Dr Nonso’s Mastery in AKT Neurology — The Complete Doctor Academy

Neuropathic & Chronic Pain

⚡ High-Yield Core Teaching

Diagnosing neuropathic pain

Burning feet — first test: Fasting glucose to exclude diabetes. Then B12, TFTs, renal function.
Meralgia paraesthetica: Burning pain over the lateral thigh. Confirm with pelvic compression test or NCS; manage with weight loss and loose clothing.
Examine both ends: Test sensation proximally and distally — length-dependent loss is the neuropathic signature.

First-line drugs (any neuropathic pain except trigeminal neuralgia)

Drug	High-yield note
Amitriptyline	First-line; also tension-headache prophylaxis. Caution in liver disease/elderly.
Duloxetine	First-line; preferred in diabetic neuropathy.
Gabapentin	First-line.
Pregabalin	First-line; also 2nd-line in fibromyalgia.

Fibromyalgia

1st line: Behavioural therapy or supervised aerobic exercise.
2nd line: Pregabalin, duloxetine or amitriptyline.
Techniques: Mindfulness, relaxation, EMG biofeedback.

Clinical pearlPost-fracture burning pain (e.g. 8 months post-tibia fracture) is neuropathic — start amitriptyline, not codeine.

Suspected neuropathic pain

↓

Try one first-line: amitriptyline / duloxetine / gabapentin / pregabalin

↓

Ineffective or not tolerated → SWITCH to another first-line

↓

Still uncontrolled → refer to pain specialist; consider capsaicin for localised pain

🎯 SBA Test Bank (4)

A 60-year-old woman with obesity and hypertension on bendroflumethiazide complains of burning in both feet. What is the single most important initial investigation?

ARenal function
BVitamin B12
CFasting glucose / HbA1c
DThyroid function
ELiver function

Correct answer: C — Fasting glucose / HbA1c

Why it’s right: Diabetes is the commonest cause of a burning peripheral neuropathy, so glucose/HbA1c is the priority screen.

Options:

B12 is a secondary test.
(correct)
TFTs are secondary.
LFTs are not the primary screen.
Renal function is secondary.

A 54-year-old woman has burning pain in the right foot 8 months after a tibial fracture; paracetamol and codeine have not helped. What is the most appropriate treatment?

AIncrease codeine
BAmitriptyline
CIbuprofen
DTramadol
EMorphine

Correct answer: B — Amitriptyline

Why it’s right: This is neuropathic pain; a first-line neuropathic agent such as amitriptyline is indicated. Opioids are ineffective for neuropathic pain.

Options:

Opioids don’t treat neuropathic pain.
(correct)
NSAIDs don’t treat neuropathic pain.
Opioid — ineffective.
Opioid — ineffective.

A 58-year-old woman describes burning, numbness and hypersensitivity over the outer aspect of the right thigh. Examination is normal apart from altered sensation there; the pelvic compression test reproduces symptoms. What is the diagnosis?

AL5 radiculopathy
BMeralgia paraesthetica
CDiabetic amyotrophy
DFemoral neuropathy
ETrochanteric bursitis

Correct answer: B — Meralgia paraesthetica

Why it’s right: Burning sensory symptoms confined to the lateral thigh from lateral femoral cutaneous nerve entrapment is meralgia paraesthetica. It is managed with weight loss and looser clothing.

Options:

L5 affects the dorsum of the foot.
(correct)
Amyotrophy causes proximal weakness/wasting.
Femoral neuropathy weakens knee extension.
Bursitis causes local hip tenderness, not burning sensory loss.

A 45-year-old with fibromyalgia has widespread pain unrelieved by exercise and simple analgesia. Which is the most appropriate next step?

ALong-term opioids
BPregabalin, duloxetine or amitriptyline
COral corticosteroids
DRegular NSAIDs
EDiazepam

Correct answer: B — Pregabalin, duloxetine or amitriptyline

Why it’s right: After first-line non-drug measures (exercise, behavioural therapy), pregabalin, duloxetine or amitriptyline are the pharmacological options in fibromyalgia. Opioids and steroids have no role.

Options:

Opioids are not recommended.
(correct)
Steroids don’t help fibromyalgia.
NSAIDs are largely ineffective.
Benzodiazepines are inappropriate long-term.

Movement Disorders

⚡ High-Yield Core Teaching

Parkinson’s disease — core features

Triad: Bradykinesia + resting tremor + cogwheel/lead-pipe rigidity.
Trap: Hypotonia is NOT Parkinson’s — tone is increased; hypotonia suggests another diagnosis.

