Q7: A 40 year old woman presented with a 13 day history of progressive
weakness that started in her lower limbs and rapidly involved her upper limbs.
She had an attack of diarrhea before 2 weeks and made an uneventful recovery
at that time. She did admit to the presence of simultaneous lower back and thigh
dull aching pain. There is no history of back trauma and she denied any
sphicnteric problems. Examination revealed a flaccid proximal and distal
weakness of grade 2, arelfexia throughout with unresponsive planters and intact
pinprick and temperature sensations. No sensory level on the trunk.
What is your next step?
a. Stool examination and culture for campylobacter.
b. Complete blood count.
c. Nerve conduction study.
d. MRI of the lumbosacral spine.
e. Brain CTscan.
Q8: A 64 year old woman presented with a 1 year history of progressive
clumsiness in hand writing. She reported a difficulty in swallowing and her
husband stated that her speech is somewhat labored. Examination revealed small
spastic tongue, sluggish palatal movements, dysarthric speech, wasting in both
hand muscles, and spastic lower limbs and upgoing planters. The reflexes are
exaggerated in the lower limbs and absent in the upper limbs. No sensory or
cerebellar signs, and her eye movements are intact with full range and no
diplopia.
What is your next step?
a. EMG
b. Nerve conduction study.
c. MRI of the dorsal spine.
d. Visual evoked responses.
e. Sural nerve biopsy.
Q9: A 53 year old woman presents with 1 year history of a depressed mood and
painful burning feet. Examination of the lower limbs revealed absent ankle jerks,
upgoing planters, impaired vibration and join position, and a stocking sensory
loss of pin prick and temperature sensations. Her gait is wide based with a
positive Rombergism, early bilateral primary optic atrophy, no sensory level at
the trunk, and her upper limbs are normal.
Which one of the followings is not used in the assessment?
a. MCV.
b. Blood film.
c. Red cell folate.
d. Serum vitamin b12 level.
e. Bone marrow study.
Q10: A 28 year old man presents with few days history of a terrible headache
episodes that start at 2 am at night every day for the last 5 days and each attack
lasts for about 1 hour and does not respond to paracetamol. During the attack,
the pain is piercing-like behind his right eye, with excessive tearing and nasal
discharge. He reported similar attacks when he was 18 years old. What is your
next step?
a. Start high dose prednisolone
b. Continue on same dose paracetamol.
c. Increase the daily doses of paracetamol.
d. Alcohol Gasserian's ganglion ablasion.
e. LASER iridotomy
Q11: A 25 year old woman presents with a 3 week history of generalized
headache, early morning vomiting, and a double vision. No neck stiffness or
fever. Examination revealed only a right sided abducens palsy and a florid
bilateral papilloedema with enlargement of the physiological blind spot of a
double size of ours. Brain CT scan with contrast showed slit like ventricles and
no mass lesion or midline shift. What is your next step?
a- Dorsal spine CT scan.

b- EMG of the facial musculature.
c- CSF opening pressure.
d MRI of the cervical spine with contrast.
e- Intraocular pressure recording

