Neurology & Stroke Exam for FCPS with Dr Sohrab

A 38-year-old man is referred to the neurology outpatient department by his general practitioner with reports of a recurrent sense of déjà vu. He has no significant past medical history otherwise. During the course of the examination, he appears to start smacking his lips. This occurs for approximately sixty seconds. After the event, he has transient difficulty with fluently expressing words, which resolves without intervention. Given the likely diagnosis, to which part of the brain can the pathology be localized?

A 70-year-old male patient presented to the neurology clinic with weakness in both lower limbs, progressively worsening tingling with difficulty getting up from a chair. He reports laxity in his ankles for a while now with a tendency for his feet to turn inwards. As a result, he has been using orthotics for one to two years. Physical exam was remarkable for bilateral high arched feet with a visible pes cavus deformity, wasting of distal legs and feet, and weakness in bilateral toe flexors. What is the most likely diagnosis in this case?

A 45-year-old man presents with dizziness and right-sided hearing loss. Which one of the following tests would most likely indicate an acoustic neuroma?

A 30-year-old lady with no past medical history presents to the emergency department with a 2-day history of pins and needles in the lower limbs and progressive walking difficulties. She offers a history of a diarrhoeal illness 1 week ago. On examination, there is a loss of pinprick sensation in the lower limbs from mid-thigh distally and in the upper limbs from MCP joints distally. There is a bilateral weakness of ankle dorsiflexion to 3/5 and knee flexion and extension is weak to 4/5 bilaterally. Power in upper and lower limbs is otherwise normal. Knee and ankle deep tendon reflexes are absent. What is the most likely diagnosis?

A 67-year-old man is diagnosed with an acute ischaemic stroke. On assessment, you identify a right superior visual field defect. He is aphasic. His speech is fluent and voluminous but makes little sense. His comprehension and production of written language are also impaired. What type of aphasia does this represent?

A 67-year-old male attends the Emergency department with sudden onset dizziness and vomiting, which has been present for the past 2 hours. He has a background of hypertension and hypercholesterolaemia for which he takes ramipril and simvastatin. Examination reveals vertical nystagmus and difficulty standing without support. What is the most appropriate next step in this patient's management?

Which one of the following is least associated with Miller-Fisher syndrome?

A 34-year-old woman who presents with confusion, headache and fever is admitted to the Emergency Department. Shortly after admission she has a seizure. A MRI scan is performed which shows patchy haemorrhagic changes in the temporal lobe. Given the likely diagnosis, what is the treatment of choice?

Supportive treatment + intravenous cefotaxime
Supportive treatment + intravenous acyclovir
Supportive treatment + intravenous amphotericin B
Supportive treatment alone
Supportive treatment + intravenous immunoglobulin

An 80-year-old man presents to the Emergency Department reporting that he awoke this morning with dizziness and vomiting. On further questioning, you establish that he has a sensation of the room spinning around him, which is worse when he moves his head quickly, although persists with his head still, and that he vomits when these symptoms are at their most severe. He is unsteady on his feet and staggers when you try to walk him around his bed. He has no other symptoms or signs. He has a past medical history of hypertension, high cholesterol, type II diabetes which is diet controlled, and osteoarthritis. Which of the following diagnoses is it most important to exclude?

A 67-year-old man presented to the emergency department with sudden onset double vision on rightward gaze. He had a background of ischaemic heart disease and hypercholesterolemia. He smoked 10 cigarettes per day. On examination, he was found to have a normal gait and a normal peripheral neurological examination. Examination of the cranial the left eye did not adduct on rightward gaze and the right eye exhibited nystagmus. The pupils were equal and reactive the light. The emergency department team arrange an urgent MRI of the brain to rule out a possible stroke. Where is the neurological lesion that would account for the clinical presentation?

A 29-year-old man presents complaining of visual disturbance. Examination reveals a right superior homonymous quadrantanopia. Where is the lesion most likely to be?

A 47-year-old with polycythaemia is admitted to the stroke unit with right leg weakness and difficulty speaking. His speech is halting and labored, although the words he is saying are making sense and he is not repeating himself. An MRI brain confirms a partial anterior circulation stroke affecting the middle cerebral artery (MCA) territory. Given his symptoms, where is the most likely location of the infarct?

A 23-year-old man is referred to neurology clinic. He describes episodes of leg weakness following bouts of laughing whilst out with friends. The following weekend his friends described a brief collapse following a similar episode. What is the most likely diagnosis?

A 37-year-old carpenter presents to his GP with a history of clumsiness at work worsening over the last 6 months. He has noticed 'fumbling' for tools on several occasions and is particularly concerned he has fallen repeatedly due to 'tripping over his feet'. He is normally fit and well apart from well controlled type 1 diabetes and has no other symptoms. Insulin is his only medication. There is no family history of illness. On examination of this patient's reflexes he has absent ankle jerks and extensor plantars. Sensation is intact. Which of the following is a possible cause for his symptoms?

