Neurology 🧠

A 28 year old woman with epilepsy is started on sodium valproate in the neurology clinic as there is no effective anti-epileptic drug alternative. What is the most appropriate advice to give her?

A 33 year old man who works as a lorry driver has a seizure and loss consciousness when he was walking in a shopping mall. He was seen in A&E and referred to the first fit clinic who have informed him that he suffered from an epileptic seizure. He has never suffered from a seizure prior to this one. What is the SINGLE most appropriate advice?

A 31 year old woman, no known case of medical illnesses, presents to the clinic with numbness and tingling of her hands and fingers followed by a severe throbbing headache localized to her left side. At home she tried to relieve her headache with cold packs, paracetamol, and ibuprofen but there was no relief. She has had similar episodes in the past. Currently, she is nauseated. On examination, she required the lights to be dimmed. What is the SINGLE most appropriate next step pharmacological management?

A 65 year old man with a history of metastatic lung cancer has had a fall involving a head injury 6 hours ago. He fell unconscious for a few minutes. His previous oncology team’s notes mention that no further active treatment for his lung cancer would be beneficial for him. He has been mostly bedbound for the past few months and requires full support with his activities of daily living. He is on the palliative register. He has a GCS of 8/15 and a blood pressure of 87/64 mmHg. His respiratory rate is 16 breaths/minute and his heart rate is 90 beats/minute. A CT was done as shown below:

What is the most appropriate management?

A 59 year old woman has a sudden onset of visual loss while jogging with her husband. She finds it difficult to see the right side of her visual field. There is no pain in her eyes. Her husband immediately takes her to the hospital but within 30 minutes, her vision returns back to normal. There was no associated limb weakness. Which is the SINGLE most likely artery that is affected?

A 72 year old woman who is in long-term residential care has recently become delirious and distressed following a chest infection. She has already been prescribed antibiotics for the chest infection which she started taking a day ago. The staff are concerned that she is a risk to herself. They have attempted verbal and non-verbal de-escalation techniques however she continues to be agitated and restless. What is the SINGLE most appropriate short-term medication?

A 70 year old man complains of a sudden onset of dizziness, numbness and weakness of the right side of his body and face accompanied by homonymous hemianopia, nystagmus and gait ataxia. He is nauseous and vomiting. On examination, he has gaze-evoked jerk nystagmus. What test would likely lead to a diagnosis?

A 73 year old woman presents to the clinic accompanied by her son with a 6-month history of weight loss and altered bowel habits. She has no significant past medical history and is on aspirin. On examination, the patient has an expressionless face, she takes many steps to turn, has a resting tremor in predominantly in her right hand, and cogwheel rigidity. Cognition is intact. What is the SINGLE most likely diagnosis?

A 42 year old man has increasing daytime sleepiness. He feels that his tiredness is affecting his work as he is unable to keep awake during meetings. He also complains of chaking episodes during his sleep. On examination, his BMI is 36 kg/m2, blood pressure is 150/70 mmHg, and respiratory exam was normal. What is the SINGLE most likely diagnosis?

A 45 year old man has acute back pain radiating down to his legs and faecal incontinence. On examination, a perineal sensory loss is noted. What is the SINGLE most likely diagnosis?

A 64 year old housewife, who has a past medical history of two previous episodes of hypertensive urgency, diabetes mellitus and hyperlipidaemia presents to Accident & Emergency (A&E) with the complaints of dysphagia and falling toward her right-hand side. She also reports loss of sensation of her right face and loss sensation on the left side of her body. Which of the following is the SINGLE most likely area of the brain that is affected?

A 50 year old woman presents following a fall. She reports pain and weakness in her hands for several months, swallowing difficulties, and has bilateral wasting of the small muscles of her hands. Her back and shoulders feel stiff. The reflexes in her upper limbs are absent. Both legs show increased tone and hyperreflexia. Pain and temperature sensation are impaired in the upper limbs. She is also noted to have a facial palsy. What is the SINGLE most likely diagnosis?

A 38 year old epileptic man is seen in the GP surgery for his annual medication review. His records show that he used to suffer from epileptic seizures while awake and would lose consciousness. During the consultation, he discloses that he still drives his son to school on school days. He has been taking the same dose of levetiracetam for the past 4 years. His last neurology appointment was 3 months ago. What is the most appropriate next step in management?

A 75 year old man has tremors in both his hands. He used to have intermittent tremors on both his hands since he was 20 years of age but it has gradually worsened over time and is now persistent. Movements such as reaching for a cup of tea are affected by his tremors. The tremor is seen to be worse when he is tired or stressed. He has no cognitive impairment. On examination, the tremor continues to be present even when the patient is distracted and even at rest. He has a normal gait. What is the SINGLE most likely diagnosis?

A 22 year old woman presents with progressive difficulty in walking due to lower back pain. A few days later she had tingling and numbness in her hands that has radiated towards her elbows. On examination, cranial nerves are intact. There is no sensation of vibration or pin prick in her upper limbs to elbows and from lower limbs to hips. There are absent reflexes and mute plantars. Blood pressure is 124/85 mmHg and heart rate is 68 beats/minute. The patient had an episode of food poisoning two months ago. What is the SINGLE most likely diagnosis?

A 44 year old man presents to the Emergency Department after falling from a third-floor building. His Glasgow Coma Scale is 4/15. He is intubated and ventilated on arrival. Neurological examination reveals unequal pupils. A CT head and neck reveals a midline shift and a left-sided convex enhancing area. He has been referred to the neurosurgical team. What is the SINGLE most appropriate action?

A 78 year old man presents with a history of urinary incontinence and a change in behaviour. He has mild memory loss. On neurological exam, he is oriented to person and time but not to place. His speech is clear and fluent. His pupils are equal and reactive to light. On examination, he has a broad-based gait pattern with postural instability with short, slow steps. What is the SINGLE most likely diagnosis?

A 65 year old man is seen in the GP surgery for his medication review. He has a history of an ischaemic stroke 2 months ago. He also has a medical history of type 2 diabetes mellitus and hypertension. His regular medications include amlodipine, metformin, clopidogrel and simvastatin. His blood pressure is 159/97 mmHg, temperature is 37.1°C and respiratory rate is 18 breaths/minute, pulse rate is 99 beats/minute. His recent blood test show.

HbA1c 48 mmol/mol (<48)

His ECG is seen below.

A zoomed-in image of lead II can be seen below:

What is the most appropriate measure to reduce the risk of further strokes?

A 7 year old child is brought to the hospital by his teacher. The child was playing with other children and suddenly fell down and hit the table and went unconscious for a few seconds before returning to his normal self. On probing further, the diagnosis of absence seizure was made. What is the SINGLE most likely reason that could have led to this diagnosis?

A 75 year old woman has been admitted from a nursing home with sudden onset of right hemiplegia and homonymous hemianopia. She is dysphasic. She remains conscious throughout and on examination, brisk reflexes and several beats of clonus are noted. What is the SINGLE most likely artery to be occluded?

A 75 year old lady on warfarin for atrial fibrillation is brought into the clinic by her daughter. Her daughter is concerned as her mother is progressively getting more confused over the last couple of weeks. On physical examination, the lady was noticed to have bruises on her arms. She has an INR of 7. What is the SINGLE most likely diagnosis?

An 8 year old boy developed a seizure first affecting his right arm. The seizure lasted for several minutes. He was unconscious throughout the seizure and has no recollection of the events that occurred leading to his seizure. A computed tomography scan of his head was organised after the seizure and has been reported as having a lesion on the left cerebral hemisphere. What is the SINGLE most likely reason for his seizure?

