200 SBAs for Medical Students in Neurology and Neurosurgery PDF

 NEUROLOGY AND NEUROSURGERY 200 SBAs for Medical Students 12666_9789811250309_TP.indd 1 25/8/22 7:45 AM January 19, 2018 9:17 ws-book961x669 Beyond the Triangle: B...

 NEUROLOGY AND NEUROSURGERY 200 SBAs for Medical Students 12666_9789811250309_TP.indd 1 25/8/22 7:45 AM January 19, 2018 9:17 ws-book961x669 Beyond the Triangle: Brownian Motion...Planck Equation-10734 HKU˙book page vi This page intentionally left blank  NEUROLOGY AND NEUROSURGERY 200 SBAs for Medical Students Conor Gillespie Ameer Khan University of Liverpool, UK NEW JERSEY LONDON SINGAPORE BEIJING SHANGHAI HONG KONG TAIPEI CHENNAI TOKYO 12666_9789811250309_TP.indd 2 25/8/22 7:45 AM  Published by World Scientific Publishing Co. Pte. Ltd. 5 Toh Tuck Link, Singapore 596224 USA office: 27 Warren Street, Suite 401-402, Hackensack, NJ 07601 UK office: 57 Shelton Street, Covent Garden, London WC2H 9HE British Library Cataloguing-in-Publication Data A catalogue record for this book is available from the British Library. NEUROLOGY AND NEUROSURGERY 200 SBAs for Medical Students Copyright © 2023 by World Scientific Publishing Co. Pte. Ltd. All rights reserved. This book, or parts thereof, may not be reproduced in any form or by any means, electronic or mechanical, including photocopying, recording or any information storage and retrieval system now known or to be invented, without written permission from the publisher. For photocopying of material in this volume, please pay a copying fee through the Copyright Clearance Center, Inc., 222 Rosewood Drive, Danvers, MA 01923, USA. In this case permission to photocopy is not required from the publisher. ISBN 978-981-125-030-9 (hardcover) ISBN 978-981-125-101-6 (paperback) ISBN 978-981-125-031-6 (ebook for institutions) ISBN 978-981-125-032-3 (ebook for individuals) For any available supplementary material, please visit https://www.worldscientific.com/worldscibooks/10.1142/12666#t=suppl Printed in Singapore SC - 12666 - Neurology and Neurosurgery.indd 1 26/8/2022 1:24:49 pm  9.61”x6.69” b4659   Neurology and Neurosurgery: 200 SBAs for Medical Students 200 SBAs for Medical Students v Dedications To Alex, Ben, and Sam, thank you for your unwavering support and friendship. Abed, I couldn’t have wished for a better mentor. Natasha, thank you for helping me get through a difficult time. I’ll always be grateful. — Conor Gillespie To my dearest Mum and Dad and all my family and friends who have pushed and supported me to get to this position in life. — Ameer Khan b4659_FM.indd 5 26-Aug-22 7:48:57 PM January 19, 2018 9:17 ws-book961x669 Beyond the Triangle: Brownian Motion...Planck Equation-10734 HKU˙book page vi This page intentionally left blank  9.61”x6.69” b4659   Neurology and Neurosurgery: 200 SBAs for Medical Students 200 SBAs for Medical Students vii Foreword This book presents a series of 200 questions covering neurology and neurosurgery topics for medical students taking their final exams. As clinical neuroscience can be a daunting topic for medical students, this book aims to cover all the important topics with a clear explanation of the correct answer to each question. The book was conceived and prepared by a dedicated medical student (Conor Gillespie) with input from other medical students, junior doctors, and consultants — all with the aim of making the book as relevant and as accessible as possible to those with ‘neurophobia’. To this end the goal has been achieved, and this book should sit in every medical school library and medical student book shelf. We must remember that the people who gain the most from good clinical neuroscience knowledge are our patients. — Professor Michael Jenkinson Professor of Neurosurgery and Sir John Fisher / RCSEng Chair of Surgical Trials University of Liverpool and The Walton Centre NHS Foundation Trust b4659_FM.indd 7 26-Aug-22 7:48:57 PM January 19, 2018 9:17 ws-book961x669 Beyond the Triangle: Brownian Motion...Planck Equation-10734 HKU˙book page vi This page intentionally left blank  9.61”x6.69” b4659   Neurology and Neurosurgery: 200 SBAs for Medical Students 200 SBAs for Medical Students ix Preface The goal of this book is simple. Use this, and never have to worry about clinical neuro again. The Single Best Answer (SBAs) in this book are a mixture of core knowledge and challenging questions, all designed for medical students approaching the final years of their course. One of the most reported reasons why students find neuro difficult is its depth, so we have sought to ameliorate this problem with focused questions and unique ‘one-sentence summaries’ of each neuro condition containing almost all the vital information you need to know for the purposes of exams and being a good clinician, and nothing more. A shape system is also in place detailing which topics are essential for exams (circle), less essential (square), and for those hoping to distinguish themselves clinically (triangle). My tip for the self-confessed neurophobe, who hopes that no questions on neurology or neurosurgery come up in exams, would be: just read this book; it has been tailored to this purpose. The book has been divided into 5 question papers. The papers get progressively more difficult and incorporate some of the answers to the previous papers, ensuring dynamic ascertainment and aggregation of knowledge throughout. Our advice is to go through the first paper and then the answers, as these come in useful for answering questions in the papers that follow, aiding memory recall. At the end of the book is a glossary of one-sentence summaries about each condition, which form the core essentials to be referred to. There are a few things not covered in this book, namely ENT and neuroanatomy. A lot of books do neuroanatomy better than I ever could, and I’ve never really been sharp at ENT to be honest! This book took forever and a day to finish, so I really hope you like it! — Conor Gillespie b4659_FM.indd 9 26-Aug-22 7:48:57 PM January 19, 2018 9:17 ws-book961x669 Beyond the Triangle: Brownian Motion...Planck Equation-10734 HKU˙book page vi This page intentionally left blank  9.61”x6.69” b4659   Neurology and Neurosurgery: 200 SBAs for Medical Students 200 SBAs for Medical Students xi About the Authors Conor Gillespie is a final year medical student at the University of Liverpool. He intercalated, completing an MPhil in Surgery and Oncology under Professor Michael Jenkinson at the University of Liverpool. His interests include clinical neurosciences, neuro- oncology, neurosurgery, and medical education. He is the recipient of a grant from the Wolfson foundation, a national award for intercalating students who excel academically. He was also awarded the Benjamin Ordman prize, given to the highest exam performance in the third year of medical school out of 290 students. He was the clinical and overall winner of the 2021 National Undergraduate Neuroanatomy Competition (NUNC). Outside of medicine, Conor enjoys football and formula one. He is also passionate about mental health and community work. Ameer Khan is a final year medical student at the University of Liverpool. During his fourth year, he served as the BMA rep for Liverpool before being promoted to the regional north west committee. He is interested in Cardiology, general medicine, and medical education. He is a coffee enthusiast, a big foodie, and an even bigger Liverpool FC fan. b4659_FM.indd 11 26-Aug-22 7:48:58 PM January 19, 2018 9:17 ws-book961x669 Beyond the Triangle: Brownian Motion...Planck Equation-10734 HKU˙book page vi This page intentionally left blank  9.61”x6.69” b4659   Neurology and