance venography (MRV). Treatment is with anticoagulation, initially with heparin and subsequently with warfarin. -
This question is part of the following fields:
- Nervous System
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Question 82
Incorrect
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A 53-year-old cashier with a history of chronic back pain presents for a check-up. He is aware of a dragging feeling affecting his left foot when he tries to walk. This has developed since a minor injury to his left knee. On examination, he has weakness of dorsiflexion and eversion of the left foot. The right is unaffected and plantar flexion and inversion are normal on the left. MRI of the spinal cord shows degenerative disc changes at multiple levels, but no evidence of cord or nerve root impingement. Nerve conduction studies and EMG results are pending. Which of the following sensory loss patterns would you expect to find in association with this motor defect?
Your Answer:
Correct Answer: Sensory loss over the dorsum of the foot and anterolateral leg
Explanation:This patient presentation is unlikely to be an L5 nerve root lesion given the results of the MRI scan. Therefore, the most likely diagnosis is a mononeuritis affecting the left common peroneal nerve. This would lead to sensory loss over the dorsum of the foot and anterolateral leg on the left.
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This question is part of the following fields:
- Nervous System
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Question 83
Incorrect
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A 40 year-old lawyer suffered a road traffic accident. MRI reveals that he may have hemisection of the spinal cord. Which of the following findings is most likely to occur?
Your Answer:
Correct Answer: Ipsilateral hyperreflexia
Explanation:Spinal cord hemisection, also known as Brown-Sequard syndrome, is associated with symptoms affecting one spinothalamic and one corticospinal tract. Symptoms include ipsilateral paralysis, loss of vibration and position sense, and hyperreflexia below the level of the lesion. Contralateral loss of pain and temperature sensation is also seen, usually beginning 2-3 segments below the level of the lesion.
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This question is part of the following fields:
- Nervous System
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Question 84
Incorrect
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A 51-year-old woman complains of sudden onset of severe headache and vomiting that is worse when she is lying flat. Fundoscopy confirms bilateral papilledema. Which is the definitive investigation in this case?
Your Answer:
Correct Answer: Computed tomography scan
Explanation:A head CT scan is the best step to rule out a mass lesion or bleed. Since the patient has symptoms that may suggest elevated intracranial pressure (ICP), a lumbar puncture should be consulted first with a neurologist since it is contraindicated in this case due to raised ICP and risk of coning.
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This question is part of the following fields:
- Nervous System
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Question 85
Incorrect
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Which one of the following is a contraindication to the use of a triptan in the management of migraine?
Your Answer:
Correct Answer: A history of ischaemic heart disease
Explanation:A history of ischaemic heart disease in a contraindication for prescribing triptans because they act by constricting cerebral and also coronary vessels, increasing the risk of stroke.
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This question is part of the following fields:
- Nervous System
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Question 86
Incorrect
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A 35-year-old male has presented with a wrist drop of his right hand. After a medical examination, an area of sensory loss on the dorsum is revealed. Choose the nerve most likely to be affected from the list of options.
Your Answer:
Correct Answer: Radial nerve
Explanation:The radial nerve supplies the following: brachioradialis, extensor carpi radialis longus, and the extensor muscles of the forearm (which is via the posterior interosseous nerve). The sensory branches supply the following: dorsum of the thumb, dorsum of the fingers up to the PIPJ (proximal interphalangeal joint), and the middle of the ring finger. The loss of muscle power depends on the extent of the nerve damage – the usual posture is a wrist drop, coupled with thumb adduction and hand pronation. Sensation in this male patient is impaired in this area. The thoracic nerve supplies the serratus anterior muscle, and thus, damage causes winging of the scapula. A median nerve palsy causes the following: the inability to abduct and oppose the thumb; weakness in the forearm, pronation and finger flexion; and sensory loss of the thumb. A T1 nerve root lesion causes Klimke’s palsy – this is a loss of finger flexion, abduction and adduction, and reduced sensation in the medial upper limb. The ulnar nerve is usually compromised at the elbow which causes numbness in the 5th finger, the medial aspect of the ring finger, and the dorsum of the hand (over the 5th finger). A clawed hand can develop (the little and ring fingers curl in towards the palm) if the weakness of the small muscles of the hand is allowed to progress.
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This question is part of the following fields:
- Nervous System
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Question 87
Incorrect
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A 58-year-old psychologist with small cell lung cancer complains of muscle weakness. Each one of the following are features of Lambert-Eaton syndrome, except:
Your Answer:
Correct Answer: Repeated muscle contractions lead to decreased muscle strength
Explanation:In myasthenia gravis, repeated muscle contractions lead to reduced muscle strength. The opposite is however classically seen in the related disorder Lambert-Eaton syndrome. Lambert-Eaton myasthenic syndrome is seen in association with small cell lung cancer, and to a lesser extent breast and ovarian cancer. It may also occur independently as an autoimmune disorder. Lambert-Eaton myasthenic syndrome is caused by an antibody directed against pre-synaptic voltage gated calcium channel in the peripheral nervous system.
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This question is part of the following fields:
- Nervous System
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Question 88
Incorrect
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A 25-year-old athlete presented with a 7-month history of difficulty gripping things. He complained of finding it particularly difficult in cold weather. He remembered his father having similar problems. Upon examination, he had a bilateral ptosis with weakness of the facial muscles. He also had difficulty opening his eyes quickly. Limb examination revealed distal weakness in both hands with difficulty opening and closing both hands quickly. Which of the following is the most likely diagnosis?
Your Answer:
Correct Answer: Myotonic dystrophy
Explanation:Myotonic dystrophy is the most likely diagnosis here.
It is a multisystem disorder causing cognitive impairment, cataracts, cardiac problems and testicular atrophy, as well as affecting the muscles. Patients have muscle weakness, normally worse distally, and/or myotonia (which is worse in cold weather).
On examination, patients may also have frontal balding, a myopathic facies, bilateral ptosis, an ophthalmoplegia and wasting of facial muscles and other limb muscles. Myotonic dystrophy is associated with diabetes mellitus and pituitary dysfunction.
Diagnosis is normally based on clinical features with a characteristic electromyogram (EMG) of myotonic discharges. Creatine kinase is generally normal and muscle biopsy is non-specific. -
This question is part of the following fields:
- Nervous System
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Question 89
Incorrect
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A 74-year-old man presents with a history of falls and enuresis. Recently his behaviour has been bizarre but the falling has persisted for the last 12 months. Upon examination he's found to be disorientated for time and place. His gait is clumsy and broad-based. What is the most likely diagnosis?
Your Answer:
Correct Answer: Normal pressure hydrocephalus
Explanation:The patient has a history of:
1 – Balance and gait disturbance – falls and broad based clumsy gait
2 – Dementia – strange behaviour and disorientation to time and place
3 – Urinary incontinence – episodes of enuresis.
All of the symptoms constitute the classic triad of normal pressure hydrocephalus. -
This question is part of the following fields:
- Nervous System
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Question 90
Incorrect
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A 77-year-old mail carrier presents to the emergency department with severe flinging movements of his right arm. Where would the causative lesion be located?
Your Answer:
Correct Answer: Right subthalamic nucleus
Explanation:Hemiballismus is a movement disorder which manifests as unilateral involuntary flinging movements of the proximal upper limbs. The lesion is located in the ipsilateral subthalamic nucleus.
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This question is part of the following fields:
- Nervous System
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Question 91
Incorrect
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A 23-year-old designer is requesting the combined oral contraceptive pill. During the history taking, she states that in the past she has had migraines with aura. She asks why the combined oral contraceptive pill is contraindicated. Which of the following is the most appropriate response?
Your Answer:
Correct Answer: Significantly increased risk of ischaemic stroke
Explanation:SIGN produced guidelines in 2008 on the management of migraines. Key points include that if patients have migraines with aura then the combined oral contraceptive (COC) is absolutely contraindicated due to an increased risk of stroke (relative risk 8.72).
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This question is part of the following fields:
- Nervous System
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Question 92
Incorrect
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A 17-year-old girl presented with fever, headache and photophobia. Cerebrospinal fluid examination reveals:
Opening pressure 260 mm H20 (50-180)
Total protein 0.8 g/l (0.15-0.45)
Glucose 4.2 mmol/l (3.3-4.4)
White cell count 60 per ml (<5)
Lymphocytes 90%
Plasma glucose 6.4 mmol/l (3.0-6.0)
Which of the following is the most likely diagnosis?Your Answer:
Correct Answer: Viral meningitis
Explanation:Normal cerebrospinal fluid (CSF) glucose together with lymphocytosis, an increased opening pressure and raised CSF protein are typical of a viral meningitis.
