Neurology

A 52 year old banker has recurrent episodes of short lived, severe pains in his jaw on the left. These
cause him to screw his face up. e has seen a dentist who feels that the most likely cause for his
problem is trigeminal neuralgia. e seeks your advice. !hich of the following are not true of this
condition"
#ptions
A. $t affects women more commonly than men
%. $t may respond to phenytoin treatment
&. Around '() of cases are bilateral
*. $t can be a manifestation of multiple sclerosis
+. #nset is most commonly after the age of 5(
&
Theme, Trigeminal Neuralgia
Trigeminal Neuralgia
-ore common after the age of 5(
-ore common in women than men
.aro/ysmal attacks lasting seconds 0 affect any of the three divisions of the trigeminal nerve
Triggered by touching the face, chewing or speaking
Treated with carbama1epine or phenytoin, may respond to surgical microvascular decompressiom
*ifferentiate from,
.ostherpetic neuralgia, structural lesion 2, cluster headache, migraine, tempero3mandibular joint pain
0 by length 4 location of attacks.
A 25 year old woman with a previous history of optic neuritis is admitted with sudden onset of
diplopia. !hich of the following would favour a diagnosis of -ultiple 5clerosis"
#ptions
A. 6aised +56
%. 7ymphocytic pleocytosis in the &58
&. .revious history of episodic gait disturbance
*. .eriventricular high signal lesions on T2 weighted -6$
+. .eripheral neuropathy
&
Theme, #ptic neuritis and -5
-ultiple 5clerosis 9-5: may be mimicked by a range of inflammatory conditions including 57+,
sarcoidosis, 7yme disease and 5jogren;s syndrome. +vidence of a remitting relapsing nature of the
condition would be the most suggestive of the available choices. A raised +56, peripheral neuropathy
and lymphocytic pleocytosis 9although seen in -5: raise the possibility of another diagnosis.
.eriventricular high signal lesions on T2 weighted scans are characteristic of -5 but may be seen in
other conditions.
A <= year old develops acute di11yness. 5he had a >cold> the previous week, but felt that this had
cleared up. 5he is unable to walk because of the di11yness which is constant and severe. There is
tinnitus in her left ear, and some sensori3neural hearing loss, on e/amination. There is no nystagmus,
and the rest of the e/amination is normal. !hat is the most likely diagnosis ,3
#ptions
A. 2estibular neuronitis
%. %enign positional vertigo
&. 7eft cerebello3pontine angle lesion
*. 2estibular 5chwannoma
+. Acute labyrinthitis
+
Theme, 2ertigo
The acute onset, constant course and history of preceeding viral infection make acute labyrinthitis the
most likely cause. This is thought to be an acute, infective process affecting the middle ear. $t is
treatable with bed rest and anti3emetics.
2estibular neuronitis tends to run a more chronic relapsing course. A vestibular schwannoma
9acoustic neuroma: is a cerebello3pontine angle lesion. These tend to be more chronic in
presentation, and often involve other cranial nerves. er vertigo is clearly not positional?
A '@ year3old man complains of gradual onset of blurred vision in his right eye. #n direct Auestioning
he admits to having some difficulty in his job as a wine critic. e has no other neurological
symptoms. e has a history of treated hypertension and impaired glucose tolerance. e has been on
ramipril for the past B years. There is no family history of note. e smokes 5 cigars a day and drinks
in moderation. +/amination reveals a right sided relative afferent pupillary defect, right sided optic
atrophy and right sided central scotoma with an upper Auadrantic visual field defect in the left eye.
7ower cranial nerves and the peripheral nervous system are normal. !here is the lesion ,3
#ptions
A. 6ight optic nerve
%. 6ight anterior optic chiasm
&. #ptic chiasm
*. %oth retinae
+. #ccipital lobe
%
Theme, 2isual fields
7esions of the anterior chiasm 9junction of optic nerve and chiasm: tend to produce an ipsilateral
scotoma and a contralateral superior Auadrantanopia. The contralateral defect is due to interruption
of the crossing nasal fibres 9!illebrandCs Dnee:.
A lesion of the nerve would produce total blindness.
&hiasmal lesions produce bitemporal hemianopia.
#ccipital lobe lesions may produce homonymous hemianopia.
A 52 year old labourer has a two week history of increasing weakness. e has found it increasingly
difficult to climb stairs and get up out of his chair. e smokes 2( cigarettes a day and drinks around B
pints of lager a day. e has no previous medical history and takes paracetamol for headaches.
!hich of the following features would make a peripheral neuropathy much more likely than a
myopathy as a cause of his weakness,3
#ptions
A. .redominantly pro/imal pattern of weakness
%. 7oss of refle/es
&. 8ibrillations
*. .ain in the limbs
+. $nvolvement of the cranial nerves
%
Theme, Neurological e/amination
7oss of refle/es
8eature Neuropathy -yopathy
*istribution *istal .ro/imal
.ain .ossible .ossible
6efle/es 7ost 6etained
Atrophy .resent Esually absent
+-F 8ibrillations 5mall motor units
&D Normal $ncreased
&ranial nerves Esually spares 5ometimes involved
-uscle biopsy Froup atrophy Necrosis
A 22 year old trainee policeman has been increasingly confused over a three day period. e has a
generalised headache. e has become disorientated in time and place, with speech disturbance.
e has a temperature of B@&, pulse GG( bpm. There is mild neck stiffness but no focal neurological
abnormalities. 5ystemic e/amination is normal. A lumbar puncture is performed, it shows a protein of
2g4l, glucose ' 9serumH<:, !&& ' 9lymphocytes:, 6&& 2.
