Davidson Practice of Medicine Questions Chapter 21 to 22

Based on all the chapters of  Davidson’s Medicine- Fleshandbones
Candidates  preparing for competitive examinations are recommended to read the appropriate chapter from the text book and then to asses themselves using these questions.  Otherwise it seems to difficult. Try to record your reasoning before checking the correct answer.

CHAPTER – 21

Question 1. The following statements about the skin are true

• the surface area of an adult is approximately 2 m2 (True)
• Explanation: Comprising the epidermis, dermis and subcutis layers
• the predominant cell of the dermis is the fibroblast (True)
• keratinocytes comprise 10% of the epidermal cell mass (False)
• Explanation: They comprise 95% of epidermal cells
• Langerhans cells synthesise vitamin D in the epidermis (False)
• Explanation: These are modified macrophages; keratinocytes synthesise vitamin D
• eccrine sweat glands are innervated by the parasympathetic nervous system (False)
• Explanation: They are innervated by cholinergic fibres of the sympathetic system

Question 2. In the terminology of skin lesions

• papules are solid skin elevations > 20 mm in diameter (False)
• Explanation: Papules < 5 mm in diameter
• nodules are solid skin masses > 5 mm in diameter (True)
• Explanation: Larger than papules
• vesicles are fluid-containing skin elevations > 5 mm in diameter (False)
• Explanation: Vesicles < 5 mm in diameter
• petechiae are pinhead-sized macules of blood within the skin (True)
• Explanation: They are not palpable
• macules are small raised areas of skin of altered colour (False)
• Explanation: Macules are flat, with altered skin colour or texture

Question 3. Typical features of melanocytic naevi include the following

• usually present from birth (False)
• Explanation: Most appear in early childhood
• development after the age of 40 years (False)
• Explanation: Should raise suspicion of malignancy
• junctional naevi are smooth, papillomatous, hairy nodules (False)
• Explanation: Not hairy and are macular
• intradermal naevi are circular brown macules < 10 mm in diameter (False)
• Explanation: They are nodular
• 30% life-time risk of malignant transformation (False)
• Explanation: 6% in congenital melanocytic naevi

Question 4. Typical features of malignant melanoma include

• changing appearance of a preceding melanocytic naevus (True)
• Explanation: 30-50% develop in this way
• diameter of the lesion > 5 mm (True)
• Explanation: But smaller lesions may be malignant
• irregular colour, border and elevation (True)
• Explanation: Typically asymmetrical
• personal or family history of melanoma (True)
• Explanation: Risk is also increased with fair skin and blonde hair
• painless, expanding, subungual area of pigmentation (True)
• Explanation: Characteristically painless

Question 5. Characteristic features of eczema include

• epidermal oedema and intra-epidermal vesicles (True)
• Explanation: Epidermal oedema (spongiosis) and epidermal thickening (acanthosis)
• delayed hypersensitivity reaction in seborrhoeic eczema (False)
• Explanation: This is a feature of allergic contact eczema
• increased serum IgA concentration in discoid eczema (False)
• Explanation: Serum IgE concentrations are elevated
• eyelid and scrotal oedema in allergic contact eczema (True)
• Explanation: The initial eruption occurs at the contact site
• occurrence in the flexures of the elbows and knees in pompholyx (False)
• Explanation: Occurs on palms and plantar surfaces of hands and feet

Question 6. The following blistering eruptions are typically associated with mucosal involvement

• dermatitis herpetiformis (False)
• Explanation: An intensely itchy rash without oral mucosal involvement
• bullous pemphigoid (False)
• pemphigus (True)
• Explanation: Often erosive and with mucosal involvement
• toxic epidermal necrolysis (True)
• porphyria cutanea tarda (False)

Question 7. The following are recognised causes of leg ulcers

• leprosy (True)
• Explanation: Typically painless
• sickle-cell disease (True)
• Explanation: And also cryoglobulinaemia
• diabetes mellitus (True)
• Explanation: Arterial and neuropathic aetiology
• pyoderma gangrenosum (True)
• Explanation: Associated with inflammatory bowel disease
• syphilis (True)

Question 8. The following cause alopecia with scarring

• tinea capitis (False)
• alopecia areata (False)
• discoid lupus erythematosus (True)
• Explanation: Typically patchy
• telogen effluvium (False)
• androgenetic alopecia (False)
• Explanation: Male-pattern baldness

Question 9. With regard to psoriasis

• a child with one affected parent has a 50% chance of developing the disease (False)
• Explanation: 15% if there is one affected parent
• the cellular infiltrate is typically lymphocytic (True)
• Explanation: Of helper type in the dermis
• guttate psoriasis may be preceded by ß-haemolytic streptococcal infection (True)
• Explanation: Typically throat infection
• nail pitting is associated with distal interphalangeal arthropathy (True)
• Explanation: And onycholysis
• about 5% of patients develop arthropathy (True)

Question 10. Typical features of psoriasis include

• well-defined erythematous plaques with adherent silvery scales (True)
• Explanation: Typically on the elbows, knees and lower back
• epidermal thickening and nucleated horny layer cells (parakeratosis) (True)
• Explanation: Also a dermal T lymphocyte infiltrate
• induction of plaques by local trauma (True)
• Explanation: Including surgical wounds (Köbner phenomenon)
• an association with HLA Cw6 (True)
• Explanation: Inheritance is probably polygenic
• exacerbation by propranolol and lithium carbonate therapy (True)
• Explanation: Also antimalarial drugs