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This question is part of the following fields:
- Nervous System
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Question 93
Incorrect
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A 71 year-old dentist is seen in clinic with a history of worsening memory problems and confusion. His wife had noted that his sleep was becoming more disturbed and he complains of vivid nightmares and visual hallucinations. Over the past few weeks, he has had increasing difficulty in dressing himself, and his mobility has deteriorated. On examination, he is bradykinesia with a resting tremor and rigidity affecting his arms and legs. His Mini-Mental-State Examination (MMSE) is 18/30. Which of the following is the most likely diagnosis?
Your Answer:
Correct Answer: Lewy body disease
Explanation:Lewy body dementia is the second most common cause of dementia in the elderly after Alzheimer’s disease. The core feature is a progressive dementia, but other characteristic features include Parkinsonism, visual hallucinations, fluctuating cognitive abilities and executive function, and an increased risk of falls or autonomic failure.
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This question is part of the following fields:
- Nervous System
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Question 94
Incorrect
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Three days after being admitted for a myocardial infarction, a male patient complains of sudden change in vision. The medical registrar examines the patient and finds that the patient's vision in both eyes is significantly reduced although the patient still claims that he can see. The pupils are equal in size, and the pupil responses are normal with normal fundoscopy. Significantly, the patient has now developed atrial fibrillation.
A referral is made to the ophthalmologist who confirms bilateral blindness. Despite this, however, the patient fervently believes that he can see and has taken to describing objects that he has never seen previously, in discriminating detail.
What is the most likely diagnosis?Your Answer:
Correct Answer: Bilateral occipital cortex infarction
Explanation:Bilateral occipital cortex infarction will produce varying degrees of cortical blindness, wherein the patient has no vision but fundoscopy findings are normal. When there are extensive lesions, patients my present with denial of their condition, known as Anton’s Syndrome, and begin to describe objects that they have never seen before.
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This question is part of the following fields:
- Nervous System
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Question 95
Incorrect
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A 72-year-old woman presents with 18 month history of gait ataxia, dysarthria, and dysphagia.
On examination there is down beating nystagmus and slurred speech. There is past pointing in both upper limbs and a wide-based ataxic gait. Reflexes and sensation are normal. There is no wasting or fasciculations. Plantar response is flexor bilaterally.
What is the most likely diagnosis?Your Answer:
Correct Answer: Arnold-Chiari malformation
Explanation:Downbeat nystagmus (DBN) suggests a lesion in the lower part of the medulla. Arnold-Chiari malformation usually presents with symptoms due to brainstem and lower cranial nerve dysfunction such as DBN.
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This question is part of the following fields:
- Nervous System
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Question 96
Incorrect
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A 29 year-old new mother presented with a headache that was first noticed as she was picking up her 5 week-old baby. On admission, she was unable to tolerate the lights and complained of feeling sick. Fundoscopy showed bilateral papilledema, and she was complaining that she was unable to see on her left side. CT head showed a small right occipital bleed. Which of the following treatments is most appropriate?
Your Answer:
Correct Answer: Heparin
Explanation:This patient has developed a venous sinus thrombosis peri-partum, resulting in her symptoms. Anticoagulation therapy including Heparin improves outcomes.
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This question is part of the following fields:
- Nervous System
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Question 97
Incorrect
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A 35-year-old woman was on a camping holiday in Spain. She awoke at three o'clock one morning with severe neck pain radiating down into her left shoulder and down to her forearm. The next day it spread to the dorsal aspect of the forearm. She was otherwise well. Her symptoms resolved after 24 hours. She noticed that after a week she was unable to wind down the car window with her left arm.
On examination of the left arm there was wasting of brachioradialis, shoulder, biceps and winging of left scapula.
What is the diagnosis?Your Answer:
Correct Answer: Amyotrophic neuralgia
Explanation:This patient present with the classical symptoms of Amyotrophic neuralgia, characterised by sudden onset of pain in the shoulders that radiate down to the forearms and later resolve spontaneously but is followed by muscle wasting.
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This question is part of the following fields:
- Nervous System
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Question 98
Incorrect
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A 32 year-old man presents with his first generalized tonic-clonic seizure (GTCS). He has been complaining of headaches for the past 2 weeks, although he has been able to continue working at his job. Upon examination, he has mild left hemiparesis and bilateral extensor plantar responses. General examination is otherwise unremarkable. An urgent CT scan of the brain shows a 5cm multicentric mass lesion in the right frontal lobe with surrounding vasogenic oedema and some hemisphere shift. Which of the following is the most likely underlying pathology?
Your Answer:
Correct Answer: Glioblastoma
Explanation:Glioblastoma multiforme, also considered as grade IV astrocytoma, is the most malignant form of the tumour and accounts for about 20% of all cerebral tumours. These often remain clinically silent until they have reached a large enough size. In adults, glioblastoma multiforme usually occurs in the cerebral hemispheres, especially the frontal and temporal lobes of the brain. About half occupy more than one hemisphere at presentation, and some are multicentric. Biopsy shows high cellularity with mitoses, pleomorphism, and vascular hyperplasia. Prognosis is extremely poor, with only 20% surviving beyond 1 year and 10% beyond 2 years.
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This question is part of the following fields:
- Nervous System
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Question 99
Incorrect
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A 20-year-old gentleman presents with drop foot following a sports injury.
On examination there is weakness of ankle dorsiflexion and eversion, and weakness of extension of the big toe. He has some sensory loss restricted to the dorsum of his foot surrounding the base of his big toe. Other examination is within normal limits.
Where is the most likely site of the lesion?Your Answer:
Correct Answer: Common peroneal nerve at the head of the fibula
Explanation:Peroneal nerve injury is also known as foot drop. The common peroneal nerve supplies the ankle and toe extensor muscle groups as well as sensation over the dorsum of the foot; thus, there is also loss of sensation in these cases.
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This question is part of the following fields:
- Nervous System
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Question 100
Incorrect
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An alcoholic man was found in a critical condition outside the pub. He was sweating heavily, was drowsy and there were some empty cans of cider lying near him. What is the most appropriate initial test that should be done in such patients?
Your Answer:
Correct Answer: Capillary blood sugar
Explanation:The most appropriate initial test should be checking the blood sugar level. Patients with hypoglycaemia can present with drowsiness, profuse sweating and dizziness.
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This question is part of the following fields:
- Nervous System
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Question 101
Incorrect
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A 39 year-old engineer presents with progressive weakness of his hands. Upon examination, you notice wasting of the small muscles of the hand. A diagnosis of syringomyelia is suspected. Which one of the following features would most support this diagnosis?
Your Answer:
Correct Answer: Loss of temperature sensation in the hands
Explanation:Syringomyelia is a development of a cavity (syrinx) within the spinal cord. Signs and symptoms include loss of feeling, paralysis, weakness, and stiffness in the back, shoulders, and extremities. Syringomyelia may also cause a loss of the ability to feel extremes of hot or cold, especially in the hands. Symptoms typically vary depending on the extent and, often more critically, on the location of the syrinx within the spinal cord.
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This question is part of the following fields:
- Nervous System
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Question 102
Incorrect
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A 52-year-old chef presents to the ED with acute visual changes. He has a past medical history of hypertension and type 2 diabetes mellitus. On neurological examination, his upper and lower limbs are normal however he has a homonymous hemianopia with central preservation. Where is the most likely cause of his problems within the central nervous system?
Your Answer:
Correct Answer: Optic radiation
Explanation:Lesions in the optic radiation can cause a homonymous hemianopia with macular sparing, as a result of collateral circulation offered to macular tracts by the middle cerebral artery.
Lesions in the optic tract also cause a homonymous hemianopia, but without macular sparing.
Lesions in the optic chiasm, optic nerve, and temporal lobe cause bitemporal hemianopia, ipsilateral complete blindness, and superior homonymous quadrantanopia respectively. -
This question is part of the following fields:
- Nervous System
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Question 103
Incorrect
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A 65-year-old female with a history of memory loss, presents with progressive decline of her cognitive functions. She had a MI 6 years ago. What is the most probable diagnosis?
Your Answer:
Correct Answer: Vascular dementia
Explanation:The patient has a history of MI and thus ischemic heart disease. This together with her age and progressive decline in cognitive functions and memory suggest vascular dementia.
Pick’s dementia presents with personality and behavioural changes.
Lewy body dementia is associated with frequent syncopal episodes, while Huntington’s disease presents with gait abnormalities.