A 79 year old man attends the neurology clinic with his daughter who showed concern that her father has been more forgetful and becoming more confused. He has difficulty trying to express himself. He is unable to find words to describe certain scenarios. He is disorientated and has mood and behavioural changes. He has forgotten most of his GP appointments. He has stopped going out by himself because he gets last when he does. His blood tests are unremarkable. An MRI scan shows mesial temporal lobe atrophy and temporoparietal cortical atrophy. His ECG is shown below

Which of the following is the most appropriate medication to prescribe?

A 72 year old man with a history of hypertension and an ex-smoker presents to the clinic with his wife due to change in behavior. For the past year and a half, he has slowly become socially withdrawn with a decrease interest in his usual hobbies. There are times where he forgets to groom himself and there was an incident once where his wife found him urinating on the sofa. Over the past few months there has been a gradual struggle with finding the right word choice while talking. What is the SINGLE most likely diagnosis?

A 44 year old man presents to the Emergency Department with pain in his back and bilateral leg weakness worsening over the last three to four days. He has a diminished sensation of pain, temperature and vibration below xiphisternum. He feels the muscles of his legs and arms going into spasm. He started having urinary retention which a urinary catheter was inserted to relieve him. He has no respiratory issues. On examination, there is weakness in his legs, increased tone and brisk reflexes. What is the SINGLE most likely diagnosis?

A 43 year old woman presented with a blurred vision on her left eye and intermittent clumsiness for 3 months. She complains that she has a weakness of her left arm and she feels unsteady on her feet. On examination, her reflexes are brisk in her left arm and her left optic disc is pale. What is the SINGLE most appropriate test to confirm the diagnosis?

A 71 year old man on the ward was seen to be shouting at a nurse in an open bay mistaking her for his daughter who he was in an argument with. When approached by another nurse to calm the situation, he became aggressive and started throwing his belongings at them. As things are getting out of hand, you are called to the scene to assess the patient. His regular medications include atorvastatin, ramipril and co- beneldopa. Which is the SINGLE most appropriate medication to prescribe?

A 45 year old man has tremors in both his hands. The tremors are absent at rest but present when arms are held outstretched and persist on movement. Movements such as writing are affected by his tremor. The tremor is seen to be worse when he is tired or stressed. On examination, the tremor continues to be present even when the patient is distracted. What is the SINGLE most likely diagnosis?

A 81 year old woman is seen in the neurology clinic with features of a progressive decline in cognition and memory over 3 years. She complains about forgetting important events, such as her son’s birthday. She gets lost when driving, even in familiar areas. She has forgotten to attend her haircut appointments. She finds difficulty in remembering what she has eaten earlier in the day. She has a family history of Alzheimer’s disease. What is the SINGLE most appropriate scoring system to use?

A 86 year old man was brought in by the police to the emergency department after being found wandering the streets in the middle of the night outside his home. He has been living alone since his wife died a year ago. The police had recorded accounts from neighbours that had reported him to have had increased forgetfulness and requiring help to get back home in the past eight to nine months. When neighbours have found him at times, they report that he has been talking to himself. What is the SINGLE most likely diagnosis?

A 54 year old man attends the GP surgery with blurry vision on both eyes and a history of a headache over the past 4 weeks. He has a history of hypertension. On examination, his left eye is displaced outward and downwards. What is the SINGLE most appropriate investigation?

A 68 year old man presents to his GP with overall slowness and rigidity in the neck and trunk. Symptoms started in the last year, and he has fallen backwards several times during that time. His family also report some dysphagia and being irritable. Examination shows bradykinesia, bilateral rigidity and an unstable gait. He impulsively jumps out of his seat when told to stand up. His eye movements show downgaze restriction and are slow in all directions. His speech is slow and slurred. What is the likely diagnosis?

A 44 year old lady with established multiple sclerosis attends A&E with the complaint of weakness and a reduction in sensation on the left side of her face. She also complains of hearing loss in her left ear, as well as unsteadiness when she tries to walk. She is noted to have difficulty in coordinating her hand movements. What is the SINGLE most likely neuroanatomical structure affected?

A 62 year old man attends the Emergency Department with confusion that has developed over the past few days and an unsteady gait. He has liver cirrhosis from alcohol abuse. He is afebrile and infective markers are all unremarkable. His blood test shows a deranged liver function. He is admitted and given lactulose as part of the management. What is the underlying mechanism of his confusion?

A 34 year old man is hit by a car. He loses consciousness but is found to regain consciousness later when met by the paramedics. When awaiting doctors review in the Emergency Department he suddenly becomes unconscious. His Glasgow Coma Scale falls to 10/15 from 15/15. His left eye becomes dilated and unresponsive to light. His right eye is reactive. What is the SINGLE most likely diagnosis?

Mr Thorpe, a 67 year old man, is accompanied by his wife. On his way into the neurology clinic, you notice that he walks slowly and in a shuffling fashion. His wife tells you that he has become increasingly forgetful over the past year or so and tends to lose his concentration from time to time. A few days ago, he asked her to give the dog some food when, in fact, they never had a dog. She claims that he has also been talking to an imaginary friend who he calls Vincent. Mrs Thorpe is concerned about his behaviour. After careful evaluation, a diagnosis of Lewy body dementia is made. Which of the following symptoms helps confirm the diagnosis?

A 73 year old man presents with cold sensations and pain in the right arm, leg and face after a hemispheric stroke a few months ago. He describes the pain as a stabbing sensation. His right arms and legs are floppy with a loss of motor power. What is the most appropriate management?

A 55 year old woman presents to the Emergency Department with a severe headache that started several hours ago. Her medical history includes chronic kidney disease which was diagnosed 5 years ago. Her blood pressure is 170/80 mmHg. She is worried about her headache as her brother died at age 40 from a cerebrovascular insult. What is the likely cause of the brother’s death?

A 45 year old man has been admitted for an elective surgery. 2 days later he develops agitation, sweating and complains of seeing snakes on the hospital wall. A history of chronic alcohol abuse is revealed and lorazepam has been started. What is the SINGLE most appropriate next course of action?

A 55 year old alcoholic attends the memory clinic for issues in relation to his memory. He drinks 10 units of alcohol a day. His family describe him as irritable with motor slowing and severe memory impairment. He often forgets where he is. His memory problems are thought to be related to his long-term alcohol abuse. An MRI scan was arranged. What features can be expected to see in an MRI scan?

A 33 year old man presents with facial asymmetry to the GP surgery. His symptoms started two days ago. The left hand corner of his mouth started drooping. He also finds it difficult to close his left eye. He has been prescribed aciclovir. Below is a picture of his face:

What is the SINGLE most medication to add on?

A 70 year old man with a known case of ischaemic heart disease presents to emergency with paralysis of his left arm, sensory loss on the left side of his face, right sided gaze preference and homonymous hemianopsia. Which of the following is the SINGLE most likely artery to be affected?

An 8 year old girl is brought to the clinic due to abnormal behavior noticed by her teacher. She would stare blankly towards the wall, sometimes with an upturning of the eyes for around 15 seconds and has fluttering of eyelids. This would occur several times during the day. The teacher notes that while she would resume her activity after these events she would be tired and unable to concentrate. What is the SINGLE most likely diagnosis?

A 52 year old woman diagnosed with breast cancer presents with urinary frequency and extreme thirst. She finds herself passing large amounts of urine even at night. Which part of the brain is the metastasis likely to have spread to?