!hich of the following would be an une/pected investigation result ,3
#ptions
A. %ilateral temporal hypodensity on -6$ scanning
%. Negative &58 culture
&. Abnormal ++F
*. .ositive gram stain
+. .ositive viral .&6
*
Theme, Acute confusion
The clinical picture of confusion associated with fever is suggestive of a central nervous system
infection. The main differential is between a bacterial, viral or fungal infection. Alternatively, there are
a number of rarer aseptic causes of meningitis.
$n this case, however, there are abnormalities of the lumbar puncture. The lack of neutrophils and
normal glucose would make a bacterial meningitis very unlikely. $n view of the history and the
elevated protein in the cerebrospinal fluid, the most likely diagnosis would be a herpes simple/
encephalitis. There is no history given of immunocompromise, that would make you think of T% or
brucellosis.
A B2 year old psychologist is seen in the emergency department. 5he awoke that morning with a
severe left sided headache, and blurring of her vision in the left eye. 5he was nauseous and di11y.
#f note in her past medical history, she had had an episode of optic neuritis B years beforehand, in
the right eye, which had resolved spontaneously. 5he drank around thirty units of alcohol a week and
used cannabis recreationally. 5he was married since the age of 2B.
#n e/amination, there was a left afferent pupillary defect with weakness of the facial muscles on the
right. Tone and refle/es were brisk on the right with power of B45 in the arm and the leg. 5he was
apyre/ial. -6$ of the brain revealed a large left temperoparietal mass, which was incompletely ring
enhancing. There were one or two small white matter lesions also visible.
!hat is the most likely diagnosis ,3
#ptions
A. &erebral abcess
%. 7ymphoma
&. -etastatic lesion
*. -ultiple sclerosis
+. -alignant glioma
*
Theme, %rain mass
A large mass like this may be due to infection, malignancy or inflammation.
The possibilty of infection with an atypical agent would rise in the conte/t of immunocompromise.
This also applies for the risk of cerebral lymphoma. %ut there are no risk factors for $2, here. A
typical abcess would usually be associated with a fever and complete ring enhancement.
A secondary malignancy would be unlikely in someone this young, but this should be considered, as
should a primary malignancy, like a glioma.
$n view of the appearance of the lesion on -6$, the associated white matter changes and the
previous optic neuritis, the most likely cause would be a demyelinating lesion, which may present in
this fashion. This should be confirmed with visual evoked potentials and oligoclonal band analysis.
A B( year old man presents with hand tremor. #n e/amination he has a fine postural tremor in both
hands. !hich of the following would disprove the likely diagnosis"
#ptions
A. +/acerbation with alcohol
%. -ild intention tremor
&. Titubation
*. 8amily history
+. $mprovement with beta blockers
A
Theme, Tremor
This is benign essential tremor. $t may occur at any age and has an autosomal dominant inheritance.
$t is predominantly postural although there may be a mild intention component. There may be head
involvement 9titubation:. $mprovement with alcohol and beta blockers is characteristic. Treatment can
be difficult, and significant disability may result.
A 25 year old woman presents to clinic with a < month history of right hand tremor. The freAuency is
appro/imately <1. 5he says that her mother also has a similar problem. !hich of the statements
about her disease is true ,3
#ptions
A. $t is inherited in an Autosomal *ominant fashion with very variable penetrance
%. Tremor of the head be associated with hand tremor
&. There is an association with .arkinson;s *isease
*. Alcohol will worsen her tremor considerably
+. The lower limbs are often eAually severely affected
%
Theme, +ssential Tremor
+ssential 98amilial: Tremor
&ommonest type of action tremor 9'3@ 1:
A* trait with virtually complete penetrance
Esually symmetrical
Almost always begins in arms but can also occur in head
&lassically ameliorated by Alcohol
A 22 year old video editor developed had developed difficulty in climbing stairs. e felt that for the
past few years he had had noted that his voice had become Auieter and that his face was not as
e/pressive. #n e/amination, he has weakness of the hips bilaterally, with normal tone and refle/es in
all ' limbs. There are some visible fasiculations in all muscle groups. &ranial nerve e/amination is
normal apart from some bilateral facial weakness and perioral fasiculation. Feneral e/amination is
entirely normal apart from pronounced gynaecomastia. is F. has performed a &D which is elevated
at 5(((. !hat is the diagnosis ,3
#ptions
A. *uchenne -uscular dystrophy
%. -otor Neuron *isease
&. DennedyCs 5yndrome
*. 8ascioscapulohumeral dystrophy
+. 7imb girdle dystrophy
&
Theme, &hronic weak legs
This man has the features of DennedyCs 5yndrome. This is an I linked recessive disease which may
affect peripheral nerves and muscle, thus producing an elevation of creatinine kinase. $t is one of the
trinucleotide repeat diseases. Abnormalities are found in the androgen receptors, leading to
gynaecomastia. .eri3oral fasiculations are also a relatively specific feature.
DennedyCs 5yndrome may present with cramps, facial weakness, pro/imal limb weakness, tremor,
absent refle/es, fasiculations or dysarthria.
The absence of upper motor neuron features make motor neuron disease unlikely, while a primary
muscule disease does not usually produce fasiculations.