Question 11. The characteristic clinical features of psoriasis include

• sparing of the skin over the head, face and neck (False)
• Explanation: The scalp is frequently involved
• guttate psoriasis usually affects the elderly (False)
• Explanation: Usually seen in children
• nail changes with pitting and onycholysis (True)
• Explanation: Also subungual hyperkeratosis
• oligoarthritis particularly associated with nail changes occurring in 5% of cases (True)
• Explanation: Perhaps mimicking rheumatoid arthritis
• red non-scaly skin areas in the natal cleft and submammary folds (True)
• Explanation: Axillary folds may be similarly affected

Question 12. The typical features of acne vulgaris include

• involvement of pilosebaceous glands and their ducts (True)
• Explanation: Ducts may be obstructed
• distribution over the face and upper torso (True)
• Explanation: Lesions elsewhere suggest an alternative diagnosis
• infection with the skin commensal Propionibacterium acnes (True)
• Explanation: Antibiotics are helpful
• increased sebum production containing excess free fatty acids (True)
• Explanation: Largely hormonally mediated
• open and closed comedones, inflammatory papules, nodules and cysts (True)
• Explanation: Seborrhoea (greasy skin) is often present also

Question 13. Therapies of proven value in acne vulgaris include

• oral tetracycline or erythromycin therapy (True)
• Explanation: For a minimum of 3 months
• topical preparations of benzoyl peroxide and retinoic acid (True)
• Explanation: Antibacterials such as chlorhexidine may also help
• oral contraceptive pill (False)
• Explanation: Unless given with cyproterone acetate
• cyproterone acetate (True)
• Explanation: Anti-androgen therapy often in combination with an oestrogen
• oral isotretinoin (True)
• Explanation: Reduces sebum secretion; highly teratogenic

Question 14. The characteristic features of rosacea include

• predominantly affects adolescents (False)
• Explanation: Commonest in middle age
• increased secretion of sebum (False)
• Explanation: Sebum secretion is normal
• facial erythema, telangiectasia, pustules and papules (True)
• rhinophyma, conjunctivitis and keratitis (True)
• non-responsive to oral tetracycline therapy (False)
• Explanation: Repeated courses may be necessary

Question 15. Medical conditions that cause pruritus include

• oral contraceptives and pregnancy (True)
• hypothyroidism and hyperthyroidism (True)
• Explanation: Also caused by biliary obstruction
• lymphoproliferative and myeloproliferative diseases (True)
• iron deficiency anaemia (True)
• Explanation: Also caused by chronic renal failure
• opiate and antidepressant drug therapy (True)

Question 16. Skin diseases associated with marked pruritus include

• cutaneous vasculitis (False)
• Explanation: The rash is non-pruritic
• lichen planus (True)
• Explanation: Usually intensely itchy
• atopic eczema (True)
• Explanation: Classically pruritic
• seborrhoeic keratosis (False)
• Explanation: Non-pruritic
• dermatitis herpetiformis (True)
• Explanation: Associated with coeliac disease

Question 17. Skin diseases associated with blistering eruptions include

• erythema multiforme (True)
• Explanation: Perhaps with target lesions
• dermatitis herpetiformis (True)
• Explanation: Typically on extensor surfaces
• pemphigoid (True)
• Explanation: Tense blood-filled lesions
• pemphigus vulgaris (True)
• Explanation: Superficial flaccid lesions
• guttate psoriasis (False)
• Explanation: Small scaly raised lesions

Question 18. Skin diseases associated with photosensitivity include

• variegate and hepatic porphyrias (True)
• Explanation: Disordered haem metabolism
• atopic eczema (True)
• Explanation: Perhaps progressing to chronic actinic dermatitis
• drug reactions to phenothiazine, thiazide and tetracycline (True)
• Explanation: And also to amiodarone and enalapril therapy
• pyoderma gangrenosum (False)
• Explanation: Associated with inflammatory bowel disease
• pityriasis rosea (False)
• Explanation: Unaffected by sunlight

Question 19. Recognised causes of erythema multiforme include

• herpes simplex infection (True)
• Explanation: Also orf and other viruses
• mycoplasmal pneumonia (True)
• Explanation: Classical
• sulphonamide therapy (True)
• Explanation: Also penicillins and barbiturates
• systemic lupus erythematosus (True)
• Explanation: And other connective tissue disorders
• bronchogenic carcinoma (True)
• Explanation: And especially post-radiotherapy

Question 20. Recognised causes of erythema nodosum include

• sarcoidosis (True)
• Explanation: Also brucellosis
• ß-haemolytic streptococcal infection (True)
• Explanation: Also mycoplasmal and chlamydial infections
• inflammatory bowel disease (True)
• Explanation: Also leukaemias and Hodgkin’s disease
• tuberculosis (True)
• Explanation: Also leprosy
• contraceptive drug therapy (True)
• Explanation: Erythema nodosum can also be caused by some other drugs, e.g. iodides and sulphonamides

Question 21. The typical features of basal cell carcinoma include the following

• predominantly affects the elderly (True)
• Explanation: Rare in young adults
• metastatic spread to the lungs if untreated (False)
• Explanation: Spread by local invasion
• occurrence in areas exposed to light or X-irradiation (True)
• Explanation: Typically on the face or head
• papule with surface telangiectasia or ulcerated nodule (True)
• Explanation: With a rolled, pearly edge
• unresponsive to radiotherapy (False)
• Explanation: Radiosensitive but surgery is preferred