54 year old patient is seen at the clinic for muscle weakness and tingling sensation which initially started at the level of his feet, progressed quickly to his legs and now it is affecting his arms too. The progression of symptoms occurred over the period of a few days. He gives a history of having severe diarrhoea and vomiting nearly two weeks ago which resolved in a few days. On examination, he has loss of tendon reflexes and decreased muscle strength on his lower limbs. What is the SINGLE most likely mechanism of this weakness?

A 53 year old with a neurological condition which initially started with symptoms of urinary incontinence, erectile dysfunction and dizziness when standing. He is seen to have ataxia, rigidity, slow movements and a slight tremor of the hands. On examination, postural hypotension is seen. Which SINGLE condition best describes this man’s symptoms?

A 58 year old man has visual hallucinations of animals walking around his room. He is amused by them but is conscious that they are not real. He is noted to have fluctuating levels of awareness and attention and a decline in problem solving ability. Signs of mild parkinsonism are also seen. What is the SINGLE most likely diagnosis?

A 22 year old female was hit on the side of her head with a cricket ball during a match. She initially lost consciousness but spontaneously recovered but is now experiencing increasing headache with one episode of vomiting. Her roommate has noticed that there is a slowing of responses. What is the SINGLE most likely diagnosis?

A 55 year old man presents to the clinic with shortness of breath and increased daytime sleepiness. He drinks 25 units of alcohol weekly. On examination, his BMI is 35 kg/m2, blood pressure is 150/70 mmHg, and respiratory exam was normal. His wife complains that he snores loudly at night. What is the SINGLE most appropriate investigation likely to confirm his diagnosis?

A 61 year old female is brought to the hospital by her daughter following a drastic change in her behaviour. Her daughter says that her mother’s behaviour began to change three days ago whereby she became restless and aggressive. The daughter describes going to visit her mother three days ago and getting complaints from the neighbours that they hear banging and shouting all night. The patient herself claims that there are people who enter her room at night and that she makes those noises to scare them off. There is no evidence to backup the patient’s claims. What is the SINGLE most likely diagnosis for her condition?

A 39 year old chronic alcoholic stopped drinking alcohol for the last 2 days. He present to A&E with symptoms of feeling anxious, having tremors and is seen sweating profusely. His heart rate is 103 beats/minute. What is the SINGLE most appropriate treatment?

A 13 year old girl presents with spina bifida with persistent urinary incontinence. She has a history of repeated UTIs in past which were treated with antibiotics successfully. At present, she does not have a urinary infection but incontinence is present. Her urine culture is sterile. Urodynamic study is suggestive of increased bladder pressure and urinary retention. What is the SINGLE most appropriate management for this patient?

A 19 year old woman complains of episodic headaches preceded by fortification spectra. These episodes can sometimes last for 2-3 days. When these headaches occur, she prefers to be in a quiet, dark room. What is the SINGLE most appropriate management for the acute phase?

A 72 year old woman presents with the complaint of forgetfulness for three months. She used to live with her husband but since his passing four months ago, has been living alone. For the past three months, she has been increasingly forgetful and more socially withdrawn. She contacts her children less frequently than she used to and has been late in paying her bills. She blames her recent memory impairment on tiredness. Her medical history includes having depression more than 20 years ago. What is the SINGLE most likely diagnosis?

A 61 year old man has been suffering from short term memory impairment. He is a retired accountant. Over the past 6 months, he finds arithmetics extremely difficult. He has lost the ability to write. He finds it difficult to distinguish between his right side and left side of his body. He finds it difficult to distinguish the fingers of his hands. Which anatomical site is likely to be involved?

A 28 year old woman has a short history of double vision. She tires easily, especially as the day progresses. There are difficulty climbing stairs, reaching for items on shelves, and brushing her hair. As she speaks, her speech fades gradually. Over the last week, she has had difficulty chewing and swallowing. On examination, there were no significant findings. She has a family history of thyroid disease. What is the SINGLE most likely diagnosis?

A 33 year old woman has pain and a funny sensation in her legs especially at night when she sleeps. Her symptoms have been ongoing for the past 3 months. She describes the funny sensations as having insects crawling up her legs which wake her up at night. She finds relieve almost immediately when she moves her legs. She has no previous psychiatry history of note. Her blood results show:

Haemoglobin 140 g/L

Ferritin 250 ng/ml

Which of the following medications is effective in treating this condition?

A 49 year old patient has Parkinson’s disease which is currently being treated with co- careldopa. What is the SINGLE most useful medication in the management of his tremar and dystonia which is particularly disturbing?

A 63 year old man presents after having a seizure. He is alert and orientated. On examination, inattention on the left side is noticed with hyperreflexia of the arm. What is the SINGLE most likely diagnosis?

A 40 year old man who has recently lost his job was found to be stumbling and wandering around the local park, muttering to himself with plans to kill himself. The police have brought him to the hospital in an unkempt and dishevelled state and he displays a general level of bad hygiene. He is pale and smells of stale sweat. The police officer who brought him to the hospital says that he had administered an alcohol breath test for the patient which showed zero percent level of alcohol. The patient is now confused, uncooperative and has become increasingly agitated. All attempts to calm him have been unsuccessful. What is the SINGLE best initial management for this patient?

A 43 year old man presents with neck stiffness, headache and vomiting. The headache is severe, persistent and on the left side. He also has ear pain and discharge coming from his left ear. On examination, he has weakness of the right hand and leg. He has a temperature of 38.5°C. What is the SINGLE most likely diagnosis?

A 35 year old lady is seen by a neurologist for funny turns. These episodes were witnessed by her husband who describes 15 minute episodes of inability to talk without losing consciousness. This have been ongoing every 2-3 days since the sudden unexpected death of her mother 2 months ago. What is the SINGLE most useful investigation to help aid in diagnosis?

A 58 year old man has a progressively worsening headache and confusion. He had a fall three days ago after slipping and hitting his head in the garden. He has a history of alcohol abuse. What is the SINGLE most appropriate investigation?

A 35 year old woman presents with bilateral lower limb weakness which began four days ago. She reports that the weakness started with her feet and legs and progressed to involve her thigh and lower back. She can no longer walk nor get up from a chair without assistance. She also reports that she feels cramping pain in her lower back along with a tingling sensation of her lower limbs. She has not passed stool in over a day and noticed that she takes a long time to start a flow of urine. She does not have a significant past medical or surgical history apart from having gastroenteritis three weeks ago, which settled on its own. On examination, her heart rate is 110 beats/minute, blood pressure is 110/70 mmHg, and respiratory rate is 16 breaths/minute. On assessment, hypotonia of the lower limbs are noted, and there are absent patellar reflexes. Which of the following investigations may be used to confirm the diagnosis?

A 26 year old woman complains of headache of 1 day duration that has been intensifying in severity over the last few hours. There is discomfort while turning her head and cannot tolerate bright lights. On examination, there is no papilloedema nor rashes. Kernig’s sign is negative. Lumbar puncture results reveal: elevated protein, normal glucose, and lymphocytosis. She is generally unwell but haemodynamically stable. What is the single most likely diagnosis?

A 5 year old girl is brought to the hospital by her mother with complaints of sudden right facial weakness, numbness and pain around her ear. She reports no other symptoms. On examination, her right eyebrow is unable to raise and the right hand corner of her mouth is drooping. What is the SINGLE most likely diagnosis?

A 15 year old girl appears confused and agitated for the past 24 hours. She has a fever, stiff neck and a headache. Her blood test show the following:

White cell count 16 x 10^9/L (4-11)

CRP 130 mg/L (<10)

A lumbar puncture shows a low glucose level when compared to serum glucose, increased protein and a high amount of white blood cells predominantly neutrophils. A gram positive diplococci is seen on microscopy. What is the most likely causative organism?