A J23year3old man complains of headaches and malaise of three weeks duration.e has also had
difficulties getting out of his car and e/perienced peculiar facial pain on chewingmeat.b GB<g4lK !&&
5.@ /l#=4: 9normal differential:K .lat 'G2 /3$#=4?, +56 J@ mm4hr!hat would be your immediate
management ,3
#ptions
A. Ergent cardiology referral
%. Arterial blood gases plus G(( #a
&. #ral methotre/ate
*. igh dose steroids
+. &T brain
*
Theme, Acute -anagement
The combination of headache and an elevated +56 is strongly suggestive of temporal arteritis. igh
dose steroids are indicated to prevent possible loss of sight from progression of the condition. #ther
suggestive features of this diagnosis are advancing age and atypical scalp or facial pain.
An arterial biopsy is reAuired to make a definitive diagnosis, but this should not delay treatment in
the acute phase.
A '= year old hairdresser is referred from his F. with LshakesM. !hich of the following features would
make a diagnosis of .arkinsonism more likely than essential tremor"
#ptions
A. Gst degree relatives being affected with similar problems
%. Tremor restricted to the arms
&. A response of the tremor to ben1odia1epines
*. Enilaterality
+. Tremor that involves his voice
*
Theme, Tremor
*ifferentiating .arkinson;s disease and essential tremor
Age 0 .arkinson;s tends to come on later in life.
7ocation 0 +ssential tremor is more generalised and symmetrical. $t often affects the head and voice.
8irst degree relatives 0 -ore commonly affected in essential tremor
Associated neurological signs 0 rigidity, bradykinesia in .arkinson;s, usually none in essential tremor.
6esponse 0 .arkinson;s will respond to 73*opa, anticholinergics and dopamine agonists. +ssential
tremor is often responsive to alcohol, ben1odia1epines and beta3blockers
!riting 0 .arkinson;s sufferers often demonstrate micrographia, while essential tremor often involves
tremulous writing.
A 25 year old man is diagnosed with relapsing3remitting multiple sclerosis following B attacks of optic
neuritis and ata/ia over a 2 year period. e is now severely disabled, and cannot mobilise without the
aid of a wheelchair. Although previously continent, he has had increasing problems with urinary
urgency and freAuency and G episode of retention. !hich of the following is not an appropriate
management strategy,3
#ptions
A. &lean intermittent self catheterisation
%. Trial of o/ybutinin
&. $nstitution of a bowel regime
*. Trial of steroids
+. +/clusion of a urinary tract infection
*
Theme, -ultiple sclerosis
%ladder problems are common in multiple sclerosis. They may involve urgency and freAuency
alongside episodes of retention. $ndeed, retention with overflow can occur. $t is important to rule out
associated constipation, and la/ative use is important.
$nfections of the urinary tract occur in where there are voiding difficulties. &oncurrent
immunosupression can cause major problems when this happens.
*epending on the results of urodynamics and post3mictruition residual measurement, the use of anti3
cholinergics and4or catheterisation may be appropriate. An indwelling supra3pubic catheter is a
possible option for some patients. .
%ladder and bowel management are very important to patients, but are often forgotten or not
discussed.
Neurology -6&.G 9part two:
A 25 year old woman with a previous history of optic neuritis is admitted with sudden onset of
diplopia. !hich of the following would favour a diagnosis of -ultiple 5clerosis"
#ptions
A. 6aised +56
%. 7ymphocytic pleocytosis in the &58
&. .revious history of episodic gait disturbance
*. .eriventricular high signal lesions on T2 weighted -6$
+. .eripheral neuropathy
&
Theme, #ptic neuritis and -5
-ultiple 5clerosis 9-5: may be mimicked by a range of inflammatory conditions including 57+,
sarcoidosis, 7yme disease and 5jogren;s syndrome. +vidence of a remitting relapsing nature of the
condition would be the most suggestive of the available choices. A raised +56, peripheral neuropathy
and lymphocytic pleocytosis 9although seen in -5: raise the possibility of another diagnosis.
.eriventricular high signal lesions on T2 weighted scans are characteristic of -5 but may be seen in
other conditions.
A G< year old boy is falling behind in school. e has become withdrawn and depressed. e has begun
falling over and has difficulty performing simple tasks. #n e/amination, he is of normal height, build
and general appearance. e has slurred speech and has difficulty with finger3nose co3ordination. e
has ata/ia, with a broad3based gait. Tone, power and refle/es are all normal, as is his sensory
e/amination. Nou notice that he occasionally adopts bi1arre and prolonged postures where he e/tends
his arms or legs and, sometimes, his neck, pulling his head back. e appears to be drooling
significantly. !hat is the diagnosis"
#ptions
A. -yotonia *ystrophica
%. &erebellar tumour
&. Ouvenile .arkinsonism
*. !ilson;s disease
+. Ata/ia3Telangiectasia
*
Theme, &erebellar disease in children
The basic elements are,
3&erebellar disease 9ata/ia, co3ordination problems, speech:
3&ognitive $nvolvement 9low mood poor school performance:
3*ystonia 9posturing:.
A cerebellar tumour does not produce secondary dystonia or 9generally: cognitive disturbance.
-yotonia *ystrophia involves the musculature rather than co3ordination Ouvenoile .arkinsonism can
give secondary dystonia, but not the other features. Ata/ia Telangiectasia would not involve dystonia
and would usually have presented before this point.
This makes !ilson;s disease the best answer. *iagnosis would be confirmed by a 2' hour urinary
copper level, slit lamp e/amination 9for Dayser38leischer 6ings: or demonstration of copper in the
liver if this was involved.