Targeted symptom treatment

Symptom	Treatment
Drooling	Glycopyrronium bromide
Orthostatic hypotension	Midodrine
Daytime somnolence	Modafinil

Drug choice by quality of life

Situation	Drug
QoL affected	Levodopa (co-beneldopa / co-careldopa)
QoL not affected	Ropinirole (dopamine agonist) or MAO-B inhibitor
Refractory motor fluctuations	Apomorphine (D2 agonist)

Mechanisms

Drug	MOA
Selegiline	MAO-B inhibitor
Entacapone	COMT inhibitor
Procyclidine	Anticholinergic (drug-induced parkinsonism)
Apomorphine / ropinirole	D2 agonist

Red flag / must-knowAvoid dopamine blockers in Parkinson’s: metoclopramide, prochlorperazine, and antipsychotics (haloperidol, flupentixol, sulpiride, pimozide).

Clinical pearlNMS is triggered by starting an antipsychotic OR abruptly stopping levodopa. Look for rigidity, fever, autonomic instability and a raised creatine kinase.

Mimics

Multiple system atrophy (Shy-Drager): Parkinsonism + autonomic failure (postural hypotension, incontinence, ED).
Essential tremor: Autosomal dominant; improves with alcohol and rest. First-line: propranolol.
Distinguishing test: SPECT (DaT) scan separates Parkinson’s from essential tremor.

Tremor at a glance

Feature	Parkinson’s	Essential tremor
Character	Resting, pill-rolling	Postural/action
With movement	Improves	Worsens
Alcohol	No effect	Improves
Family history	Usually none	Often autosomal dominant
First-line	Levodopa/agonist	Propranolol

🎯 SBA Test Bank (4)

A 76-year-old man with Parkinson’s on co-careldopa develops rigidity, a temperature of 39°C, pulse 102 and BP 170 mmHg after three days unable to take his medication with gastroenteritis. Which single test best supports the likely diagnosis?

ABlood cultures
BCreatine kinase
CCT head
DLumbar puncture
EUrine culture

Correct answer: B — Creatine kinase

Why it’s right: Abrupt levodopa withdrawal has precipitated a neuroleptic-malignant-like syndrome; muscle breakdown markedly raises creatine kinase.

Options:

Cultures address infection, not NMS.
(correct)
CT won’t confirm NMS.
LP won’t confirm NMS.
Urine culture is unrelated.

A 70-year-old with mild right-hand rest tremor and micrographia has symptoms that do not yet affect his daily life. Which initial treatment best fits current guidance?

ALevodopa
BRopinirole (dopamine agonist)
CMetoclopramide
DHaloperidol
ENo treatment ever

Correct answer: B — Ropinirole (dopamine agonist)

Why it’s right: When quality of life is not yet affected, a dopamine agonist (or MAO-B inhibitor) is appropriate; levodopa is reserved for when QoL is impaired.

Options:

Levodopa is for QoL-affecting symptoms.
(correct)
Dopamine blocker — worsens PD.
Dopamine blocker — worsens PD.
Treatment is appropriate here.

A 62-year-old man has a 6-month history of resting tremor, slowness and stiffness that is now affecting his job as a carpenter. Which initial treatment best fits guidance?

ARopinirole
BLevodopa (co-careldopa)
CSelegiline
DProcyclidine
EAmantadine

Correct answer: B — Levodopa (co-careldopa)

Why it’s right: When motor symptoms impair quality of life, levodopa is first-line as the most effective symptom control. Dopamine agonists or MAO-B inhibitors are reserved for when QoL is not yet affected.

Options:

Agonist is for QoL-unaffected disease.
(correct)
MAO-B is less effective as monotherapy here.
Anticholinergic is for drug-induced parkinsonism.
Amantadine is adjunctive.

A 70-year-old with essential tremor finds it socially disabling. He has asthma. Which first-line drug is problematic and what is the concern?

APropranolol — may worsen asthma
BPrimidone — causes tremor
CLevodopa — ineffective
DClonazepam — first-line
ETopiramate — contraindicated in tremor

Correct answer: A — Propranolol — may worsen asthma

Why it’s right: Propranolol is first-line for essential tremor but is a non-selective beta-blocker that can worsen asthma. Primidone is the main alternative in that situation.

Options:

(correct)
Primidone is a valid alternative.
Levodopa isn’t used for essential tremor.
Clonazepam is not first-line.
Topiramate is a second-line option, not contraindicated.

Headache & Craniofacial Neuralgias

⚡ High-Yield Core Teaching

Neuralgias

Trigeminal neuralgia: Brief stabbing facial pain triggered by touch/chewing. First-line: carbamazepine. May lose the corneal reflex.
Glossopharyngeal neuralgia: Severe tongue/ear pain with intermittent sore throat and a normal ENT exam.