A 44 year old woman has left leg weakness. She does not have any weakness in any of her ather limbs. The weakness has occurred gradually over 18 months. She has no history of seizures over the past year but her medical history includes epilepsy which she takes lamotrigine regularly. An MRI of the brain and spinal cord are reported as normal. On examination, the power of her right leg is 5/5 but the left leg is 2/5. When the patient is lying supine, flexion of her left hip against resistance is not followed by extension of the right hip. Her reflexes on the left limb are found to be normal. The sensation of her left limb is intact. What is the SINGLE most likely diagnosis?

A 26 year old woman is seen in the neurology clinic with a history of 3 episodes of convulsions. Her husband has observed all three episodes. They last around 15 minutes and begin by her lasing awareness and becoming unresponsive. This is followed by strange and repeated movements of her arms, legs and pelvis. During the episodes, her eyes are closed. There was no drooling of saliva, and no incontinence in any of the episodes. What is the SINGLE most appropriate investigation?

A 35 year old woman complains of dizziness. She awoke in the morning with a mild headache and the dizziness started when she sat up in bed. She felt that the room was spinning for a few minutes. If she is at rest the spinning stops but is aggravated again by movement. There are no other neurological symptoms. What is the SINGLE most likely diagnosis?

A 52 year old lady has upper limb pain which worsens when coughing. She was found to have burn marks on fingertips. Her hands looked wasted. Her upper limbs are weak with diminished reflexes and dissociated sensory loss. She also has weak spastic lower limbs. What is the SINGLE most likely diagnosis?

A 50 year old presents to the emergency department with right hemiplegia and complete loss of vision in the left eye. Which artery is likely to be accluded?

A 32 year old female presents with a history of recurring headaches. They are usually unilateral, last for 24-48 hours, have a pulsatile quality, and are associated with nausea and photophobia. The patient describes the headaches as intense, usually requiring her to limit her activities. She has tried several over-the-counter medications with no relief. Which of the following is the SINGLE most appropriate choice for first-line management of her condition?

A 40 year old woman with a history of epilepsy presents to the clinic with multiple fleshy nodules and several light brown, round macules with a smooth border on her back, arms and legs. There are also freckles under her arms. She has a degree of scoliosis. Her mother suffered from a similar condition. What is the SINGLE most likely diagnosis?

A 65 year old female patient has become increasingly distressed. She cries all the time and has been forgetting to lock her doors at night and turn off the stove after she has used it. She is forgetful, having forgotten her son’s birthday this year, which she has never done before. She also gets lost when she goes out, and has difficulty in finding her way back home. On occasion she puts her house keys in the microwave, and she does not appear to know how to use it to cook food anymore. She also has a prominent impairment of recent memory but has an intact immediate recall. She has no impairment in her level of consciousness. She has no significant past medical history of note and is not on any chronic medications. A mini mental state examination was done for her (MMSE) and she was scored 26 out of 30. What is the SINGLE most likely diagnosis for this patient?

A 26 year old man was found on the street to be unsteady and drunk by police. On admission to Emergency, he had a sudden onset of headache with severe intensity. The headache is localized to his occipital area and is continuous. On examination, his GCS is 15/15, afebrile and no focal neurological signs. What is the SINGLE most likely diagnosis

A 16 year old woman has moderate to severe unilateral throbbing headaches at her right temporal region which can last several hours with associated nausea, vomiting, visual impairment and right-sided tinnitus. Her symptoms fully resolve on the same day. She gets these attacks once a week. Occasionally, she would have these symptoms of nausea, vomiting, visual impairment and right-sided tinnitus without a headache. She is not on any regular medications. What is the SINGLE most likely diagnosis?

A 71 year old woman is brought to A&E by ambulance. She presents with speech disturbance, loss of balance and left facial and arm weakness. Her symptoms began 3 hours ago but has started to resolve. She has a medical history of hypertension which is treated well. An ECG was performed, which shows the patient to be in sinus rhythm. A CT scan of the head shows no evidence of haemorrhage. Shortly after the CT scan, she has no further symptoms. Which is the SINGLE most appropriate medication to prescribe?

A 42 year old female had a sudden onset of severe headache and vomiting. She took paracetamol and an hour later she collapsed. Her medical history is significant for Ehlers- Danlos syndrome. What is the SINGLE most likely diagnosis?

A 26 year old female presents with bladder incontinence, clumsiness when walking, shooting lower back pain, and blurry vision, and sensory loss. These symptoms have occurred all at once or in different combinations approximately every few months and each event lasts 3-4 days. There is swelling of the optic disc on fundoscopy, inability to walk heel to toe, and weakness at the hip girdles. What is the SINGLE most appropriate diagnostic test?

A 33 year old woman previously in good health presents with sudden onset of severe occipital headache and vomiting a few hours ago. Her only physical sign on examination is a stiff neck. What is the SINGLE most likely diagnosis?

A 55 year old man presents to clinic for gradual weakness of his arms bilaterally over the past year. He is now unable to lift heavy loads above his head and has difficulty breathing while going up the stairs. In the past month, he has noticed hoarseness and difficulty in swallowing liquids. On examination, there were muscle atrophy and weakness in the trunk, neck, back and both proximal upper limbs for lower motor signs. Deep tendon reflexes the upper and lower limbs were positive for upper motor signs with atrophy of the tongue. Hoffman’s sign was positive and autoimmune panel is normal. What is the SINGLE most likely diagnosis?

A 58 year old woman presents with acute onset of back pain following a rough and long journey in a car. On examination, there is tenderness at the mid-thoracic vertebra. The pain is goes away when she bends forward. What is the SINGLE most likely diagnosis?

A 67 year old woman developed sudden onset left-sided face and arm weakness which lasted 30 minutes. On arrival to the Emergency Department, she was completely symptom-free. A 12-lead ECG done in the department shows atrial fibrillation. She takes losartan for her high blood pressure. What is the SINGLE most appropriate investigation?

A 66 year old female patient presents to Accident & Emergency with a 12 hour history of a severe headache with associated nausea and vomiting. She has no other complaints other than the headache which she describes as feeling like she was “kicked in the head”. She claims that the headache is felt worse at the back of her head. Morphine and metoclopramide have been given for the pain and a CT scan of the head was done which was reported as no acute abnormalities seen. What is the SINGLE most appropriate next action in this patient’s management?

A 50 year old man, known case of hypertension and deep vein thrombosis, presents to the Emergency Department with a sudden onset of vision loss in his right eye. It is painless and lasted for approximately 5 minutes. He describes the vision loss as a ‘black curtain coming down’. On examination, there is a bruit on his neck. What is the SINGLE most likely condition?

A 38 year old heroin addict was involved in a car crash and, as a result, is now paraplegic. He was agitated and cried every day during the first two weeks after the accident while he was in the hospital. Upon questioning, he was unable to remember the accident at all and refused to talk about it. What is the SINGLE most likely diagnosis?

A 52 year old woman presents to her GP with blurry vision and occasionally seeing double over the past six months. This mainly occurs after being on her computer for long periods of time and in the evenings. Her friend remarked that her left eyelid looked droopy last night but she did not see anything of concern this morning. What is the most likely diagnosis?

A 79 year old man presents to the Emergency Department with an acute onset of double vision and vertigo. He has paraesthesia of his upper limbs. He is becoming increasingly drowsy with an unsteady gait. What is the SINGLE most likely diagnosis?