A 25 year old woman with a previous history of optic neuritis is admitted with sudden onset of
diplopia. !hich of the following would most favour a diagnosis of multiple sclerosis"
#ptions
A. 6aised +56
%. 7ymphocytic pleocytosis in the &58
&. .revious history of episodic gait disturbance
*. .eriventricular high signal lesions on T2 weighted -6$
+. .eripheral neuropathy
&
Theme, *iagnosing multiple sclerosis
-5 may be mimicked by a range of inflammatory conditions including 57+, sarcoidosis, 7yme disease
and 5jogren;s syndrome. +vidence of a remitting relapsing nature of the condition would be the most
suggestive of the available choices. A raised +56, peripheral neuropathy and lymphocytic pleocytosis
9although seen in -5: raise the possibility of another diagnosis. .eriventricular high signal lesions on
T2 weighted scans are characteristic of -5 but may be seen in other conditions.
The 7ambert3+aton myasthenic syndrome,3
#ptions
A. *oes not respond to treatment with cholinesterase inhibitors
%. &ommonly causes distal rather than pro/imal weakness
&. $s associated with antibodies to post3synaptic voltage gated &a channels
*. $s commonly associated with non3small cell lung cancer
+. -ay be associated with postural hypotension
+
Theme, 7ambert3+aton myasthenic3myopathic3 syndrome 97+-5:
The clinical features are pro/imal weakness, loss of tendon refle/es with post3tetanic potentiation,
and autonomic dysfunction. 5i/ty per cent of cases are paraneoplastic. Antibodies to pre3synaptic
voltage3gated &a channels are foundK the underlying malignancy 9as in most paraneoplastic
neurological syndromes: is usually small cell lung carcinoma.
A 5( year3old man presents with a history of severe daily unilateral headaches for the past week
which wake him up at night. +/amination is normal e/cept for a right ornerCs syndrome. &T head is
normal. !hat is the diagnosis,3
#ptions
A. -igraine
%. &arotid dissection
&. &luster headache
*. Trigeminal neuralgia
+. Tension headache
&
Theme, eadache and ornerCs syndrome
Enilateral, severe, throbbing headache associated with lacrimation and occurring daily 9often at the
same time: for several days on end is usually cluster headache. #ccasionally ornerCs syndrome may
be seen.
A '' year old advertising e/ecutive is admitted with worsening difficulty in swallowing. is wife has
recently returned from holiday in Freece.
#n e/amination, there are bilateral <th nerve palsies and ptosis. is face is weak. There is a
dysarthria, associated with a large, flacid tongue.
+/amination of the peripheral nervous system is normal, apart from generally sluggish refle/es.
!hich is the most likely to/in that would produce these symptoms ,3
#ptions
A. 7ead
%. &holera to/in
&. %otulinum
*. + coli G5J
+. -ercury
&
Theme, 8ood .oisoning
%otulinum to/in ingestion produces a lower motor neurone syndrome that may involve multiple
cranial nerves and bulbar symptoms. $tCs action is due to an inhibition of acetyl choline release at the
neuromuscular junction. $tCs spores can occur in spoiled tinned food or, sometimes, honey. *iagnosis
is made by isolation of the to/in from serum. The condition may progress to produce severe
respiratory depression, therefore admission and early notification of $TE is mandatory.
A J' year old man is referred following the development of a right seventh nerve palsy. !hich of the
following referCs to %ellCs phenomenon 9on the affected side: ,3
#ptions
A. $nvoluntary tear production
%. Altered taste over the anterior two thirds of the tongue
&. $nvoluntary blinking
*. &hronic pain in the distribution of the nerve
+. The eyeball rolling upward upon eye closure
+
Theme, %ellCs .alsy
A seventh nerve palsy often produces a %ellCs phenomenon. The eyeball usually rolls upward on
closure because of rela/ation of the inferior recti and contraction of the superior recti. This is not
usually visible, but when the eyelid fails to close fully, as in a %ellCs palsy, it may be seen.
!hich of the following are true of neuroimaging in acute thromboembolic stroke ,3
#ptions
A. T2 weighted -6$ is usually normal in the first weeks following a stroke
%. *iffusion weighted images are of less use in the acute setting
&. TG weighted -6$ is less likely to demonstrate meningeal enhancement over an affected area in
acute stroke
*. %oth gray and white matter are affected on &T scans in the days following a stroke
+. T2 weighted images give hypointense images of the affected area following a stroke
*
Theme, $maging in acute stroke
&T scans are often 95(): normal in the immediate post3stroke period. 7ater, gray and white matter
abnormalities are apparent and eventuallly involutional change and atrophy become apparent.
TG weighted images may show no abnormality in the acute phase although gadolinium enhancement
can pick up to J5) of cases. 7ater, sulcal effacement and overlying meningeal enhancement may
become apparent.
T2 weighted images may show a signal flow void in the acute phase. $n the longer term,
hrperintensity of the affected area becomes apparent.
*iffusion weighted images are useful in diagnosing acute thromboembolus.
A <B year old man develops weakness of his right hand over a three month period. #n e/amination,
there are fasiculations of the small muscles of the hand and the forearm. %iceps jerk and triceps jerk
are brisk. There is weakness of the small muscles of the hand with increased tone. Apart from a brisk
jaw jerk, there are no other abnormalities to detect. !hat is the most likely diagnosis ,3
#ptions
A. -ulti focal motor neuropathy
%. &hronic inflammatory demyelinating polyneuropathy
&. -otor neurone disease
*. 7ead poisoning
+. -ultiple sclerosis
&
Theme, !eak hand
This man has relatively isolated upper 9brisk refle/es and tone: and lower motor 9fasiculations:
neuron findings in his hand. There is also a brisk jaw jerk. These features, along with the absence of
sensory signs make chronic inflammatory demyelinating neuropathy very unlikely. -otor neuropathy
from lead to/icity or multifocal neuropathy is also unlikely. -ultiple sclerosis is a disease of the
central nervous system. This makes motor neuron disease the most likely diagnosis. $t should always
be high on a list of differentials where there are upper and lower motor neuron signs present.