Question 22. The typical features of squamous cell carcinoma include

• occurrence in areas exposed to light or X-irradiation (True)
• Explanation: Typically in Caucasians living in equatorial regions
• association with chronic immunosuppressant drug therapy (True)
• Explanation: E.g. following organ transplantation
• preceded by leucoplakia on the lips, mouth or genitalia (True)
• Explanation: Or actinic keratosis on the skin
• metastatic spread to the liver and lungs (False)
• Explanation: Haematogenous dissemination is rare
• unresponsive to radiotherapy (False)
• Explanation: Radiosensitive but surgery is preferred

CHAPTER – 22

Question 1. The predominant segmental innervation of the following tendon reflexes is

• biceps jerk-C5 (True)
• supinator jerk-C6 (True)
• Explanation: Same as the biceps jerk
• triceps jerk-C7 (True)
• Explanation: Finger flexion jerk-C8
• knee jerk-L4 (True)
• ankle jerk-S1 (True)

Question 2. A right homonymous hemianopia would be an expected finding in disorders of the

• left optic tract (True)
• Explanation: The optic tract runs between optic chiasm and lateral geniculate body
• left optic radiation (True)
• Explanation: Upper fibre damage causes lower field defect
• optic chiasm (False)
• Explanation: Midline lesions cause bitemporal hemianopia
• right lateral geniculate body (False)
• Explanation: Left lateral geniculate body
• left optic nerve (False)
• Explanation: Left monocular visual loss

Question 3. Features suggesting a 3rd cranial nerve palsy include

• paralysis of abduction (False)
• Explanation: Suggests 6th cranial nerve palsy
• absence of facial sweating (False)
• Explanation: Occurs in Horner’s syndrome
• complete ptosis (True)
• Explanation: Paralysis of levator palpebrae superioris
• pupillary dilatation (True)
• Explanation: Impaired parasympathetic flow
• absence of the accommodation reflex (True)
• Explanation: And direct light response impaired

Question 4. Paralysis of the 4th cranial nerve produces

• weakness of the inferior oblique muscle (False)
• Explanation: Superior oblique
• pupillary dilatation (False)
• Explanation: No pupillary change
• impaired downward gaze in adduction (True)
• Explanation: May be difficult to detect clinically
• elevation and abduction of the eye (True)
• Explanation: Head may tilt towards normal side
• nystagmus more marked in the abducted eye (False)
• Explanation: Suggests internuclear ophthalmoplegia

Question 5. Paralysis of the 6th cranial nerve

• produces impaired adduction of the eye (False)
• Explanation: Impaired abduction
• produces enophthalmos (False)
• Explanation: May be a feature of Horner’s syndrome
• is a characteristic feature of Wernicke’s encephalopathy (True)
• Explanation: Usually bilateral, perhaps other ocular nerves also involved
• results from disease of the upper pons (True)
• Explanation: Infarction, haemorrhage or demyelination typically
• is a recognised feature of posterior fossa tumour (True)
• Explanation: May be ‘false localising sign’ in raised intracranial pressure

Question 6. Drooping of the upper eyelid results from a lesion of the

• levator palpebrae superioris (True)
• Explanation: Partial or complete ptosis
• 3rd cranial nerve (True)
• Explanation: With pupillary dilatation
• cervical sympathetic outflow (True)
• Explanation: With pupillary constriction
• 7th cranial nerve (False)
• Explanation: Orbicularis oculi may be affected
• abducens nucleus (False)
• Explanation: No ptosis, just a lateral rectus palsy

Question 7. Absence of pupillary constriction in either eye on shining a light into the right pupil suggests

• bilateral Argyll Robertson pupils (True)
• Explanation: Accommodation preserved
• bilateral Holmes-Adie pupils (True)
• Explanation: Defect is probably in the ciliary ganglia
• right optic nerve lesion (True)
• Explanation: An afferent defect
• right oculomotor nerve lesion (False)
• Explanation: Reaction in right eye only is impaired
• bilateral Horner’s syndrome (True)
• Explanation: Both pupils may be small but response preserved

Question 8. Features of an intracranial lower motor neuron lesion of the facial nerve include

• inability to wrinkle the forehead (True)
• Explanation: Frontalis weakness
• increased lacrimation on the affected side (False)
• Explanation: Decreased due to involvement of nervus intermedius
• upward deviation of the eye on attempted eyelid closure (True)
• Explanation: Bell’s sign
• deafness due to loss of the nerve to the stapedius muscle (False)
• Explanation: Produces hyperacusis
• loss of taste over the anterior two-thirds of the tongue (True)
• Explanation: Involvement of the chorda tympani

Question 9. Characteristic features of pseudobulbar palsy include

• dysarthria (True)
• Explanation: With dysphonia
• dysphagia (True)
• Explanation: Often with aspiration
• emotional lability (True)
• Explanation: Particularly in cerebrovascular disease
• wasting and fasciculation of the tongue (False)
• Explanation: Suggest lower motor neuron lesion, 12th nerve
• absence of the jaw jerk (False)
• Explanation: Jaw jerk is typically brisk

Question 10. The following statements about bladder innervation are correct

• sacral cord lesions usually produce urinary retention (True)
• Explanation: Parasympathetic innervation impaired
• thoracic cord lesions produce urinary urge incontinence (True)
• Explanation: And incomplete bladder emptying
• pelvic nerve parasympathetic stimulation causes bladder emptying (True)
• Explanation: Internal sphincter relaxation and detrusor contraction
• pudendal nerve lesions produce automatic bladder emptying (False)
• Explanation: Feature of spinal cord lesions
• the L1-L2 segment sympathetic outflow mediates bladder relaxation (True)
• Explanation: And internal sphincter contraction