A 28 year old woman has unilateral headaches which can last several hours with associated nausea, vomiting and light sensitivity. She gets these attacks once every few weeks. She is not on any regular medications. Which is the SINGLE most appropriate medication to prescribe as the first line to reduce the frequency of her symptoms?

A 65 year old lady presents to the Accident and Emergency department with a 6 hour history of facial droop and weakness on her left side of her body. A CT scan was performed and ruled out a haemorrhagic stroke. She is allergic to Penicillin and takes Simvastatin and Amlodipine regularly. What is the SINGLE most appropriate medication to be prescribed long term for this patient?

A 60 year old man presents to the Emergency Department with dizziness. The onset was sudden and described as “the room spinning around”. He also is bumping into things on his right side. On examination, his blood pressure is 159/91 mmHg, heart rate is 72 bpm. He is positive for nystagmus and dysdiadochokinesia. Imaging of the brain confirms ischaemic stroke. Where is the SINGLE most likely location of his stroke?

A 43 year old chronic alcoholic stopped drinking alcohol for the last 3 days. He is anxious, has tremors and is very agitated. His heart rate is 106 beats/minute and is seen sweating profusely. What is the SINGLE most appropriate treatment?

A 66 year old woman has a sudden onset headache, nausea, vomiting and dizziness. It started 6 hours ago and has been gradually worsening. She has noticed weakness in her left arm and left leg. She does not complain of hearing difficulties. On examination, she has reduced power on the left arm and left leg compared to the right side. She has a negative Romberg test. What is the SINGLE most likely diagnosis?

A 43 year old smoker presents with double vision. She tires easily, has difficulty climbing stairs, and reaching for items on shelves. On examination, reflexes are absent but elicited after exercise. The power in shoulder abduction after repeated testing is 4+/5 from 3/5. What is the SINGLE most likely pathology associated with this patient’s diagnosis?

A 45 year old man presents to the Emergency Department with an acute back pain radiating down to his legs. He also developed difficulty in trying to pass urine earlier in the day. On examination, a perineal sensory loss is noted. What is the SINGLE most appropriate investigation?

A 78 year old woman admitted for a urinary tract infection for the last 10 days has become increasingly confused. Her son has noted her level of consciousness has been fluctuating and is disoriented to time and place. She is more withdrawn but intermittently becomes very noisy and agitated. What is the SINGLE most likely diagnosis?

A 62 year old man presents with his daughter to the clinic with complaints of visual hallucinations and features of cognitive impairment including memory loss. His symptoms of attention and levels of consciousness seem to fluctuate. He has a tremor and a festinating gait which started within a few months of noticing his memory loss. What is the SINGLE most likely diagnosis?

A 56 year old lady has developed severe right sided headache which worsens whenever she goes into a room with bright light. This has been occurring for the last 3 days. She feels nauseated, but has not vomited. She does not take any medication and has no relevant medical history. What is the SINGLE most likely diagnosis?

A 79 year old man was seen in the memory clinic as an outpatient. On his mental state examination, he was noted to be disengaged, expressing boredom as well as making inappropriate comments to the doctor of a sexual nature. What is the SINGLE most likely diagnosis?

A 22 year old woman attends the Emergency Department with a history of a severe headache, weakness of her left arm and tingling on her left face. She feels nauseous and has increased sensitivity to light and sound. The pain is described as throbbing on her left side of the head. The pain started gradually in the morning but became more intense after a few hours. She takes regular combined oral contraceptive pills. She is a non- smoker. Her blood pressure is 120/70 mmHg. A CT scan of her head was performed which showed no evidence of a stroke or a mass. A few hours later, her symptoms resolve. What is the SINGLE most appropriate action?

A 71 year old lady has a history of a fall 3 days ago with an injury to the head. She is increasingly drowsy and has recently become confused and disoriented. What is the SINGLE most likely vessel to be involved?

A 78 year old smoker collapses and is brought into accident and emergency. He is unable to lift his right hand or leg. He also complains of double vision. His left pupil is mydriatic and his left eyelid droops downwards. His left eye is deviated downwards and outwards. He is a known diabetic and has a history of hypertension. Where is the SINGLE most likely area of the lesion?

A 45 year old man presents to the clinic for his routine diabetic check-up. Upon examination, the patient has a normal tone, 5/5 power, normal plantar reflexes and normal proprioception. There is a deficit in fine touch sensation on the medial side of the right lower leg. Which of the following is the SINGLE most likely dermatome to be affected?

A 33 year old woman who is 8 weeks gestation is seen in the neurology clinic for her generalised tonic-clonic seizures. She had two seizures 3 months ago before she was pregnant and a further seizure 2 weeks ago. She is not on any medications at present. Her neurologist has informed her that it would be beneficial for her to take an anti- epileptic even during pregnancy. What is the SINGLE most appropriate anti-epileptic medication to prescribe?

A 74 year old retired lawyer attends his GP surgery accompanied by his wife complaining that for the past three months he has been seeing people walking in and out of his walls. He sees objects like flowers in the room which are not there. He knows they are not real. He has no auditory hallucinations. The visual hallucinations do not appear to distress him. His wife says that he occasionally becomes confused in the morning. On examination, he is alert and oriented to person and time but not to place. His eye examination done one month ago was normal. What is the SINGLE most appropriate investigation?

A 46 year old chronic alcoholic man is brought to the Emergency Department in a drowsy state. He is responding vaguely to questions. He denies any alcohol intake over the past few hours. He would usually drink around 10 cans of beer a day. He walks with an ataxic gait. Examination reveals spontaneous upbeat nystagmus and hyperreflexia.

Haemoglobin 128 g/L (130-180)

Mean cell volume (MCV) 99 fL (76-96)

What is the SINGLE most likely cause for his cognitive impairment?

A 68 year old man has slowness of movements and rigidity in the neck and trunk. He has had unexplained episodes of falling backwards in the past few months. He also has had worsening akinesia, dysarthria and dysphagia over the past few months. He has a tendency to be unstable when standing. He also has a shuffling and a freezing gait. His family reports that he has recently been displaying inappropriate behaviour with apathy, impulsivity and irritability. He appears irritable and forgetful. Examination reveals difficulty voluntarily shifting his gaze vertically, especially with a downward gaze. Which condition is described here?

A previously healthy 20 year old woman presents to the Emergency Department with the complaint of “falling out.” She was with her friends at a restaurant when she felt faint and, according to friends, lost consciousness for about a minute. There was no seizure activity noted, but the friends did notice her arms twitching irregularly. She is now acting normally. She denies chest pain or palpitations, and her electrocardiogram is normal. What is the SINGLE most likely diagnosis?

A 45 year old man with terminal cancer who has recently completed his course of chemotherapy develops tingling and numbness of the fingertips of both arms. He describes a constant mild burning discomfort in his hands and feet. Occasionally, he experiences a sharp, shooting, and electric-shock-like pain in his feet. What is the SINGLE most likely cause of his symptoms?

A 45 year old man has tremors in both his hands. He has noticed the gradual onset of the tremor over the past few months. The tremor was initially transient but has now become persistent. The tremar is symmetrical. His tremor does not occur when he sleeps. Small amounts of alcohol help reduce the tremor. On examination, the tremor is worsened when he holds both his arms outstretched. The tremor amplitude increases as he performs voluntary movements such as moving the wrist up. He has a normal gait. His blood tests show the following:

Thyroid stimulating hormone (TSH) 0.6 mU/L (0.5-5.7)

What is the SINGLE most likely diagnosis?

An 82 year old male with established Parkinson’s disease presents with an episode of acute psychosis. He is agitated and shouting at the hospital staff. He refuses to be reasoned with and punches anyone who approaches him in the face. What is the SINGLE most appropriate immediate treatment to give this patient?