Neurosurgery: 200 SBAs for Medical Students 200 SBAs for Medical Students xiii List of Editors and Illustrators Senior authors: Rhys Davies MA BMBCh, PhD, FRCP Consultant Neurologist and Honorary Senior Lecturer, The Walton Centre NHS Foundation Trust, Liverpool, UK Viraj Bharambe BM BSc (Hons) MRCP Neurology specialist registrar, The Walton Centre NHS Foundation Trust, Liverpool, UK Benedict D. Michael MBChB, MRCP, PhD Senior Clinician Scientist Fellow and Honorary Consultant Neurologist, University of Liverpool, Walton Centre NHS Foundation Trust, Liverpool, UK Abdurrahman Islim MPhil, MBChB Academic Foundation Doctor, Royal Liverpool and Broadgreen NHS Foundation Trust, Liverpool, UK Ali Bakhsh MRCS, BMBS (dist), MSc, BSc (Hons), FHEA Academic Clinical Fellow in Neurosurgery, the Walton Centre NHS Foundation Trust, Liverpool, UK Christopher Paul Millward MRCS, MSc, MBBS, BSc Neurosurgery Trainee, The Walton Centre NHS Foundation Trust, Liverpool, UK Michael D. Jenkinson MBChB (Hons), PhD, FRCSEd (Neuro Surg) Professor of Neurosurgery and Sir John Fisher / RCSEng Chair of Surgical Trials, University of Liverpool, The Walton Centre NHS Foundation Trust, Liverpool, UK b4659_FM.indd 13 26-Aug-22 7:48:58 PM January 19, 2018 9:17 ws-book961x669 Beyond the Triangle: Brownian Motion...Planck Equation-10734 HKU˙book page vi This page intentionally left blank  9.61”x6.69” b4659   Neurology and Neurosurgery: 200 SBAs for Medical Students 200 SBAs for Medical Students xv Chapter Editors and Reviewers Practice paper 2: George E Richardson MRes (candidate), MBChB (candidate) and Mohammad A Mustafa MRes (candidate), MBChB (candidate) Medical student, University of Liverpool, Liverpool, UK Practice paper 3: Basel A Taweel MPhil (candidate), MBChB (candidate) and Khaleefa Al- Naham MBChB Medical student, University of Liverpool, UK Practice paper 4: Roshan K Babar MPhil (candidate), MBChB (candidate) Medical student, University of Liverpool, UK Practice paper 5: Ali Bakhsh MRCS, BMBS (dist), MSc, BSc (Hons), FHEA Academic Clinical Fellow in Neurosurgery, the Walton Centre NHS Foundation Trust, Liverpool, UK b4659_FM.indd 15 26-Aug-22 7:48:58 PM January 19, 2018 9:17 ws-book961x669 Beyond the Triangle: Brownian Motion...Planck Equation-10734 HKU˙book page vi This page intentionally left blank  9.61”x6.69” b4659   Neurology and Neurosurgery: 200 SBAs for Medical Students 200 SBAs for Medical Students xvii Acknowledgments The authors would like to thank all of the brilliant staff at the Walton Centre NHS Foundation Trust — without their mentorship, inspiration and support, this book would not have been possible. The front cover of this book was designed by rawpixel.com / Freepik. b4659_FM.indd 17 26-Aug-22 7:48:58 PM January 19, 2018 9:17 ws-book961x669 Beyond the Triangle: Brownian Motion...Planck Equation-10734 HKU˙book page vi This page intentionally left blank  9.61”x6.69” b4659   Neurology and Neurosurgery: 200 SBAs for Medical Students 200 SBAs for Medical Students xix Disclaimer This book is for educational purposes only and should not be used to directly guide clinical practice. Many of the things reported in this book may change as guidelines evolve. If ever in doubt, please use your local trust/hospital guidelines. b4659_FM.indd 19 26-Aug-22 7:48:58 PM January 19, 2018 9:17 ws-book961x669 Beyond the Triangle: Brownian Motion...Planck Equation-10734 HKU˙book page vi This page intentionally left blank  9.61”x6.69” b4659   Neurology and Neurosurgery: 200 SBAs for Medical Students 200 SBAs for Medical Students xxi Contents Dedicationsv Forewordvii Prefaceix About the Authorsxi List of Editors and Illustratorsxiii Chapter Editors and Reviewersxv Acknowledgmentsxvii Disclaimerxix Practice Paper 1 1 Practice Paper 2 17 Practice Paper 3 33 Practice Paper 4 47 Practice Paper 5 63 Answers77 Practice Paper 1 — Answers 79 Practice Paper 2 — Answers 101 Practice Paper 3 — Answers 123 Practice Paper 4 — Answers 139 Practice Paper 5 — Answers 157 One Sentence Summaries Index (in Alphabetical Order) 167 Index175 b4659_FM.indd 21 26-Aug-22 7:48:58 PM January 19, 2018 9:17 ws-book961x669 Beyond the Triangle: Brownian Motion...Planck Equation-10734 HKU˙book page vi This page intentionally left blank  9.61”x6.69” b4659   Neurology and Neurosurgery: 200 SBAs for Medical Students 200 SBAs for Medical Students 1 Practice Paper 1 1. Cushing’s triad of raised intracranial pressure includes what? A. Hypertension, tachycardia, irregular respiration B. Hypotension, bradycardia, tachypnoea C. Supranuclear gaze palsy, pseudo-argyll Robertson pupils, nystagmus D. Bradycardia, hypertension, irregular respiration E. Ptosis, miosis, facial anhidrosis 2. A patient has recently been diagnosed as having a chronic subdural haematoma. What patient presentation would most likely represent this case? A. 23-year-old male who sustained an injury whilst playing cricket. He lost consciousness initially, recovered quickly, before deteriorating again an hour later. B. 65-year-old with chronic alcohol dependency presents to the emergency department 4 hours after falling down a flight of stairs. On examination, she has 3/5 power on the left-hand side. C. 28-year-old male presents with sudden onset headache that occurred during sexual intercourse with his partner. On examination, he has marked neck stiffness. D. 85-year-old female presents to the A&E accompanied by her daughter. For the last two weeks she has been intermittently confused and her daughter does not know why. She has diabetic peripheral neuropathy and atrial fibrillation, and takes warfarin for this. E. 55-year-old male presents with a 2-hour history of sudden onset left arm weakness that occurred whilst watching TV. 3. A 63-year-old patient presents to the hospital’s A&E department after tripping over one of the plants in his garden and hitting his head on a plant pot. He is normally fit and well with no medical history. He did not lose consciousness and has a GCS of 15 on examination, in addition to bruising behind the mastoid process and some clear nasal discharge. He is now 2 hours post-injury. His mini mental state examination is normal and he reports feeling well. What is the most appropriate management for this patient in the A&E? A. 300mg Aspirin, bleep stroke consultant B. Refer for neurosurgery outpatient appointment C. No requirement for CT head scan, can be discharged with safety netting D. CT head scan within the next 8 hours E. CT head scan within 1 hour b4659_Practice paper 1.indd 1 26-Aug-22 7:54:19 PM  9.61”x6.69” b4659   Neurology and Neurosurgery: 200 SBAs for Medical Students 2 Neurology and Neurosurgery Neuro 4. A 22-year-old female presents with worsening headaches for 3 months. These headaches are worse when she gets out of bed, bends over, or coughs. She also complains of reduced visual quality. She has a recent diagnosis of polycystic ovarian syndrome and has gained around 2 stone (13 kg) in the past year — her body mass index is now 38. On examination you find papilloedema and no other deficits, but her CT head scan results are normal. What is the most likely diagnosis? A. Tension headache B. Glioblastoma C. Idiopathic intracranial hypertension D. Cavernous sinus thrombosis E. Chronic subdural haematoma 5. Janice, an 82-year-old female, presents with sudden onset left-sided weakness whilst watching TV. Her husband also noted that her speech is slurred. She is normally fit and well and does not take any medications. She is seen by the stroke consultant on-call and diagnosed with a suspected acute right total anterior circulatory stroke, and after a normal CT head scan undergoes thrombolysis 4 hours after symptom onset. 