Question 11. The following statements about the Glasgow coma scale are correct

• the best response to an arousal stimulus should be measured (True)
• Explanation: Test at least twice
• appropriate motor responses to verbal commands = score 6 (True)
• Explanation: No response to pain = 1
• spontaneous eye opening = score 4 (True)
• Explanation: No eye opening = 1
• verbal responses with normal speech and orientation = score 5 (True)
• Explanation: No speech = 1
• the minimum total score = 3 (True)
• Explanation: Maximum score = 15

Question 12. The diagnosis of brain death is supported by

• pin-point pupils (False)
• Explanation: Dilated and unreactive to light
• absent corneal reflexes (True)
• Explanation: A brain-stem reflex
• absent vestibulo-ocular responses to caloric testing (True)
• Explanation: 20 ml ice-cold water into each ear in turn
• absence of spontaneous respiration (True)
• Explanation: With PaCO2 > 6.7 kPa
• preservation of the cough and gag reflexes (False)
• Explanation: All brain-stem reflexes absent

Question 13. Typical features of prefrontal lobe lesions include

• positive grasp reflex (True)
• Explanation: And other ‘primitive’ reflexes
• astereognosis (False)
• Explanation: Suggests a parietal lobe lesion
• sensory dysphasia (False)
• Explanation: Posterior temporo-parietal lesion (Wernicke’s area)
• olfactory hallucinations (False)
• Explanation: Temporal lobe sign
• social disinhibition (True)
• Explanation: Perhaps with antisocial behaviour

Question 14. Typical features of posterior parietal lobe lesions include

• lower homonymous quadrantanopia (False)
• Explanation: Contralateral to lesion
• constructional apraxia (False)
• Explanation: Non-dominant hemisphere
• sensory inattention (False)
• Explanation: Perhaps with sensory neglect
• motor dysphasia (True)
• Explanation: Broca’s area in the inferior frontal lobe
• agnosia and acalculia (False)
• Explanation: Gerstmann’s syndrome of the dominant angular gyral region

Question 15. In the evaluation of a patient with headache

• thunderclap headache is invariably associated with subarachnoid haemorrhage (False)
• Explanation: Only associated in 1 in 8 patients
• patients with viral meningitis invariably display meningism (False)
• Explanation: Meningism less common than in bacterial infection
• the presence of concurrent focal limb weakness excludes migraine (False)
• Explanation: Migrainous hemiparesis is well recognised
• improvement with simple analgesia suggests tension headache (False)
• Explanation: Tension headaches are typically poorly responsive
• headache on waking suggests raised intracranial pressure (True)
• Explanation: As does morning vomiting

Question 16. Migrainous neuralgia (cluster headache) is

• more common in females than in males (False)
• Explanation: Male to female ratio is 5:1
• the commonest form of migraine (False)
• Explanation: 10-50 times less common
• associated with Horner’s syndrome in some patients (True)
• Explanation: And unilateral lacrimation
• likely to be cured by prophylactic propranolol treatment (False)
• Explanation: Prophylaxis may not be helpful
• likely to respond well to sumatriptan therapy (True)

Question 17. In the evaluation of a patient with true vertigo

• short-lived symptoms favour a labyrinthine cause (True)
• Explanation: Persistent vertigo is more often central
• the presence of nystagmus excludes viral labyrinthitis (False)
• Explanation: Often present although transient
• associated paroxysmal tinnitus suggests Ménière’s disease (True)
• Explanation: Exclude acoustic neuroma
• positional vertigo fatigues rapidly when due to central cause (False)
• Explanation: Tends to persist
• temporal lobe epilepsy should be considered (True)
• Explanation: But a rare cause

Question 18. Features suggesting vasovagal faint rather than epilepsy in a patient with a blackout include

• an olfactory aura (False)
• Explanation: But many patients are aware that something is about to happen
• confusion following the event (False)
• headache following the event (False)
• Explanation: Also absence of injury or tongue-biting
• memory loss surrounding the event (False)
• tongue-biting (False)
• Explanation: Also pallor rather than central cyanosis suggests fainting

Question 19. In the analysis of gait

• circumduction of a leg suggests pyramidal weakness (True)
• Explanation: Often with dragging of the affected foot
• a high-stepping gait suggests foot drop (True)
• Explanation: Perhaps with slapping steps
• inability to walk heel-to-toe suggests cerebellar disease (True)
• Explanation: Classically of the vermis
• difficulty negotiating doorways suggests parkinsonism (True)
• Explanation: Associated with festination
• a waddling gait suggests proximal muscle weakness (True)
• Explanation: Usually myopathic in nature

Question 20. Jerking nystagmus that changes in direction with the direction of gaze is

• compatible with cerebellar hemisphere disease (True)
• Explanation: Maximal on gaze towards lesion if cerebellar disease is unilateral
• indicative of a brain-stem disorder (True)
• Explanation: May be more marked in the abducting eye (ataxic nystagmus)
• compatible with a vestibular nerve lesion (False)
• Explanation: Typically present only when looking away from side of lesion
• typically accompanied by vertigo and tinnitus (False)
• Explanation: Suggests vestibulocochlear disease
• likely to continue following closure of the eyes (True)
• Explanation: Demonstrable using electronystagmography

Question 21. The characteristic features of trigeminal neuralgia include

• pain lasting several hours at a time (False)
• Explanation: Lancinating paroxysms lasting a few seconds
• pain precipitated by touching the face and/or chewing (True)
• Explanation: ‘Trigger areas’ may exist
• absence of the corneal reflex (False)
• Explanation: No abnormal signs
• predominance in young females (False)
• Explanation: Occurs in elderly subjects
• response to anticonvulsants (True)
• Explanation: E.g. carbamazepine