Alzheimer’s dementia usually starts before the age of 65 and an ischemic heart disease history is not necessary. -
This question is part of the following fields:
- Nervous System
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Question 104
Incorrect
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A 73-year-old post-menopausal woman with an ESR of 72mm/hr, complains of pain on chewing and unilateral headache. Which additional treatment would you choose if she is already on oral steroids?
Your Answer:
Correct Answer: Bisphosphonates
Explanation:The symptoms in concordance with the elevated ESR and the age of the patient should make you think of temporal arteritis. Temporal arteritis is treated with steroids which predispose the patient to develop osteopenia and finally osteoporosis. Its very important to take into account the sex and the age of the patient because osteoporosis is common in post-menopausal women. Bisphosphonates are protective towards osteoporosis and they should be administered next.
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This question is part of the following fields:
- Nervous System
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Question 105
Incorrect
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A 55-year-old female school teacher complains of double vision when she writes on the school blackboard. She has no history of trauma. Her most recent visit to her GP was to seek attention for a rash which developed after she was bitten when walking through the forest on a school trip. Choose the cranial nerve most likely to be affected here.
Your Answer:
Correct Answer: Abducens
Explanation:This nerve is responsible for the side to side movement of the eye, hence why damage can cause double vision.
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This question is part of the following fields:
- Nervous System
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Question 106
Incorrect
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A 22-year-old male presented with a cut injury at his wrist. Which of the following would be the expected clinical signs if his ulnar nerve was damaged?
Your Answer:
Correct Answer: Wasting of the interossei
Explanation:Damage to the ulnar nerve at wrist will cause wasting of the interossei and adductor pollicis muscle. There won’t be any sensory loss, weakness of wrist flexion or wasting of hypothenar muscles.
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This question is part of the following fields:
- Nervous System
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Question 107
Incorrect
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A 21 year-old software developer undergoes a planned lumbar puncture (LP) as part of a neurological investigation for possible multiple sclerosis. During the consent process, she expresses concern about a post-LP headache. What is the mechanism of post-LP headaches?
Your Answer:
Correct Answer: Leaking cerebrospinal fluid from the dura
Explanation:Leaking of cerebrospinal fluid from the dura is the most likely explanation for post-lumbar puncture headaches. It is thought that ongoing leak of cerebrospinal fluid (CSF) through the puncture site causes ongoing CSF loss, leading to low pressure. A post-LP headache is typically frontal or occipital and occurs within three days. It is normally associated with worsening on standing and improvement when lying down. Treatment in severe cases includes an epidural blood patch, but most resolve on their own.
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This question is part of the following fields:
- Nervous System
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Question 108
Incorrect
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A 20-year-old football player has fallen and hit his head on the ground. He did not lose consciousness but has a left side subconjunctival haemorrhage, swelling, and tenderness over his left cheek. Which of the following is the most appropriate initial investigation?
Your Answer:
Correct Answer: Facial XR
Explanation:History and examination findings are suggestive of facial injury and intracranial haemorrhage is unlikely. To exclude any facial fracture, an X-ray is suggested.
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This question is part of the following fields:
- Nervous System
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Question 109
Incorrect
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A 24-year-old gentleman presents with visual loss in his right eye, and this is diagnosed as optic neuritis.
Which one of the following statements would be seen in an afferent pupillary defect?Your Answer:
Correct Answer: Accommodation response is unaffected
Explanation:Afferent pupillary defect is simply a delayed pupillary response to light. Accommodation is otherwise unaffected.
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This question is part of the following fields:
- Nervous System
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Question 110
Incorrect
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A 22-year-old male has had complex tics since childhood. He repeatedly bends his knees and rubs his nose. He is prone to loud vocalisations, sometimes including swear-words. A diagnosis of Gilles de la Tourette syndrome has been made. Which of the following is the best treatment option?
Your Answer:
Correct Answer: Risperidone
Explanation:Gilles de la Tourette syndrome is the most severe and rare of the tic syndromes, consisting of multiple tics involving both motor actions and vocalisation. Onset is usually in childhood. Symptoms include utterance of obscenities (coprolalia); echolalia (repetition of another person’s spoken words) and palilalia (involuntary repetition of words, phrases, or sentences).
The underlying cause is unknown, with no particular imaging or standard histopathological abnormalities having been identified. The EEG shows non-specific abnormalities in about half of patients. However, more recent immunocytochemical studies have suggested altered dopamine uptake in the striatal system.
Risperidone is an effective therapeutic option without the effects associated with chlorpromazine and haloperidol. -
This question is part of the following fields:
- Nervous System
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Question 111
Incorrect
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A patient presented with complaints of difficulty in swallowing, diplopia on left lateral gaze and ptosis of his left eye. The investigation of choice would be?
Your Answer:
Correct Answer: Serum anti-acetylcholine receptor antibodies
Explanation:Myasthenia gravis clinically manifests with ptosis, diplopia and difficulty in swallowing. The initial investigation which is needed to confirm the diagnosis would be serum anti-acetylene receptor antibodies, after which other investigations like an EMG should be done.
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This question is part of the following fields:
- Nervous System
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Question 112
Incorrect
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A 26-year-old technician with no past medical history presents to the neurology clinic complaining of muscle pain. He describes severe bilateral cramping calf pain on minimal exercise. This has been present since his late teens and as such he has avoided exercise. Recently, he has attended the local gym to try and lose weight, but attempts at exercise have been dampened by the pain. He does note that if he perseveres with exercise, the pain settles. He has noticed passing dark urine in the evenings following a prolonged bout of exercise. Which of the following clinical tests would be most useful in aiding the diagnosis in this patient?
Your Answer:
Correct Answer: Muscle biopsy
Explanation:The differential diagnosis of bilateral exercise-induced pain would include metabolic muscle disease, lumbar canal stenosis and intermittent claudication. The patient’s age, history and lack of other risk factors make the latter two options unlikely.
The syndrome described is in fact McArdle’s disease (myophosphorylase deficiency). This is a disorder of carbohydrate metabolism. Clinical features of pain and fatigue are precipitated in early exercise, as carbohydrates cannot be mobilized to provide an energy substrate to the muscle. With prolonged exercise, fatty acid metabolism provides energy, and symptoms lessen. The dark urine described is likely to represent myoglobinuria following rhabdomyolysis. Definitive diagnosis of most metabolic muscle diseases relies on muscle biopsy and enzyme analysis.
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This question is part of the following fields:
- Nervous System
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Question 113
Incorrect
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A 65-year-old female presented with episodes of unilateral blindness, which spontaneously resolved. Her cardiovascular examination was normal. What is the single most appropriate investigation that can be performed to arrive at a diagnosis?
Your Answer:
Correct Answer: Carotid duplex ultrasonography
Explanation:Amaurosis fugax (transient ipsilateral visual loss) and transient ischemic attacks (TIAs) are presentations of atherosclerotic disease of the carotid artery which can be identified by carotid duplex ultrasonography (US), with or without colour, which is the screening test of choice to evaluate for carotid stenosis.
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This question is part of the following fields:
- Nervous System
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Question 114
Incorrect
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A 10-year-old gentleman is referred with a six month history of daily headache, which is mostly frontal in location and occasionally associated with nausea.
He has been taking paracetamol 3 g daily, aspirin 300 mg thrice daily, and codeine 40 mg thrice daily, all of which have had only a temporary effect. He has a two year history of depression treated with paroxetine. No abnormalities were found on examination.
What is the most likely diagnosis?Your Answer:
Correct Answer: Analgesic misuse headache
Explanation:Because of the patient’s history of chronic analgesic use of daily paracetamol intake, the most likely diagnosis of this case is Analgesic misuse headache. In these cases, the headache is only temporarily relieved by analgesics. Treatment involves gradual withdrawal of analgesics.
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This question is part of the following fields:
- Nervous System
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Question 115
Incorrect
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A 6-year-old boy is referred by his GP to the neurology clinic with abnormal movements. His mother noticed that for the last year, the boy has been falling over more and more frequently. He has also been having increasingly slurred speech. These have been getting progressively worse. He has had recurrent chest infections in his childhood.
What is the most likely diagnosis?Your Answer:
Correct Answer: Ataxic telangiectasia
Explanation:Ataxic telangiectasia is an inherited combined immunodeficiency disorder that is characterised by cerebellar ataxia and telangiectasia as seen in this child, as well as frequent infections as noted in this child’s history. The other differentials would not present with this clinical picture:
Friedreich’s ataxia and Infantile-onset spinocerebellar ataxia do not present with immune problems, whereas Cerebral palsy and Di-George Syndrome do not present with ataxia.
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This question is part of the following fields:
- Nervous System
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Question 116
Incorrect
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Which of the following features is not associated with an oculomotor nerve palsy?