3 hours later, she appears drowsy and suddenly becomes unresponsive. What is the most likely diagnosis? A. Overuse of opiate medication B. Malignant middle cerebral artery syndrome C. Subarachnoid haemorrhage D. Haemorrhagic transformation of infarct E. Hypoglycaemia 6. A 28-year-old male who is normally fit and well presents in a dishevelled state. His wife tells you he reported headaches for the past week, with the worst ones occurring first thing in the morning. In the past 4 days, he has developed a fever of 39.5°C and left leg weakness, and he is confused. His past history is unremarkable apart from having occasional migraines, and he recovered from an episode of sinusitis 2 weeks ago. He has not travelled abroad recently and does not use intravenous drugs. A CT scan shows a round, ring-enhancing lesion in the frontal lobe. What is the most likely diagnosis? A. Encephalitis B. Meningitis C. Central nervous system lymphoma D. Cerebral abscess E. Tuberculosis b4659_Practice paper 1.indd 2 26-Aug-22 7:54:19 PM  9.61”x6.69” b4659   Neurology and Neurosurgery: 200 SBAs for Medical Students 200 SBAs for Medical Students 3 7. A 65-year-old male presents to the general practitioner with bilateral leg pains. He has a 15-year history of poorly controlled type 2 diabetes and benign prostatic hyperplasia. He describes the pain as ‘dull’ and ‘like an electric shock’, and it is stopping him from sleeping. Which of the following agents should be avoided when treating this man’s pain? A. Pregabalin B. Duloxetine C. Amitriptyline D. Gabapentin E. Paracetamol 8. A 23-year-old male presents to the A&E after an assault. On examination, he opens his eyes when a trapezius squeeze is applied, and he is groaning but not formulating any words. When you apply a pain stimulus to his shoulder, he pulls his limb away from the stimulus. What is the likely score on the patient’s Glasgow Coma Scale? A. 6 B. 7 C. 8 D. 9 E. 10 9. A patient is referred to a neurologist outpatient clinic with a suspected diagnosis of Horner’s syndrome. What describes the classical features of this syndrome? A. Ptosis, mydriasis, exophthalmos B. Ptosis, miosis, facial anhydrosis, enophthalmos C. Miosis, mydriasis, exophthalmos D. Ataxia, ophthalmoplegia, confusion E. Headache, fever, altered consciousness b4659_Practice paper 1.indd 3 26-Aug-22 7:54:19 PM  9.61”x6.69” b4659   Neurology and Neurosurgery: 200 SBAs for Medical Students 4 Neurology and Neurosurgery Neuro 10. A 36-year-old female attends the A&E department with a 2-hour history of sudden onset headache, which she describes as like ‘being hit over the head with a baseball bat’. The on-call neurologist suspects a subarachnoid haemorrhage. Her CT head scan at 2 hours after onset is reported as normal by a consultant radiologist. What is the most appropriate next investigation to undertake? A. CT angiography at 24 hours B. Repeat CT head scan at 12 hours C. Repeat CT head scan at 2 hours D. Lumbar puncture immediately E. Lumbar puncture at 12 hours 11. A 65-year-old retired army sergeant attends the GP with his wife. She reports that for the past two years, he has appeared lethargic, lost significant muscle mass compared to his army days, and has had problems swallowing food. On examination, the patient appears emaciated with widespread muscle wasting, and you note the presence of fasciculations on his tongue. His reflexes are weak, he has a positive Babinski sign in both legs, and his sensory function is intact. What is the most likely diagnosis? A. Amyotrophic lateral sclerosis B. Parkinson’s disease C. Huntington’s disease D. Multiple sclerosis E. Duchenne’s muscular dystrophy 12. A patient is referred to a neurology outpatient clinic with memory loss. After taking his history, the doctor suspects normal pressure hydrocephalus. What is the triad associated with this presentation of symptoms? A. Personality change, frequent falls, leg weakness B. Dementia, impotence, fluctuating consciousness C. Dementia, dysarthria, dysphonia D. Urinary incontinence, gait ataxia, dementia E. Urinary frequency, dementia, frequent falls b4659_Practice paper 1.indd 4 26-Aug-22 7:54:19 PM  9.61”x6.69” b4659   Neurology and Neurosurgery: 200 SBAs for Medical Students 200 SBAs for Medical Students 5 13. A 57-year-old male is diagnosed with a brain tumour after presenting with a 2-month history of headaches. The tumour is removed and diagnosed as a brain metastasis. Which cancer is the most common primary source of brain metastases? A. Breast B. Melanoma C. Kidney D. Lung E. Liver 14. Which of the following is NOT an absolute contraindication to having a lumbar puncture? A. Glasgow Coma Scale of 8 B. Heart rate of 45 and blood pressure of 180/105, five minutes before the lumbar puncture C. Papilloedema D. Cardio or respiratory instability E. Headache 15. A 23-year-old male patient attends an epilepsy review, diagnosed after having two tonic-clonic seizures one year ago. While his seizures have stopped since commencing medication, he complains of unintentional weight gain of 8kg since starting them. Which anti-convulsant medication is most associated with weight gain? A. Sodium valproate B. Levetiracetam (Keppra®) C. Lamotrigine D. Carbamazepine E. Phenytoin b4659_Practice paper 1.indd 5 26-Aug-22 7:54:19 PM  9.61”x6.69” b4659   Neurology and Neurosurgery: 200 SBAs for Medical Students 6 Neurology and Neurosurgery Neuro 16. A 28-year-old male accountant attends his GP with troublesome right-sided headaches for the past 6 months. He describes experiencing up to two episodes of headache each day, always around 8pm. The episodes last for 2 hours each time. When he has an episode, it is excruciatingly painful, and he reports having to walk around in circles until the pain subsides. On occasion, he reports excessive tearing from the right eye. Neurological examination is normal, there is no neck stiffness, and ophthalmoscopy is normal. Which of the following is the most likely diagnosis? A. Migraine B. Tension headache C. Cluster headache D. Space-occupying lesion E. Medication overuse headache 17. A 31-year-old female dental nurse attends the GP. For the past two weeks she has been extremely troubled by intense left-sided facial pain. The pain originates from the angle of her jaw and travels to the corner of her mouth, and she describes the pain as ‘like little electric shocks’. She has noticed that area of her face is now extremely sensitive, and the pain can be brought on by touching the area. She is normally fit and well, has no allergies, and does not take any medication. The week before, she went for a check-up with her dentist, who gave her the all-clear. What is the most likely diagnosis? A. Temporomandibular joint dysfunction B. Paroxysmal hemicrania C. Multiple sclerosis D. Dental-related pain E. Trigeminal neuralgia 18. For the previous question (17), assuming there are no contraindications, what is the first line treatment to start the patient on? A. Lithium B. Propranolol C. Primidone D. Carbamazepine E. Sodium valproate b4659_Practice paper 1.indd 6 26-Aug-22 7:54:19 PM  9.61”x6.69” b4659   Neurology and Neurosurgery: 200 SBAs for Medical Students 200 SBAs for Medical Students 7 19. A 73-year-old male presents to the A&E department. 