Migraine

Acute: Triptan (± NSAID/paracetamol). Contraindicated after MI/IHD.
Prophylaxis: Topiramate (needs two forms of contraception — teratogenic), propranolol (avoid in asthma), or riboflavin (vitamin B2) 400 mg daily.
Menstrual migraine: Frovatriptan or zolmitriptan.
Aura: Combined pill contraindicated.
Children: Nasal triptan (adolescent); paracetamol + specialist follow-up (younger). Avoid aspirin and metoclopramide.

Cluster vs tension

	Cluster	Tension-type
Pattern	Unilateral, nocturnal restlessness, lacrimation, ptosis	Bifrontal, non-pulsatile, band-like
Acute	100% oxygen + SC/nasal triptan	Aspirin/paracetamol/NSAID (no opioids)
Prophylaxis	Verapamil	Acupuncture (10 sessions over 5–8 weeks)

Giant cell (temporal) arteritis

Scalp tenderness only: Prednisolone 50 mg daily.
Any visual loss: Prednisolone 60 mg immediately + same-day ophthalmology.
Labs: ESR + temporal artery biopsy.

Red flag / must-knowNew temporal headache with jaw claudication or visual symptoms in someone over 50 = GCA. Start high-dose steroids before the biopsy — do not wait.

Suspected giant cell arteritis (>50, new temporal headache)

↓

Any visual symptoms? — YES → prednisolone 60 mg NOW + same-day ophthalmology

↓

NO visual symptoms → prednisolone ~40–60 mg (min 50 mg if uncomplicated)

↓

Urgent ESR/CRP + arrange temporal artery biopsy (do not delay steroids)

🎯 SBA Test Bank (4)

A 72-year-old man reports a new right temporal headache noticed while combing his hair and pain in the jaw on eating, with transient blurring in the right eye. What is the most appropriate immediate management?

ASumatriptan
BPrednisolone 60 mg immediately + same-day ophthalmology
CCarbamazepine
DAmitriptyline
ERoutine ESR and review in a week

Correct answer: B — Prednisolone 60 mg immediately + same-day ophthalmology

Why it’s right: Visual symptoms in GCA are a sight-threatening emergency; give high-dose steroids at once and refer the same day. Investigations must not delay treatment.

Options:

Triptans treat migraine.
(correct)
Carbamazepine is for trigeminal neuralgia.
Amitriptyline is not the treatment.
Delay risks blindness.

A 30-year-old woman with migraine with aura requests contraception. Which option is contraindicated?

AProgestogen-only pill
BCopper IUD
CCombined oral contraceptive pill
DProgestogen implant
EDepot progestogen

Correct answer: C — Combined oral contraceptive pill

Why it’s right: Migraine with aura is UKMEC 4 for combined hormonal contraception because of stroke risk. Progestogen-only and non-hormonal methods are safe.

Options:

POP is safe.
Copper IUD is safe.
(correct)
Implant is safe.
Depot is acceptable.

A 38-year-old man has week-long bouts of severe strictly right-sided pain around the eye, each lasting an hour, with a red watering eye and restlessness, several times a day. What is the most effective acute treatment?

AOral paracetamol
BHigh-flow oxygen + subcutaneous sumatriptan
COral codeine
DAmitriptyline
EVerapamil

Correct answer: B — High-flow oxygen + subcutaneous sumatriptan

Why it’s right: This is cluster headache; acute attacks respond to high-flow oxygen and a fast-acting (subcutaneous/nasal) triptan. Verapamil is for prevention, not the acute attack.

Options:

Simple analgesia is ineffective.
(correct)
Opioids don’t work.
Amitriptyline is not acute treatment.
Verapamil is prophylaxis.

A 33-year-old woman has migraine on 3 days a month and asthma. She needs prophylaxis. Which is most appropriate?

APropranolol
BTopiramate
CAmitriptyline is contraindicated
DVerapamil
ECombined oral contraceptive

Correct answer: B — Topiramate

Why it’s right: Propranolol is avoided in asthma, so topiramate is the appropriate migraine preventive here (with counselling on teratogenicity and contraception). Amitriptyline is also an option.

Options:

Beta-blocker — avoid in asthma.
(correct)
Amitriptyline is actually a valid option.
Verapamil is for cluster, not migraine, prophylaxis.
COC is avoided in migraine, especially with aura.

Vascular Neurology: Stroke & TIA

⚡ High-Yield Core Teaching

TIA review windows

Time since event	Specialist review
Within 7 days	Within 24 hours
Over 7 days	Within 1 week

Secondary prevention

Standard: Atorvastatin 80 mg + clopidogrel 75 mg.
Clopidogrel intolerant: Aspirin + dipyridamole.
Surgery: Carotid endarterectomy if stenosis >70% (NASCET) or >50% (ECST).