Your Answer:
Correct Answer: Miosis
Explanation:Oculomotor nerve palsy is an eye condition resulting from damage to the third cranial nerve or a branch thereof. A complete oculomotor nerve palsy will result in a characteristic down and out position in the affected eye. This is because the lateral rectus (innervated by the sixth cranial nerve) and superior oblique (innervated by the fourth cranial or trochlear nerve), is unantagonized by the paralyzed superior rectus, inferior rectus and inferior oblique. The affected individual will also have a ptosis, or drooping of the eyelid, and mydriasis (pupil dilation), not miosis.
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This question is part of the following fields:
- Nervous System
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Question 117
Incorrect
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A 60-year-old male with a history of diabetes and hypertension presented with left sided arm and leg weakness and loss of vision in the left eye for a brief period. His symptoms improved within a few hours. Which of the following is the most appropriate investigation that can be done at this stage?
Your Answer:
Correct Answer: Doppler USG
Explanation:Amaurosis fugax (transient ipsilateral visual loss) and transient ischemic attacks (TIAs) are presentations of atherosclerotic disease of the carotid artery which can be identified by carotid duplex ultrasonography (US), with or without colour. This is the screening test of choice to evaluate for carotid stenosis.
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This question is part of the following fields:
- Nervous System
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Question 118
Incorrect
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A 48-year-old hairdresser presents to the GP with loss of sensation over the lateral three and a half fingers of her right hand, tenderness over her right forearm, and inability to make a tight fist. She complains of pain in her right arm when twisting door handles anticlockwise. Phalen's and Tinel's tests are negative. She is otherwise neurologically intact. Which of the following is the most likely diagnosis?
Your Answer:
Correct Answer: Pronator teres syndrome
Explanation:Entrapment of the median nerve by pronator teres causes a median nerve neuropathy, which is worse during pronation of the forearm. Examination should involve excluding carpal tunnel syndrome and pronation of the affected forearm against resistance, which brings on the pain. Unlike carpal tunnel syndrome, the median nerve proximal to the wrist may be tender to palpation.
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This question is part of the following fields:
- Nervous System
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Question 119
Incorrect
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Which of the following may cause a downbeat nystagmus?
Your Answer:
Correct Answer: Chiari type I malformation
Explanation:Downbeat nystagmus (DBN) suggests a lesion in the lower part of the medulla. Chiari Type I malformation usually presents with symptoms due to brain stem and lower cranial nerve dysfunction, which includes DBN.
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This question is part of the following fields:
- Nervous System
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Question 120
Incorrect
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A 7-year-old boy was brought to the ED in an unconscious and apnoeic state. What is your immediate management of this case?
Your Answer:
Correct Answer: Secure airway
Explanation:ABC : Airway, breathing, circulation is the order of assessment in any patient that is unconscious and apnoeic.
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This question is part of the following fields:
- Nervous System
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Question 121
Incorrect
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A 75-year-old woman experienced right sided weakness shortly after she woke up. However, the weakness resolved in 30 minutes and left no disability. Her CT and ECG appear normal. What extra actions should be taken if she is already on Aspirin, Simvastatin, Amlodipine and Bendroflumethiazide?
Your Answer:
Correct Answer: Start Aspirin 300 mg for 2 weeks
Explanation:The patient has most probably experienced a transient ischemic attack which should be initially managed with aspirin 300 mg for two weeks.
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This question is part of the following fields:
- Nervous System
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Question 122
Incorrect
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A 67 year-old attorney presents with a 2 month history of tremors affecting his left arm. He suffers from depressive psychosis for the last 10 years, for which he has been receiving intermittent chlorpromazine and amitriptyline but has not been on any therapy for the last 4 months. He describes that his two brothers also had tremors. Upon examination, he has a resting tremor of his left hand with cogwheel rigidity of that arm and mild generalized bradykinesia. Which of the following is the most likely diagnosis?
Your Answer:
Correct Answer: Idiopathic Parkinson's disease
Explanation:The most likely diagnosis is idiopathic Parkinson’s disease because of the unilateral presentation. In addition, cogwheel rigidity is a classic presenting symptom. Neuroleptic-induced parkinsonism is usually bilateral and symmetrical. Essential tremors do not cause rest tremors.
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This question is part of the following fields:
- Nervous System
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Question 123
Incorrect
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A 32-year-old female has had an episode of a severe occipital headache. This is accompanied by vomiting and unconsciousness. She has been taken to the emergency department, where she is conscious and completely alert. Her pulse is normal and no abnormal neurological signs are found. From the list of options, choose the next step in her treatment.
Your Answer:
Correct Answer: CT brain
Explanation:Severe headaches and LOC can be caused by basilar migraines (but here the patient has no neurological deficit and becomes completely alert when recovering from unconscious periods). In order to diagnose basilar migraines, there needs to be a history of at least two other migraine attacks with an aura. The diagnostic criteria of a basilar migraine are not fulfilled and so the patient must not be discharged without a CT scan (or MRI).
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This question is part of the following fields:
- Nervous System
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Question 124
Incorrect
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A 33-year-old artist who recently arrived in the UK from New York presents in ED. He has a past history of insulin-dependant diabetes mellitus. He describes a few days of fever, headache and myalgia. Admission was prompted by worsening headache and back pain. While waiting in the medical receiving unit, he becomes progressively drowsier. Examination revealed flaccid paralysis and depressed tendon reflexes. He was reviewed by the intensive care team and arrangements were made for ventilation. A computerised tomography (CT) brain is performed that is normal.
Cerebrospinal fluid examination reveals:
Protein 0.9 g/l (<0.45 g/l)
Glucose 4 mmol/l
White cell count (WCC) 28/mm3 (mostly lymphocytes)
Blood testing reveals:
Haemoglobin (Hb) 14 g/dl (13-18)
Platelets 620 x 109/l (150-400 x 109)
WCC 12 x 109/l (4-11 x 109)
Sodium 135 mmol/l (137-144)
Potassium 4.6 mmol/l (3.5-4.9)
Urea 8 mmol/l (2.5-7.5)
Creatinine 120 mmol/l (60-110)
Glucose 6 mmol/l
Which of the following is the most likely infective process?Your Answer:
Correct Answer: West Nile disease
Explanation: -
This question is part of the following fields:
- Nervous System
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Question 125
Incorrect
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A 47-year-old hypertensive man presents with difficulty using his right arm, slow walking and occasional loss of balance. He has a broad-based gait with cogwheel rigidity and intention tremor of his right arm. His blood pressure is 140/80 mmHg sitting and 100/60 mmHg standing. Which of the following is the most likely diagnosis?
Your Answer:
Correct Answer: Multiple system atrophy
Explanation:This patient presents with a combination of akinetic rigid syndrome, cerebellar signs and the suggestion of autonomic features. This is most indicative of a diagnosis of multiple system atrophy.
Multiple system atrophy (MSA) is a rare neurodegenerative disorder characterized by autonomic dysfunction, tremors, slow movement, muscle rigidity, and postural instability (collectively known as parkinsonism) and ataxia.
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This question is part of the following fields:
- Nervous System
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Question 126
Incorrect
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The chorda tympani of the facial nerve (CN VII) carries:
Your Answer:
Correct Answer: parasympathetic fibres to the submandibular and sublingual glands and taste fibres from the anterior two-thirds of the tongue
Explanation:In the petrous temporal bone the facial nerve produces three branches:
1. The greater petrosal nerve, which transmits preganglionic parasympathetic fibres to the sphenopalatine ganglion. These postganglionic fibres supply the lacrimal gland and the glands in the nasal cavity;
2. The nerve to stapedius;
3. Parasympathetic fibres to the submandibular and sublingual glands and taste fibres from the anterior two-thirds of the tongue. -
This question is part of the following fields:
- Nervous System
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Question 127
Incorrect
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A 14-year-old girl came to the emergency room in a bizarre state with altered consciousness, presenting with symptoms of insomnia, logorrhoea, and anxiety, with incoherent discourse and amnesia of recent events. She has started calling herself The Queen, and is refusing to be her parents' daughter. What is the most likely diagnosis?
Your Answer:
Correct Answer: Ganser syndrome
Explanation:Ganser syndrome is a condition in which a person acts as if he is suffering from a specific psychological disorder in order to gain sympathy and relief.
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This question is part of the following fields:
- Nervous System
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Question 128
Incorrect
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A 32 year-old active male presents with a three month history of pain in his feet and lower legs. He was previously diagnosed with diabetes at age 14 and treated with insulin. He admits to drinking 30 units of alcohol per week and is a current cannabis smoker. On examination, pain and temperature sensation in his feet are diminished, but joint position and vibratory sensation appear normal. What is the most likely diagnosis?