4 hours earlier, his wife noticed that, while watching TV, his speech suddenly became slurred and he could not move his left arm. He has a past medical history of hypertension and type 2 diabetes, for which he currently takes ramipril and gliclazide respectively. An acute stroke is suspected. What is the most appropriate initial investigation for this patient (whilst in the emergency department)? A. Immediate contrast CT head scan B. Immediate non-contrast CT head scan C. Urgent MRI brain scan D. Urine dipstick E. Capillary blood glucose 20. The concerned parents of a 9-month-old baby bring him to a GP. Over the past 2 months, they describe the child as having frequent episodes of flexing his arms towards his chest before straightening them out, whilst drawing his knees up to his chest. On examination, he cannot sit upright, has poor head control, and does not babble or say any words. They had attended a GP appointment 3 months ago and the locum GP diagnosed him with colic, but this has not resolved. What is the most likely diagnosis? A. Infantile spasms (West syndrome) B. Absence seizures C. Benign Rolandic epilepsy D. Juvenile myoclonic epilepsy E. Panayiotopoulos syndrome 21. You are an F1 doctor doing a ward round on a stroke ward. The stroke consultant asks the next patient, who is recovering from a left partial anterior circulation stroke, how he is doing. The patient replies, ‘Nice very breakfast my own horse but then spaceships purple today’. What best describes the patient’s speech issue? A. Broca’s aphasia B. Wernicke’s aphasia C. Conduction aphasia D. Dysarthria E. Dysphagia b4659_Practice paper 1.indd 7 26-Aug-22 7:54:19 PM  9.61”x6.69” b4659   Neurology and Neurosurgery: 200 SBAs for Medical Students 8 Neurology and Neurosurgery Neuro 22. Which of the following is NOT a risk factor for Carpal tunnel syndrome? A. Female gender B. Pregnancy C. Multiple sclerosis D. Rheumatoid arthritis E. Hypothyroidism 23. You see a 48-year-old homeless male with a history of alcohol misuse and chronic pancreatitis, who was brought into the ward after being found confused by a friend. His friend reports that he had not eaten or drank anything for days and is confused and struggling to walk. You suspect that he may have Wernicke’s encephalopathy. What is the triad for Wernicke’s encephalopathy? A. Confusion, dysarthria, dysphasia B. Confusion, ataxia, ophthalmoplegia C. Nystagmus, ataxia, ophthalmoplegia D. Confusion, vomiting, dementia E. Diarrhoea, dermatitis, dementia 24. A 12-year-old boy is accompanied by his mother to a GP appointment, and he states that his legs feel tired after walking. He was adopted as a young child and has no other past medical history. On examination, the patient appears to have grossly misshapen feet in a concave appearance, hammer toes, and some evidence of distal muscle wasting of the leg. The patient otherwise appears well. What is the inheritance pattern of the most likely diagnosis? A. Autosomal dominant B. Autosomal recessive C. X-linked recessive D. X-linked dominant E. Mitochondrial b4659_Practice paper 1.indd 8 26-Aug-22 7:54:19 PM  9.61”x6.69” b4659   Neurology and Neurosurgery: 200 SBAs for Medical Students 200 SBAs for Medical Students 9 25. You are in clinic with a neurology registrar, during which he gets bored and decides to grill you on your neuroanatomy. He asks which dermatome supplies the ventral aspect of the little finger. What is the correct answer? A. C6 B. C7 C. C8 D. T1 E. T2 26. In the same clinic with the neurology registrar, you examine a patient with suspected degenerative cervical myelopathy, referred for her first specialist appointment by her GP. The neurology registrar holds the patient’s hand and flicks the nail of the middle finger, and you notice the patient’s thumb and index finger flex spontaneously. What is the sign being elicited? A. Babinski’s sign B. Hoover’s sign C. Hoffman’s sign D. Brudzinski’s sign E. Lhermitte’s sign 27. You are a final year medical student with your own clinic in a GP surgery. Your next patient is a 70-year-old male. For the past 6 months, he appears to have slowed down, taking much longer to get dressed in the morning and return from the shops. On further questioning, he trivially reports losing his sense of smell 2 years ago, and his handwriting appears much smaller than it used to. On examination, you notice a 3–5 Hz tremor that disappears when he moves his arm, and he has a fixed, limited facial expression. What is the most likely diagnosis? A. Multiple systems atrophy B. Motor neurone disease C. Idiopathic Parkinson’s disease D. Corticobasal degeneration E. Frontotemporal dementia b4659_Practice paper 1.indd 9 26-Aug-22 7:54:19 PM  9.61”x6.69” b4659   Neurology and Neurosurgery: 200 SBAs for Medical Students 10 Neurology and Neurosurgery Neuro 28. Which of the following is a feature of an upper motor neuron lesion? A. Muscle wasting B. Fasciculations C. Diminished or absent reflexes D. Positive Babinski’s sign E. Hypotonia 29. A 75-year-old female is brought by ambulance to the A&E after falling down a flight of stairs while celebrating a friend’s diamond wedding anniversary. She has a past history of alcohol misuse and atrial fibrillation, for which she takes apixaban 5mg once daily. Her only other regular medication is atorvastatin 20mg once nightly. She appears confused, and the paramedics hand over that she has a GCS of 10. A CT head scan shows a hyperdense, crescent-shaped opacity that crosses suture lines with no skull fractures. What is the most likely diagnosis? A. Acute extradural haematoma B. Acute subdural haematoma C. Chronic subdural haematoma D. Basal skull fracture E. Pneumocephalus 30. A 2-week-old baby is referred to the neurosurgical team after being found to have a rapidly enlarging head circumference, which is now measured to be in the 98th percentile. She was born prematurely at 32 weeks due to foetal distress and suffered an intraventricular haemorrhage at 2 days old. The paediatric neurosurgery registrar suspects hydrocephalus. Which of the following examination signs will NOT be present? A. Enlarged head circumference B. Dilated scalp veins C. Sun setting of eyes D. Microcephaly E. Bulging anterior fontanelle b4659_Practice paper 1.indd 10 26-Aug-22 7:54:19 PM  9.61”x6.69” b4659   Neurology and Neurosurgery: 200 SBAs for Medical Students 200 SBAs for Medical Students 11 31. Ben, a 22-year-old medical student, attends his GP in a very concerned state. For the past 2 months, he has complained of feeling dizzy, often after standing up. He is very worried that he might have an arrythmia, and he has read all about them as part of his studies. His lying and standing blood pressure measurements are within normal range, and his 7-day ambulatory ECG reveals 8 ectopic beats along with sinus rhythm. He does not take these results well. In his notes over the last 4 years, he has undergone checks at a genitourinary medicine clinic with an eventual diagnosis of non-gonococcal urethritis, was investigated for dysphagia with no pathological cause found, and had a benign skin mole removed after expressing concern. What is the most likely diagnosis? A. Somatisation disorder B. Arrythmia C. Munchausen’s syndrome D. Hypochondriac disorder E. Acquired immunodeficiency 32. Mohammed, a 72-year-old retired pilot presents to his GP with a sudden onset of back pain for the last 2 days. He describes having a pain ‘like an elastic band’ in his upper abdomen and back for 8 weeks, but did not seek treatment because he ‘did not want to be a bother’. He is normally fully mobile, but for the last 2 days has found getting about the house difficult. He has no urinary incontinence. He has a past history of prostate cancer, and he underwent radiotherapy 12 months ago for a recurrence. On examination, he has MRC grade 2/5 power in both lower limbs. What is the most appropriate immediate management for this patient? A. Immediate neurosurgical decompression B. Urgent oncology referral for radiotherapy C. Position the patient upright D. Give the