Acute reperfusion

Alteplase: Within 4.5 hours. Contraindications: pregnancy, LP within 7 days, prior intracranial bleed, SAH, seizure at onset.
Thrombectomy: Window of 6–24 hours for large-vessel occlusion.

Stroke localisation

Territory	Signs
Lateral medullary (PICA)	Ataxia, vertigo, hoarseness, dysphagia
ACA	Legs > arms weakness, disinhibition, grasp reflex, urinary incontinence
MCA	Arms/face > legs weakness, aphasia
Amaurosis fugax	‘Curtain’ monocular visual loss; ophthalmic artery; carotid bruit

FAST-positive / ongoing deficit

↓

Urgent CT to exclude bleed

↓

Ischaemic + ≤4.5 h → alteplase

↓

Large-vessel occlusion 6–24 h → thrombectomy

↓

Bleed excluded → aspirin 300 mg × 2 weeks → clopidogrel

Territory → syndrome

Territory	Hallmark
ACA	Legs > arms; incontinence; disinhibition
MCA	Face/arm > leg; aphasia (dominant)
PCA	Homonymous hemianopia; visual
Lateral medullary (PICA)	Vertigo, ataxia, dysphagia, hoarseness
Lacunar	Pure motor or pure sensory, no cortical signs

🎯 SBA Test Bank (4)

A 68-year-old presents 3 days after a fully-resolved episode of transient right-arm weakness. Examination is normal. What is the most appropriate management?

AManage in primary care
BAspirin 300 mg now + specialist review within 24 hours
CAspirin 75 mg + review in a month
DWarfarin now
ECT head then discharge

Correct answer: B — Aspirin 300 mg now + specialist review within 24 hours

Why it’s right: A suspected TIA within the last 7 days needs aspirin 300 mg immediately and specialist assessment within 24 hours. Antiplatelet loading reduces early recurrent-stroke risk.

Options:

Needs specialist review.
(correct)
Dose/timing wrong.
Anticoagulation only if AF.
Does not address risk.

A 70-year-old has sudden painless loss of vision in one eye described as a curtain descending, lasting minutes, with a carotid bruit. What is the underlying mechanism?

ACentral retinal vein occlusion
BAmaurosis fugax from carotid embolism
COptic neuritis
DGiant cell arteritis
ERetinal detachment

Correct answer: B — Amaurosis fugax from carotid embolism

Why it’s right: Transient monocular visual loss (amaurosis fugax) reflects emboli through the ophthalmic artery from carotid disease. It is a TIA equivalent needing carotid assessment.

Options:

CRVO is not transient/curtain-like.
(correct)
Optic neuritis is painful with slower loss.
GCA usually gives persistent loss + systemic features.
Detachment gives flashes/floaters.

A 66-year-old is brought in 2 hours after sudden right-sided face and arm weakness with expressive aphasia. CT excludes haemorrhage. What is the most appropriate immediate treatment?

AAspirin 300 mg only
BIntravenous thrombolysis (alteplase)
CClopidogrel 75 mg
DWarfarin
EDipyridamole

Correct answer: B — Intravenous thrombolysis (alteplase)

Why it’s right: Within 4.5 hours of onset and with haemorrhage excluded, thrombolysis is indicated for disabling deficit. Aspirin 300 mg is given after thrombolysis (or immediately if thrombolysis is not appropriate).

Options:

Aspirin alone under-treats an eligible patient.
(correct)
Clopidogrel is secondary prevention.
Warfarin is not acute treatment.
Dipyridamole is secondary prevention.

A 72-year-old had a right-carotid-territory TIA with full recovery; Doppler shows 80% ipsilateral internal carotid stenosis. Besides best medical therapy, what should be arranged?

ANo further action
BCarotid endarterectomy
CLifelong warfarin
DRepeat scan in 1 year
EBilateral stenting regardless

Correct answer: B — Carotid endarterectomy

Why it’s right: Symptomatic carotid stenosis greater than 70% (NASCET) warrants carotid endarterectomy to reduce recurrent stroke, done promptly after the event. Medical therapy alone is insufficient here.

Options:

Action is needed.
(correct)
Anticoagulation is for cardioembolic stroke.
Delay risks recurrence.
Intervention is for the symptomatic side.

Neuromuscular & Spinal Disorders

⚡ High-Yield Core Teaching

Motor neurone disease

Key pearl: Sensory function is preserved — pure motor signs (mixed UMN + LMN).
Prognosis: About 3 in 4 die within 5 years; worse with dysarthria, weight loss, older age, fasciculation.
Riluzole monitoring: LFTs at baseline, monthly ×3, then 3-monthly ×9, then annually.
Bulbar vs pseudobulbar: Bulbar = LMN (tongue fasciculation); pseudobulbar = UMN (no fasciculation, emotional lability).