A 72 year old man was involved in a major road traffic accident and was brought in by ambulance. He has extensive bruises to his face and head. He has a Glasgow Coma Scale of 7. He has already been intubated using an endotracheal tube by the paramedics. On examination, his right pupil is fixed and dilated. His left pupil reacts to light. What is the most likely diagnosis?

A 47 year old is admitted with a femoral shaft fracture following a major road traffic accident. On his second-day post-intramedullary nailing, he becomes increasingly confused in the orthopaedic ward. On examination, there is evidence of hyperreflexia, nystagmus and his pupils are equal but sluggish to react to light. His friend who is with him says that he drinks around 20 cans of beer a night for the past several years. There is no reported evidence of head injury on the admission notes. He is given lorazepam intravenously. What is the SINGLE most appropriate next action?

A 53 year old chronic alcoholic was brought to the Emergency Department with an alternating state of consciousness, nausea and vomiting. He has unsteady, uncoordinated walking and complains of double vision. He denies having taken alcohol in the last 12 hours. On examination of his face, his eyelids seem to be drooping and nystagmus is seen. A mental status examination reveals that he is confused. His blood pressure is 130/80 mmHg and has a heart rate of 80 beats/minute. What is the SINGLE most appropriate management?

A 32 year old man has fever, malaise, headache and a stiff neck for the past 5 days. He is HIV positive. He has not been taking anti-retroviral therapy. He has a temperature of 37.7°C, heart rate of 99 beats/minute and blood pressure of 130/80 mmHg.

Investigations:

CD4 count 90 cells/mm3

Cerebrospinal fluid analysis through immunodiagnostic test detects cryptococcal antigen

What is the most appropriate medication to prescribe?

A 55 year old woman presents with loss of vision in the right eye and pain on ocular movement, which began 2 days ago. She complains of a dull headache in the frontal region for 3 days which is worse in the morning. 2 days ago, she developed weakness of the left half of her body and describes a similar weakness and numbness of the right upper limb 2 months ago, which resolved completely over a week. Her vital signs are within normal limits. Power in the left upper and lower limb is 3/5. The power on the right upper and lower limb is 5/5. Additionally, a swollen optic disc is visualised on ophthalmoscopy. What is the SINGLE most likely diagnosis?

A 33 year old woman has a daily throbbing frontotemporal headache over the past few months. The headache is worse in the morning and is now beginning to be associated with nausea, vomiting, a blurry vision and tinnitus. Her headaches are better when she is standing. Her BMI is 31 kg/m2. She is not on any regular medications. What is the SINGLE most likely diagnosis?

A 51 year old male with a Pancoast tumour presents with unilateral partial ptosis, anhidrosis and miosis on the right side of his face. What is the SINGLE most likely underlying mechanism for the syndrome?

A 49 year old man first presented with increasing difficulty in swallowing. Several months later he developed weakness in his right foot. Now he can no longer feed himself, he chokes on food and has become confined to a wheelchair. What is SINGLE most likely diagnosis?

A 26 year old man complains of leg weakness. He first felt pins and needles on his feet which was followed by weakness of his legs for the past 2 days. He describes himself as a fit man who goes jogging every day however he now finds himself with great difficulty trying to stand due to his leg weakness. He gives a history of feeling unwell and having flu-like symptoms last week which has resolved after a few days. On examination, he has mild bilateral facial weakness, reflexes are diminished and has impaired sensation in his legs. What is the SINGLE most likely diagnosis?

A 16 year old boy was found jerking his limbs on the floor in the car park of the shopping mall. He is brought into the Accidents and Emergency Department by his mother who witnessed the event. He was seizing for a period of 2 minutes with complete loss of consciousness and tongue biting. He was reportedly drowsy for the next 15 minutes after the seizure. His blood sugars, sodium and calcium levels are within normal range. His ECG is seen to be normal. He has no previous relevant medical history. What is the SINGLE most appropriate action?

A 69 year old man presented to clinic with worsening balance and difficulty walking over the past year. Recently, he has been prone to falling more frequently and his wife notes he forgets to turn off the stove or water taps. He has also started to have urinary urgency and incontinence. On examination he is walking with a cane and has difficulty turning. What is the SINGLE most likely diagnosis?

A 77 year old woman has had a progressive decline in cognition and memory over 2 years. She complains about forgetting day-to-day events. She gets lost when walking. even in familiar areas. She cannot remember the names of her friends and places she has been. She finds difficulty in using the right word to describe her personal belongings. Her family members can see that she has been more agitated and aggressive over the past few months. An MRI scan of her head shows evidence of ventricle enlargement and temporoparietal cortical atrophy. What is the SINGLE most likely diagnosis?

A 63 year old man, who is a known hypertensive and smoker, presents to the clinic with a sudden onset of weakness in the right arm and changes in his speech 1 day ago which has resolved within a 2 hour period. On examination, there were no residual neurological findings. His ECG shows sinus rhythm. His chest is clear with normal heart sounds. What is the SINGLE most appropriate next step in management?

A 55 year old male has a history of slurred speech and left arm weakness that lasted for 5 minutes and resolved completely. An ECG performed in the Emergency Department showed a heart rate of 80 beats/minute in sinus rhythm. He takes regular antihypertensive medications. He does not have any other medical conditions. He was discharged from the hospital and asked to be seen in a TIA clinic for follow up. What is the SINGLE most appropriate long term medication(s) to be prescribed?

A 66 year old woman is admitted to the hospital with sudden onset blurred vision, speech difficulties and vertigo which began a few hours ago. She does not have any unilateral limb weakness. On examination, she has horizontal nystagmus and dysarthria. Her symptoms improve after 4 hours but she continues to have persistent dysarthria. Her medical history includes hypertension. A CT scan done in the A&E department was reported as normal. She has a Glasgow Coma Scale (GCS) of 15. What is the SINGLE most appropriate action?

A 34 year old housemaid presents with severe headaches in the back of her head for several days and pain on flexing her neck. The pain is worsened by movements. On examination, there is limited range of movement of the neck. She has stopped driving because she cannot turn her head behind. What is the SINGLE most likely diagnosis?

A 66 year old woman with a recent diagnosis of idiopathic Parkinson’s disease is started on co-careldopa (Sinemet) by her neurologist. The dose was increased according to her response over the next few days. She reports her muscle stiffness and rests tremors improving with treatment. On the fifteenth day of treatment, she begins hallucinating. She has been compliant with her medications. What is the most appropriate action?

A 44 year old woman is suffering from fever, headache and neck pain for the past 10 days. His headache started gradually over a period of a day and has worsened since. It is predominantly over the left temporal region. He has had significant weight loss and a decreased appetite over the past 2 months. She was diagnosed with HIV 6 years ago and has not been on antiviral therapy. She has a temperature of 38.1°C, heart rate of 90 beats/minute and blood pressure of 130/80 mmHg. She describes weakness on his right arm and right leg.

Investigations:

CD4 count 40 cells/mm3

MRI scan of the brain reveals multiple homogenous ring enhancements on contrast administration.

What is the SINGLE most appropriate treatment?

A 34 year old man involved in a road traffic accident is brought to the Emergency Department. He has a reduced Glasgow Coma Scale. His CT scan shows the following:

What is the SINGLE most likely diagnosis?

A 25 year old woman presents with a severe headache. She had migraines for the last 14 years but has been symptom free for the last year. There are no other neurological signs. She has no other medical history of note. Her observations are stable. What is the SINGLE most appropriate investigation for this woman?