patient dexamethasone 16mg E. Urgent MRI scan (within 12 hours) 33. A patient is brought into the A&E after suffering a stab wound to the back during a fight in the city centre. On examination, the patient has considerable neurological deficits and a right-sided stab wound. The consultant suspects a diagnosis of Brown-Séquard syndrome. What examination findings would you expect? A. Right-sided loss of pain and temperature, left-sided weakness B. Right-sided leg weakness and loss of pain and temperature, left-sided loss of proprioception and vibration C. Right-sided weakness, right-sided loss of pain and temperature D. Left-sided loss of pain and temperature only E. Right-sided leg weakness and loss of vibration and proprioception, left-sided loss of pain and temperature b4659_Practice paper 1.indd 11 26-Aug-22 7:54:20 PM  9.61”x6.69” b4659   Neurology and Neurosurgery: 200 SBAs for Medical Students 12 Neurology and Neurosurgery Neuro 34. You are on rotation at a medical ward when one of the senior house officers suggests that you examine the eyes of a 65-year-old patient. On examination, the patient’s right eyelid is significantly lower than that of the left, and his right pupil is fixed and unreactive to light. When the patient is asked to look straight ahead, the left eye looks forward, but the right eye appears located in the right lower quadrant of the eye. Which cranial nerve is affected? A. Second cranial nerve (optic) B. Third cranial nerve (oculomotor) C. Fourth cranial nerve (trochlear) D. Fifth cranial nerve (trigeminal) E. Sixth cranial nerve (abducens) 35. Kyle, a 12-year-old boy, is brought to his GP by his concerned parents. They have noticed that over the last few months, his performance in school has steadily declined. He used to be at the top of his class for mathematics, but now he struggles to do basic sums. His mum reports that he forgot the names of his friends when they came over to play football last week, and he has become a lot more quiet. On examination, the patient has a resting tremor, and you note the presence of a golden-brown ring around his eyes. He is normally fit and well, and there is no family history. What is the most likely diagnosis? A. Inherited Parkinson’s disease B. Subacute sclerosing panencephalitis C. Wilson’s disease D. Huntington’s E. Tertiary syphilis 36. Reginald, a 70-year-old retired navy captain, comes to see his GP. He apologises, saying his wife made him come in. In the last 6 months, his shoe size has gone up three sizes, and he has noticed his wedding ring no longer fits on his finger, but he denies recent weight gain. His past medical history includes hypertension resistant to 3 anti-hypertensive medications and bilateral carpal tunnel syndrome. On examination, you note prognathism and a very large tongue. What is the most likely visual deficit you will see on examination? A. Unilateral blindness B. Bitemporal superior hemianopia C. Bitemporal inferior hemianopia D. Left-sided homonymous hemianopia E. Bilateral homonymous hemianopia with macular sparing b4659_Practice paper 1.indd 12 26-Aug-22 7:54:20 PM  9.61”x6.69” b4659   Neurology and Neurosurgery: 200 SBAs for Medical Students 200 SBAs for Medical Students 13 37. A 55-year-old man has been at the intensive care unit for the past 6 weeks after being involved in a high-speed motor vehicle accident. He was not wearing a seatbelt and he had a GCS of 3 at the scene. His recovery has been slow and he is unable to be taken off the ventilator. A CT head scan shows small punctate contusions but is otherwise normal. What is the most likely diagnosis? A. Extradural haematoma B. Coning due to raised intracranial pressure C. Hydrocephalus D. Diffuse axonal Injury E. Subdural haematoma 38. You are in the A&E as a foundation doctor and the consultant shows you the image below. What is the most likely diagnosis? *With permission from Dr Christopher McLeavy, Royal Liverpool and Broadgreen University Hospitals NHS Trust, UK A. Hydrocephalus B. Acute extradural haematoma C. Normal scan D. Subarachnoid haemorrhage E. Acute subdural haematoma b4659_Practice paper 1.indd 13 26-Aug-22 7:54:20 PM  9.61”x6.69” b4659   Neurology and Neurosurgery: 200 SBAs for Medical Students 14 Neurology and Neurosurgery Neuro 39. On the same shift, another F1 approaches you and asks you to help them interpret another scan. This patient was admitted to their acute medical ward after being found unresponsive at home, and he has a significant focal neurological deficit. Based on their CT scan taken 2 hours ago, what is the most likely diagnosis? *With permission from Dr Christopher McLeavy, Royal Liverpool and Broadgreen University Hospitals NHS Trust, UK A. Chronic subdural haematoma B. Middle cerebral artery infarction C. Diffuse axonal injury D. Hydrocephalus E. Acute extradural haematoma b4659_Practice paper 1.indd 14 26-Aug-22 7:54:22 PM  9.61”x6.69” b4659   Neurology and Neurosurgery: 200 SBAs for Medical Students 200 SBAs for Medical Students 15 40. A 38-year-old scaffolder attends the A&E department after an accident at work where 12 bricks fell on his neck, causing it to bend downwards. He noticed immediate weakness and altered sensation afterwards. On examination, he has MRC grade 2/5 power in both legs, but grade 4/5 power in both arms and grade 5/5 power in the rest of the upper limbs. He cannot feel a pinprick on his legs, but can recognise when a tuning fork is placed on them. What is the most likely diagnosis? A. Anterior cord syndrome B. Central cord syndrome C. Syringomyelia D. Brown-Sequard syndrome E. Spinal shock b4659_Practice paper 1.indd 15 26-Aug-22 7:54:22 PM January 19, 2018 9:17 ws-book961x669 Beyond the Triangle: Brownian Motion...Planck Equation-10734 HKU˙book page vi This page intentionally left blank  9.61”x6.69” b4659   Neurology and Neurosurgery: 200 SBAs for Medical Students 200 SBAs for Medical Students 17 Practice Paper 2 1. Mary is a 78-year-old female who was referred by her GP to the movement disorders clinic with a suspected diagnosis of Parkinson’s. She has noticed that, over the last 6 months, she has developed a resting tremor that improves with movement, and she has slowed significantly. On taking a more detailed history, she reports that before her symptoms started, she began suffering from frequent falls and now uses a wheelchair to prevent them from happening. On examination, she has limited eye movements and cannot move them upwards, as well as a fixed facial expression with the appearance of looking surprised. What is the most likely diagnosis? A. Idiopathic Parkinson’s disease B. Corticobasal degeneration C. Multiple systems atrophy D. Progressive supranuclear palsy E. Drug-induced parkinsonism 2. Annie is a 36-year-old Caucasian female who has presented to her GP. Last week, she noticed a gradual onset of left eye pain with associated blurred vision, which has now thankfully settled down. She has a past medical history of hypothyroidism and depression, and is taking thyroxine and sertraline for these respectively. She reports no headaches or previous episodes and no other symptoms, although she does report having a sudden onset of numbness with mild weakness of her right leg for 2 days in the previous year. On examination, her vision is normal. What is the most likely diagnosis? A. Amaurosis fugax B. Primary angle glaucoma C. Multiple sclerosis D. Conversion disorder E. Space-occupying lesion b4659_Practice paper 2.indd 17 26-Aug-22 7:53:11 PM  9.61”x6.69” b4659   Neurology and Neurosurgery: 200 SBAs for Medical Students 18 Neurology and Neurosurgery Neuro 3. Mahmood is a 65-year-old male with a new diagnosis of