Guillain–Barré syndrome

Picture: Ascending weakness + absent reflexes after gastroenteritis (Campylobacter jejuni).
Monitoring: Serial spirometry (FVC) for impending respiratory failure.

Myasthenia gravis / Lambert–Eaton

MG: Fatigable ptosis/diplopia, worse at day’s end. Treat with pyridostigmine.
MG exacerbators: Beta-blockers, lithium, quinolones, macrolides, gentamicin.
Lambert–Eaton: Associated with small-cell lung cancer; improves with use.

Spinal cord syndromes

Syndrome	Signature
Syringomyelia	Dissociated loss (pain/temp lost, vibration/proprioception kept); Charcot joints
Tabes dorsalis	Late syphilis; loss of vibration and proprioception
Brown-Séquard	Cord hemisection: ipsilateral weakness, contralateral pain/temp loss

Weakness pattern differentials

Feature	MND	Myasthenia gravis	Guillain–Barré
Onset	Gradual	Fatigable, fluctuating	Acute, ascending
Sensation	Normal	Normal	Often paraesthesiae
Reflexes	Mixed UMN/LMN	Normal	Absent
Key test/Rx	Riluzole; LFTs	Pyridostigmine	FVC monitoring

🎯 SBA Test Bank (4)

A 25-year-old develops ascending leg weakness with absent reflexes two weeks after a diarrhoeal illness. Which bedside test is most important to monitor?

ANerve conduction studies
BSerial forced vital capacity (spirometry)
CMRI spine
DCampylobacter serology
ECT head

Correct answer: B — Serial forced vital capacity (spirometry)

Why it’s right: Guillain–Barré can progress to respiratory-muscle failure; serial FVC detects deterioration needing ventilatory support. It is the priority monitoring test.

Options:

NCS confirm but don’t monitor safety.
(correct)
MRI is not the safety monitor.
Serology is confirmatory, not urgent.
CT head is unrelated.

A 62-year-old has progressive limb weakness with both wasting/fasciculation and brisk reflexes, but entirely normal sensation. What is the most likely diagnosis?

AMultiple sclerosis
BMotor neurone disease
CGuillain–Barré syndrome
DPeripheral neuropathy
EMyasthenia gravis

Correct answer: B — Motor neurone disease

Why it’s right: Mixed upper and lower motor neurone signs with preserved sensation are characteristic of motor neurone disease. Sensory sparing is the key discriminator.

Options:

MS has sensory/visual signs.
(correct)
GBS is areflexic and acute.
Neuropathy has sensory loss.
MG is fatigable weakness, no wasting early.

A 40-year-old woman has drooping eyelids and double vision that worsen through the day and improve after rest. Which is the most appropriate first-line treatment?

APrednisolone alone
BPyridostigmine
CPropranolol
DGabapentin
EBaclofen

Correct answer: B — Pyridostigmine

Why it’s right: Fatigable ptosis and diplopia point to myasthenia gravis; pyridostigmine (an acetylcholinesterase inhibitor) is first-line symptomatic treatment. Beta-blockers and aminoglycosides can worsen it.

Options:

Steroids are added later under specialist care.
(correct)
Beta-blockers worsen MG.
Gabapentin is unrelated.
Baclofen treats spasticity.

A 60-year-old smoker has proximal leg weakness that improves after sustained exertion, with reduced reflexes. A chest lesion is found. What is the likely diagnosis?

AMyasthenia gravis
BLambert–Eaton myasthenic syndrome
CPolymyositis
DMotor neurone disease
EGuillain–Barré syndrome

Correct answer: B — Lambert–Eaton myasthenic syndrome

Why it’s right: Weakness that improves with use plus an underlying small-cell lung cancer is Lambert–Eaton myasthenic syndrome, an antibody-mediated paraneoplastic disorder. It contrasts with the fatigability of myasthenia gravis.

Options:

MG worsens with use.
(correct)
Polymyositis causes painful proximal weakness without the lung link.
MND has mixed UMN/LMN signs.
GBS is acute and areflexic.

Epilepsy & Seizure Management

⚡ High-Yield Core Teaching

Classification clues

Type	Clue / EEG
Absence	Daydreaming + eyelid flutter; 3 Hz spike-and-wave
Juvenile myoclonic	Early-morning myoclonic jerks in a teenager
Infantile spasms (West)	Flexion spasms in infancy; hypsarrhythmia on EEG

First-line drugs

Seizure	1st line	Female of childbearing potential / 2nd line
Generalised tonic-clonic	Sodium valproate*	Lamotrigine / levetiracetam
Absence	Ethosuximide	Sodium valproate*
Focal	Lamotrigine or levetiracetam	Carbamazepine

Red flag / must-knowSodium valproate is prohibited in anyone able to become pregnant unless the Pregnancy Prevention Programme is met, and new MHRA rules bar starting it in patients under 55 without two specialists’ sign-off. It is highly teratogenic and also causes hyponatraemia, thrombocytopenia, alopecia and weight gain.