A '5 year old male complains of slowly progressive weakness involving his hands. +/amination shows
muscle atrophy, weakness, wasting and fasciculations in his upper limbs. 7ower limb e/amination
shows hypertonia, clonus, brisk deep tendon refle/es and upgoing plantars. -6$ of his spinal cord is
normal. !hich of the following is associated with the shortest life e/pectancy in this disease ,3
#ptions
A. Atrophy of biceps
%. 8asciculations in triceps
&. Atrophy of triceps
*. Epgoing plantar refle/es
+. Tongue fasciculations
+
Theme, prognosis in motor neurone disease
This combination of upper and lower motor neuron dysfunction is strongly suggestive of motor
neuron disease. This has a generally poor prognosis, with death usually occuring within 5 years of
onset, as a result of respiratory muscle involvement. Tongue fasiculations imply the onset of a bulbar
palsy which has a worse prognosis.
A 22 year old .h* student is referred with a B year history of abnormal movements of the right foot.
e noted that his foot would invert spontaneously at different points during the day. The movement
would be associated with a cramping sensation in the foot. e felt that this would occur more
freAuently if he were >stressed> or tired. +ach episode lasts for around G5 minutes and resolves
spontaneously. Neurological and physical e/amination, including slit lamp, were entirely normal. #n
tapping the right foot for over a minute, the foot would e/tend and invert. !hat therapeutic trial
would you instigate"
#ptions
A. A trial of levodopa
%. A trial of amitryptilline
&. A trial of carbama1epine
*. A trial of chlorproma1ine
+. A trial of lora1epam
A
Theme, &ramping of the foot
This patient has a localised dystonia which is a prolonged contracture of a particular muscle group.
There are no other disorders that are present. !riterCs cramp, torticolis and blepharospasm are all
types of adult onset focal dystonias. *ystonias like this are defined as primary in order to
differentiate them from the large number of conditions that produce dystonia as a secondary feature.
A sub group of primary dystonias are dramatically dopa3responsive. Therefore, of the options
available, a trial of levodopa would be the most appropriate option.
Amitryptilline and carbama1epine are used in the treatment of neuropathic pain. &hlorproma1ine is
an old antipsychotic while lora1epam is a short acting sedating be1odia1epine.
A B( year old builder has acute onset of 6ight orbital pain at work. The ne/t day he notices that his
right eye appears odd. #n e/amination, he has a mild right ptosis and the right pupil is 2mm smaller
than the left, but both react normally to light. 2isual acuity, fields and eye movements are normal.
The site of injury is to which of the following structures"
#ptions
A. #ptic Tract
%. 7eft #ccipital corte/
&. #culomotor Nerve
*. TG Nerve 6oot
+. 5uperior &ervical Fanglion
+
Theme, Enilateral ptosis
This patient has a unilateral ornerCs syndrome. A ornerCs syndrome involves ptosis, pupillary
constriction 9but reaction to light: and a loss of sweating on the affected side. The lesion is in the
superior cervical ganglion as this is the major synpathetic outflow to the head. Normal e/tra3ocular
movements and fields rule out the other causes.
Any lesion to the sympathetic chain on the ipsilateral side may produce a ornerCs.
A '< year old man presents with painless bilateral arm weakness and abdominal pain. #n
e/amination he has bilateral wrist drop. !hich one of the following substances is the -#5T likely
cause of his symptoms"
#ptions
A. 7ead
%. -ercury
&. #rganophosphate
*. Arsenic
+. Thallium
A
Theme, .oisons
7ead neuropathy3chronic ingestion of lead produces similar condition to Acute $ntermittent .orphyria.
$n adults causes colic, anaemia and peripheral neuropathy. %ilateral wrist drop is classic 9i.e.,. rare:
presentation. -ercury3neurospyschiatric manifestations 9mad hatter?: and movement disorders.
#rganophosphate3immediate anticholinesterase effect 9headache, vomiting, abdo cramps, salivation,
miosis: delayed distal polyneuropathy
Arsenic3symptoms of encephalopathy or peripheral neuropathy.
Thallium3rapidly progressive painful polyneuropathy, ophthalmoplegia and optic atrophy.
A 5' year3old accountant presents to casualty at 2 a.m. with a B day history of being woken up in the
early morning with severe headache which lasts G32 hours. The headache is Pboring; in character,
involves the eye and frontal region on the left side, and is associated with eye3watering. e says it is
the worst pain that he has ever had, and he is unable to sleep until it subsides. e denies any visual
symptoms. #n e/amination he appears in pain. There is no neck stiffness. The left conjunctiva is
injected and there is a left orner;s syndrome. !hat is the diagnosis ,
#ptions
A. -igraine
%. &luster headache
&. .aro/ysmal hemicrania
*. Trigeminal neuralgia
+. Transient ischaemic attack
%
Theme, eadache
Enilateral headaches that occur periodically, mostly at night, with episodes lasting for <(3=( minutes
and autonomic symptoms are cluster headaches. .aro/ysmal hemicrania occurs throughout the day,
the attacks tend to be shorter, and the pain is centered around the occipito3temporal region.