Your Answer:
Correct Answer: Diabetic polyneuropathy
Explanation:The given history suggests a small fibre painful peripheral sensory neuropathy, the most common cause of which is diabetes. Joint position sense and vibratory sensation are carried through large fibres, and therefore are not currently affected. Sensory nerves are affected more often than motor, so reflexes usually remain in tact.
Vitamin B12 deficiency causes impairment of joint position and vibratory sensation.
Chronic inflammatory demyelinating polyneuropathy (CIPD) causes a large fibre peripheral neuropathy with areflexia.
In syringomyelia there is impaired pain and temperature noted in the upper limbs.
Finally, with alcoholic polyneuropathy, all fibre types are affected (sensory and motor loss). It is usually gradual with long term alcohol abuse and may be accompanied by a nutritional deficiency. In addition, pain is a more dominant feature.
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This question is part of the following fields:
- Nervous System
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Question 129
Incorrect
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A 78-year-old retired journalist known to have prostatic carcinoma presents to the ED complaining of pain in the spine and the onset of severe lower-leg weakness accompanied by a loss of sensation. On examination, he is found to have percussion tenderness of his spine, loss of sensation up to the umbilicus and a distended bladder. He has markedly reduced power of the lower legs with hyperreflexia. Which of the following should not be part of your management of this patient?
Your Answer:
Correct Answer: Spinal X-rays
Explanation:Acute cord compression is a medical emergency. Typically, signs of segmental damage at the level of compression are usually combined with corticospinal tract dysfunction (e.g., hyperreflexia, Babinski’s sign and weakness) and sensory deficits below the level of compression. Symptoms include spinal pain that precedes the development of weak legs and sensory loss. There may be loss of bladder (and anal) sphincter control, manifesting as hesitancy, frequency and, finally, painless retention.
Spinal X-rays are rarely diagnostic. MRI is usually the investigation of choice and should not be delayed, but if not available consider doing a CT scan and myelography to confirm cord compression and fully define the level and extent of the lesion. If malignancy is the cause, it is important to give dexamethasone (oral or intravenous) while considering therapy more specific to the cause. -
This question is part of the following fields:
- Nervous System
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Question 130
Incorrect
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A young woman presents to the emergency after being involved in a fight where she was stabbed in the neck. On examination, her tongue deviates to the right side on protrusion. Which of the following nerves is involved?
Your Answer:
Correct Answer: Hypoglossal nerve injury
Explanation:The motor functions of the intrinsic tongue muscles, as well as the genioglossus, hyoglossus, and styloglossus muscles, are all innervated by the hypoglossal nerve. These muscles are essential for swallowing and speech. To test nerve function, the physical examiner has a patient protrude his or her tongue. In intranuclear, or lower motor neuron lesions, the tongue deviates toward the injured side, as the contralateral genioglossus is acting unopposed. In contrast, supranuclear (upper motor neuron) lesions result in deviation away from the lesion. In addition to causing deviation toward the lesion, an injury involving a hypoglossal nucleus may result in tongue atrophy and fasciculation
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This question is part of the following fields:
- Nervous System
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Question 131
Incorrect
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A 37-year-old teacher with multiple sclerosis complains that her vision becomes blurred during a hot bath. Which of the following explain this?
Your Answer:
Correct Answer: Uhthoff's phenomenon
Explanation:Uhthoff’s phenomenon is worsening of vision following a rise in body temperature.
Lhermitte’s sign describes paraesthesia in the limbs on neck flexion.
Oppenheim’s sign is seen when scratching of the inner side of leg leads to extension of the toes. It is a sign of cerebral irritation and is not related to multiple sclerosis.
Werdnig-Hoffman’s disease is also known as spinal muscular atrophy. -
This question is part of the following fields:
- Nervous System
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Question 132
Incorrect
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A 45-year-old male presents to A&E, after hitting his car multiple times when reversing. He complains of double vision when he looked back during reversing. He also complains of double vision when looking with an outward gaze. Which is the nerve involved in this patient?
Your Answer:
Correct Answer: Abducent nerve
Explanation:This nerve is responsible for the side to side movement of the eye, hence why damage can cause double vision.
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This question is part of the following fields:
- Nervous System
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Question 133
Incorrect
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A 30-year-old male with a scaphoid fracture came to the clinic after 2 weeks of applying the scaphoid cast. After removing the cast he had difficulty moving his thumb, index and middle fingers. Which of the following is the most appropriate management for this presentation?
Your Answer:
Correct Answer: Release of flexor retinaculum
Explanation:This patient has carpal tunnel syndrome which involves the median nerve. The treatment is releasing of the flexor retinaculum.
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This question is part of the following fields:
- Nervous System
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Question 134
Incorrect
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A 61-year-old woman with a history of fluent dysphasia is brought by her husband because she's no longer able to understand instructions. Which is the most probable site of arterial occlusion?
Your Answer:
Correct Answer: Inferior division of middle cerebral artery (dominant hemisphere)
Explanation:The condition described is called Wernicke’s aphasia and is the result of occlusion of the inferior division of the middle cerebral artery. This type of aphasia is classified as fluent aphasia in which understanding is impaired.
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This question is part of the following fields:
- Nervous System
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Question 135
Incorrect
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A 62-year-old male has woken up to find his speech is altered. He recently suffered from a flu-like illness. The movement of his eyelids and lips are weak on the right-hand side. Which anatomical site is most likely to be affected in this patient?
Your Answer:
Correct Answer: Facial nerve
Explanation:Viral infection is a very common cause of facial nerve palsy, which is consistent with the symptoms described.
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This question is part of the following fields:
- Nervous System
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Question 136
Incorrect
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An old woman complains of sudden bilateral complete visual loss. Her pupillary reaction to light is preserved and there are no noted abnormalities on the anterior chamber or the retina. Which is the most likely site of arterial occlusion?
Your Answer:
Correct Answer: Posterior cerebral arteries
Explanation:Cortical blindness is due to a bilateral infarction in the area covered by the distal posterior cerebral arteries and pupillary reflex is preserved. Patients may not notice this blindness (called Anton’s syndrome). Anton-Babinski syndrome, also known as Anton’s blindness and visual anosognosia, is a rare symptom of brain damage occurring in the occipital lobe. Those who have it are cortically blind, but affirm that they are capable of seeing.
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This question is part of the following fields:
- Nervous System
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Question 137
Incorrect
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A 45-year-old male complains of numbness in the little and ring fingers of his left hand. Which of the following nerves is responsible for this presentation?
Your Answer:
Correct Answer: Ulnar Nerve
Explanation:There are three branches of the ulnar nerve that are responsible for its sensory innervation. The palmar cutaneous branch innervates the medial half of the palm. The dorsal cutaneous branch innervates the dorsal surface of the medial one and a half fingers, and the associated dorsal hand area. The superficial branch innervates the palmar surface of the medial one and a half fingers. According to the given history, the superficial branch of ulnar nerve has been affected.
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This question is part of the following fields:
- Nervous System
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Question 138
Incorrect
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A 19-year-old patient in casualty only opens her eyes upon painful stimuli, extends her limbs, and occasionally says inappropriate words. What is her Glasgow coma score?
Your Answer:
Correct Answer: 7
Explanation:The Glasgow Coma Scale provides a score for assessment of impaired consciousness in response to specific stimuli considering the eye opening, verbal response and motor response. The score runs from 3 to 15, a coma being defined as a GCS of 8 or less. According to this patient’s responses and the respective points for each response, the score is 7 and the patient is in a coma.
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This question is part of the following fields:
- Nervous System
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Question 139
Incorrect
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A 60-year-old male presented in OPD with a complaint of inability to walk properly because of his left foot. History reveals he has undergone left knee surgery to for severe arthritis. On examination, dorsiflexion of his left foot was found to be compromised, and sensation over the dorsum of his left foot was impaired. Which of the following conditions is this man most likely suffering from?
Your Answer:
Correct Answer: Compression of common peroneal nerve
Explanation:The branches of the common peroneal nerve innervate the skin of the dorsum of the foot as well as the muscles which help to carry out dorsiflexion of the foot. Compression of the common peroneal nerve cause foot drop as well as the loss in sensation of the skin on the dorsum of the foot.