Contraception on enzyme-inducers

Carbamazepine + contraception: Depot progestogen injection (or copper/LNG-IUD) is the reliable choice; oral hormones and the implant are compromised.

Convulsive seizure ≥5 min = status epilepticus

↓

1. Benzodiazepine (IV lorazepam / rectal diazepam)

↓

2. Phenytoin

↓

3. Phenobarbitone

↓

4. General anaesthesia

🎯 SBA Test Bank (4)

A 23-year-old woman with generalised tonic-clonic epilepsy needs long-term treatment and may wish to conceive in future. Which drug is most appropriate?

ASodium valproate
BLamotrigine
CPhenytoin
DCarbamazepine
EEthosuximide

Correct answer: B — Lamotrigine

Why it’s right: Valproate is contraindicated in those who could become pregnant; lamotrigine (or levetiracetam) is the appropriate first-line choice for generalised seizures in this group.

Options:

Valproate is teratogenic — avoid.
(correct)
Phenytoin is not first-line here.
Carbamazepine can worsen some generalised seizures.
Ethosuximide is for absence only.

A convulsive seizure has continued for 6 minutes in the community. What is the first-line treatment?

AIV phenytoin
BBuccal midazolam or rectal diazepam
CPhenobarbitone
DGeneral anaesthesia
ELevetiracetam infusion

Correct answer: B — Buccal midazolam or rectal diazepam

Why it’s right: A seizure lasting 5 minutes or more is status epilepticus; a benzodiazepine is first-line (buccal midazolam or rectal diazepam out of hospital). Phenytoin is the second step.

Options:

Phenytoin is step 2.
(correct)
Phenobarbitone is later.
GA is a last resort.
Not first-line.

A 19-year-old man has generalised tonic-clonic seizures. He is otherwise well. Which first-line drug is most appropriate?

ASodium valproate
BEthosuximide
CLamotrigine
DCarbamazepine
EGabapentin

Correct answer: C — Lamotrigine

Why it’s right: For generalised tonic-clonic epilepsy, lamotrigine or levetiracetam are appropriate first-line choices; valproate is effective but carries strict restrictions (and is avoided where pregnancy is possible). Modern practice favours lamotrigine/levetiracetam broadly.

Options:

Valproate has strict MHRA restrictions.
Ethosuximide is for absence only.
(correct)
Carbamazepine can worsen some generalised seizures.
Gabapentin is not first-line for generalised seizures.

A 26-year-old woman on carbamazepine for focal epilepsy wants reliable contraception. Which method is least affected by this enzyme-inducer?

ACombined oral pill
BProgestogen-only pill
CEtonogestrel implant
DDepot medroxyprogesterone injection
EStandard-dose emergency pill

Correct answer: D — Depot medroxyprogesterone injection

Why it’s right: Carbamazepine induces hepatic enzymes and reduces the efficacy of most hormonal methods; the depot injection (and copper/LNG-IUD) remain reliable. The implant and oral hormones are compromised.

Options:

COC efficacy is reduced.
POP is reduced.
Implant efficacy is reduced.
(correct)
Emergency-pill dose would need adjusting.

Multiple Sclerosis

⚡ High-Yield Core Teaching

Diagnosis & relapse

MRI: Multiple plaques (lesions disseminated in time and space); often presents with optic neuritis.
Acute relapse: Methylprednisolone for 5 days.
Relapse definition: New symptoms lasting >24 hours without infection/fever.

Disease-modifying therapy

Efficacy: Natalizumab (~68%) is more effective than beta-interferon (~30%); specialist-initiated.

Symptom management

Symptom	Treatment
Fatigue	Amantadine
Spasticity	Baclofen or gabapentin
Nocturia	Desmopressin
Urge incontinence (no retention)	Oxybutynin
Urinary retention	Intermittent self-catheterisation

Clinical pearlA febrile MS patient whose old symptoms flare is likely having a pseudo-relapse (Uhthoff’s) from the fever, not a true relapse — treat the infection.

🎯 SBA Test Bank (3)

A 35-year-old woman with relapsing–remitting MS has troublesome nocturia; urinalysis, renal function and ultrasound are normal. Which treatment is most appropriate?

ATrimethoprim
BOxybutynin
CDesmopressin
DDoxazosin
EIntermittent self-catheterisation

Correct answer: C — Desmopressin

Why it’s right: For nocturnal polyuria with a normal urinary tract, desmopressin reduces overnight urine output. Oxybutynin targets urge incontinence rather than isolated nocturia.