-igraines are not usually unilateral, and last longer.
Trigeminal neuralgia attacks tend to be much shorter.
T$A does not usually produce headache.
!hich of these features are most inconsistent with a diagnosis of cervical myelopathy ,3
#ptions
A. $nverted biceps jerks
%. %ladder disturbance
&. +/tensor plantar responses
*. 8inger pseudoathetosis
+. 7oss of vibration sense in the hands
%
Theme, &ervical myelopathy
&ervical myelopathy usually due to spondylosis occurs at &53&J. There is spatic weakness of the legs
with hypetronia, clonus and upgoing plantars. 5phincter involvement is unusual. Ooint position sense
and vibration tend to be lost rather than the spinothalamic tract sensory modalities. .seudoathetosis
refers to the slow writhing movements of the outstretched fingers when the eyes are closed 3 due to
a loss of position sense. An inverted biceps jerk refers to the brisk finger fle/ion that accompanies
attempts to elicit it, the biceps jerk, itself, does not occur.
Although spondylosis is the commonest cause, an intrinsic lesion may cause a similar clinical picture.
.sychiatry
A 25 year old is admitted following a suicide attempt. e admits to being troubled by freAuent
thoughts of performing embarrassing acts and recurrent thoughts of uncleanliness which he is unable
to suppress and which lead to repeated hand3washing. !hich of the following features do not point to
the likely diagnosis ,3
#ptions
A. *epression
%. Tics
&. $mpaired insight
*. -arked an/iety
+. -arked improvement with treatment
&
Theme, #bsessive behaviour
There are a number of features of obsessive3compulsive disorder. Treatment with cognitive3
behavioural therapy usually has a good response. Associated neuroses such as an/iety and
depression are a common part of the disease. Tics are, sometimes, seen but obsessional symptoms
also occur in patients with TouretteCs.
An impairment of insight suggests psychosis or organic brain disease which would be outside a
diagnosis of obsessive compulsive disorder.
A seventy3year3old woman was referred by her F. with ' months history of forgetfulness. !hich one
of the following statements supports a diagnosis of pseudodementia ,3
#ptions
A. .oor response to antidepressant treatment
%. *enial of memory problems
&. Answering L$ do not knowM to Auestions on the -ini3-ental 5tate +/amination
*. 5trong family history of Al1heimer;s disease
+. 5hort term memory only affected
&
Theme, .seudodementias
The clinical picture of pseudodementia resembles that of Al1heimer;s disease, however, patients with
pseudodementia, unlike those with Al1heimer;s disease, often complain about their memory. There is
some retention of insight. $n pseudodementia both the short term and long term memory appear to
be eAually affected in the early stage of the disease, unlike Al1heimer;s disease where only the short
term memory is initially involved. $n pseudodementia improvement in cognitive testing usually occurs
following treatment with antidepressants.
A B< year old man is still unable to return to work si/ months after the death of his partner. All the
symptoms described below are consistent with normal grief reactions e/cept ,3
#ptions
A. &omplaints regarding e/haustion or lack of strength
%. 8eelings of increased emotional distance
&. .re3occupation with guilt and personal responsibility
*. $ncreased activity without feelings of loss
+. 8eelings of irritability, hostility and anger
*
Theme, Frief
Acute grief is a definite syndrome with psychological and somatic symptoms. $t may present
immediately after a crisis or onset maybe delayed. The clinical presentation includes sensations of
somatic distress, feelings of diminished strength or physical e/haustion, feelings of mild
depersonalisation or de3realisation, recurrent dreams or ruminations about the death itself or the
deceased person, feelings of guilt and personal responsibility for the loss, diminished desire for inter3
personal contact, mood lability and irritability. .athological grief reactions may present as over3
activity without a sense of loss, acAuisition of physical symptoms belonging to the deceased, onset of
any medical condition, conspicuous alteration in social adjustment, e/treme deterioration in mood
and character, and frank depression or psychosis.
A B( year old man is admitted following a suicide attempt. !hich of the following does not increase
the risk of a successful attempt ,3
#ptions
A. +pilepsy
%. -5
&. 5chi1ophrenia
*. %eing married
+. .ersonality disorder
*
Theme, 6isk factors for suicide
6isk factors for suicide include chronic illnesses or pain, alcoholism, depression, unemployment and
access to the means. 5ome factors are protective, such as being in a close relationship and
religiosity. Around 2() of those who attempt self harm will, eventually, comit suicide.
A BJ3year3old &aucasian man presents to &asualty after having turned up for his work on his day off
and behaved unusually. At interview his speech is rapid and slurred. e is aroused, animated and
over3familiar with clang3associations and tangentiality. e states that there are voices in his head,
that the T2 and radio talk directly to him, that his father has been a secret agent and his mother
assassinated. e states that he has saved a girl;s life and complains of a four3month headache. e is
too distractible for cognitive stage e/amination and no further history is available. .hysical
e/amination 0 no abnormalities are elicited.
%lood investigations reveal a neutrophilia of =.J 92.23J.5: and a lymphopenia of (.'J 9G.23'.(:.
#verall the white cell count was GG.G 9B.@3GG.(:. 6%&, T, -&2 and platelet counts are all within
normal parameters as were biochemistry results.