A 42 year old lady presents with a history of double vision, ptosis and facial numbness. Which anatomical site is the most likely to be affected?

A 63 year old woman presents to the Emergency Department with a 3-hour history of facial droop and weakness on her left side of her body. On examination, the power of her left hand is significantly reduced. Her blood pressure is 160/90 mmHg. She has a medical history of hypertension. A CT scan was performed and ruled out a haemorrhagic stroke. What is the SINGLE most appropriate medication to be prescribed that will reduce the chance of a long term brain injury from this insult?

A 36 year old woman presents to clinic with intermittent episodes of dizziness that lasts 1 day each time for the past 6 months. Recently, she has experienced ringing and increased pressure in her ears. Her husband noticed that she has had to increase the volume of her television. MRI head is normal. What is the SINGLE most likely diagnosis?

A 26 year old woman who is a known epileptic with generalised seizures wants to start a family. She takes sodium valproate for her epilepsy which has been well controlled and has been seizure-free for the past year. She and her husband have been using condoms as contraception till present. She attends clinic seeking advice regarding her antiepileptic medication as she would like to get pregnant. What is the SINGLE most appropriate advice to give?

A 45 year old woman has a sharp pain in her left jaw which lasts for approximately 2 to 5 seconds. It occurs several times a day. She describes it as an excruciating jab that spontaneously abates. There are no abnormal neurological signs. Which medication group is likely to benefit this patient?

A 79 year old man attends the neurology clinic with his daughter who is concern that her father has been more forgetful around the house. He does not remember where he puts his keys and often forgets the names of his grandchildren. He is progressively becoming more confused and disoriented. He is unable to remember recent events. An MRI scan shows diffuse cortical atrophy. On examination, his blood pressure was 135/100 mmH His ECG is seen below:

Zoomed images can be seen here:

Which of the following is the MOST appropriate medication to prescribe?

A 68 year old man with a diagnosis of idiopathic Parkinson’s disease was started on co- careldopa (Sinemet) by his neurologist 2 years ago. He has been having low moods for the past 2 months. He reports muscle stiffness and rigidity. He has a resting tremor throughout the day. He has frequent fluctuations in lucidity. He also has cognitive difficulties around memory and executive function. He has been on the same dose of co- careldopa for the past 2 years. What is the SINGLE most likely reason for his symptoms?

79 year old stumbled at home and sustained a minor head injury 2 weeks ago. He did not become unconscious and was well after the fall. His son has brought him to the clinic because he has become increasingly confused, drowsy and unsteady over the past few days. He has a GCS of 13. His past medical history includes atrial fibrillation in which he takes warfarin for. What is the SINGLE most likely diagnosis?

A 33 year old man presents with the complaint of a headache with photophobia that has gradually gotten worse over the past week. His temperature is 38.2°C. He has no neck stiffness and has a negative Kernig sign. He appears slightly confused. A lumbar puncture was done and no organisms were cultured on the cerebrospinal fluid (CSF). A computed tomography scan is unremarkable. What is the SINGLE most likely diagnosis in this patient?

A 44 year old woman patient presents to Accident & Emergency with a 15 hour history of a severe headache with associated nausea and vomiting. There is no history of trauma. She has photophobia. She is afebrile. Her neurological examination is normal. Pain relief has been given and a CT scan of the head was done which was reported as no acute abnormalities seen. What is the SINGLE most appropriate action?

A 67 year old man presents to the GP surgery with a history of loss of balance and decreased walking speed. He developed a gradual decline in his balance over the past few months. He had 3 episodes of falling backwards over the past month. He has been feeling depressed, and his wife has noticed personality changes. He has minor bilateral tremors and neck rigidity. He leans backwards when he walks. He has a restricted downward gaze on examination. What is the likely diagnosis?

A 30 year old presents to the emergency department with confusion and ataxia. She had with a surgical abortion a 3 days ago at 13 weeks gestation. Her pregnancy was complicated severe hyperemesis gravidarum. On examination, she has horizontal ophthalmoplegia. She is unsteady and has uncoordinated walking. She denies alcohol intake. What is the SINGLE most appropriate management?

A 33 year old man presents with speech difficulties. He has an irregular breakdown of articulation. On examination, nystagmus is seen. Which anatomical site is most likely to be affected?

A 62 year old male is brought to the emergency department by his daughter as he is confused, and has an unsteady, uncoordinated walking. He is a known alcoholic and has been admitted recently with delirium tremens. On questioning, he denies any problem with his memory. He knows his name and address and convincingly states that he was at a betting shop in the morning. His daughter interjects saying that, that is untrue as he was at home. What is the SINGLE most likely diagnosis?

A 78 year old man is brought into the Emergency Department by his wife as he seems confused in the morning. He has noticed people walking in and out of his walls. He is unable to recollect what he did yesterday. He had an eye check 2 weeks ago with his optician and his visual assessment was normal. On examination, he looks drowsy. What is the SINGLE most appropriate next step in the investigation?

A 66 year old patient woke up with slurred speech and right-sided weakness. He was brought to the hospital by his wife 2 hours ago. Computed tomography was ordered and shows a cerebral infarction. What is the SINGLE most appropriate treatment to be given?

A 44 year old man was seen in the Emergency Department with severe lower back pain which started two weeks ago and gradually worsened. His wife had to help shower and change him earlier in the day as he was unable to do them on his own. He cannot walk without the support of his wife. He was doing some gardening and lifting pats when the lower back pain initially started. The A&E doctor admits him and refers him to the neurosurgeons. Which worrisome feature would warrant an urgent referral to the neurosurgical team?

A 55 year old chronic alcoholic who lives alone, brought in the Emergency Department having been found confused at home. He is brought in by his wife who reports that he fell a week ago. His wife says that he is having worsening agitation and confusion. What is the SINGLE most likely diagnosis?

A 66 year old man with a known case of uncontrolled hypertension presents to the clinic with his wife complaining of deterioration of his memory and confusion. He has a past history of transient ischaemic attack where he temporarily suffered from left-arm paralysis. Throughout the year, his wife has noticed a decline in his memory, along with clumsy gait which has made him prone to falls, as well as progressive urinary incontinence. He is a heavy smoker. On examination, his BMI is 31 kg/m2 and he has an irritable mood. He scores 19 out of 30 on his mini-mental state examination An MRI of the brain was requested and showed multiple subcortical lacunar old infarcts. What is the SINGLE most likely diagnosis?

A 78 year old man has a 12-month history of tremors in both his hands. He has been losing his balance and falling forward, especially when trying to turn. He has a slow gait and has difficulty stopping. He leans forwards when he walks. He finds his muscles more tense. His speech has become slow and monotonous. He has no impairment of his downward gaze. What is the SINGLE most likely diagnosis?

A 66 year old lady with a history of hypertension and diabetes. She got arrested by police for saying inappropriate sexual content to her 15-year-old nephew during a family gathering. She later insisted on expressing no regret about what she said. What is the most likely anatomical structure affected?

A 33 year old woman with multiple sclerosis complains of vertigo and double vision. She has also noticed recent drooping of her lips on the left side. She has loss of sensation over her face, reports intermittent shooting pains over the face and has increasing difficulty with hearing. She has a lack of voluntary coordination of muscle movements. The symptoms have been worsening over the past 3 days. What is the SINGLE most likely anatomical site affected?