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This question is part of the following fields:
- Nervous System
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Question 140
Incorrect
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A 43-year-old police officer is admitted with a history of unsteadiness and slurring of speech. This has worsened over a period of three months. He complains of a tremor affecting his right hand and diplopia on right lateral gaze. He smokes 30 cigarettes a day and takes regular diclofenac for his arthritis. On examination, he is dysarthric and feels nauseated. Fundoscopy is normal, however there is marked horizontal nystagmus and evidence of a right VI nerve palsy. There also appears to be some mild facial weakness on the right side. Upon conducting Weber's test, a louder tone is heard in the left ear. On conducting the Rinne test, both ears are normal. On examination of the upper limb, there is a right intention tremor and dysdiadochokinesis. Tone, power and reflexes are normal. On examination of the lower limb, tone, power and reflexes are normal, however he appears to walk with a broad-based gait and is leaning to the right.
Lumbar puncture:
Opening pressure 13 cm H20 (5-18)
Protein 0.67 g/l (0.15-0.45)
WCC 3 cells/ml (<5)
Red cell count (RCC) 2 cells/ml (<5)
Glucose 3.2 mmol/l (3.3-4.4)
Blood glucose 5.8 mmol/l (3.0-6.0)
Oligoclonal bands Present
Serum oligoclonal bands Present
Magnetic resonance scan shows a calcified lesion broadly attached to the petrous part of the temporal bone. In view of the above history and findings, what is the likely cause of this patient's symptoms?Your Answer:
Correct Answer: Meningioma of the cerebellar pontine angle
Explanation:This patient has a combination of right cerebellar dysfunction with right-sided cranial nerve palsies (VI, VII, and VIII). The magnetic resonance imaging (MRI) shows a calcified meningioma within the right cerebellar pontine area, which would account for these findings. The cerebrospinal fluid (CSF) analysis shows oligoclonal bands, however, these are matched in the serum, which reflects a systemic inflammatory response from his rheumatoid arthritis.
The MRI scan and CSF analysis would not be consistent with progressive multiple sclerosis. The progressive nature of her symptoms would be against a diagnosis of brainstem infarct, and one would expect more pyramidal signs in the peripheral nervous system.
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This question is part of the following fields:
- Nervous System
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Question 141
Incorrect
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A 44-year-old alcoholic man was operated on for a strangulated abdominal hernia, however a few days after the operation he became agitated. According to the patient, he used to see snakes curling over his body. O/E he was agitated, tachycardiac and confused. The most likely diagnosis would be?
Your Answer:
Correct Answer: Delirium tremens
Explanation:Delirium tremens occurs due to alcohol withdrawal and presents clinically with hallucinations, agitations, confusion and hyperthermia. Wernicke’s encephalopathy is characterised by encephalopathy, oculomotor dysfunction and ataxic gait. In Korsakoff’s syndrome, there is marked short term memory loss, however the long term memory is preserved & the sensorium is also intact.
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This question is part of the following fields:
- Nervous System
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Question 142
Incorrect
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A 45-year-old male, came to the OPD with a complaint of severe headache on the right side with right-sided jaw pain and additional blurred vision in the right eye. The headache was throbbing in character. What is the single most appropriate investigation?
Your Answer:
Correct Answer: ESR
Explanation:The age of the patient, one sided headache and loss of vision on that side suggest temporal arteritis, also known as giant cell arteritis. The laboratory hallmark of this condition is a raised ESR.
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This question is part of the following fields:
- Nervous System
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Question 143
Incorrect
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A 14 year-old is brought to the ED after being hit on the head with a cricket ball during a match. His teacher describes that he initially collapsed on the ground and complained of a sore head. Two minutes later, he got up and said he felt OK and continued playing. However, 30 minutes later he suddenly collapsed and lost consciousness. What injury is he most likely to have sustained?
Your Answer:
Correct Answer: Extradural haematoma
Explanation:A lucid interval, in which the patient portrays a temporary improvement in condition after a traumatic brain injury, is especially indicative of an epidural haematoma.
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This question is part of the following fields:
- Nervous System
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Question 144
Incorrect
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A 18-year-old gentleman is referred to dermatology. He has around 10 hyperpigmented macules on his torso which vary in size from 1.5-5 cm in size. His GP also noted some freckles in the groin region. He is also currently under orthopaedic review due to a worsening scoliosis of the spine. His father suffered from similar problems before having a fatal myocardial infarction two years ago. Which chromosome is most likely to have a gene defect?
Your Answer:
Correct Answer: Chromosome 17
Explanation:The patient’s history and presentation and familial history, meets the diagnostic criteria for Neurofibromatosis type I, presenting with neurofibromas noted in this patient as hyperpigmented macules and freckles, musculoskeletal disorders like the scoliosis in this case, and a familial history. Neurofibromatosis type I is caused by a mutation on Chromosome 17.
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This question is part of the following fields:
- Nervous System
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Question 145
Incorrect
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A patient presented with acute onset of mild right hemiparesis affecting the body. He also has evidence of sensory loss on the right hand side. There is evidence of Horner's syndrome and sensory loss on the face on the left hand side.
Which of the following structures are involved?Your Answer:
Correct Answer: Brain stem
Explanation:The patient is presenting with symptoms of lateral medullary syndrome also known as Wallenberg’s syndrome or posterior inferior cerebellar artery syndrome, where the symptoms are due to an ischemia in the brainstem. The classical symptoms include contralateral sensory deficits of the trunk region paired with ipsilateral facial sensory deficits.
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This question is part of the following fields:
- Nervous System
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Question 146
Incorrect
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A 66 year-old marketing analyst presents to the respiratory clinic with a 2-month history of progressive weakness and shortness of breath. He finds it difficult to stand from sitting, and struggles climbing stairs. He is an ex-smoker with chronic obstructive pulmonary disease (COPD). He had a recent exacerbation one month ago for which he was treated by the GP with a course of oral prednisolone, during which time his weakness transiently improved. On examination, you note a left-sided monophonic wheeze and reduced breath sounds at the left lung base. Blood tests and a chest x-ray are requested.
Hb 145 g/L
WCC10.5 109/l
Na+136 mmol/L
K+ 4.3 mmol/L
Urea 6.8 mmol/L
Creatinine 93 mmol/L
Calcium 2.62 mmol/L
Phosphate 1.44 mmol/L
Chest x-ray shows hyperinflated lungs, left lower lobe collapse and a bulky left hilum
What is the most likely cause of this patient's weakness?Your Answer:
Correct Answer: Lambert-Eaton myasthenic syndrome
Explanation:This man has a small-cell lung cancer (SCLC) and associated Lambert-Eaton myasthenic syndrome – a well-recognized paraneoplastic manifestation of SCLC. This classically affects the proximal muscles, especially in the legs, causing difficulty in standing from a seated position and climbing stairs. In contrast to myasthenia gravis, eye involvement is uncommon. Treatment with steroids is often helpful, which explains his transient symptomatic improvement during treatment for his COPD exacerbation. Steroid myopathy does not fit as the symptoms started well before his course of prednisolone. Although the patient is mildly hypercalcaemic, this would not be sufficient to produce his presenting symptoms, although it does reinforce the suspicion of lung malignancy. Motor neurone disease would be unlikely in this context and would not improve with steroids. Myasthenia gravis could produce these symptoms, but in the context of a new lung mass is a less viable diagnosis.
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This question is part of the following fields:
- Nervous System
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Question 147
Incorrect
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A 55-year-old female with a history of osteoarthritis of the knee, obesity and depression, presents with neck and right arm pain. She claims that the pain is present for two months and is triggered by flexing her neck. Clinical examination reveals sensory loss over the middle finger and palm of the hand without any obvious muscle atrophy or weakness. Which nerve root is most probably affected?
Your Answer:
Correct Answer: C7
Explanation:The most common cause of cervical radiculopathy is degenerative disease in the cervical spine. In 80-90% of patients with cervical radiculopathy, the C5/C6 or C6/C7 motion segments are affected by degenerative disease and the nearby C6 and/or C7 nerve roots are producing the symptoms. Patients with cervical radiculopathy complain of neck pain and radiating pain in the arm sometimes combined with sensory and motor disturbances in the arm and/or hand. These symptoms are accepted as being caused by the nerve root compression. Middle finger and palm of the hand are mostly rising the suspicion for C7 nerve root and median nerve involvement.
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This question is part of the following fields:
- Nervous System
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Question 148
Incorrect
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A 25-year-old woman with Charcot-Marie-Tooth disease (type 1) asks how likely it is that any future children will have the disease. What is the most accurate answer?
Your Answer:
Correct Answer: 0.5
Explanation:Because Charcot-Marie-Tooth disease (type 1) is an autosomal dominant condition; therefore, there is a 50% chance that the children of this patient will be affected.