Q12: A 26 year old woman presents with a 5 week history of easy fatigability and
intermittent diplopia and a change in her voice quality. She stated that her
symptoms are more prominent in the evening. She did admit to the presence of
some difficulty in drinking fluids but she is not bothered by this.
Examination revealed asymmetrical non tender weakness of both proximal
upper limbs, with no fasciculation or atrophy, which became more obvious after
sustained forward arm abduction for 2 minutes. All other aspects in the clinical
examination were normal.
Which on of the followings is not useful in your workup?
a- Tetanic EMG.
b- Anti-actylcholine receptors antibodies.
c- Edrophonium test.
d- Mediastinal CT scan.
e- Nerve conduction study.
Q13: A 38 year old man brought by an ambulance with impaired mentation
since 10 hours. His roommate said that the patient developed a sudden severe
pain at the back of his head to be followed by a short lived lapse of consciousness.
His roommate stated that his friend is on no medications including illicit drug
abuse but denied any head trauma. Examination revealed a drowsy middle age
man with severe neck stiffness, bilateral papillodema, right sided subhyaloid
hemorrhage, and extensor planters. What is your next step?
a. Brain MRI with contratst.
b. Non-contrast brain CT scan.
c. Lumbar puncture and CSF analysis.
d. Blood culture.
e. Echocardiography.
Q14: A 59 year old life long heavy smoker man, presents with few weeks history
of generalized weakness and undue fatigability. He complained of mouth dryness
and a poor erection. Examination revealed a prominent postural hypotension,
proximal symmetrical non-tender weakness, a hyporeflexia which improves for a
while after a sustained muscle contraction, intact ocular movements with
sluggish papillary reaction to light. EMG revealed an increamental response of
the compound muscle action potential upon repetitive stimulation.
Which one of the followings would be useless in your workup?
a. Anti P/Q calcium channel antibodies.
b. Chest CT scan.
c. Anti-acetylcholine receptors antibodies.
d. Sputum cytology.
e. Bronchoscopy.
Q15: A 20 year old alcoholic man presents with 2 day history of altered
mutation. His brother stated that his consciousness gradually deteriorated.
Examination revealed a young drowsy man, who is febrile (temperature 39.1 C),
with multiple skin bruises, and severe neck stiffness. No papillodema. Noncontrast brain CT scan is normal. What is your next step?
a. Repeat the brain CT scan with contrast.
b. CSF analysis.
c. Sputum culture.
d. Tuberculin skin testing.
e. MRV.

Q16: A 70 year old man presents with vague personality changes and altered
mentation during the last 3 eeks. His wife said that her husband complains of
headache and infrequent vomiting, and his left arm and leg are not that powerful
when compared with the right side. No history of head trauma or a fall, and his
past medical history is unremarkable. Examination revealed a drowsy old man,
with bilateral papillodema, left sided pyramidal weakness of grade 4 plus and
left sided upgoing planter. What is your next step?
a. Lumabr puncture and CSF opening pressure measurement.
b. Plain lateral skull X ray.
c. Brain CT scan with contrast.
d. Brain CT scan without contrast.
e. Emergency lumboperitoneal shunting.
Q17: A 60 year old man presents with few months history of abnormal shaking
movements involving his arms and head. He said that these movements become
less upon drinking alcohol. Examination revealed symmetrical fine tremor of
both hands with prominent postural component, somewhat regular head shaking
movements but no jaw tremor. What is your next step?
a. Brain CT scan with contrast.
b. 24 hours urinary copper measurement.
c. T3, T4, and TSH blood level.
d. No investigation is needed to confirm the diagnosis.
e. EMG and nerve conduction studies.
Q18: A 67 year old man was brought by his son to see you. His son said that his
father was reasonably well and healthy with no medical illnesses, is now
becoming easily forgetful these days, easily irritable, and his mood is low. The
patient denied any memory loss. Examination revealed prominent loss of recent
memory with relative preservation of immediate recall. Examination of the
cranial nerves, upper limbs, lower limbs and gait was normal. He scored 21 on
mini mental state examination. What is your reasonable next step?
a. Serum B12 level.
b. TSH.
c. Brain CT scan.
d. Brain biopsy.
e. CSF protein 14-3-3 level.
Q19: A 35 year old man was brought by his brother to consult you. His brother
stated that patient has strange irregular involuntary movements involving the
head and upper limbs since 1 year, and he has slow thinking, and a depressed
mood. He is on no medications. Their father died of a similar illness when he was
40 years old. You noticed variable choreic movements, and he scored 22 in the
mini mental status examination. What is your next step?
a. Brain MRI.
b. Serum ferritin.
c. Visual evoked responses.
d. Urinary toxicology screen.
e. Muscle biopsy for ragged red fibers.
Q20: A 25 year old woman presents with weakness in her both hands since
several months. She feels thirsty most of the times, and passes large amount of
urine. Examination revealed a long thin face and neck, with bilateral partial
symmetrical ptoses but no frontalis overaction, early cataract, and a dysarthric
speech. Percussion of the thenar imminence produced a sustained contraction of
that group of muscles for 10 seconds. She is wearing a wig. Her random blood
sugar is 290 mg/ dl. What is your next step?
a. Ischemic forearm exercise test.
b. EMG.
c. Anti-acetylcholine receptors antibodies.
d. Nerve conduction study looking for F-waves.
e. MRI of the brain.