A 72 year old male presents to the GP surgery with difficulty in performing the activities of daily living. Three months earlier he suffered a stroke and during discharge, he abruptly departed the hospital rejecting any further medical appointments. He complaints that he struggles to perform tasks such as brushing his teeth, getting dressed and preparing food. He finds it increasingly more difficult to walk up the stairs. His bedroom is on the second floor. He is taking clopidogrel, simvastatin, and amlodipine as prescribed. His pulse is 78 bpm and BP 135/84 mmHg. On examination, he has paralysed right arm which he suffered from the earlier stroke. What is the SINGLE most appropriate action?

A 54 year old man had a recent stroke. He now presents with ataxia, intentional tremors and dysarthria. Which part of the brain is most likely affected by the stroke?

A 31 year old man, known case of alcohol abuse, is brought into Emergency by his friend from a nightclub. The friend saw the patient suddenly collapse on the dance floor where his body went stiff then there was twitching of his legs followed by involuntary voiding. When he gained consciousness, he was drowsy and confused for several minutes before full recovery. What is the SINGLE most likely diagnosis?

A 40 year old woman suddenly collapsed and died. At the post-mortem autopsy, it was found that there was a bleed from a berry aneurysm from the circle of Willis. Which is the most likely space that the bleeding occurred in?

A 50 year old lady presents with a sudden onset of severe accipital headache associated with neck pain and vomiting. CT brain was inconclusive and a lumbar puncture was performed which revealed xanthochromia. What is the SINGLE most likely diagnosis?

A 54 year old man with a history of poorly controlled diabetes presents to the GP surgery with progressive left leg weakness and a 4-month history of pain on his left hip. On examination, there is evidence of wasting of the left quadriceps muscles more than the right. There is a moderate weakness of left hip flexion and left knee extension. The strength of foot plantar flexion and dorsiflexion are within normal limits. Left patellar reflexes are absent. Her recent blood results show a normal CRP and normal ESR. What is the most likely diagnosis?

A 68 year old lady complains of falls to the ground without any warning. She maintains consciousness throughout and remembers the event. There is no confusion after the fall. What is the SINGLE most likely diagnosis?

A 50 year old diabetic woman presents with facial asymmetry to the GP surgery. The right hand corner of her mouth started drooping this morning with dribbling. She had pain behind her right ear yesterday but without any obvious rashes seen. She also complains of dryness in her right eye. On examination, she is unable to move her right side of her face or raise her right eyebrow. What is the SINGLE most likely diagnosis?

A 33 year old patient presents with gradual onset of headache, neck stiffness, photophobia and fluctuating loss of consciousness. Cerebral spinal fluid shows lymphocytosis and decreased glucose but no organism on gram stain. A CT scan of the head was read as normal. What is the SINGLE most likely causative organism?

A 55 year old man is seen in the neurology clinic as he suffers with a disabling condition after his stroke where he is unaware of items on one side. He is unaware of objects or people who are on his left side. He eats on one side of the plate. He denies that there is anything wrong with his perception A drawing of a clock in the neurology clinic is seen below.

Where is the likely pathology?

A 37 year old woman has a unilateral severe headache that started 2 hours ago. She is experiencing nausea and has blurred vision. She has been vomiting over the past hour. She denies any weakness in her limbs. Her cranial nerves II to XII are assessed to be grossly normal. She has no focal neurological deficits. She has no gait abnormalities. There is no pupilloedema. She has a temperature of 36.2°C, heart rate of 90 beats/minute, blood pressure of 120/70 mmHg, and respiratory rate of 18 breaths/minute. She has been given paracetamol and ibuprofen an hour ago, but the pain continues. Her CT head scan is unremarkable. What is the SINGLE most appropriate next step?

A 67 year old woman with a history of atrial fibrillation with presents to emergency with slurred speech, asymmetric facial weakness, left sided hemi-paresis and ataxia. On arrival to the A&E her GCS is 14/15. She is increasingly agitated. Which is the SINGLE most appropriate next course of action?

A 44 year old woman has a two week history of electric shock-like stabbing facial pain starting from her left jaw and radiates towards her forehead. The pain is unilateral and it is described as very severe and coming in spasms. The pain is triggered by chewing but occurs at other times as well. Her corneal reflexes are found to be normal. What is the SINGLE most likely diagnosis?

A 41 year old male with hypertension and recurrent kidney stones presents to the Emergency Department with a headache of intense severity. He is also noted to have neck stiffness and pain. Labs were done and revealed a serum sodium of 131 mmol/L What is the SINGLE most likely mechanism behind his serum sodium results?

A 28 year old attends the GP surgery wanting advice on combined oral contraceptive pills. She has been taking combined hormonal contraception for the past year but has recently develop symptoms of migraines. She read online that combined hormonal contraception should not be used in migraine with aura sufferers. Which of the following is a characteristic of a migraine with aura?

A 35 year old woman presents to the Emergency Department complaining of a headache for the past 6 weeks. She describes the headache as a throbbing type of pain that is marked in the morning hours, worsens on bending over, and reduces on standing up. Over the past week, she noticed that her vision momentarily ‘greys out when she bends over. She also reports that her vision is blurry as of late. Additionally, she feels nauseous at times and vomited twice over the past week. She does not have a significant past medical or surgical history, apart from being on isotretinoin for acne. On examination, she has a BMI of 29.5 kg/m2. Her blood pressure is 120/80 mmHg, heart rate is 90 beats/minute, and her systemic examination is unremarkable. However, on ophthalmoscopy, bilateral papilloedema is noted. An MRI and MR venogram of the brain are performed but neither indicate any notable abnormality. Which of the following is the SINGLE most appropriate investigation to perform?

A 35 year old woman attends the neurology clinic with a history of episodes of severe headaches, temporary weakness of her left arm and tingling on her left face. The episodes of symptoms can last for up to 24 hours. The weakness and tingling is usually followed by a headache. During these episodes, she feels nauseous and has ringing in her ears. The pain is described as throbbing on her left side of the head. She has around 2 episodes a month. Her blood pressure is 120/70 mmHg. Which group of medications are suitable as prophylactic medication?

A 58 year old man presents with dizziness, difficulty walking and slurred speech. He has a history of smoking, hypertension and hypercholesterolaemia. He denies alcohol use. On examination he has hypotonia, dysmetria, and nystagmus. Which imaging method is the modality of choice for diagnosing this condition?

A 52 year old man has incoherent speech. He is aware of his speech difficulties but finds difficulty in using the right words when speaking. He has no other symptoms apart from his speech issue. He has good comprehension. Which anatomical site is most likely to be affected?

A 30 year old man presents with facial asymmetry to the GP surgery. The right hand corner of his mouth started drooping in the morning. He also finds it difficult to close his right eye. He does not have any limb weakness. He does not complain of vertigo. On examination, he is unable to move his right side of his face or raise his right eyebrow. His ear examination is normal. He does not have slurred speech. Below is a picture of his face:

What is the SINGLE most appropriate treatment?

A 31 year old woman who suffers with complex partial seizures is started on sodium valproate in the neurology clinic as there is no effective anti-epileptic drug alternative. She is sexually active. What is the most appropriate action?

A 50 year old man complains of being pursued by the police for a crime he denies committing however on further investigation, this was found to be untrue. He has poor concentration and impaired short-term memory. He admits to drinking large amounts of alcohol for the last 20 years. He is able to carry on a coherent conversation, but moments later he is unable to recall that the conversation took place. What is the SINGLE most likely diagnosis?

A 74 year old man has been admitted to the hospital for a lower respiratory tract infection. During his stay in the hospital, he develops confusion, anxiety and becomes verbally aggressive towards medical staff. He says that he feels people are watching him and filming his actions every hour of the day. His son who lives with him says that his dad does not usually act this way. What is the SINGLE most likely diagnosis?