amyotrophic lateral sclerosis by his neurologist. The prognosis and clinical course have been explained to him. He asks the neurologist if there are any medications that may help him live longer, as his daughter is currently a third year medical student and it would mean everything to him to see her graduate. What drug improves survival in patients with his condition? A. Riluzole B. Dexamethasone C. Prednisolone D. Tetrabenazine E. Natalizumab 4. Gerry, a 34-year-old male patient at your GP clinic, has recently been diagnosed with Huntington’s. The inherited nature of the condition has been explained to him. After being quite reserved throughout the consultation, he tells you that his wife is currently 28 weeks pregnant with their first child, a baby boy. He is worried about passing the condition on to his son and asks you what his son’s chances are of inheriting the disease. His wife is not affected by the condition. What do you tell him? A. Impossible to determine without further family history B. 25% C. 50% D. 100% E. 0% 5. A 25-year-old PhD student attends the epilepsy clinic after having a suspected first seizure. This was noticed by her partner, who describes finding her ‘shaking her limbs and then going stiff’ for ten minutes in the morning. The episode resolved spontaneously, and she had no urinary or faecal incontinence, bit the centre of her tongue, and was noticeably tearful immediately afterwards. He describes her eyes as being clenched shut during the episode. She has no past medical history, but reports being ‘stressed out’ as her PhD thesis is due next week. What is the most likely diagnosis? A. Generalised tonic-clonic seizure B. Non-epileptic attack disorder C. Conversion disorder D. Munchausen’s syndrome E. Status epilepticus b4659_Practice paper 2.indd 18 26-Aug-22 7:53:11 PM  9.61”x6.69” b4659   Neurology and Neurosurgery: 200 SBAs for Medical Students 200 SBAs for Medical Students 19 6. As an F2 doctor at work on Saturday, you are bleeped to see to an emergency at one of the wards. There, you find a worried nurse who explains that the patient is a 53-year-old male who underwent surgery to remove a brain tumour and has been fitting for the last 10 minutes. The nurse has secured his airway and is giving high flow oxygen via a non-rebreathe mask, and the patient is fitting continuously. You note a pink cannula located on the dorsum of the wrist placed by the anaesthetic team yesterday. After calling for help, what is your next immediate management? A. Call the anaesthetic team for immediate support before commencing any management B. Give IV phenytoin 15–25 mg/kg after setting up a large bore cannula C. Give rectal diazepam 10 mg D. Give IV lorazepam 4 mg E. Wait another 20 minutes before intervening 7. You are in a GP and your next patient is a 28-year-old female who is 12 weeks pregnant. For the past 6 weeks, she has been troubled by intense headaches. They happen once every few days and are dull and achy in nature. During an episode, she lies still and tries to go into a dark room, which sometimes helps. There are no associated visual disturbances and her blood pressure on examination is normal. The headaches impact her work as a primary school teacher and she is desperate to resolve them. Apart from well-controlled asthma with a salbutamol inhaler, she is well. What medication would you offer her to prevent her headaches? A. Propranolol B. Topiramate C. Amitriptyline D. Metoclopramide E. Codeine phosphate 8. You are the GP of Jean, a 78-year-old retired teacher from Wales. One day, she comes to you with a 2-week history of troublesome headache. The headache presented over a few days and is 8/10 in intensity. She also describes feeling tired and weak during the same period. She has noticed that the pain is brought on by combing her hair, and she has had some difficulty chewing foods which she thinks is unrelated. Bloods have already been taken and sent off to test for markers that would support the diagnosis. What is the most appropriate management step? A. Wait for blood tests to come back before deciding on management B. Urgent rheumatology referral C. Book an urgent MRI brain scan D. Start prednisolone 60–80 mg E. Start prednisolone 15–20 mg b4659_Practice paper 2.indd 19 26-Aug-22 7:53:11 PM  9.61”x6.69” b4659   Neurology and Neurosurgery: 200 SBAs for Medical Students 20 Neurology and Neurosurgery Neuro 9. A 35-year-old female patient presents to the neurology clinic. For the past 6 months, she has been feeling extremely tired and weak, most often at the end of her long day working as an accountant. She also complains of double vision, which occurs exclusively in the evenings. She had seen an optometrist who ruled out ophthalmological causes. On examination, she has MRC grade 5 power throughout initially; however, after flexing her arm 3 times, her power reduces to MRC grade 3. What is the most likely diagnosis? A. Myaesthenia gravis B. Lambert-Eaton myaesthenic syndrome C. Multiple sclerosis D. Amyotrophic lateral sclerosis E. Polymyalgia rheumatica 10. You are in the A&E as a medical student and you see the consultant rush to a new patient in triage, thought to be having an acute stroke. While the patient is getting their CT scan, the registrar asks you, how long, after symptom onset, are patients eligible to receive thrombolysis and thrombectomy, respectively. What would the answer be? A. 3 hours for thrombolysis, 6 hours for thrombectomy B. 4.5 hours for thrombolysis, 18 hours for thrombectomy C. 4.5 hours for thrombolysis, 6 hours for thrombectomy D. 6 hours for thrombolysis, 24 hours for thrombectomy E. 4.5 hours for thrombolysis, thrombectomy no longer recommended in stroke 11. You are shadowing doctors as part of the acute medical unit ward round and come across the same patient you saw in the A&E the previous day (Question 10). The patient was not eligible for thrombolysis and suffered a large stroke. On examination, the patient’s speech is slurred, and they appear frustrated when trying to answer the consultant’s questions. They have a dense hemiplegia affecting the left-hand side of their whole body, and the consultant notes left-sided homonymous hemianopia on examination. According to the Bamford classification, what type of stroke do they have? A. Left total anterior circulatory stroke B. Right total anterior circulatory stroke C. Left partial anterior circulatory stroke D. Right partial anterior circulatory stroke E. Lacunar stroke b4659_Practice paper 2.indd 20 26-Aug-22 7:53:11 PM  9.61”x6.69” b4659   Neurology and Neurosurgery: 200 SBAs for Medical Students 200 SBAs for Medical Students 21 12. A 25-year-old male railway engineer attends a GP surgery with his concerned parents. 