Options:

No infection present.
Oxybutynin is for urge incontinence.
(correct)
Doxazosin is for outflow symptoms.
Self-catheterisation is for retention.

A 28-year-old woman has painful loss of vision in one eye over two days with reduced colour perception and a relative afferent pupillary defect. What is the most likely diagnosis?

AAcute angle-closure glaucoma
BOptic neuritis
CCentral retinal artery occlusion
DGiant cell arteritis
EAmaurosis fugax

Correct answer: B — Optic neuritis

Why it’s right: Subacute painful monocular visual loss with colour desaturation and an RAPD in a young adult is optic neuritis, a common first presentation of multiple sclerosis. It is confirmed on MRI and often treated with steroids.

Options:

Glaucoma gives a red painful eye with haloes.
(correct)
CRAO is sudden and painless.
GCA affects older patients with systemic features.
Amaurosis fugax is transient.

A 34-year-old with relapsing–remitting MS develops a new limb weakness lasting 3 days, with no fever or infection. What is the most appropriate acute treatment?

AOral antibiotics
BHigh-dose methylprednisolone
CNatalizumab now
DBaclofen
EAmantadine

Correct answer: B — High-dose methylprednisolone

Why it’s right: A relapse (new symptoms >24 hours without infection) is treated acutely with a short course of high-dose methylprednisolone to speed recovery. Disease-modifying drugs like natalizumab are specialist-initiated for prevention, not acute relapse.

Options:

No infection is present.
(correct)
DMT is preventive, specialist-started.
Baclofen treats spasticity.
Amantadine treats fatigue.

Cognitive & Developmental Neurology

⚡ High-Yield Core Teaching

Dementia differential

Type	Signature
Alzheimer’s	Commonest; higher risk in Down syndrome (trisomy 21)
Vascular	Step-wise; HTN, AF, high cholesterol
Frontotemporal (Pick’s)	Personality/behaviour change under 65
Normal-pressure hydrocephalus	‘Wet, wacky, wobbly’ — incontinence, dementia, shuffling gait

Cerebral palsy types

Type	Features
Spastic diplegia	Commonest; stiffness of the lower limbs
Spastic quadriplegia	All four limbs, impaired speech, poor head control
Athetoid/dyskinetic	Uncontrolled movements + drooling
Ataxic	Balance and fine-motor difficulty

Clinical pearlNormal-pressure hydrocephalus is a reversible cause of dementia — the ‘wet, wacky, wobbly’ triad should prompt referral for possible shunting.

🎯 SBA Test Bank (3)

A 74-year-old has urinary incontinence, a shuffling ‘magnetic’ gait and cognitive decline, with enlarged ventricles on CT out of proportion to atrophy. What is the diagnosis?

AAlzheimer’s disease
BNormal-pressure hydrocephalus
CVascular dementia
DParkinson’s disease
ELewy body dementia

Correct answer: B — Normal-pressure hydrocephalus

Why it’s right: The triad of incontinence, gait disturbance and dementia with ventriculomegaly is normal-pressure hydrocephalus — a potentially reversible cause treated by shunting.

Options:

Alzheimer’s lacks this triad.
(correct)
Vascular is step-wise.
PD lacks early incontinence/dementia.
DLB has hallucinations/fluctuation.

A 58-year-old develops progressive personality change, disinhibition and poor judgement, with relatively preserved memory. What is the most likely dementia?

AAlzheimer’s disease
BFrontotemporal (Pick’s) dementia
CVascular dementia
DLewy body dementia
ENormal-pressure hydrocephalus

Correct answer: B — Frontotemporal (Pick’s) dementia

Why it’s right: Early personality and behavioural change with preserved memory in someone under 65 is frontotemporal dementia. Memory-led decline would favour Alzheimer’s.

Options:

Alzheimer’s is memory-led.
(correct)
Vascular is step-wise with vascular risk.
DLB has hallucinations/fluctuation/parkinsonism.
NPH has the wet-wacky-wobbly triad.

A child with cerebral palsy has stiffness affecting the legs more than the arms and walks with a scissoring gait, with normal cognition. Which type is most likely?

ASpastic quadriplegia
BSpastic diplegia
CAthetoid/dyskinetic
DAtaxic
EMixed

Correct answer: B — Spastic diplegia

Why it’s right: Predominant lower-limb spasticity with a scissoring gait is spastic diplegia, the commonest cerebral-palsy pattern. Quadriplegia involves all four limbs with impaired speech and head control.

Options:

Quadriplegia affects all four limbs severely.
(correct)
Athetoid causes involuntary movements.
Ataxic causes balance/coordination problems.
Mixed shows combined features.