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This question is part of the following fields:
- Nervous System
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Question 149
Incorrect
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A 23-year-old woman complains of numbness in her right hand that improves by shaking it. The surgeon has suggested a surgical option. Ligation of which of the following structures will improve the condition?
Your Answer:
Correct Answer: Flexor retinaculum
Explanation:The most likely cause is median nerve inflammation due to carpal tunnel syndrome. It is treated surgically with ablation of the flexor retinaculum.
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This question is part of the following fields:
- Nervous System
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Question 150
Incorrect
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A 23-year-old woman experiences visual disturbances and anxiety associated with sudden change in posture. She also has nausea, vomiting, and dizziness occasionally. What is the most likely diagnosis?
Your Answer:
Correct Answer: BPPV
Explanation:The most probable diagnosis is benign paroxysmal positional vertigo (BPPV). It is a peripheral vestibular disorder characterized by short episodes of mild to intense dizziness and influenced by specific changes in head position. BPPV is the most common cause of vertigo accounting for nearly one-half of patients with peripheral vestibular dysfunction. In order to establish the diagnosis, the head roll test is performed where the head is turned about 90° to each side while supine.
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This question is part of the following fields:
- Nervous System
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Question 151
Incorrect
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A 25-year-old patient has presented with symptoms which all point to the cerebellopontine angle (CPA) a tumour. These are numbness in the face, vertigo, and tinnitus. Choose the most appropriate investigation from the list of options.
Your Answer:
Correct Answer: MRI Brain
Explanation:MRI scans are used to diagnose tumours in the cerebellopontine angle.
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This question is part of the following fields:
- Nervous System
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Question 152
Incorrect
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Causes of dilated pupils include which of the following?
Your Answer:
Correct Answer: Ethylene glycol poisoning
Explanation:Ethylene glycol poisoning is the only poison listed that will cause dilation of the pupils whereas all the other listed conditions and poisons will present with small pupils other than in the case of Myotonic dystrophy wherein the patient will present with a cortical cataract.
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This question is part of the following fields:
- Nervous System
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Question 153
Incorrect
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A 33-year-old male was brought in with complaints of an unsteady gait. According to the patient, he suffered a severe headache in the morning, with associated vomiting. Slowly his condition deteriorated until he was unable to walk. On exam, he had nystagmus and there was past pointing of the right arm. He speech was slurred, his uvula was deviated towards the right and there was decreased pinprick sensation on the right half of the body. The most likely site of the lesion in this patient would be?
Your Answer:
Correct Answer: Left lateral medulla
Explanation:Loss of sensations in left (ipsilateral) side of the face and contralateral (right) side of the body indicates a defect in left lateral medulla. Further cerebellar signs lead to the diagnosis of Lateral Medullary Syndrome.
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This question is part of the following fields:
- Nervous System
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Question 154
Incorrect
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A 43-year-old right-handed migraineur is admitted to hospital having developed paraesthesia affecting her left arm. This came on suddenly during a migrainous attack while out shopping. The paraesthesia appeared to affect the entire left arm and in the last few hours, has spread to involve the left side of the face. She had had a similar episode several months ago whereby she developed some right-sided leg and arm weakness while at work. The weakness lasted several minutes and subsequently abated. At the time, she was also having one of her migraines. She has a long-standing history of migraines, which typically start with a prolonged aura and fortification spectra. Other than migraines, for which she has been taking pizotifen, she has no other past medical history. Her sister also suffers from migraines, and her mother has a history of dementia in her 50s. She is a non-smoker and drinks minimal alcohol.
On examination she was orientated but apathetic. Her blood pressure was 130/65 mmHg, pulse 62/min, and temperature 36.2ºC. There were no carotid bruits and heart sounds were entirely normal. There was reduced sensation to all modalities over the left side of the face extending to the vertex and the entire left arm. Tone and reflexes appeared intact; however, handgrip was reduced on the left due to numbness. The lower limb appeared entirely normal.
Magnetic resonance (MR) scan showed bilateral, multifocal, T2/FLAIR (fluid attenuated inversion recovery ) hyperintensities in the deep white matter. MR Spinal cord was normal.
What is the diagnosis?Your Answer:
Correct Answer: CADASIL (cerebral autosomal dominant arteriopathy with subcortical infarcts and leucoencephalopathy)
Explanation:CADASIL is the most common form of hereditary stroke disorder. This case has a strong history of migraine with aura with stroke-like episodes, characteristic of CADASIL. Additionally, there is positive family history of migraine and early dementia but no other vascular risk factors like hypertension, diabetes, or hypercholesterolaemia, which all confirm the suspicion of CADASIL, an arteriopathy where there is thickening of the smooth muscle cells in the blood vessels.
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This question is part of the following fields:
- Nervous System
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Question 155
Incorrect
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A 44-year-old hairdresser with a history of myasthenia gravis is admitted to the Emergency Department. She is currently taking pyridostigmine, but there has been a significant worsening of her symptoms following antibiotic treatment for a chest infection. On examination she is dyspnoeic and cyanotic with quiet breath sounds in both lungs. Other than respiratory support, what are the two other treatments of choice?
Your Answer:
Correct Answer: Plasmapheresis or intravenous immunoglobulins
Explanation:This patient is having a myasthenic crisis. Opinions vary as to whether plasmapheresis or intravenous immunoglobulins should be given first-line. Plasmapheresis usually works much faster, but is more costly due to equipment.
Myasthenia gravis is an autoimmune disorder resulting in insufficient functioning acetylcholine receptors. Antibodies to acetylcholine receptors are seen in 85-90% of cases. Myasthenia gravis is more common in women (2:1). -
This question is part of the following fields:
- Nervous System
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Question 156
Incorrect
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A 13-year-old boy complains of several episodes of collapse. He describes the majority of these episodes occurring when he is laughing. He states that he loses power in his legs and falls to the ground. He is alert throughout and recovers quickly. He also describes excessive daytime sleepiness with episodes in the morning of being awake but being unable to move his body. Examination is unremarkable. A diagnosis of narcolepsy is made. Which of the following is the first line treatment for excessive daytime sleepiness?
Your Answer:
Correct Answer: Modafinil
Explanation:Narcolepsy is a rare condition characterised by excessive daytime sleepiness, sleep paralysis, hypnagogic hallucinations, and cataplexy (sudden collapse triggered by emotion such as laughing or crying). There is no cure for narcolepsy. Treatment options include stimulants, such as methylphenidate (Ritalin) or modafinil (Provigil), antidepressants, such as fluoxetine (Prozac), citalopram (Celexa), paroxetine (Paxil), sertraline (Zoloft) and sodium oxybate (Xyrem). Modafinil has replaced methylphenidate and amphetamine as the first-line treatment of excessive daytime sleepiness (EDS).
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This question is part of the following fields:
- Nervous System
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Question 157
Incorrect
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A 67-year-old butcher presents with a six month history of a gradually increasing burning sensation in his feet. Examination reveals normal cranial nerves and higher mental function. He has normal bulk, tone, power, light touch, pinprick sensation, coordination and reflexes in upper and lower limbs.
These clinical findings are consistent with which of the following?Your Answer:
Correct Answer: Small fibre sensory neuropathy
Explanation:The burning sensation described is typical of a neuropathy affecting the small unmyelinated and thinly myelinated nerve fibres. General neurological examination and reflexes are usually normal in this type of neuropathy unless there is coexisting large (myelinated) fibre involvement. Neuropathy affecting the large myelinated sensory fibres generally causes glove and stocking sensory loss and loss of reflexes.
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This question is part of the following fields:
- Nervous System
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Question 158
Incorrect
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A 42-year-old man with a 6 month history of progressive weakness of both lower limbs, complains of lethargy and of difficulties climbing stairs. He also claims he's experienced muscle loss in his lower limbs. History reveals type 2 diabetes mellitus and heavy alcohol use for the last 4 years. Clinical examination reveals marked loss of fine touch and proprioception. The distribution is in a stocking manner and bilateral. However, no evidence of ataxia is present. What is the most probable diagnosis?
Your Answer:
Correct Answer: Dry beriberi
Explanation:Hypovitaminosis B1, consistent with dry beriberi is crucially a treatable condition, although sometimes with incomplete recovery, but it is probably under-recognized yet increasingly common given increasing levels of alcohol abuse in the western world. Dry beriberi or ‘acute nutritional polyneuropathy’ is considered to be rare in the western world. Rapid deterioration can occur, typically with weakness, paraesthesia and neuropathic pain. Striking motor nerve involvement can occur, mimicking Guillain-Barre syndrome (GBS). In the context of increasing alcohol abuse in the western world, it is possible that alcoholic neuropathy associated with abrupt deterioration due to concomitant nutritional hypovitaminosis B1 may be seen increasingly often.