8 weeks ago, he was working on the tracks when part of the track flew up and hit him on the head. Before the accident, he was very mild mannered, but since then he has become more aggressive, been in several bar fights, and lost ten thousand pounds of savings on slot machines. The patient does not appear concerned, swearing excessively throughout the consultation and demanding that he be allowed to leave as ‘there is nothing wrong with me’. Which part of the brain is most likely affected? A. Global brain dysfunction B. Frontal lobe C. Parietal lobe D. Temporal lobe E. Occipital lobe 13. An 82-year-old male sheepishly walks into a memory clinic with his wife. She is concerned about his memory, which has gradually declined over the past 2 years. He was an avid solver of newspaper crossword puzzles for many years, but now he cannot come up with a single answer. She has also noticed that, occasionally at night, he fails to recognise who she is even though they have been married for 50 years. He has worked as a bus driver all his life and is fit and well. On examination, he makes an active effort to address all questions asked, and his Montreal Cognitive Assessment score is 17/30. What is the most likely diagnosis? A. Mild cognitive impairment B. Depressive pseudodementia C. Alzheimer’s disease D. Vascular dementia E. Frontotemporal dementia 14. A 23-year-old male presents to the emergency department complaining of limb weakness starting with his legs, which has now moved up to his knee. He is very worried as the weakness has been getting worse since it started 10 days ago. Other than an episode of bad food poisoning 2 weeks ago after a ‘dodgy takeaway’, he is normally fit and well. Examination reveals MRC grade 2/5 power in both lower limbs, and reflexes are absent. What is the most likely diagnosis? A. Peripheral neuropathy B. Charcot-Marie-Tooth disease C. Space-occupying lesion D. Guillain-Barré syndrome E. Brown-Sequard syndrome b4659_Practice paper 2.indd 21 26-Aug-22 7:53:11 PM  9.61”x6.69” b4659   Neurology and Neurosurgery: 200 SBAs for Medical Students 22 Neurology and Neurosurgery Neuro 15. You are in your final year OSCE assessment and have been asked to carry out a neurological motor examination. The patient’s right side has normal power, but both the left arm and leg are weak. The patient cannot raise their arm or leg when asked to, but there is a flicker of contraction and the patient can flex the arm and leg when both are placed flat on the examination couch. The examiner asks you: What MRC grade power does this patient have on the left side? A. Grade 5 B. Grade 4 C. Grade 3 D. Grade 2 E. Grade 1 16. A 28-year-old female attends the neuro-ophthalmology clinic over an abnormality found during a routine eye test by her optician. She is asymptomatic. On examination, the right pupil is dilated and does not respond to the light reflex, but responds slowly to accommodation. Her eye movements are normal and there is no ptosis. The only other notable finding on examination is absent knee and ankle jerks. What is the most likely diagnosis? A. Relative afferent pupillary defect B. Holmes-Adie pupil C. Argyll Robertson pupil D. Vitamin B12 deficiency E. Third cranial nerve palsy 17. A 32-year-old male patient has a recent diagnosis of Creutzfeldt-Jakob disease and is seeing a neurologist. He complains of odd movements and describes them as sudden and uncontrollable electric shock-like jerks of his arm that last a second or two before resolving. He describes not experiencing restlessness. What movement disorder is he describing? A. Dystonia B. Akathisia C. Tardive dyskinesia D. Hemiballismus E. Myoclonus b4659_Practice paper 2.indd 22 26-Aug-22 7:53:12 PM  9.61”x6.69” b4659   Neurology and Neurosurgery: 200 SBAs for Medical Students 200 SBAs for Medical Students 23 18. An 18-year-old male from a travelling family presents to his local GP. For years, his parents have noticed irregular lumps throughout his whole body, but did not seek medical attention as he was asymptomatic and is otherwise well. On examination, he has several bumpy lesions occupying a dermatomal pattern in his upper limbs, strange freckles over his axilla, and a series of light, brown macules on his lower back. What is the most likely diagnosis? A. Tuberous sclerosis B. Sturge-Weber syndrome C. Neurofibromatosis type 1 D. Neurofibromatosis type 2 E. Adenoma sebaceum 19. Whilst in clinic examining a patient with intractable vomiting, the consultant decides to test your anatomy and asks: in what region of the brain is the vomiting centre located? A. Midbrain B. Pons C. Medulla D. Area postrema E. Cerebrum 20. A 19-year-old male is brought to the emergency department with a reduced consciousness level. He was playing cricket when a wayward ball struck him in the side of the head. His friend reports that he ‘was out’ for a few minutes but quickly regained consciousness, seemed fine and continued playing, until he collapsed 30 minutes later. His current GCS is 9. What is the most likely diagnosis? A. Acute subdural haematoma B. Acute extradural haematoma C. Post-concussion syndrome D. Subarachnoid haemorrhage E. Malignant MCA infarction b4659_Practice paper 2.indd 23 26-Aug-22 7:53:12 PM  9.61”x6.69” b4659   Neurology and Neurosurgery: 200 SBAs for Medical Students 24 Neurology and Neurosurgery Neuro 21. Adel, a 54-year-old male, attends the neurosurgical clinic after an incidental mass was found during an MRI brain scan as part of a private health check. He is asymptomatic. The consultant explains to you that it is likely a tumour, located on the parietal convexity, with no brain invasion. The tumour is spherical and calcified. What is the most likely cause of his lesion? A. Gliosis from previous surgery B. Glioblastoma C. Astrocytoma D. Meningioma E. Medulloblastoma 22. A 35-year-old female attends the emergency department after experiencing a sudden onset of headache whilst having sexual intercourse with her husband. The pain is 10/10 in severity, and she describes it as ‘like being hit over the head with a cricket bat’ and it came on suddenly over 2–3 minutes. She has a past medical history of hypertension and currently takes amlodipine but nothing else. On examination, she has marked neck stiffness and is in considerable pain. What is the most likely diagnosis? A. Meningitis B. Encephalitis C. Post-coital headache D. Subarachnoid haemorrhage E. Benign thunderclap headache 23. Oliver, a 61-year-old semi-retired neurologist, comes to see you. He has been struggling over the past few months to use both his hands. He finds it difficult to do his buttons up in the morning, and finds it even harder to type up patient notes on the ward computers. He also says that the strength in his arms is ‘a lot less than it used to be’. On examination, there is reduced power in the upper arms and muscles of the hand, and there is a positive Hoffman’s sign. What is the most likely diagnosis? A. Degenerative cervical myelopathy B. Motor neurone disease C. Primary lateral sclerosis D. Lumbar radiculopathy E. Multiple sclerosis b4659_Practice paper 2.indd 24 26-Aug-22 7:53:12 PM  9.61”x6.69” b4659   Neurology and Neurosurgery: 200 SBAs for Medical Students 200 SBAs for Medical Students 25 24. Jennie, an 82-year-old female, visits the GP for her first appointment in ten years (she ‘doesn’t like to be a bother’). Over the last 24 hours, she has been troubled by terrible back pain, which came on without any trigger. Since then, she reports leg weakness and could not get out of her chair this morning, so she asks the GP for her first appointment in ten years. She reluctantly admits that she has had ‘a few accidents’ with her bowels and urine over the same period. On examination, she has reduced power in the legs and cannot feel any pinprick sensation in the peri-anal area. What is the most likely diagnosis? A. Lumbar disc prolapse B. Malignancy C. Cauda equina syndrome D. Osteoporotic vertebral fracture E. Urinary tract infection 25. A 53-year-old male who has a known diagnosis of glioblastoma and is being managed with the best supportive care presents to the A&E department, acutely unwell with a reduced consciousness level. He was found by his ex-wife, and you have little history. On examination, his GCS is 8, breathing is regular, right pupil is fixed, dilated and unresponsive to light, and entire left-hand side is affected by a dense hemiparesis. What complication has the patient developed? A. Tonsillar herniation B. Subfalcine herniation C. Hydrocephalus D. Uncal (transtentorial) herniation E. New onset stroke 