A 64-year-old woman presents with migraine and her daughter says that she noticed that when she asked her mum to repeat a phrase she said she could not. The patient has been having migraines for years and they have always been accompanied by a visual aura of flashing lights and nil else. There are no focal neurological signs and CT brain is unremarkable. Upon further questioning, the patient can follow simple and complex commands (open eyes and touch left hand to right ear) and when asked can name 4 animals in a minute. She is also fluent and understandable when asking her general questions. However, when the patient is asked to repeat 3 simple words and a sentence she cannot. What is this type of dysphasia?

A 56-year-old woman presents with facial asymmetry. Whilst brushing her teeth this morning she noted that the right hand corner of her mouth was drooping. She is generally well but noted some pain behind her right ear yesterday and says her right eye is becoming dry. On examination she has a complete paralysis of the facial nerve on the right side, extending from the forehead to the mouth. Ear, nose and throat examination is normal. Clinical examination of the peripheral nervous system is normal. What is the most likely diagnosis?

A 78-year-old right-handed female is admitted with an acute onset stroke of 2 hours duration. The decision was taken by the stroke team for thrombolysis which cures her symptoms. She is subsequently transferred to the high dependency unit for closer monitoring. Overnight, she has three bouts of vomiting and is seen by an FY2 who detects a new onset right-left disorientation and acalculia. An urgent CT scan is requested which reveals an intracerebral haemorrhage. Which area of the brain is most likely to have been affected?

A 20-year-old man presents to the neurology clinic with a 6 month history of deteriorating gait. On examination he has a wide based gait, with past pointing and high arched feet. Knee and ankle reflexes are absent, but he has an extensor plantar response bilaterally. Fundoscopy reveals a pale optic disc. There is no impairment of cognition. What is the most likely diagnosis?

A 31-year-old man attends his appointment with an oncologist after being referred by his family physician. The man reported feeling nauseous and having a persistent headache for the past month. The pain was not relieved by the regular over-thecounter painkiller. The patient confirms that he has a significant family history of cancer and this is why he has been referred to see the oncologist. After chromosome analysis which revealed an abnormality related to the chromosome 3p, the patient is explained that his condition will put him at higher risk of developing several tumors, which could be both benign and malignant. The oncologist tells the patient that this condition can be passed on to future generations and that the patient's children have a fifty-percent chance of developing the condition, given his spouse does not carry the mutation as well. The patient is happy to know that he will not need a screening flexible sigmoidoscopy. Which of the following diseases is the patient at the highest risk of developing due to his underlying condition?

A 45-year-old female is diagnosed with a glioma in the parietal lobe after being investigated for new onset seizures. Which one of the following features is she most likely to develop?

An 18-year-old man is reviewed in the neurology clinic after a recent attendance to the emergency department with new-onset seizures. He described three episodes of sudden, forceful contraction of both arms and legs, each lasting one-to-two seconds with no loss of consciousness. Two episodes occurred whilst walking and caused a fall; the third was whilst working at a café and caused him to spill a drink on a customer. He has no other medical history and no regular medication. Clinical examination, vital signs, and routine blood tests are all within normal ranges. Which is the appropriate first-line pharmacological treatment for this type of seizure?

A 34-year-old man presents with progressive loss of pain and temperature sensations over his arms and shoulders. He also complains of weakness in his hands and legs. His wife notes he had burnt his hands on several occasions without realising. He denies incontinence or peri-anal numbness. On examination, there is a spastic weakness of the lower limbs and bilateral upgoing plantars. Proprioception and vibration sensations are preserved. He is usually fit and well. What is the most likely cause of his symptoms?

A 54-year-old woman is admitted to the hospital after an acute confusion episode following taking part in a half marathon in August. She repeatedly asks the same questions and seems unable to retain any new information. She has a history of ischaemic heart disease and hyperlipidemia. She has not had any head injuries, and physical examination, including a full neurological exam, is normal. A toxicology screen, alcohol level, and basic labs including glucose and electrolytes are normal. CT head is awaited, and it is 13 hours since the onset of symptoms. What is the most likely diagnosis?

A 19-year-old female presents complaining of visual disturbance. Examination reveals a bitemporal hemianopia with predominately the lower quadrants being affected. What is the most likely lesion?

A 61-year-old man with a chronic cough and gradual weight loss presents to the clinic with gradually worsening proximal myopathy over the past few weeks. A hilar mass has been identified on chest x-ray and he is awaiting referral to the respiratory oncology clinic. Neurological testing confirms weakness which is improved by reinforcement and movement repetition. Which of the following autoantibodies is most likely to be found?