&ollateral history reveals that his father had been a diplomat and had possibly performed for the
intelligent services. is mother had died in a car crash. e had not saved a girl;s life as claimed. The
patient claimed to have had an accident after being sideswiped on a motorway, while driving a
powerful motorbike at great speed. is family stated that it was a farm accident on a moped. The
patient has recently lost his flat after accumulating substantial debts for non3payment of his
mortgage. is supervisor reports that he has had difficulties at work for the last two years and has
reAuired e/tra support. e has been moved repeatedly from positions of responsibility to lesser ones
and has been over3familiar with customers via the loudspeaker system and has had to be removed
from cash related tasks as he had been found to be less than careful in his duty.
The following morning the patient had two tonic3clonic sei1ures, was pyre/ial and had increased tone
in the right side of his body.
A lumbar puncture shows an elevated &58 protein of (.@5 9.G23. <: and a glucose of 5.(. -icroscopy
shows a 6%& of <(( and !%& of 5 and a negative culture growth. The most likely cause is viral
encephalitis, or bacterial encephalitis. 2iral encephalitis is presumed. Antiviral treatment was started.
Acyclovir J((mg tds. 5yphilis serology is finally obtained revealing a serum T.A level of G4@(,(((
and a 2*67 titres of G4G2@. A repeat lumbar puncture shows levels of &58 of G45,G25 and G4@
respectively. .enicillin treatment G.2 -E daily for three weeks with steroid cover is commenced. A &T
scan reveals an old left frontal infarct.
The most likely cognitive deficits would include ,3
#ptions
A. $mpaired wisconsin card sort test
%. *ressing dyspra/ia
&. 7eft4right disorientation
*. *yscalculia
+. *ysgraphia
A
Theme, &ognition following stroke
The !isconsin card sort test is the only test of frotal lobe function. *ressing dyspra/ia, 7eft4right
disorientation, *yscalculia, and *ysgraphia are all functions of the parietal lobes.
*& is a 253year3old white male, referred for a court report for stealing a bottle of vodka. e has had
a turbulent childhood, spending time in a school for disturbed children. 8ellow pupils and
schoolteachers repeatedly beat him up. e engaged in sniffing solvents and persisted in this activity
on a near daily basis from the age of GJ. 8rom G532B he has used cocaine, 75*, ecstasy,
amphetamines and smoked heroin. e still uses cannabis. 8or the last few years the only illegal drug
he has been using is cannabis once or twice weekly and psilocybin. 8rom the age of G5 to the current
day his alcohol intake has been at most 23B litres of whisky a day two to three times a week and
drinking slightly less on other days.
e drinks immediately upon wakening to prevent tremors and freAuently describes blackouts. #n
several occasions he has e/perienced the sensation of objects crawling over his skin.
e regularly has tremors and has been through deto/ification ten times during his life. #ver the last
three to four weeks he has voluntarily cut down his alcohol and is currently drinking less than 2(
units per week. e has failed to remain abstinent.
At the age of G@ he was in a serious road traffic accident when one passenger died and another
fractured his back and &* fractured his pelvis. As a result he has a residual fear which occasionally
manifests in difficulty in getting into cars and crossing the street.
5ymptoms, which would lead you to suspect post3traumatic stress disorder rather than another
diagnosis, include ,3
#ptions
A. 6ecurrent and intrusive recollections or dreams
%. 8lashbacks only when into/icated
&. .sychological distress at e/posure to cues or events that resemble the trauma
*. .ersistent symptoms of decreased arousal, including difficulty sleeping, irritability, poor
concentration, hyper3vigilance, e/aggerated startle response
+. $ncreased serum cortisol levels
A
Theme, .ost traumatic stress disorder
8lashbacks do occur but not only when into/icated, this would cause some suspicion to be raised.
*ifficulty sleeping, irritability, poor concentration, hyper3vigilance, and e/aggerated startle response
are all seen in this condition, but would also be a prominent feature of a depressive illness. $ncreased
serum cortisol levels occur in some patients, but is not diagnostic. %oth recurrent and intrusive
recollections or dreams and psychological distress at e/posure to cues or events that resemble the
trauma occur. The latter though can occur in simple phobias.
An @J year old lady is admitted with confusion. There are no other abnormal findings. !hich of the
following is unlikely to be a contributory factor ,3
#ptions
A. 7ow dose amitriptyline
%. *igo/in
&. New onset A8
*. 5tandard dose sertraline
+. 6ecent oral steroid use
*
Theme, &onfusion in the elderly
There are a large number of causes of confusion in the elderly, and many people in this age group are
taking a number of different medications which have the potential to interact. $t is important to take
a detailed drug history. $llnesses which may not affect younger people to the same degree can often
present with confusion in the elderly. 7one atrial fibrillation and infections are common cuases.
5ertraline is not known to commonly produce confusion and 556$s are useful in the elderly for this
reason.
A B2 year old scientist is brought in by his wife because she is concerned when she finds him wearing
her underwear. $ntermittent but regular dressing by a man in women;s clothes to become se/ually
aroused is,3
#ptions
A. 2oyeurism
%. Transse/uality
&. Transvestism
*. $ncest
+. 8etishism
&
Theme, .araphilia
Fender identity with the opposite se/ is called transse/ualism. Transse/uals believe that they belong
to the opposite se/ but are trapped in the body of their biological se/ of birth. 2oyeurism involves
se/ual gratification from watching se/ual acts or naked bodies, particularly the genitals. &ompulsive
se/ual interest in pre3pubertal children by an adult who is at least G( years older than the child is
called paedophilia. 5e/ual activity between members of a family is called incest. Transvestism is seen
in males who have an irresistible and regular compulsion to dress in women;s clothes and gain se/ual
arousal from it. 8etishism is se/ual gratification from an inanimate object like an item of clothing or
body part.