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This question is part of the following fields:
- Nervous System
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Question 159
Incorrect
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A 50-year-old known patient with chronic liver cell disease was admitted complaining of unsteadiness and double vision following an episode of heavy alcohol consumption. On examination, he was confused. there was nystagmus and ataxia. What is the most possible cause for this presentation?
Your Answer:
Correct Answer: Wernicke's encephalopathy
Explanation:Wernicke’s encephalopathy is a neurological disorder induced by thiamine deficiency and presents with the classic triad of ocular findings, cerebellar dysfunction, and confusion. As alcohol affects thiamine uptake and utilization, thiamine deficiency is usually associated with chronic alcoholism.
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This question is part of the following fields:
- Nervous System
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Question 160
Incorrect
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Which of the following physical findings is least typical on a patient with multiple sclerosis?
Your Answer:
Correct Answer: Decreased tone
Explanation:Attacks or exacerbations of multiple sclerosis (MS) are characterized by symptoms that reflect central nervous system (CNS) involvement, hence upper motor neuron symptoms are seen.
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This question is part of the following fields:
- Nervous System
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Question 161
Incorrect
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A 73-year-old gentleman with type 2 diabetes mellitus, complains of difficulty walking and trouble with his hands. It began with a tingling sensation in his soles, which later extended up to his ankles. He now feels unsteady when walking, and more recently, has noticed numbness and tingling in the fingers of both hands.
On examination, he has absent ankle reflexes, a high steppage gait, and altered sensation to his mid-calves.
What is the underlying pathological process?Your Answer:
Correct Answer: Axonal degeneration
Explanation:This case presents with sensorimotor neuropathy secondary to his DM. The progression of the neuropathy, known dying-back neuropathy, is a distal axonopathy or axonal degeneration as where the sensorimotor loss begins distally and travels proximally.
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This question is part of the following fields:
- Nervous System
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Question 162
Incorrect
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Which of the following types of motor neuron diseases carries the worst prognosis?
Your Answer:
Correct Answer: Progressive bulbar palsy
Explanation:Motor neuron disease is a neurological condition of unknown cause which can present with both upper and lower motor neuron signs. It rarely presents before 40 years and various patterns of disease are recognised including amyotrophic lateral sclerosis, primary lateral sclerosis, progressive muscular atrophy and progressive bulbar palsy. In some patients however, there is a combination of clinical patterns. In progressive bulbar palsy there is palsy of the tongue and muscles of chewing/swallowing and facial muscles due to loss of function of brainstem motor nuclei. This carries the worst prognosis.
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This question is part of the following fields:
- Nervous System
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Question 163
Incorrect
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A 50-year-old female was examined after complaining of weak limbs. It was discovered she had burn marks on her fingers, diminished reflexes, and wasted and weak hands. Additionally, she has dissociated sensory loss and weak spastic legs. What is the diagnosis for this patient?
Your Answer:
Correct Answer: Syringomyelia
Explanation:All of the symptoms experienced by this patient are consistent with Syringomyelia. The sensory features are as follows: loss of temperature and pain sensation; sensory loss in the arms, shoulders, and upper body; touch, vibration, and position senses are affected in the feet as the syrinx enlarges into the dorsal column. Motor features are as follows: muscle wasting and weakness which begins in the hand, and moves onto the forearms and shoulders; loss of tendon reflexes. Autonomic involvement, such as the bladder and bowel, can occur.
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This question is part of the following fields:
- Nervous System
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Question 164
Incorrect
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A 38-year-old alcoholic presented with an ataxic gait, nystagmus and confusion. What is the most likely clinical diagnosis?
Your Answer:
Correct Answer: Wernicke's encephalopathy
Explanation:Wernicke’s encephalopathy is a clinical triad of encephalopathy, gait ataxia and nystagmus.
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This question is part of the following fields:
- Nervous System
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Question 165
Incorrect
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Which of the following is true concerning baclofen?
Your Answer:
Correct Answer: Causes hallucinations when withdrawn
Explanation:Baclofen is used to treat spastic movement symptoms such as those seen in cerebral palsy and multiple sclerosis. It is known to be associated with a withdrawal syndrome similar to alcohol withdrawal; thus, gradual withdrawal is necessary to avoid this.
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This question is part of the following fields:
- Nervous System
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Question 166
Incorrect
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A 45-year-old male who is a heavy alcoholic was admitted with loss of memory, hallucinations and difficulty walking. On examination, he had an ataxic gait. He was given Acamprosate. Which one of the following can be given with the above drug?
Your Answer:
Correct Answer: Thiamine
Explanation:Wernicke’s encephalopathy is characterised by the triad of ophthalmoplegia, ataxia, and confusion. It must be viewed as a medical emergency with rapid correction of thiamine deficiency as the goal of therapy. Acamprosate is a medication used to treat alcohol dependence by stabilizing chemical signalling in the brain that would otherwise be disrupted by alcohol withdrawal
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This question is part of the following fields:
- Nervous System
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Question 167
Incorrect
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A 41-year-old yoga instructor presents with a 2-month history of left-hand weakness. She has no significant past medical history. On examination, there is mild weakness of the left upper and lower limbs with a right sided facial weakness, which spares the forehead. Which of the following is the most likely location of the lesion?
Your Answer:
Correct Answer: Right pons
Explanation:The pons is above the level of decussation of the corticospinal tracts so a pontine lesion would cause a contralateral limb weakness.
The facial motor nucleus is located in the pons and supplies the ipsilateral facial muscles.
A right cerebral lesion would give left upper and lower limb weakness. It would also cause a left sided facial weakness.
A left cerebral lesion would give right upper and lower limb weakness with right facial weakness.
Finally, a cervical spinal cord lesion would not cause a facial weakness. -
This question is part of the following fields:
- Nervous System
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Question 168
Incorrect
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A 59-year-old scientist is referred to you with a 2-year history of ascending lower limb numbness and, more recently, foot drop. In the last 6 months he has also developed numbness in his fingers. He has a distal reduction to pinprick and relatively preserved muscle power, except for ankle dorsiflexion and hyporeflexia in his legs. The GP has already organised nerve conduction studies and the report is sent along with the patient. Which of the following would be suggestive of an axonal neuropathy?
Your Answer:
Correct Answer: Reduced compound muscle action potential amplitude
Explanation:Reduced conduction velocity is associated with demyelinating neuropathies. An abnormally slow response is associated with very proximal disease, i.e. radiculopathies. Delayed P100 latency is a feature of performing visual evoked potentials in those with optic nerve disease. Conduction block is usually associated with certain types of demyelinating neuropathy.
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This question is part of the following fields:
- Nervous System
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Question 169
Incorrect
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All of the following statements suggesting a poor prognosis of Guillain-Barre syndrome are correct except?
Your Answer:
Correct Answer: Evidence demyelination on nerve conduction studies
Explanation:Guillain barre syndrome is a neurological disorder characterised by neuropathy along with ascending paralysis. Denervation rather than demyelination suggests poor prognosis in GB syndrome.
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This question is part of the following fields:
- Nervous System
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Question 170
Incorrect
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A 22 year-old university graduate presented with progressive unsteadiness during walking over the last year. She had been otherwise healthy apart from recent difficulty hearing her lecturer in classes. She took no prescription medication but had occasionally taken cocaine during her first year of college. She also admits to drinking up to 30 units of alcohol per week and smoked 10 cigarettes per day. Her parents were both well, but her father's sister had problems with walking before she died. Examination reveals normal tone and power throughout all four limbs. Reflexes were normal in the upper limbs but decreased at the knees and absent at the ankles. Coordination was normal in all four limbs but her gait was ataxic. Sensation in the upper limbs was normal but decreased vibratory sensation and proprioception was noted to the ankles bilaterally. What is the most likely diagnosis?
Your Answer:
Correct Answer: Friedreich's ataxia
Explanation:Friedreich’s ataxia is an autosomal recessive disorder that usually begins before the end of the teens. It has an estimated prevalence in Europe of 1 in 50,000 and life expectancy is around 40-50 years. Neurological features include a progressive ataxia, cerebellar dysarthria, lower limb areflexia, decreased vibratory sensation and proprioception, and pyramidal weakness. Pes cavus and scoliosis are also both seen. Cardiomyopathy occurs in over 70% of cases. Less common features include optic atrophic, diabetes mellitus, and deafness.
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This question is part of the following fields:
- Nervous System
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SESSION STATS - PERFORMANCE PER SPECIALTY