Question 22. The typical features of Ménière’s disease include

• sudden onset of vertigo, nausea and vomiting (True)
• Explanation: May be disabling
• progressive sensorineural deafness and tinnitus (True)
• Explanation: Usually unilateral
• jerking nystagmus and ataxic gait (True)
• Explanation: Typically during attacks
• nystagmus usually persists between attacks (False)
• Explanation: Suggests benign positional vertigo
• restoration of hearing following effective treatment (False)
• Explanation: May delay progression but cannot restore auditory loss

Question 23. Typical causes of vertigo include

• cardiac arrhythmia (False)
• Explanation: Postural instability and syncopal symptoms
• acoustic neuroma (True)
• Explanation: Or other pathology of the 8th nerve
• vestibular neuronitis (True)
• Explanation: Usually associated with vertebral artery ischaemia
• gentamicin drug therapy (True)
• Explanation: And other ototoxic drugs
• otitis media (True)
• Explanation: With secondary labyrinthine inflammation

Question 24. Typical features of generalised epilepsy include

• loss of consciousness accompanied by symmetrical EEG discharge (True)
• Explanation: May follow focal EEG abnormality and symptoms-partial seizures
• invariable presence of an aura (False)
• Explanation: Often absent
• lesion demonstrable on CT of the brain (False)
• Explanation: Usually no obvious abnormality
• induction by photic stimulation (True)
• Explanation: TV or computer games may induce fits
• induction by hyperventilation (True)
• Explanation: Often used during the recording of an EEG

Question 25. The clinical features of tonic clonic seizures include

• prodromal phase lasting hours or days (True)
• Explanation: With vague irritability or lethargy
• onset with an audible cry due to the aura (False)
• Explanation: Audible cry may occur at the onset of the tonic phase
• sustained spasm of all muscles lasting 30 seconds (True)
• Explanation: Tonic phase
• interrupted jerking movements lasting 1-5 minutes (True)
• Explanation: Clonic phase
• flaccid post-ictal state with bilateral extensor plantars (True)
• Explanation: Variable duration

Question 26. The typical features of absence (petit mal) seizures include

• loss of consciousness lasting up to 10 seconds (True)
• Explanation: Sometimes with loss of posture
• onset around age 25-30 years (False)
• Explanation: Typically in childhood
• synchronous three per second spike and wave activity on EEG (True)
• Explanation: May be detected inter-ictally
• later development of tonic clonic seizures in 40% of patients (True)
• Explanation: May not occur until adulthood
• sleepiness lasting several hours post-ictally (False)
• Explanation: Rapid recovery although may occur very frequently

Question 27. The following statements about epilepsy are correct

• treatment should be started following a single witnessed seizure (False)
• Explanation: Await evidence of recurrent seizures
• 25% of patients will have a further seizure within 1 year of a first seizure (False)
• Explanation: 70%, mostly in first 2 months
• trigger factors for epilepsy include sleep deprivation and physical exhaustion (True)
• Explanation: Also febrile illnesses and metabolic disturbances
• the lifetime risk of a single seizure is 20% (False)
• Explanation: 5%
• sharp waves on EEG are highly specific for epilepsy (True)
• Explanation: Only one in 1000 are false positives

Question 28. A patient with seizures in the UK can

• drive a private car following a single seizure after 1 year free of recurrence (True)
• hold a heavy goods vehicle licence if all seizures occurred before the age of 5 years (True)
• Explanation: Providing no potentially epileptogenic brain lesion identified
• drive a private car during the withdrawal of anticonvulsant therapy (False)
• Explanation: Should stop driving for 6 months after their withdrawal
• drive a heavy goods vehicle only if seizure-free for 5 years (False)
• Explanation: 10 years
• drive a private car if seizures have only occurred during sleep in the previous 3 years (True)

Question 29. The following statements about anticonvulsants are correct

• plasma level monitoring is particularly useful in sodium valproate therapy (False)
• Explanation: Phenytoin and carbamazepine
• primidone is likely to cause sideroblastic anaemia (False)
• Explanation: Megaloblastic anaemia
• clonazepam is the first-line treatment of absence seizures (False)
• Explanation: Ethosuximide
• sodium valproate is the first-line treatment in primary generalised tonic clonic seizures (True)
• carbamazepine is a recognised cause of hyponatraemia (True)
• Explanation: Particularly in older patients

Question 30. Features suggesting epilepsy rather than a simple faint as the cause of blackouts include

• impairment of vision heralding the attack (False)
• Explanation: Suggests syncopal episode
• tongue-biting during the attack (True)
• Explanation: Not specific, especially in the elderly
• eye-witness account of sustained jerking movements during the attack (True)
• Explanation: Some jerking movements are common in simple faints
• attacks aborted by lying supine (False)
• Explanation: Suggests vasovagal syncope
• attacks confined to the sleeping hours (True)
• Explanation: May occur in blackouts due to bradycardias

Question 31. Clinical features of raised intracranial pressure include

• tachycardia and hypotension (False)
• Explanation: Bradycardia and hypertension
• dizziness and lightheadedness (True)
• Explanation: And vomiting
• headache aggravated by bending and straining (True)
• Explanation: And coughing
• behavioural and personality changes (True)
• Explanation: And impairment of conscious level
• 6th or 3rd cranial nerve palsies (True)
• Explanation: ‘False localising signs’