A << year old retired nurse has become confused. !hich of the following would be least consistent
with a diagnosis of Al1heimer;s *isease ,3
#ptions
A. Esually develops insidiously
%. allucinations are often a prominent early feature
&. $t may begin with the amnesic syndrome
*. -ay present with dementia accompanied by delirium, delusions or depression
+. Altered handwriting is seen in the later phases
%
Theme, *ementia
Al1heimer;s *isease is a primary degenerative dementia that usually manifests itself between the
ages of 5( and <( years. $t will usually develop insidiously and may present with amnesia and
dementia accompanied by delirium, delusions or depression. owever, no symptom comple/ is
particularly characteristic. -irror sign and catastrophic reaction are two signs which are seen in the
later phases of the illness. *iagnosis is usually clinical. .rogression is slow, as opposed to -ulti3
infarct dementia, where onset is abrupt, with step wise deterioration and a fluctuating course.
allucinations are more common in 7ewy body dementia.
A 2<3year3old patient was admitted for the first time with delusional ideas, hallucinations, depressed
mood and speech abnormalities. A diagnosis of acute schi1ophrenia was subseAuently made. !hich
of the following most applies to this patient ,3
#ptions
A. .atient is most likely to be a male
%. .atient is most likely to be a female
&. A brain scan would most likely show shrunken ventricles
*. The patient illness could have resulted from a hyperdopaminergic state
+. A brain scan would most likely show enlarged cortical si1e
*
Theme, 5chi1ophrenia
5chi1ophrenia occurs about eAually among males and females, although females usually present few
years later. The brain of schi1ophrenia patients either shows a normal si1e or a decrease in si1e on
scan while the ventricles may be enlarged. $t is suspected that a hyperdopaminergic state e/ists in
the brain of schi1ophrenia patients 9the dopamine hypothesis:.
A B2 year old man is brought into hospital in a state of e/citement. All of the following describes
mania e/cept ,3
#ptions
A. -ay occur in children
%. The mean onset of the disease is in the third decade of life
&. -ay follow cerebrovascular disease
*. 7ithium is effective in J(3=( ) of patients
+. %en1odia1epines may be used in the acute stage
*
Theme, -ania
Treatment of a manic episode may involve the use of antipsychotics, ben1odia1epines, lithium and
other mood stabilisers. 7ithium is effective in less than J() of cases.
-ania may be a manifestation of organic brain disease such as cerebrovascular disease or a space
occupying lesion.
A 2< year old man has low mood and difficulty in getting to sleep. $n depression which one of the
following is true ,3
#ptions
A. Those who talk about suicide rarely do it.
%. 5elective serotonin uptake inhibitors 9556$s: have been shown to be more effective than tricylic
antidepressants.
&. +&T has no place in modern psychiatry
*. Antidepressant drugs are valuable in endogenous depression but have little if any effect if the
cause is e/ogenous.
+. +/ercise can have a positive effect on elevating mood.
+
Theme, *epression
.eople who commit suicide have often talked about it before. 556$s are no more effective than T&As
but much less to/ic. +&T is still valuable in refractory cases. *rugs are much more use in endogenous
depression in that they do not get rid of the cause of e/ogenous cases but they do help the sufferer
get through it. +/ercise induced endorphins and elevates mood.
A 'B year old copywriter has been repeatedly absent from work over the last three weeks. e has a
fine resting tremor and appears dishevelled. e tells you that he is drinking >most nights>.
The current safe levels of drinking recommended by the government for men are ,
#ptions
A. G( units per week
%. G5 units per week
&. 2( units per week
*. 2G units per week
+. 22 units per week
*
Theme, Alcohol use
2G units per week is the recommended limit for men. 8or women it is G' units per week.
A unit of alcohol is a glass of wine, a measure of spirits or half a pint of beer.
.atientCs alcohol histories are often not the same as their actual intake. A mean corpuscle volume or
transaminase assay may indicate a high level of intake, although this is not a specific or sensitive
screening test.
A J53year3old man presents with a G2 months history of cognitive impairment. $nitial investigations
usually include all of the following e/cept ,3
#ptions
A. 5yphilis serology
%. Neurological e/amination
&. ++F
*. &T4-6$ scan of the brain
+. *etailed mental state e/amination
&
Theme, $nvestigation of dementia
++F is non3specific and only shows slowed wave activities in dementia. $t has a role in the differential
diagnosis of difficult cases but is not routinely reAuested as part of the initial investigations.
A =< year old nursing home resident is becoming withdrawn and forgettful. All of the following are
correct in relation to dementia disorders e/cept ,
#ptions
A. *ementia with 7ewy bodies account for about 2() of all dementia patients
%. .oint prevalence of dementia in those in their eighties is 53= )
&. Anticholinesterase inhibitors may be useful in patients with vascular dementia
*. The -ini3-ental 5tate +/amination is not a sensitive test for frontotemporal dementia
+. The Lmirror signM may be seen in patients with severe Al1heimer;s disease
%
Theme, *ementia
.oint prevalence of dementia in all those over the age of <5 years is about 5). This rises to about
G5) in those above the age of @(.
Around 5() of patients with dementia have Al1heimer;s disease while around 2() have dementia
with 7ewy bodies and 2() have vascular dementia.
Although anticholinesterase inhibitors have been licensed only for the use of Al1heimer;s disease,
they may also be helpful in vascular dementia and dementia with 7ewy bodies.
-ini3-ental 5tate +/amination is a good screening test for Al1heimer;s disease but not frontotemporal
dementia.