GCS, Nerve Injuries, Dermatomes

⚡ High-Yield Core Teaching

GCS worked cases

Case	E / V / M	Total
Ladder fall (54M): extends to pain	E1 V1 M2	4
Drunk (48F): localises pain	E2 V4 M5	11
Garage fall (72M): inappropriate words, withdraws	E3 V3 M4	10
Alcoholic, nystagmus	E4 V4 M6	14
Chest sepsis (87M): abnormal flexion	E2 V2 M3	7

Nerve injuries

Nerve	Deficit / cause
Radial	Wrist drop; ‘Saturday-night palsy’
Common peroneal	Foot drop; fibular-neck fracture
Axillary	Loss of shoulder abduction; humeral fracture/dislocation
Facial (Bell’s)	10 days corticosteroids; poor prognosis if >60, complete palsy, no recovery by 6 weeks

Dermatomes & myotomes

Root	Landmark	Motor / reflex
C2	Posterior skull (cap)	—
T4	Nipples	—
T10	Umbilicus	—
L3	Anterior thigh	Weak quads; ↓ knee reflex
L4	Kneecap	↓ knee reflex
L5	Dorsum of foot / big toe	Weak big-toe dorsiflexion
S1	Lateral foot / small toe	Weak plantar flexion; ↓ ankle reflex

🎯 SBA Test Bank (3)

A 54-year-old fell from a ladder: he does not open his eyes, makes no sounds, and extends his limbs to a painful stimulus. What is his GCS?

Correct answer: B — 4

Why it’s right: No eye opening (E1), no verbal response (V1) and extension to pain (M2) sum to a GCS of 4. Extension is decerebrate (M2), scoring one above no response.

Options:

E1V1M1 would be 3.
(correct)
Too high.
Too high.
Too high.

A patient cannot extend the wrist after falling asleep with the arm over a chair, and has numbness over the dorsal thumb web space. Which nerve is injured?

AUlnar
BMedian
CRadial
DAxillary
ECommon peroneal

Correct answer: C — Radial

Why it’s right: Wrist drop with dorsal first-web-space sensory loss is a radial nerve palsy (‘Saturday-night palsy’) from compression in the spiral groove.

Options:

Ulnar → claw hand.
Median → carpal tunnel.
(correct)
Axillary → shoulder abduction.
Peroneal → foot drop.

A patient opens eyes to speech, is confused in conversation, and localises to pain. What is the GCS?

Correct answer: C — 13

Why it’s right: Eyes to speech (E3), confused speech (V4) and localising to pain (M5) sum to 13. Confused-but-conversant is V4; localisation is M5.

Options:

Too low.
Too low.
(correct)
Too high.
Too low.

DVLA Standards

⚡ High-Yield Core Teaching

Driving rules

Condition	Group 1 (car)	Group 2 (HGV/PSV)
Stroke / TIA	1 month	1 year
First unprovoked seizure	6–12 months	5–10 years
Epilepsy	12 months seizure-free	10 years fit-free, off medication
Narcolepsy	3 months symptom control	Cease until symptom-free

Clinical pearlA 65-year-old Group 2 driver, seizure-free for 2 years, must still wait 8 more years (10 years fit-free) to regain the HGV licence.

Red flag / must-knowIt is the patient’s legal duty to notify the DVLA; the GP should advise this clearly and document it.

🎯 SBA Test Bank (2)

A patient has a single unprovoked seizure and holds an ordinary (Group 1) car licence. What must you advise about driving?

ANo restriction
BStop driving, notify DVLA; typically 6–12 months off
CStop for 1 week
DStop for 1 month
ENever drive again

Correct answer: B — Stop driving, notify DVLA; typically 6–12 months off

Why it’s right: After a first unprovoked seizure the patient must stop driving and inform the DVLA, with a licence typically withheld for 6–12 months depending on assessment. Group 2 rules are far stricter.

Options:

A restriction applies.
(correct)
Too short.
Too short.
Not necessarily permanent.

A 60-year-old car driver (Group 1) has a TIA with full recovery. What is the correct driving advice?

ANo restriction
BMust not drive for 1 month; need not notify DVLA if fully recovered
CMust not drive for 1 year
DMust notify DVLA and stop for 6 months
ENever drive again

Correct answer: B — Must not drive for 1 month; need not notify DVLA if fully recovered

Why it’s right: After a single TIA/stroke with full recovery, a Group 1 driver must not drive for 1 month and need not notify the DVLA if there is no residual deficit. Group 2 requires 1 year and DVLA notification.

Options:

A restriction applies.
(correct)
1 year is the Group 2 rule.
6 months is not the standard for a recovered TIA.
Not permanent if recovered.