Question 32. The following statements about primary brain tumours are correct

• meningiomas are the most common type in the middle-aged (True)
• Explanation: 20% of all cerebral tumours
• gliomas are the most common type in childhood (False)
• Explanation: 40% of all cerebral tumours
• most childhood brain tumours arise within the posterior fossa (True)
• Explanation: They are usually cerebellar tumours
• presentation with adult-onset partial seizures is typical (True)
• Explanation: Indication for CT
• acoustic neuromas usually present in the 6th and 7th decades (False)
• Explanation: Fourth and fifth decades

Question 33. Typical causes of transient cerebral ischaemic attacks include

• carotid artery stenosis (True)
• Explanation: Usually contralateral motor, sensory, speech disturbance
• atrial fibrillation (True)
• Explanation: Bilateral events may occur
• hypotension (True)
• Explanation: Associated with standing
• intracerebellar haemorrhage (False)
• Explanation: Fixed deficit stroke
• intracerebral tumour (False)
• Explanation: Slowly progressive typically

Question 34. Clinical features suggesting lacunar stroke include

• homonymous hemianopia (False)
• Explanation: The optic pathway is only affected by larger lesions
• motor or sensory dysphasia (False)
• Explanation: Suggests cortical damage
• facial weakness and arm monoparesis (True)
• Explanation: Internal capsule lacuna
• isolated hemiparesis or hemianaesthesia (True)
• Explanation: Internal capsule lacuna
• history of hypertension or diabetes mellitus (True)
• Explanation: Account for > 80% of lacunar strokes

Question 35. The following statements about stroke are correct

• 65% of completed strokes are due to cerebral infarction (False)
• Explanation: 85%
• most strokes are complete in < 6 hours (True)
• Explanation: Minority ‘stutter’ over a longer period
• 20% of cerebral infarcts are secondary to cardiogenic embolism (True)
• Explanation: Another 20% are lacunar infarcts
• following an ischaemic stroke, aspirin reduces the risk of death or further stroke by 25% (True)
• Explanation: 75-150 mg daily
• 20% of patients with carotid territory symptoms have a major (> 70%) stenosis (True)
• Explanation: Carotid endarterectomy may then be beneficial

Question 36. Clinical features suggesting intracerebral haemorrhage include

• abrupt onset of severe headache followed by coma (True)
• Explanation: Headache is not specific to haemorrhage
• 3rd cranial nerve palsy (True)
• Explanation: In midbrain haemorrhage
• retinal haemorrhages and/or papilloedema (True)
• Explanation: With subhyaloid retinal haemorrhage
• vomiting and neck stiffness (True)
• Explanation: Raised ICP
• tinnitus, deafness and vertigo (False)
• Explanation: Suggest peripheral 8th nerve lesion

Question 37. Intracerebral abscess is a typical complication of

• infective endocarditis (True)
• Explanation: Often streptococcal in origin
• bronchiectasis (True)
• Explanation: Usually staphylococcal in origin
• frontal sinusitis (True)
• Explanation: Typically affects the frontal lobe
• otitis media (True)
• Explanation: Cerebellar or temporal
• head injury (True)
• Explanation: Typically staphylococcal in origin

Question 38. The typical features of an intracerebral abscess include

• high fever, weight loss and peripheral blood leucocytosis (False)
• Explanation: Usually there is no suggestion of infection
• epilepsy persisting after successful treatment of the abscess (True)
• Explanation: Prophylactic anticonvulsants should be considered
• bradycardia and papilloedema (True)
• Explanation: Raised intracranial pressure
• headache, vomiting and confusion (True)
• Explanation: With focal hemispheric signs
• positive blood and CSF cultures (False)
• Explanation: Lumbar puncture may be hazardous

Question 39. The typical features of adult tuberculous meningitis include

• headache and vomiting (True)
• Explanation: And general malaise
• fever associated with neck stiffness (True)
• Explanation: Fever often low-grade
• cranial nerve palsies associated with coma (True)
• Explanation: Cranial nerve lesions in 25% of cases
• miliary tuberculosis is often present (True)
• Explanation: Usual source of infection
• CSF cell count > 400 neutrophil leucocytes per ml (False)
• Explanation: Lymphocytic meningitis

Question 40. In the treatment of adult pyogenic meningitis

• penicillin therapy should be given intrathecally initially (False)
• Explanation: Intrathecal penicillin is both unnecessary and dangerous
• chloramphenicol therapy should be considered for penicillin-allergic patients (True)
• Explanation: Covers meningococci, pneumococci and Haemophilus
• antibiotic therapy should not be given before CSF analysis has been undertaken (False)
• Explanation: Start therapy if the diagnosis is likely, given the mortality and morbidity
• parenteral fluid therapy should be instituted immediately (True)
• Explanation: Septicaemic shock often complicates the disease
• the onset of a purpuric rash suggests drug allergy is likely (False)
• Explanation: Suggests meningococcaemia

Question 41. Recognised causes of viral meningitis include

• herpes simplex (True)
• Explanation: Sometimes with encephalitis
• poliomyelitis (True)
• Explanation: With subsequent anterior horn cell infection
• arenavirus (True)
• Explanation: Lymphocytic choriomeningitis
• Coxsackie viruses (True)
• Explanation: Common cause in UK
• mumps virus (True)
• Explanation: Usually self-limiting

Question 42. Typical features of adult viral encephalitis include

• acute onset of headache and fever (True)
• Explanation: Usually no prodrome
• partial epilepsy and coma rapidly ensue (True)
• Explanation: Occasionally a mild impairment of consciousness
• decreased CSF glucose concentration (False)
• Explanation: Suggests pyogenic infection
• temporal lobe EEG abnormalities are pathognomonic of herpes simplex infection (False)
• Explanation: Other viruses may cause this
• meningism (True)
• Explanation: In 75% of patients