26. A 27-year-old female who is recovering from a bad episode of sinusitis presents to the A&E with painful eye movements and double vision. She is normally fit and well. On examination, there is significant eyeball protrusion and oedema surrounding both eyes. She has loss of forehead sensation bilaterally, and ophthalmoscopy reveals papilloedema. What is the most likely diagnosis? A. Pituitary apoplexy B. Cavernous sinus thrombosis C. Intracerebral malignancy D. Idiopathic intracranial hypertension E. Posterior communicating artery aneurysm b4659_Practice paper 2.indd 25 26-Aug-22 7:53:12 PM  9.61”x6.69” b4659   Neurology and Neurosurgery: 200 SBAs for Medical Students 26 Neurology and Neurosurgery Neuro 27. A 45-year-old male security guard collapsed at work and was brought to the A&E. He had complained to his colleagues of headaches that are most severe in the morning over the last 3 months as well as occasional double vision, but was determined to ‘soldier on’ and not seek medical advice. An emergency CT scan identifies a suspicious mass lesion in the frontal lobe with very prominent oedema around the mass. What medication should be given to reduce the oedema and help with his symptoms? A. Nimodipine B. Morphine sulphate C. Dexamethasone D. Mannitol E. Acetazolamide 28. A 52-year-old male is brought into the emergency department by his partner, who is concerned about his behaviour. For the past 2 months his memory has declined significantly and he has forgotten to pay his bills, become very ‘amped up’ lately — sleeping for only 2 hours a night — and become unsteady on his feet. He has no prior history of mental health problems, although he had a stroke ten years ago and a sudden widespread body rash that was never investigated 20 years ago. On examination, myoclonus is present, he has impaired joint proprioception and vibration, and his pupils are small and do not react to light from a pen-torch. What is the most likely diagnosis? A. Spinal tuberculosis B. Creutzfeldt-Jakob disease C. Tertiary syphilis D. Frontotemporal dementia E. Bipolar disorder 29. A 19-year-old male is brought into the A&E after falling and hitting his head on a kerb after a night out. He retained consciousness throughout and can remember the incident. On examination, he has a minor scalp laceration, his GCS is 15/15 with no focal neurological deficit, he is alert, orientated in time, place and person, and he does not complain of any neck stiffness. What is the next management step? A. CT head scan within 1 hour B. CT head scan within 8 hours C. Active neuro-observations, no CT scan indicated D. X-ray cervical spine E. MRI brain scan within 24 hours b4659_Practice paper 2.indd 26 26-Aug-22 7:53:12 PM  9.61”x6.69” b4659   Neurology and Neurosurgery: 200 SBAs for Medical Students 200 SBAs for Medical Students 27 30. During a ward round, the consultant demonstrates the knee jerk reflex to a group of medical students. What spinal cord level is this reflex testing? A. C5-C6 B. L1-L2 C. L3-L4 D. L4-L5 E. S1 31. A patient with multiple sclerosis is suffering with spasticity. Her leg is very tight and has episodes where it ‘goes into spasm’. This is causing her considerable distress as she has been falling over at work, and she does not want to draw attention to her diagnosis to her colleagues. What first line medication can be used to reduce her spasticity? A. Pyridostigmine B. Baclofen C. Diazepam D. Aspirin E. Propranolol 32. George, a 32-year-old male, presents to a neurosurgery outpatient clinic. 12 weeks ago, he was playing with his 4-year-old child in the playground and picking her up when he felt a sudden jolt of pain in his back. Since then, the pain has been unbearable and travels down his left-hand side. He says that the back of his leg gets ‘hot, cold and now numb’. On examination, he has no pain or tenderness in the back muscles, but has impaired pinprick sensation on the posterolateral aspect of the left leg, with slightly reduced power. What is the most likely diagnosis? A. Disc prolapse B. Musculoskeletal back pain C. Cauda equina syndrome D. Spinal tumour E. Metastatic spinal cord compression b4659_Practice paper 2.indd 27 26-Aug-22 7:53:12 PM  9.61”x6.69” b4659   Neurology and Neurosurgery: 200 SBAs for Medical Students 28 Neurology and Neurosurgery Neuro 33. A 20-year-old female is brought into the emergency department, complaining of sudden onset vision loss. On examination, she is visibly shaking and cannot perceive light, but notices and responds to your hand when you raise it into her field of vision. An hour ago, she was in a road traffic accident, where she unfortunately witnessed several fatalities. What is the most likely diagnosis? A. Transient ischaemic attack B. Giant cell arteritis C. Acute stress reaction D. Somatisation disorder E. Hypertensive emergency 34. A 32-year-old female with a recent diagnosis of multiple sclerosis (MS) attends a neurology clinic. She has been doing some reading on the internet and would like to know which MS ‘clinical pattern’ she has. The neurologist tells her that she has the most common pattern of MS. What type does she have? A. Primary-progressive B. Relapsing-remitting C. Secondary-progressive D. Progressive-relapsing E. Radiologically isolated 35. Samuel is a 23-year-old student who attends an outpatient first seizure clinic. He was watching TV with his girlfriend when she noticed he was acting strangely, and she took a video which she shows you. You see him stare blankly at the TV before smacking his lips repeatedly and chewing in an irregular fashion. Samuel cannot remember the event, but does recall developing a ‘metallic’ taste in his mouth 30 minutes beforehand, as well as a strange, funny sensation in his stomach. What location is the seizure he has had? A. Frontal lobe B. Parietal lobe C. Temporal lobe D. Occipital lobe E. Every lobe (generalised seizure) b4659_Practice paper 2.indd 28 26-Aug-22 7:53:12 PM  9.61”x6.69” b4659   Neurology and Neurosurgery: 200 SBAs for Medical Students 200 SBAs for Medical Students 29 36. A 26-year-old male with cluster headache attends his GP. Over the past 6 weeks, his symptoms have worsened and he now wants to explore medical options to prevent the episodes from occurring. He has no known drug allergies and takes no medication. What should the GP start him on? A. Verapamil B. Propranolol C. Lithium D. Lamotrigine E. Primidone 37. What scoring system would be used in an emergency department to assess the possibility of a patient having a stroke and to account for the possibility of stroke mimics? A. ABCD2 B. FAST C. NIHSS D. ROSIER E. GLASGOW 38. Study the image below. What is the most likely diagnosis? *With permission from Dr Christopher McLeavy, Royal Liverpool and Broadgreen University Hospitals NHS Trust, UK b4659_Practice paper 2.indd 29 26-Aug-22 7:53:13 PM  9.61”x6.69” b4659   Neurology and Neurosurgery: 200 SBAs for Medical Students 30 Neurology and Neurosurgery Neuro A. Acute subdural haematoma B. Acute on chronic subdural haematoma C. Acute extradural haematoma D. Subarachnoid haemorrhage E. Chronic subdural haematoma 39. Study the image below of a patient who presented with headaches, fever and left- sided weakness, and is a known intravenous drug user. What is the most likely diagnosis? *With permission from Dr Christopher McLeavy, Royal Liverpool and Broadgreen University Hospitals NHS Trust, UK A. Glioblastoma B. Meningioma C. Arteriovenous malformation D. Cerebral abscess E. Colloid cyst b4659_Practice paper 2.indd 30 26-Aug-22 7:53:15 PM  9.61”x6.69” b4659   Neurology and Neurosurgery: 200 SBAs for Medical Students 200 SBAs for Medical Stude