Question 43. The typical features of multiple sclerosis include

• invariable progression with relapses and remission (False)
• Explanation: Only 25% of cases have a chronically progressive course
• onset often occurs before the age of puberty (False)
• Explanation: Rare in childhood
• choreoathetosis and parkinsonism (False)
• Explanation: No extrapyramidal features
• urinary urgency, frequency and incontinence (True)
• Explanation: In spinal involvement
• epilepsy, dysphasia or hemiplegia (False)
• Explanation: Epilepsy and hemiplegia are unusual

Question 44. Useful investigations in diagnosing multiple sclerosis include

• visual and somatosensory evoked potentials (True)
• Explanation: Can detect clinically silent lesions in 75% of patients
• magnetic resonance brain scanning (True)
• Explanation: MRI more sensitive than CT
• CSF analysis for oligoclonal IgG bands (True)
• Explanation: Occurs in 70-90% of patients between attacks
• electroencephalography (False)
• Explanation: Non-specific abnormalities
• electromyography (False)
• Explanation: Test of lower motor neuronal disease

Question 45. The typical features of idiopathic parkinsonism include

• hypokinesia (True)
• Explanation: Impaired fine finger movements
• early-onset dementia (False)
• Explanation: Cognitive impairment develops in about 30% of patients as the disease progresses
• intention tremor (False)
• Explanation: Resting tremor
• ‘leadpipe’ rigidity (True)
• Explanation: Also ‘cogwheel’ rigidity if a tremor is prominent
• normal eye movements (True)

Question 46. Clinical findings consistent with the diagnosis of idiopathic Parkinson’s disease include

• unilateral onset of the disorder (True)
• Explanation: Typically arm tremor
• emotional lability (False)
• Explanation: Suggests underlying cerebrovascular disease
• oculogyric crises (False)
• Explanation: Suggests drug-induced extrapyramidal disease
• extensor plantar responses (False)
• Explanation: Suggests multisystems atrophy (MSA)
• impaired voluntary eye movements (False)
• Explanation: Impairment of conjugate eye movements suggests progressive supranuclear palsy

Question 47. In the management of Parkinson’s disease

• anticholinergic therapy is the best first-line therapy for hypokinesis (False)
• Explanation: Principally useful for tremor
• levodopa should be introduced as soon as the diagnosis is made (False)
• Explanation: Early introduction means earlier waning of effect
• hypersalivation invariably indicates overuse of levodopa (False)
• Explanation: May be a sign of undertreatment causing hypokinesis
• dopamine receptor agonists, unlike anticholinergics, do not cause confusion (False)
• Explanation: Neuropsychiatric problems occur with both types of therapy
• dyskinesia is a frequent dose-limiting side-effect of levodopa (True)
• Explanation: Sustained-release preparations sometimes help

Question 48. The characteristic features of Huntington’s disease include

• autosomal recessive inheritance (False)
• Explanation: Autosomal dominant transmission
• clinical onset before the age of puberty (False)
• Explanation: Onset in middle-aged subjects
• progress of dementia arrested with tetrabenazine therapy (False)
• Explanation: May help chorea
• choreiform movements of the face and arms particularly (True)
• Explanation: But become generalised
• cardiomyopathic changes on echocardiography (False)
• Explanation: Suggests Friedreich’s ataxia

Question 49. The clinical features of motor neuron disease (MND) include

• insidious onset in elderly males (True)
• Explanation: Prevalence of 4 per 100 000
• progressive distal muscular atrophy (True)
• Explanation: Typically with absent reflexes
• progressive bulbar palsy (True)
• Explanation: Particularly tongue fasciculation
• upper motor neuron signs in the lower limbs (True)
• Explanation: Or in the upper limbs
• lower motor neuron signs in the upper limbs (True)
• Explanation: Or in the lower limbs

Question 50. The differential diagnosis in MND includes

• syringomyelia (True)
• Explanation: But no sensory signs in MND
• diabetic amyotrophy (True)
• Explanation: Look for evidence of diabetes mellitus
• cervical myelopathy (True)
• Explanation: Treatment may limit progression
• paraneoplastic syndrome (True)
• Explanation: Protean manifestations of a number of tumours
• meningovascular syphilis (True)
• Explanation: Check syphilis serology

Question 51. Typical features of cervical radiculopathy include

• pathognomonic radiograph abnormalities of the cervical spine (False)
• Explanation: Changes are usually degenerative and non-specific
• radicular pain in the arm and shoulder (True)
• Explanation: Follows the distribution of nerve root(s)
• painful limitation of movements of the cervical spine (True)
• Explanation: Only if due to disc prolapse or destructive pathology
• C5-C7 sensory and/or motor loss in the upper limb (True)
• Explanation: C5-C7 involvement with appropriate reflex loss
• neurosurgical intervention is often required (False)
• Explanation: Conservative management is usually adequate

Question 52. The following statements about spinal cord compression are correct

• metastatic disease is a more common cause than primary tumour (True)
• Explanation: Usually extradural deposits
• the CSF protein concentration is likely to be normal (False)
• Explanation: Typically elevated with xanthochromia (Froin’s syndrome)
• local spinal pain and tenderness usually precede motor weakness (True)
• Explanation: Pain may follow nerve root distribution
• urinary urgency is commonly the presenting feature (False)
• Explanation: A late feature
• myelography is the best and most appropriate investigation (True)
• Explanation: MRI is now invaluable

Question 53. Recognised causes of paraplegia include

• intracranial parasagittal meningioma (True)
• Explanation: Important to remember if spinal investigations are normal
• vitamin B12 deficiency (True)
• Explanation: Rare in UK in this severity
• tuberculosis of the thoracic spine (True)
• Explanation: Associated with vertebral collapse (Pott’s disease)
• anterior spinal artery thrombosis (True)
• Explanation: Sudden onset typically
• spinal neurofibromas and gliomas (True)
• Explanation: Intradural pathology accounts for 20% of cases of cord compression

Question 54. The typical features of syringomyelia include

• slow insidious progression of the disease (True)
• Explanation: Onset in third or fourth decade
• dissociate sensory loss with normal touch and position sense (True)
• Explanation: Leading to trophic ulceration
• loss of one or more upper limb tendon reflexes is invariable (True)
• Explanation: Damage to anterior horn cells
• wasting of the small muscles of the hands (True)
• Explanation: A common early feature
• hyperreflexia of the lower limbs and extensor plantar responses (True)
• Explanation: Pyramidal tract damage

Question 55. Recognised features of neurofibromatosis include

• autosomal dominant inheritance (True)
• Explanation: Central and peripheral forms occur
• café-au-lait spots (True)
• Explanation: And axillary skin freckling
• association with multiple endocrine neoplasias (True)
• Explanation: E.g. phaeochromocytoma
• intraspinal and intracranial neuromas and meningiomas (True)
• Explanation: At almost any site
• nerve deafness (True)
• Explanation: Acoustic neuroma

Question 56. The following statements about dementia are correct

• 20% of the population aged over 80 years suffer a dementing illness (True)
• Explanation: Most commonly Alzheimer’s disease
• inheritance of the apolipoprotein e4 allele is associated with multi-infarct dementia (False)
• Explanation: Risk of Alzheimer’s increased four-fold
• cerebral acetylcholinesterase inhibitors arrest progression of the disease (True)
• Explanation: Particularly in Alzheimer’s
• Alzheimer’s disease is characterised by the presence of neurofibrillary tangles (True)
• Explanation: And amyloid-rich plaques
• associated parkinsonism suggests possible Lewy body disease (True)
• Explanation: Patients often made worse by levodopa therapy

Question 57. Recognised causes of a generalised polyneuropathy include

• bronchial carcinoma (True)
• Explanation: Typically sensory
• rheumatoid arthritis (True)
• Explanation: And systemic lupus erythematosus; also cause mononeuritis multiplex
• vitamin B12 deficiency and folate deficiency (True)
• Explanation: Also vitamin B1, B2, B6, A and E deficiency
• amiodarone therapy (True)
• Explanation: And numerous drugs
• diabetes mellitus (True)
• Explanation: And myxoedema

Question 58. Clinical features typical of the following polyneuropathies include

• predominantly motor loss-lead poisoning (True)
• Explanation: Look for haematological clues
• predominantly sensory loss-post-inflammatory polyneuropathy (False)
• Explanation: Motor weakness predominates
• painful sensory impairment-alcohol misuse (True)
• Explanation: Also autonomic neuropathy with local sympathetic neural dysfunction
• sparing of the cranial nerves-sarcoidosis (False)
• Explanation: The 7th nerve especially is commonly involved in neurosarcoid
• prominent postural hypotension-diabetes mellitus (True)
• Explanation: Suggests autonomic involvement

Question 59. The typical features of Guillain-Barré polyneuropathy include

• onset within 4 weeks of an acute infective illness (True)
• Explanation: 1-4 weeks, usually after viral infection
• peripheral paraesthesiae (True)
• Explanation: Paraesthesiae spread proximally
• ascending flaccid paralysis with areflexia (True)
• Explanation: Muscle wasting is usually absent
• sparing of the respiratory and facial nerves (False)
• Explanation: Cranial nerves involved in 30-40%
• normal CSF protein concentration and cell count (False)
• Explanation: CSF protein is elevated, cell count is normal

Question 60. Typical causes of proximal myopathy include

• hypothyroidism (True)
• Explanation: And also hyperthyroidism; both resolve with treatment
• type 1 diabetes mellitus (False)
• Explanation: Causes a variety of different peripheral nerve disorders
• Cushing’s syndrome (True)
• Explanation: And also acromegaly
• pernicious anaemia (False)
• Explanation: Causes a peripheral neuropathy and spinal cord degeneration
• chronic alcohol misuse (True)
• Explanation: Often with a peripheral neuropathy

Question 61. Acute confusion in the elderly is likely to be the result of

• an adverse drug reaction (True)
• Explanation: E.g. opiates, levodopa
• hypothermia (True)
• Explanation: Check core temperature with a low-reading thermometer
• bronchopneumonia (True)
• Explanation: Consider the possibility of meningitis
• myocardial infarction (True)
• Explanation: More often asymptomatic in the elderly
• cerebral infarction (True)
• Explanation: CT to exclude subdural haematoma or tumour

Question 62. Recurrent dizziness in the elderly is likely to be the result of

• an adverse drug reaction (True)
• Explanation: Especially if associated with postural hypotension
• postural hypotension (True)
• Explanation: Absence of attacks when lying in bed is suggestive
• Ménière’s disease (True)
• Explanation: Rare in the absence of hearing loss
• vertebrobasilar insufficiency (True)
• Explanation: Common and may be reproduced by head movements
• sick sinus syndrome (True)
• Explanation: Dizziness is more likely to occur with bradycardias than tachycardias .

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